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

Effective Date: August 24, 2001

Approval Date: 27

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

Surgical services covered in addition to those provided under hospital or physician services include those services provided in ambulatory surgical centers (ASC) to patients who do not require hospitalization. Services include nursing, technician, use of ASC facilities, drugs, biologicals, surgical supplies, equipment, diagnostic and therapeutic services directly related to the provision of surgical procedures. Surgery services are included as PCCM services. There are no limitations on services provided.

6.2.5. X Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services include preventive, diagnostic, therapeutic, rehabilitative, or palliative items services provided by federally qualified health centers and rural health or services under the medical direction of a physician and provided at the clinic or center. Clinic and center services are included as PCCM services and clinics and centers are eligible to be primary care providers. Services are limited to two visits per day, if the second visit is due to illness or injury sustained after the first visit.

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

Prescription drug services include the following drugs, biologicals, and related items and services that are prescribed: • Legend eye preparations, vaginal therapeutics, otic pharmaceutical preparations, or inhalations for asthmatic conditions; • Antibiotic products which are known, either by sensitivity test or product information, to be the single item of choice for the diagnosis; • All other legend prescription drugs and biologicals, except for the items listed below. • Insulin; • Concentrated cryoprecipitate used in the home treatment of hemophilia; • Legend vitamins prescribed for the prenatal care of pregnant women; • Calcitriol if used for renal impairment and determined medically necessary by the prescriber; • Spacers, such as Aerochamber and InspirEase, and solutions that