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

Effective Date:

Approval Date: 42

mother or if the pregnancy is the result of an act

of rape or incest (Section 2110(a)(16) ** state only -funded abortion services are available to CHIP OHP Plus and HKC 6.2.17. Dental services (Section 2110(a)(17))

*L/MN 6.2.18. Inpatient substance abuse treatment services

*L/MN

and residential substance abuse treatment

services (Section 2110(a)(18)) 6.2.19. Outpatient substance abuse treatment

*L/MN

services (Section 2110(a)(19)) 6.2.20. Case management services (Section 2110(a)(20))

6.2.21. Care coordination services (Section 2110(a)(21))

6.2.22. Physical therapy, occupational therapy, and services

*L/MN

for individuals with speech, hearing, and language

disorders (Section 2110(a)(22)) 6.2.23. Hospice care (Section 2110(a)(23))

6.2.24. Any other medical, diagnostic, screening, preventive,

*L/MN

restorative, remedial, therapeutic, or rehabilitative

services. (See instructions) (Section 2110(a)(24)) 6.2.25. Premiums for private health care insurance

coverage (Section 2110(a)(25))(HKC and ESI) 6.2.26. Medical transportation (Section 2110(a)(26))

*L/MN 6.2.27.Enabling services (such as transportation, translation,

and outreach services (See instructions)

(Section 2110(a)(27))(except those enrolled in HKC) 6.2.28.Any other health care services or items specified by the

Secretary and not included under this

section (Section 2110(a)(28))

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6