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39 Effective Date: July 1, 2009

Approval Date: Substance Abuse/Outpatient Yes Yes Surgical Appliances Yes Yes Total Enteral/Parenteral Nutrition Yes Yes Transportation Other than Ambulance Yes Yes X-Ray and Lab Services Yes Yes Key: Yes: Service is covered (may require prior approval or have other requirements) L: Limited coverage

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)

6.2.1.

Inpatient Services (Section 2110(a)(1)) 6.2.2.

Outpatient Services (Section 2110(a)(2)) 6.2.3.

Physician Services (Section 2110(a)(3)) 6.2.4.

Surgical Services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structural services. (Section 2110(a)(10))

These services are provided by contract through the Regional Support Services Networks (RSNs). 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

6.2.11.1 RSN’s are the primary mental health care provider for children with substantial mental health needs. RSN’s do not have a limitation on the number of hours of treatment they provide.