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therapeutically planned structural services (Section 2110(a)(10))

Limited to 30 days per year

6.2.11 Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

Limited to 52 sessions of mental health and substance abuse combined.

6.2.12 Durable medical equipment and other medically related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13 Disposable medical supplies (Section 2110(a)(13)) 6.2.14 Home and community-based health care services (See instructions) (Section 2110(a)(14))

Home Health Services with prior approval

6.2.15 Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16 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) 6.2.17 Dental services (Section 2110(a)(17))

Dental Benefits will include preventive, diagnostic, and basic restorative services as follows: • Diagnostic services o 2 oral examinations per year • Preventive o Fluoride treatments (1 year of age and older) or fluoride varnish not to exceed twice a year up to age 14 o Dental sealants for permanent molars o 2 cleanings per year • Emergency Services o 2 visits during office hours per year o 2 visits after office hours per year • Restorative services o Stainless steel crowns o Routine fillings (silver or tooth colored) • Simple extractions • Radiographs

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