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

Effective Date: August 24, 2001

Approval Date: 31

Prosthetic devices, except dental, are included for coverage, including braces, artificial limbs, artificial eyes, augmentative communication devices, items to replace all or part of an internal body organ, and the replacement of such devices required by a change in the patient's condition.

Eyeglasses and contact lenses are included in coverage and may be obtained from optical providers, physicians as described in 6.2.3, and optometrists along with professional services. Eyeglasses are limited to replacement after 15 months, unless significant vision changes have occurred.

Durable Medical Equipment and prosthetic devices are included in the PCCM program. Eyeglasses and services of vision professionals are not included in the PCCM program.

6.2.13. X Disposable medical supplies (Section 2110(a)(13))

Disposable medical supplies are covered when medically necessary under each of the forms of coverage in Section 6.2.

6.2.14. X Home and community-based health care services (See instructions) (Section 2110(a)(14))

Home and community based services are covered when medically necessary and ordered by a physician and provided by a home health agency or qualified professional. Home health services include medical supplies, skilled nursing services, home health aide services, physical therapy, speech therapy, occupational therapy, respiratory therapy when ventilator dependant, and medical social services. Individuals receiving these services must be unable to leave home without considerable effort. Services are of an intermittent nature, not more than once per day or 4 times per week. There is no limit on the number of visits a person may receive.

Extended home health aide services and private duty nursing services are covered when more than 3 consecutive hours of care are necessary. These services must be prior authorized.

Home based therapy services are also covered for children with mental disorders or who are seriously emotionally disturbed. A treatment plan must exist that documents the need for home based therapy services. Covered services include diagnostic assessment, individual therapy, family