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Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 24 - 6.2.6  Prescription drugs (Section 2110(a)(6)) 6.2.7  Over-the-counter medications (Section 2110(a)(7)) 6.2.8  Laboratory and radiological services (Section 2110(a)(8)) 6.2.9  Prenatal care and prepregnancy family services and supplies (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)) 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) 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)) 6.2.13  Disposable medical supplies (Section 2110(a)(13)) 6.2.14  Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15  Nursing care services (See instructions) (Section 2110(a)(15)) 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)) 6.2.18  Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19  Outpatient substance abuse treatment services (Section 2110(a)(19)) 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)) 6.2.25  Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26  Medical transportation (Section 2110(a)(26)) Response: NEMT is not covered for children in families with income above 150% FPL. Emergency ambulance services are covered for a recipient whose life or health is in danger. NEMT is covered for children in families with income of and less than 150% FPL.