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

Effective Date:

Approval Date: 42 • Upon delivery, coverage for the CHIP Perinatal newborn is the same as coverage for CHIP clients.

6.2.23.

Hospice Care (Section 2110 (a) (23)) Covered, medically necessary hospice services include, but are not limited to, palliative care, including medical and support services, for those children who have six months or less to live, to keep patients comfortable during the last weeks and months before death. Treatment for unrelated conditions is unaffected.

Hospice care services are for a 6-month benefit period. Limitations include: Services apply only to the hospice diagnosis; limited to a maximum of 120 days with a six-month life expectancy; and, patients electing hospice services must waive their rights to treatment related to their terminal illnesses; however, they may cancel this election at any time.

The Health Plan may require authorization and physician prescription.

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

6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Skilled Nursing Facility (including Rehabilitation Hospital) Services Covered, medically necessary skilled nursing facility and rehabilitation hospital services include, but are not limited to, semi-private room and board; regular nursing services; rehabilitation services; and medical supplies and use of appliances and equipment furnished by the facility. Skilled nursing facility services are for a12-month period. Coverage is limited to 60 days per 12-month period. Private duty nurses, television and custodial care are excluded. The Health Plan may require authorization and physician prescription.

CHIP Perinatal Program: • Skilled nursing facility and rehabilitation hospital services are not covered a benefit for the unborn child. • Upon delivery, coverage for the CHIP Perinatal newborn