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

Effective Date: August 24, 2001

Approval Date: 29

6.2.9. X Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

Covered under 6.2.3, 6.2.5,6.2.6. Family planning and prenatal maternity care services are fully covered. Family planning services are exempt from PCCM requirements. There are no limitations on services provided.

6.2.10. X 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))

Inpatient mental health services are provided in three different service settings. Psychiatric Inpatient Hospital services are covered under 6.2.1 and include psychiatric care in general acute care hospitals, psychiatric distinct part units, and free standing psychiatric hospitals, including a state operated adolescent psychiatric unit.

Inpatient psychiatric facility services are provided to children, with prior authorization. These services are exempt from PCCM requirements. There are no limitations on services provided.

Inpatient residential treatment services for children are covered in residential treatment facilities. Coverage is limited to the treatment services provided and does not include room and board costs. Services are prior authorized. There are no limitations on services provided.

6.2.11. X 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)

Outpatient mental health services are covered in 6.2.3 when provided by physicians.

• Outpatient mental health services are covered in community mental health centers and include the following services: • Evaluations completed by a psychiatrist; • Evaluations or testing completed by a psychologist; • Comprehensive evaluations completed utilizing the expertise of more than one mental health professional; • Therapy provided to an individual; • Therapy provided to groups of two or more individuals, not