Contractors are required to provide all benefits described below by way of a managed care delivery system.. The Department reserves the right to change the benefit package as required by state or federal law and/or as the Department deems appropriate to meet the needs of the CHIP population. Implementation of such changes by the contractor will be on the date determined by the Department. If changes to the Benefit Package or eligibility criteria occur, the Department will conduct an actuarial analysis to determine if there is a need for a rate change based upon data provided by contractors.
Contractors may establish and maintain a referral process to effectively manage the care of its enrollees, but that process may not restrict access to medically necessary services. Medically necessary includes a service, item, or medicine that does one of the following: 1. It will, or is reasonably expected to, prevent an illness, condition, or disability; 2. It will, or is reasonably expected to, reduce or improve the physical, mental, or developmental effects of an illness, condition, injury, or disability; 3. It will help a child get or keep the ability to perform daily tasks, taking into consideration both the child's abilities and the abilities of someone of the same age. Enrollees are permitted to use providers of their choice to the extent that those providers are (except in emergencies) in the contractor’s provider network.
Providers are prohibited from charging any co-payments or requiring after-the-fact reimbursement for any in-plan service except as permitted by law and as outlined in this policy manual. A provider may bill the difference between the covered charges and the total cost of covered services where the family opts for a selection that exceeds the dollar limit or allowances established for a particular service, e.g., eyeglasses, durable medical equipment, and hearing aids.
Issued March 31, 2023