Page 35

39 Effective Date: July 1, 2009

Approval Date: Healthy Kids (EPSDT) Yes Yes Hearing Aid Yes Yes Hospice Yes Yes Home Health Services Yes Yes Indian Health Clinics Yes Yes Inpatient Hospital Care Yes Yes Intermediate Care Facility/Services for MR Yes Yes Involuntary Commitment Yes Yes Maternity Support Services Yes Yes Medical Equipment, Durable (DME) Yes Yes Mental Health (Outpatient Services) Yes Yes Midwife Services Yes Yes Neuromuscular Centers Yes Yes Nursing Facility Services Yes Yes Nutrition Therapy Yes Yes Optometry Yes Yes Organ Transplants Yes Yes Out-of-State Care Yes Yes Outpatient Hospital Care Yes Yes Oxygen/Respiratory Therapy Yes Yes Pain Management (Chronic) Yes Yes Personal Care Services Yes Yes Physical/Occupational/Speech Therapy Yes Yes Physical Medicine and Rehabilitation Yes Yes Physician Yes Yes Podiatry Yes Yes Private Duty Nursing L L Prosthetic Devices/Mobility Aids Yes Yes Psychiatric Services Yes Yes Psychological Evaluation L L Rural Health Services & FQHC Yes Yes