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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 23 - 6.1.4.3 □ Coverage that either includes the full EPSDT benefit or that the State has extended to the entire 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) Response: Except for NEMT, Missouri will provide the identical package of covered services to SCHIP 1 and SCHIP 2 recipients as is currently provided to MO HealthNet recipients under Title XIX. NEMT is not covered for children in families with income more than 150% FPL. 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)) (42 CFR 457.490) Response: The services checked below are generally covered for MO HealthNet categorically needy eligibles and would be covered for SCHIP 1 and SCHIP 2, depending on the need of the recipient. All these services are subject to the same limitations and prior approvals as they are in the approved MO HealthNet State Plan. Please see Attachments 9 and 9a. The following specific services are found in the MO HealthNet State Plan Amendment: • Over the Counter Medicine – Section 3.1-A, page 15aa. • Outpatient Mental Health Services – Section 3.1-A, page 1. Although outpatient mental health services are not delineated, they are a covered service under Missouri's State Plan Amendment. • Dental Services - Section 3.1-A, pages 10f and 18d. • Outpatient Substance Abuse Treatment and Outpatient Substance Abuse Treatment Services - Section 3.1-A, page 17aaa.