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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-25

Effective Date: 07/01/05

25 Approval Date: _____________/06 fee-for-service program or PCCM program, Virginia provides a Title XIX look- alike program with benefits that are essentially the same as the state’s Title XIX Plan.

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

Secretary-approved coverage modeled after the state employee, Virginia’s Key Advantage State Employee Benefit Plan in effect in June 2000, is summarized in the checklist below (6.2.1 -- 6.2.28). The additional coverage provided is listed separately at the bottom of the checklist. NOTE: The FAMIS program has two separate health care services delivery systems, described immediately below and at 6.2.1.A – 6.2.28.A, below.

6.2.1. ⌧ Inpatient services (Section 2110(a)(1))

365 days per confinement; includes ancillary services.

6.2.2. ⌧ Outpatient services (Section 2110(a)(2))

Outpatient services include emergency services, surgical services, and professional provider services in a physician’s office or outpatient hospital department. Facility charge for outpatient department of a hospital or hospital emergency room, separate from physician or diagnostic services.

6.2.3. ⌧ Physician services (Section 2110(a)(3))

Physician services include services while admitted in the hospital, or in a physician’s office, or outpatient hospital department.

6.2.4. ⌧ Surgical services (Section 2110(a)(4))

Surgical services include services provided in §§ 6.2.1, 6.2.2, and 6.2.3.

6.2.5. ⌧ Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services include services provided in §§ 6.2.2 and 6.2.3. 6.2.6. ⌧ Prescription drugs (Section 2110(a)(6))

Covered for outpatient prescription drugs. Mandatory generic program.