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

Effective Date:

20 Approval Date: (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))

Certain limits and prior authorization requirements apply.

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)

Certain limits and prior authorization requirements apply.

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))

Prescribed equipment must be medically necessary.

Prior authorization required for certain items.

6.2.13

Disposable medical supplies (Section 2110(a)(13))

Prescribed medical supplies must be needed to relieve or control a medical condition.

6.2.14

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

Home health and personal care services will be provided, including part-time or intermittent nursing service provided by a home health agency, home health aid services, physical therapy, occupational therapy or speech-language pathology services, and environmental modifications to the home. Maine has 3 section 1915(c) waiver for the provision of home and community based services where appropriate as an alternative to institutionalization.

6.2.15

Nursing care services (See instructions) (Section 2110(a)(15))

Includes Nurse Practitioners, Nurse Midwives, Certified Clinical