Page 43

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

Effective Date:

Approval Date: 43 is the same as coverage for CHIP clients.

Emergency Services including Emergency Hospitals and Physician Covered, medically necessary covered services include: emergency services based on prudent lay person definition of emergency health condition; hospital emergency department room and ancillary services and physician services 24 hours a day, 7 days a week, both by in-network and out-of-network providers; medical screening examination; stabilization services; access to designated Level I and Level II trauma centers or hospitals meeting equivalent levels of care for emergency services. The Health plan cannot require authorization as a condition for payment for emergency conditions or labor and delivery; however, the health plan may require authorization for post-stabilization services.

CHIP Perinatal Program: • Covered, medically necessary emergency services are limited to those emergency services that directly relate to the delivery of the covered unborn child until birth. • Coverage for the CHIP Perinatal newborn is the same as coverage for CHIP Clients. • Post-delivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinatal newborn are not a covered benefit.

Vision Services Covered, medically necessary services include: one examination of the eyes to determine the need for, and prescription for, corrective lenses per 12-month period, without Health Plan authorization; and one pair of non-prosthetic eyewear per 12-month period. Vision services are for a 12- month benefit period. The Health Plan may reasonably limit the cost of frames/lenses. The Health Plan may require authorization for protective and polycarbonate lenses when medically necessary as part of a treatment plan for covered diseases of the eye. Vision training and vision therapy are excluded.

CHIP Perinatal Program: • Vision 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.

Transplant Services