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

Effective Date:

Approval Date: September 19, 2002 30 6.2.10.

Inpatient mental health services, other than services described in 6.2.18. (Section 2110(a)(10)) 6.2.11.

Outpatient mental health services, other than services described in 6.2.19. (Section 2110(a)(11) 6.2.12.

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.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

All services available under the State’s Title XIX State Plan that are provided to participants of home and community based waivers are included under KidCare Share and KidCare Premium. Only the specialized services unique to these waivers are excluded from these plans. The waiver programs themselves have been specifically excluded for the following reasons: 1) KidCare Share and KidCare Premium are designed to be broadly applicable and are not intended to focus on the unique circumstances addressed through the home and community based waivers; 2) Each of the waiver programs have specialized eligibility objectives, several of which include income standards above those allowed under KidCare Share and KidCare Premium; and 3) All of the waiver programs have enrollment caps.

6.2.15.

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)

No abortion services are covered by KidCare Share and KidCare Premium. A child who is pregnant when she applies is not enrolled in these plans but instead enrolled under Title XIX. If a child who becomes pregnant while she is enrolled under KidCare Share or KidCare Premium chooses to have an abortion, she must enroll under Title XIX to have abortion services covered. Abortion service limitations are defined in the Illinois Medicaid State Plan.

6.2.17.

Dental services (Section 2110(a)(17)) 6.2.18.

Inpatient substance abuse treatment services and residential