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

Effective Date:

Approval Date: 32 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)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1))

Room and board (semi-private accommodations, unless the hospital has only private rooms); medically necessary supplies; medication; laboratory tests; radiological services; operating/recovery rooms; and hospital staff. Hospital admissions must be pre-certified. The State Health Plan requires a second surgical opinion for coronary artery bypass; hysterectomy; knee surgery; revision of nasal structure; unless the procedure is performed on an emergency basis. 6.2.2.

Outpatient services (Section 2110(a)(2))

The State Employees Health Plan provides benefits for covered diagnostic services, therapies, laboratory, radiology, and surgeries provided in a hospital outpatient setting or in an ambulatory surgical facility; preadmission diagnostic tests before hospital admission within 14 days of a scheduled hospital admission.

6.2.3.

Physician services (Section 2110(a)(3))

Eligible medical providers are Doctor of Medicine; Doctor of Osteopathy; Doctor of Podiatry; Doctor of Chiropractic; office visits for preventive services such as unlimited well- baby visits up to one year of age; 1 visit per year between 2 and 7; once every three years between seven and 19 years of age. Immunizations are covered.

6.2.4.

Surgical services (Section 2110(a)(4))

Standard surgical procedures; related services; surgeon's fees, including preoperative and some post-operative visits; anesthesia. Assistant surgeons are covered when medical judgment requires surgical assistance and no hospital- employed physician in training is available. When two or more surgical procedures are covered at the same time if there are separate incisions, the surgeon will be paid at the rate of the higher usual and customary charge and 50% of