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

Effective Date: August 24, 2001

Approval Date: 25 6.1.4.6. Θ 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. Θ 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)

Services provided under SCHIP are identical to the benefits covered under the South Dakota Medicaid program for low-income children in amount, scope and duration. As such the benefits include all mandatory Medicaid services for the categorically needy and ESPDT benefits as well as all the optional services covered under the South Dakota Medicaid program.

Most medical services provided to children under South Dakota Medicaid are accessed through a primary care case management managed care system approved for Medicaid under a 1915(b) waiver. South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans. Children eligible for services under SCHIP will also be required to participate in the primary care case management system (PCCM). Under this program, a primary care physician (PCP) provides primary care services. Specialty services within the scope of the managed care program require a referral from the PCP. Emergency services, family planning services, and non-medical services (dental, chiropractic, optometry, podiatry, immunization and transportation), are exempt from all PCCM requirements. Non- waiver services are accessed directly by recipients. All services are reimbursed on a fee for service basis. There is no cost sharing for services provided to children under this plan.

Generally, all services provided under the Medicaid program must be “medically necessary”. SCHIP services must also meet the requirements of the definition of medically necessary used by Medicaid. Medically necessary services are those that: • are consistent with the recipient's symptoms, diagnosis, condition, or injury • are recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group • are provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition • are not furnished primarily for the convenience of the recipient or the provider