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Benefit/Service Children of Caretaker Relatives Categorically Needy Children KCHIP Children

EPSDT Services for Children under 21 $0 co-pay $0 co-pay $0 co-pay Outpatient Hospital/ Ambulatory Surgical Centers $0 co-pay $0 co-pay $0 co-pay Behavioral Health Services**

$0 co-pay $0 co-pay $0 co-pay Allergy Services • $2 co-pay for office visit and testing • $0 co-pay for injections • $2 co-pay for office visit and testing • $0 co-pay for injections • $2 co-pay for office visit and testing • $0 co-pay for injections Preventive Services $0 co-pay $0 co-pay $0 co-pay Emergency Ambulance $0 co-pay $0 co-pay $0 co-pay

Dental Services Including but not limited to children under 21, two cleanings per 12 months and one set of x-rays per 12 months, extractions $0 co-pay $0 co-pay $0 co-pay Family Planning

$0 co-pay $0 co-pay $0 co-pay Occupational Therapy Limited to 15 visits per 12 months $0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

Physical Therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

Speech Therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

Hospice (non-institutional)

$0 co-pay $0 co-pay $0 co-pay Non-Emergency Transportation (will be covered for all groups except BCCTP members as described in the current 1915b waiver)

Not Covered Not Covered Not Covered Benefit/Service Children of Caretaker Relatives Categorically Needy Children KCHIP Children

EPSDT Services for Children under 21 $0 co-pay $0 co-pay $0 co-pay Outpatient Hospital/ Ambulatory Surgical Centers $0 co-pay $0 co-pay $0 co-pay Behavioral Health Services**

$0 co-pay $0 co-pay $0 co-pay Allergy Services • $2 co-pay for office visit and testing • $0 co-pay for injections • $2 co-pay for office visit and testing • $0 co-pay for injections • $2 co-pay for office visit and testing • $0 co-pay for injections Preventive Services $0 co-pay $0 co-pay $0 co-pay Emergency Ambulance $0 co-pay $0 co-pay $0 co-pay

Dental Services Including but not limited to children under 21, two cleanings per 12 months and one set of x-rays per 12 months, extractions $0 co-pay $0 co-pay $0 co-pay Family Planning

$0 co-pay $0 co-pay $0 co-pay Occupational Therapy Limited to 15 visits per 12 months $0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

Physical Therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

Speech Therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

$0 co-pay 15 visits per 12 months for each therapy

Hospice (non-institutional)

$0 co-pay $0 co-pay $0 co-pay Non-Emergency Transportation (will be covered for all groups except BCCTP members as described in the current 1915b waiver)

Not Covered Not Covered Not Covered