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Medicaid Section 1115 demonstration project 6.1.4.3

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4

Coverage that includes benchmark coverage plus additional coverage

Benefits under the CoverKids program will be the same as the benefits for the HMO option of the State Employee Health Plan; however, the annual number of visits for outpatient mental health/substance abuse and PT/OT/SP has been increased from 45 to 52. Beginning in January 2008, the benefit package will also include dental and vision services. Attachment A is the summary of benefits for CoverKids. Attachment B is the benefit summary for the State Employee Health Plan.

6.1.4.5

Coverage that is the same as defined by “existing comprehensive state-based coverage” 6.1.4.6

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit-by-benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7

Other (Describe)

6.2 The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1 Inpatient services (Section 2110(a)(1)) 6.2.2 Outpatient services (Section 2110(a)(2)) 6.2.3 Physician services (Section 2110(a)(3)) 6.2.4 Surgical services (Section 2110(a)(4)) 6.2.5 Clinic services (including health center services) and other ambulatory health care services (Section 2110(a)(5)) 6.2.6 Prescription drugs (Section 2110(a)(6)) 6.2.7 Over-the-counter medications (Section 2110(a)(7)) 6.2.8 Laboratory and radiological services (Section 2110(a)(8)) 6.2.9 Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10 Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour

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