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

STATE: Virginia Page 6-30

Effective Date: 07/01/05

30 Approval Date: _____________/06 remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

Coverage of chiropractic and vision services with benefit limitations. Effective 12/1/02, the vision co-payments levels for each FPL will decrease. Reimbursement levels for frames and trifocal lenses will increase.

6.2.25. ⌧ Premiums for private health care insurance coverage (Section 2110(a)(25))

Premiums for private health care insurance coverage will be covered as outlined in § 3.1.

6.2.26. ⌧ Medical transportation (Section 2110(a)(26))

Professional ambulance services under certain conditions are covered when used locally to or from a covered facility or provider’s office. Ambulance services if prearranged by the Primary Care Physician and authorized by the Company if, because of enrollee’s medical condition, the enrollee cannot ride safely in a car when going to the provider’s office or to the outpatient department of the hospital. Ambulance services will be covered if the enrollee’s condition suddenly becomes worse and must go to a local hospital’s emergency room.

For coverage of ambulance services, the following three conditions must be met: (a) The trip to the facility or office must be to the nearest one recognized by the health plan administrator as having services adequate to treat the condition; (b) The services received in that facility or provider's office are covered services; and (c) If the health plan administrator requests it, the attending provider must explain why transportation could not occur in a private car or by any other less expensive means. 6.2.27. Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

6.2.28. ⌧ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

Enhanced Services Provided Beyond Secretary-approved coverage modeled after the state employee plan:

The services described above are the services included in the Key Advantage State Employee Benefit Package in effect in June 2000. FAMIS Secretary- approved coverage modeled after the state employee plan will include all of the