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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 33 Approval Date: November 19, 2010 6.2.4. X Surgical services (Section 2110(a)(4)) 6.2.5. X Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. X Prescription drugs (Section 2110(a)(6)) 6.2.7. ∼ Over-the-counter medications (Section 2110(a)(7)) 6.2.8. X Laboratory and radiological services (Section 2110(a)(8)) 6.2.9. X Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.X Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11. X Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12. X Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13. X Disposable medical supplies (Section 2110(a)(13)) 6.2.14. X Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15. X Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16. ∼ Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17. X Dental services (Section 2110(a)(17)) 6.2.18. X Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19. X Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20. X Case management services (Section 2110(a)(20)) 6.2.21. X Care coordination services (Section 2110(a)(21)) 6.2.22 X Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23. X Hospice care (Section 2110(a)(23)) 6.2.24. X Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25. ∼ Premiums for private health care insurance coverage (Section 2110(a)(25))