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

Effective Date:

Approval Date: 41 provided only if medically necessary and/or limited to emergency for the Unborn population it is identified with *L/MN.

Services for the Unborn population are the same benefits, regardless of county, (subject to section 4.1.8) as identified in items 6.2.1 through 6.2.28.

Section Benefit description Eligibility Groups covered by the state plan Conception to birth

6.2.1. Inpatient services (Section 2110(a)(1))

6.2.2. Outpatient services (Section 2110(a)(2))

6.2.3. Physician services (Section 2110(a)(3))

6.2.4. Surgical services (Section 2110(a)(4))

*L/MN 6.2.5. Clinic services (including health center

services) and other Ambulatory health

care services. (Section 2110(a)(5))

6.2.6. Prescription drugs (Section 2110(a)(6))

6.2.7. Over-the-counter medications (Section 2110(a)(7))

6.2.8. Laboratory and radiological services

(Section 2110(a)(8)) 6.2.9. Prenatal care and prepregnancy family

services and supplies (Section 2110(a)(9)) 6.2.10.Inpatient mental health services, other than services

described in 6.2.18., but including services furnished

in a state-operated mental hospital and including

residential or other 24-hour therapeutically planned

structural services (Section 2110(a)(10)) 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) 6.2.12.Durable medical equipment and other medically-related

*L/MN

or remedial devices (such as prosthetic devices, implants,

eyeglasses, hearing aids, dental devices, and adaptive

devices) (Section 2110(a)(12)) 6.2.13. Disposable medical supplies (Section 2110(a)(13))

*L/MN 6.2.14 .Home and community-based health care services

(See instructions) (Section 2110(a)(14)) 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