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

Effective Date:

Approval Date: 39 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))

The dental benefit consists of three tiers that cover the following services per 12-month coverage period:

Tier I covers preventive services up to $250, and therapeutic services up to $280; Tier II covers preventive services up to $250, and therapeutic services up to $425; and Tier III covers preventive services up to $250, and therapeutic services up to $565.

Preventive services include routine check-ups, x-rays, cleaning and sealants. Therapeutic services include such things as fillings, crowns, root canals and extractions.

A 12-month coverage period is defined as one 12-month enrollment period.

Limitations to dental services are that if services are all used within one 6-month enrollment period, these services are not available during the second 6-month enrollment period.

CHIP Perinatal Program: • Dental services are not a covered benefit for the unborn child. • Upon delivery, coverage for the CHIP Perinatal newborn is the same as coverage for CHIP clients.

6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Covered, medically necessary services include, but are not limited to, inpatient and residential substance abuse treatment services including detoxification and crisis stabilization, and 24- hour residential rehabilitation programs.

Inpatient substance abuse treatment services and residential substance abuse treatment services are for a 12-month benefit period. Limitations to inpatient and residential substance abuse treatment services are 14 days per 12-month period for detox/crisis stabilization services; 60 days per 12-month period for 24-hour residential rehabilitation programs, or equivalent (30 days must be held in reserve; however, 30 days may be converted to partial hospitalization or intensive outpatient