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Application for the State of Indiana Children’s Health Insurance Program Amendment #7

Effective Date:

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Approval Date: 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)

For discussion of scope of services, amount, duration, exclusions and limitations, see Attachment A. 6.2.1.

Inpatient services (Section 2110(a) (1)) 6.2.2.

Outpatient services (Section 2110(a) (2)) 6.2.3.

Physician services (Section 2110(a) (3)) 6.2.4.

Surgical services (Section 2110(a) (4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a) (5)) 6.2.6.

Prescription drugs (Section 2110(a) (6)) 6.2.7.

Over-the-counter medications (Section 2110(a) (7)) Coverage only applies to insulin. 6.2.8.

Laboratory and radiological services (Section 2110(a) (8)) 6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a) (9)) 6.2.10.

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.

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.

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)) Coverage subject to limitations. 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a) (14)) 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) 6.2.17.

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

Inpatient substance abuse treatment services and residential 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)) Not Covered. 6.2.21.

Care coordination services (Section 2110(a) (21)) Not Covered. 6.2.22.

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