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

Effective Date: August 24, 2001

Approval Date: 34 within their scope of practice when referred by physicians and required to diagnose or treat a medical condition. These services may also be provided by school districts when medically necessary and identified as part of a child’s individual education program. The services are included in the PCCM program. There are no limitations on the services provided.

6.2.23. X Hospice care (Section 2110(a)(23))

Hospice benefits will follow the amount, duration and scope of coverage as identified in the State Medicaid manual.

6.2.24. X Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Other medical services included in the plan are Chiropractic Services, Vision Services, Podiatry Services, Nutritional Services, Nursing Facility Services, Diabetes Self-management training programs, Vaccination Services and certain Organ Transplant Services.

Chiropractic services are limited to examinations and manual manipulations required to correct a subluxation of the spine. Services are outside of the PCCM program and limited to no more than one visit per day and thirty visits in a twelve-month period.

Vision services, in addition to the services of physicians in 6.2.3 include the services of optometrists. Covered services include examinations, removal of foreign bodies from the eye, vision screenings, and refractive services, eyeglasses and contact lenses. Services are outside of the PCCM program. Eyeglasses are limited to replacement after 15 months unless significant vision changes have occurred.

Podiatry services include the surgical and non-surgical diagnosis and treatment of conditions of the feet and lower extremities, excluding routine foot care. Services are outside of the PCCM program. There is no limit on the number of services provided.

Nutritional services are covered for children not able to obtain necessary nutrition through oral means. Enteral and perenteral nutrition are covered services. Perenteral nutrition services are prior authorized. Nutritional supplements are covered when physician ordered for conditions that exceed normal nutritional requirements.