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Family Choices Appendix H

The Family Choices benefit package was based on the Kentucky state employee benefit package with modifications to assure nominal cost sharing. Some benefit limit and design changes were also made to the package. Limits imposed under the Family Choices plan are soft limits which means additional visits may be authorized if medically necessary; in contrast, the limits in the state employee health benefit plan are hard limits and may not be exceeded. The differences are detailed in the following table:

State Employee Benefit Family Choices Benefit Chiropractic Services- 26 per visits per year Chiropractic Services- 7 visits per 12 months Speech Therapy- 30 visits per year Speech Therapy- 15 visits per year Physical Therapy- 30 visits per year Physical Therapy- 15 visits per year Occupational Therapy- 30 visits per year Occupational Therapy- 15 visits per year EPSDT (not fully covered) EPSDT Home Health- limited to 60 visits per year Home Health- 25 visits per 12 months Skilled Nursing Facility Services- limited to 30 days per year Skilled Nursing Facility Services- no day limitation

The Following table outlines the benefit package for Family Choices. The cost sharing requirements listed in this benefit grid will apply to all members of Family Choices. For the Family Choices populations, these cost sharing requirements shall supersede any other cost sharing requirements described elsewhere in the state plan.

Benefit/Service Children of Caretaker Relatives Categorically Needy Children KCHIP Children Medical Out-of- Pocket Maximum $225 per 12 months $225 per 12 months $225 per 12 months Pharmacy Out-of- Pocket Maximum

$225 per 12 months $225 per 12 months $225 per 12 months Acute Inpatient and Critical Access Hospital Services

$0 co-pay $0 co-pay $0 co-pay Laboratory, Diagnostic and Radiology Services

$0 co-pay $0 co-pay $0 co-pay Physician Services $0 co-pay $0 co-pay $0 co-pay