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

Effective Date: August 24, 2001

Approval Date: 35

Nursing Facility services are covered when medically necessary and individuals meet level of care and financial eligibility criteria for long term care. Nursing facility services are prior authorized.

Immunization services include all recommended vaccinations and are covered under Section 6.2.6, prescription drugs.

Organ transplant services include Kidney, Cornea, Bone Marrow, Liver and Heart Transplants. All transplant services are covered only when all other medical and surgical treatments have been exhausted, patients are free from adverse factors and there is likelihood of success or survival. Transplants are limited to the transplantation of human organs. With the exception of kidney and cornea transplants, transplant procedures are prior authorized. 6.2.25. ∼ Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26. X Medical transportation (Section 2110(a)(26))

Medical transportation includes medically necessary air ambulance, ground ambulance, wheelchair transportation and other medical transportation. Ambulance services are necessary when other forms of transportation may endanger a person’s life or health. Ground ambulance includes advanced life support and basic life support services and attendants. Air ambulance includes fixed wing emergency transportation, rotary emergency transportation, and medical air transportation. Air ambulance must be medically necessary because of time, distance and emergency. Wheelchair transportation includes transportation services to persons that are confined to wheelchairs or stretchers to and from medical services.

Other transportation services are available to assist persons obtain necessary medical services. These services include reimbursement for the use of private automobiles, meals and lodging, community transportation providers, tribal transportation providers and commercial carriers.

6.2.27. ∼ Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28. ∼ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))