Benefit Design - Service Delivery Example

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Colorado

Building strong provider networks has been an early focus of the Colorado Child Health Plan Plus (CHP+) program. Such networks are being built through careful selection of providers to be included in the network and through coordination with other health systems. SCHIP Workshop (July 1998) presenter Sarah Schulte of the Colorado Department of Healthcare Policy and Finance summarized the early Colorado CHP+ program experience as follows.

Provider Selection

Obtaining the right types of providers to meet the healthcare needs of the target population was a key issue in the development of the CHP+ service delivery system. This was ensured through:

Contract provisions which specified that the HMO must:
- Be licensed.
- Provide adequate network providers and standing specialist referrals for members with special needs.
- Provide case management when medically necessary.

Carve-outs of services such as mental health, substance abuse, dental, and transplants.

Inclusion of essential community providers who helped to ensure that the necessary providers were part of the networks.

Health Systems Coordination

Colorado CHP+ has coordinated with the mental health, substance abuse, and special healthcare needs systems throughout the State.

Mental health and substance abuse coordination includes:
- A wrap-around package for children identified with special needs.
- Coordination with mental health and substance abuse agencies which brings expertise and an established structure to the program.
- Pilot programs that will be used to test the effectiveness of the efforts.

The Healthcare Program for Children with Special Needs, developed through coordination with special needs service systems, will provide benefits to meet chronic physical healthcare needs not provided by commercial benefit packages such as:
- Special therapies.
- Durable medical equipment.
- Hearing and vision services.

Service Delivery Systems Monitoring Strategies

Quality assurance and program monitoring efforts of the Colorado SCHIP service delivery system include use of:

HMO contracts as tools to assure appropriate access to care.

Existing performance measures to assess the adequacy of provider networks.

HEDIS data to track children’s access to primary care and pediatric physician specialists.

Consumer Assessment of Health Plans (CAHPS) [http://www.ahrq.gov/qual/cahpfact.htm] data to assess ease of referrals to specialist, waiting time for appointments, and access to assessment, tests, and treatment.

Related Questions

What led to this?

Assessing Key Issues with Service Delivery

Give me an overall context

Overview of Service Delivery Statistics

Show me some lessons learned

Medicaid Plans' Advantages and Disadvantages

Managed Care-Related Service Delivery Issues

Show me more State strategies

SCHIP Guidance - State Strategies

Who presented this material?

Sarah Schulte

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