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

Effective Date:

Approval Date: 40 rehabilitation on the basis of financial equivalence against the inpatient per diem cost).

Prior authorization may be required for nonemergency services; however, PCP referral is not required.

CHIP Perinatal Program: • Inpatient substance abuse treatment services and residential substance abuse treatment 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.

6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) Medically necessary outpatient substance abuse treatment services include, but are not limited to, prevention and intervention services that are provided by physician and non- physician providers, such as screening, assessment and referral for chemical dependency disorders.

Outpatient substance abuse treatment services are for a 12- month benefit period. Limitations to outpatient substance abuse treatment services are: up to 12 weeks per 12-month period for the intensive outpatient program; and up to six months per 12-month period for outpatient services. Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day. Outpatient treatment services is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training.

These services do not require a primary care provider referral, but prior authorization may be required.

CHIP Perinatal Program: • Outpatient substance abuse treatment services and residential substance abuse treatment 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.

6.2.20.

Case management services (Section 2110(a)(20)) Medically necessary case management services above and beyond those normally provided to all members are covered for