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

Effective Date:

Approval Date: 44 Using up-to-date FDA guidelines, all non-experimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses are covered, if medically necessary. Donor non-medical expenses are not covered. The Health Plan may require prior authorization.

CHIP Perinatal Program: • Transplant 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.

Tobacco Cessation Programs A Health Plan approved tobacco cessation program is covered up to a $100 limit per 12-month period. Tobacco cessation program services are for a 12-month benefit period. The Health Plan may require prior authorization and use of a formulary.

CHIP Perinatal Program: • Tobacco Cessation programs 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.

Chiropractic Services Medically necessary services are limited to spinal sublaxation. Chiropractic services do not require physician prescription and are for a 12-month benefit period. These services are limited to 12 visits per 12-month period (regardless of number of services or modalities provided in one visit). The Health Plan may require authorization for additional visits.

CHIP Perinatal Program: • Chiropractic 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.

6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) (Note: HHSC is developing a premium assistance program through a HIFA wavier request.)

6.2.26.

Medical transportation (Section 2110(a)(26)) Emergency ground, air or water transportation is a covered service.