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

Effective Date: August 24, 2001

Approval Date: 32 therapy, and collateral services. Services must be prior authorized. 6.2.15. X Nursing care services (See instructions) (Section 2110(a)(15))

Nursing care services are covered as described in 6.2.1, 6.2.2, 6.2.3, 6.2.4, 6.2.5 and 6.2.14.

6.2.16. X Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

Coverage is the same as Medicaid coverage.

6.2.17. X Dental services (Section 2110(a)(17))

Dental services are covered including diagnostic services (oral examinations and x-rays), preventive services (prophylaxis, topical fluoride, and sealant), restorative services (amalgam restorations, resin restorations, and crowns to anterior teeth), endodontics, prosthodontics (complete and partial dentures, adjustments, and repairs).

Medical/Dental procedures are also covered including oral surgery for extraction, surgical extractions and tooth reimplantation, treatment of fractures, reduction of TMJ dysfunction, and periodontics. Medically necessary orthodontic procedures including diagnosis, minor treatment, interceptive orthodontic treatment and treatment of dentition are covered.

Dental exams, prophylaxis, and topical fluoride are limited to two services in a 12-month period, sealants are limited to once in a three year period. Orthodontic services in excess of $500 must be prior authorized.

All dental services are exempt from the PCCM program.

6.2.18. X Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Inpatient treatment for substance abuse services are covered in certified facilities designed specifically for chemically dependent adolescents. Services are not included in the PCCM program, however, referrals from a physician or court are required. Services are prior authorized. Services are limited to 45 days in a 12 month period. Programs designed for substance abusing pregnant women are covered.