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

Effective Date:

Approval Date: 35 Inpatient psychiatric services are included, up to a 12-month period limit, ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court-ordered commitments to psychiatric facilities. The court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.

Inpatient mental health services are for a 12-month benefit period, and are limited to a 45-day inpatient limit per 12-month period. Twenty-five (25) days of the inpatient benefit can be converted to residential treatment, therapeutic foster care or other 24-hour therapeutically planned and structured services or sub-acute outpatient (partial hospitalization or rehabilitative day treatment) mental health services on the basis of financial equivalence against the inpatient per diem cost. Twenty (20) of the inpatient days must be held in reserve for inpatient use only. Prior authorization may be required for non-emergency services; however, PCP referral is not required.

CHIP Perinatal Program: • Inpatient mental health services are not a covered benefit for the unborn child. • Coverage for the CHIP Perinatal newborn is the same as coverage for CHIP clients.

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state- operated facility and including community-based services. (Section 2110(a)(11) Covered, medically necessary outpatient mental health services include, but are not limited to, mental health services provided on an outpatient basis and neuropsychological and psychological testing.

Includes outpatient psychiatric services, up to an annual limit, ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court-ordered commitments to psychiatric facilities. The court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.

Outpatient mental health services are for a 12-month benefit period and are limited to up to 60 outpatient visits per 12-month period. The visits can be furnished in a variety of community-