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

Effective Date:

Approval Date: 36 reeducation or family systems therapy. Not covered are care provided by a family member, care provided by a non-skilled or unlicensed care giver, such as a sitter, when the patient's condition no longer requires a skilled level of care, when the maximum rehabilitation potential has been met.

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)

Abortion is not covered.

6.2.17.

Dental services (Section 2110(a)(17))

Oral examinations, teeth cleaning, and scaling twice during a 12-month period, full mouth X rays once every 60 months, supplemental bitewing X rays showing the back of the teeth once during a 12-month period, fluoride applications twice during a 12-month period, sealants, simple extractions, therapeutic pulpotomies, prefabricated stainless steel crowns, and routine fillings of amalgam or other tooth colored filling material to restore diseased teeth.

6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Pre-certification must be obtained from the Mental Health Case Manager (in order to be eligible, patient must be confined to a licensed substance abuse bed and treated by an eligible substance abuse provider) for the following: residential treatment in a psychiatric setting, urgent admissions, chemical dependency, psychological testing (except when included in the hospital's or treatment program's daily charge); hypnotherapy; sodium amytal interviews; electroconvulsive treatment; psychosurgery. Detoxification may be obtained on a licensed medical unit, psychiatric unit, or substance abuse unit if pre-certified by the mental health case manager.

6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19))

More than 26 outpatient visits per plan year (combined with