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Model Application Template for the State Children’s Health Insurance Program
Effective Date:
19 Approval Date: Medicaid population 6.1.4.4
Coverage that includes benchmark coverage plus additional coverage
6.1.4.5
Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6
Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through 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)
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))
Transplants as specified in the MaineCare Benefits Manual, Chapter II, Section 90, Physician Services.
Cosmetic surgery not covered.
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))
As specified in the MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy
6.2.8
Laboratory and radiological services (Section 2110(a)(8))
6.2.9
Prenatal care and pre-pregnancy family services and supplies