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6.1.4.5. Coverage that is the same as defined by Αexisting comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe) 6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490) Medicaid (M/C) services limited to emergency services and pregnancy- related services required for eligibles. These services include prenatal care and services for complication of pregnancy. Healthy Families Program for Children Medicaid (M/C) Prenatal Benefits for Eligibles 0­ 200% FPL Access for Infants and Mothers (AIM) Prenatal Benefits for Eligibles 200%-300% FPL 6.2.1. Inpatient services (Section 2110(a)(1)) X X X 6.2.2. Outpatient services (Section 2110(a)(2)) X X X 6.2.3. Physician services (Section 2110(a)(3)) X X X 6.2.4. Surgical services Section 2110(a)(4)) X X X 6.2.5. Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

X Effective Date: Approval Date: November 1, 2009 HFP Family Contribution Increase November 1, 2009 HFP Co-Payment Increase November 1, 2009 HFP Limited Dental Plan Choice for New Subscribers

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