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

Effective Date:

21 Approval Date: Nurse Specialists and Certified Registered Nurse Anesthetists.

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))

Prior authorization is required for orthodontia and certain other services.

6.2.18

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Certain limits and prior authorization requirements apply.

6.2.19

Outpatient substance abuse treatment services (Section 2110(a)(19))

Certain limits and prior authorization requirements apply.

6.2.20

Case management services (Section 2110(a)(20))

6.2.21

Care coordination services (Section 2110(a)(21))

6.2.22

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

6.2.23

Hospice care (Section 2110(a)(23))

6.2.24

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Services of chiropractors and podiatrists are covered. Prevention, Health Promotion and Optional Treatment Services (EPSDT), private duty nursing services and genetic testing services are also covered.

Podiatrists’ services are limited to non-routine procedures; treatment of plantar warts, ingrown nails, ulcerations, bursitis, and infections; and minor surgery under local anesthetic. Some routine procedures are covered if there are complications due to foot pathology.