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

Effective Date:

Approval Date: 35 24 months, and optical supplies and solutions when needed. Optical services, supplies and solutions must be obtained from licensed or certified opthamologists, optometrists, or optical dispensing laboratories. Eyeglass lenses are limited to single vision, bifocal, trifocal, or other complex lenses necessary for an enrollee's visual welfare. Coverage for oversized lenses, designer frames, photosensitive lenses, tinted contact lenses, blended lenses, progressive multifocal lenses, coated lenses, and laminated lenses is limited to the coverage of single vision, bifocal, trifocal or other complex lenses. Eyeglass frames are limited to those made of zylonite, metal or a combination of zylonite and metal. All visual aids require prior approval of the State Health Plan. Upon prior approval by the State Health Plan refractions may be covered more often than once every 12 months. HEARING: Auditory diagnostic testing services and hearing aids and accessories when provided by a licensed or certified audiologist, otolaryngologist, or other hearing aid specialist approved by the State Health Plan. Prior approval of the State Health Plan is required for hearing aids, accessories, earmolds, repairs, loaners, and rental aids.

6.2.13.

Disposable medical supplies (Section 2110(a)(13)) therapeutic only

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

The State Employees Health Plan limits home and community-based services to patients who are homebound, need for therapy that can only be performed by licensed health care professionals, physician -certified that the patient would otherwise be confined to a hospital or skilled nursing facility without home care services, must have rehabilitation potential. Require prior approval and include private nursing duty, home care aides (under the direct supervision of a registered nurse and employed by a licensed home care agency), skilled nursing visits, hospice care, therapy (speech, physical and occupational, and home intravenous (IV) therapy. Intensive in-home behavioral health services are covered under the Core Benefit portion of the plan as a specialized intensive outpatient program. These services include crisis management, parent