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

Effective Date:

Approval Date: 6-11 6.2.26.

Medical transportation (Section 2110(a)(26))

• Non-Air-Borne, pre-hospital emergency medical services provided by an ambulance service.

Scope of Coverage: Pre-hospital emergency medical services, including prompt evaluation and treatment of an emergency condition and/or non- airborne transportation to a hospital.

Level of Coverage: Services must be provided by an ambulance service issued a certificate to operate pursuant to section 3005 of the Public Health Law. Evaluation and treatment services must be for an emergency condition defined as a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the person afflicted with such condition in serious jeopardy; (ii) serious impairment to such person’s bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; or (iv) serious disfigurement of such person.

6.2.27.

Enabling services (such as transportation, translation, and outreach services (see instructions) (Section 2110(a)(27))

6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

● Maternity Care

Scope of Coverage: Inpatient hospital coverage for at least 48 hours after childbirth for any delivery other than a Caesarean section (C-Section) and at least 96 hours following a C-Section. Also coverage of parent education, assistance and training in breast or bottle feeding, and any necessary maternal and newborn clinical assessments. The mother shall have the option to be discharged earlier than the 48/96 hours, provided that at least one home care visit is covered post-discharge. Prenatal, labor and delivery care is covered, including surgical services rendered as part of a C-section.

Level of Coverage: No limitations; (However children potentially eligible for Medicaid requiring maternity care services will be referred to Medicaid. Pregnant women up to 200% net FPL are eligible for Medicaid’s PCAP program. This is a program expressly designed for pregnant women. This program allows for presumptive eligibility determined at the provider’s care site. Enrollees are required to report any change of circumstances that affect eligibility. This information will be reviewed by the health plan and the enrollee is referred to PCAP if she appears eligible.).