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39 Effective Date: July 1, 2009

Approval Date: to children eligible for Categorically Needy (CN) Medicaid under Title XIX of the Social Security Act (SSA) and CHIP under Title XXI of the SSA.

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 Demonstration Project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive State-based coverage 6.1.4.6. Coverage under a Group Health Plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison. (Please provide a sample of how the comparison will be done.) 6.1.4.7. Other (Describe) SERVICE MEDICAID CN CHIP Advanced RN Practitioner Services Yes Yes Ambulance/Ground and Air Yes Yes Anesthesia Services Yes Yes Audiology Yes Yes Blood/Blood Administration Yes Yes Case Management – Maternity L L Chiropractic Care Yes Yes Clinic Services Yes Yes Community Mental Health Centers Yes Yes Dental Services Yes Yes Dentures Only Yes Yes Detox (3 days) Yes Yes Drugs and Pharmaceutical Supplies Yes Yes Elective Surgery Yes Yes Emergency Room Services Yes Yes Emergency Surgery Yes Yes Eyeglasses and Exams Yes Yes Family Planning Services Yes Yes