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Effective Date: April 1, 2009

Approval Date: ____________ 35

This Page Relates to Plan "D" Only

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 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)

6.2.A. 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.A.1.

Inpatient services (Section 2110(a)(1)) 6.2.A.2.

Outpatient services (Section 2110(a)(2)) 6.2.A.3.

Physician services (Section 2110(a)(3)) 6.2.A.4.

Surgical services (Section 2110(a)(4)) 6.2.A.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.A.6.

Prescription drugs (Section 2110(a)(6)) 6.2.A.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.A.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.A.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))