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

Effective Date:

22 Approval Date:

Genetic testing services are diagnostic or screening services to determine risk for genetic diseases.

6.2.25

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26

Medical transportation (Section 2110(a)(26))

All transportation to medically necessary services covered by MaineCare is available without prior authorization. Out of state transportation requires prior authorization. Also, travel expenses associated with transportation, such as lodging or meals require prior authorization.

6.2.27

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

Interpreter services are covered for non-English, limited English speaking and /or deaf/hard of hearing individuals.

6.2.28

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

Rural health clinic services and other ambulatory services furnished by a rural health clinic, as well as federally qualified health center services are covered.

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the