Page 30

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

Effective Date: August 24, 2001

Approval Date: 30 exceeding ten persons; • Therapy provided to a family unit; • Partial day care services for a duration of three to six hours a day, including various types of therapy elements; and • Consultation with a psychiatrist, psychologist, or other mental health professional or physician concerning the patient's diagnosis or plan of treatment. • Outpatient mental health services are also available from licensed psychologists, certified social workers in private independent practice, and licensed professional counselors-mental health. Services include psychiatric evaluation, diagnostic interviews, individual, group and family therapy, and psychological testing. Services are limited to the equivalent of 40 hours of individual therapy per 12 month period, unless additional services are prior authorized.

Outpatient mental health services are included as PCCM services, unless provided to a person diagnosed as chronically mentally ill.

6.2.12. X Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Durable medical equipment is covered and includes devices and assistive technology including: • devices for persons confined to beds, including hospital beds, bed pans, urinals, commodes, trapeze, lifts, standers, and pressure reduction therapy devices if extensive pressure sores exist; • mobility devices including wheelchairs and accessories (seats, trays, cushions, and positioning devices), canes, crutches and walkers; • oxygen and respiratory equipment and supplies; • glucose monitoring equipment and supplies; • dialysis equipment; • apnea monitors; • infusion pumps; • hearing aids and augmentative communication devices;

Medical equipment is purchased or rented at the discretion of the Department and requires documented medical necessity. Some devices have specific coverage criteria and limitations. Disposable supplies used with the equipment are included in coverage.