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

Effective Date:

Approval Date: 6-7 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

● Outpatient visits for mental health

Scope of Coverage: Services must be provided by certified and/or licensed professionals.

Level of Coverage: No limitations.

6.2.12.

Durable medical equipment and other medically related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

● Durable Medical Equipment (DME)

Scope of Coverage: All DME must be medically necessary and ordered by a plan physician.

Level of Coverage: DME not limited except there is no coverage for cranial prostheses (i.e. wigs) and dental prostheses, except those made necessary due to accidental injury to sound, natural teeth and provided within twelve months of the accident, and except for dental prostheses needed in treatment of a congenital abnormality or as part of reconstructive surgery.

6.2.13.

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

● Diabetic Supplies and equipment

Scope of Coverage: Insulin, blood glucose monitors, blood glucose monitors for legally blind, data management systems, test strips for monitors and visual reading, urine test strips, insulin injection aids, cartridges for legally blind, syringes, insulin pumps and appurtenances thereto, insulin infusion devices, oral agents.

Level of Coverage: As prescribed by a physician or other licensed health care provider legally authorized to prescribe under Title 8 of the Education Law.

6.2.14.

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

● Home Health Care Services

Scope of Coverage: The care and treatment of a covered person who is under the care of a physician but only if hospitalization or confinement in a skilled nursing facility would have been otherwise required if home care was not provided, the service is approved in writing by such physician, and the plan covering the home health service is established by the Department.

Level of Coverage: Home care shall be provided by a certified home health