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

Effective Date:

Approval Date: 6-2 Chapter 1 of the Laws of 2002, Chapter 62 of the Laws of 2003, Chapter 58 of the Laws of 2004, and Chapter 58 of the Laws of 2005.

The 1996 state expenditures for this program were approximately $71.5 million.

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. 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))

● Inpatient Hospital Medical or Surgical Care

Scope of Coverage: Inpatient hospital medical or surgical care will be considered a covered benefit for a registered bed patient for treatment of an illness, injury or condition which cannot be treated on an outpatient basis. The hospital must be a short-term, acute care facility and New York State licensed.

Level of Coverage: Includes 365 days per year coverage for inpatient hospital services and services provided by physicians and other professional personnel for covered inpatient services; bed and board, including special diet and nutritional therapy; general, special and critical care nursing service, but not private duty nursing services; facilities, services, supplies and equipment related to surgical operations, recovery facilities, anesthesia, and facilities for intensive or special care; oxygen and other inhalation therapeutic services and supplies; drugs and medications that are not experimental; sera, biologicals,