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

Effective Date:

Approval Date: September 19, 2002 31 substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) Limited to children diagnosed with mental illness and children under the age of three who are receiving early intervention services. 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, speech therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Home health care services

Audiology services

Optometric services

Family planning services

All EPSDT services

Chiropractic services

Podiatric services

Renal dialysis

Services of Intermediate Care Facilities for the Mentally Retarded,

skilled pediatric nursing facility services

Early Intervention services, including case management, for children who meet eligibility requirements established in the State’s approved plan pursuant to Part C of the Individuals with Disabilities Education Act 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

Enabling services (such as transportation, translation, and outreach services) (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR