Page 36

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

Effective Date:

Approval Date: 36 based settings (including school and home-based settings) or in a state-operated facility. Medication management visits do not count against the outpatient visit limit. Outpatient rehabilitative day treatments are limited to up to 60 days per 12-month period.

Sixty (60) outpatient visits can be converted to skills training (psycho-educational skills development) or rehabilitative day treatment on the basis of financial equivalence against the outpatient visit cost. Sixty (60) rehabilitative day treatment days can be converted to outpatient visits on the basis of financial equivalence against the day treatment per diem cost. Inpatient days converted to sub-acute outpatient services are in addition to the outpatient limits and do not count towards those limits.

Partial hospitalization benefits are paid as described in the inpatient mental health benefits section. Prior authorization may be required; however, outpatient mental health services do not require PCP referral.

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

6.2.12.

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)) Covered services includes durable medical equipment (equipment which can withstand repeated use, and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness, injury or disability, and is appropriate for use in the home), and other medically-related or remedial devices that are medically necessary and necessary for one or more activities of daily living, and appropriate to assist in the treatment of a medical condition. These devises include, but are not limited to: orthotic braces and orthotics; prosthetic devices such as artificial eyes, limbs and braces; prosthetic eyeglasses and contact lenses for the management of severe opthomological disease; hearing aids; other artificial aides including surgical implants.

Durable medical equipment and other medically related or remedial devices are for a 12-month benefit period. Limitations include: $20,000 per 12-month period limit for DME,