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39 Effective Date: July 1, 2009

Approval Date:

6.2.11.2 Children enrolled in Healthy Options or in the Fee For Service program receive their mental health care through their Healthy Options or FFS provider if they do not meet the criteria for RSN services. Children’s mental health outpatient services to include: outpatient psychotherapy; electroconvulsive therapy; and family psychotherapy - in any combination - one hour per day, per client, up to a total of twenty hours per calendar year if medically necessary. Psychiatric diagnostic interview examinations – one per calendar year unless an additional evaluation is medically necessary. Prior authorization is required for additional services that are medically necessary.

6.2.12.

Durable medical equipment and other medically related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.1 Dental services (Section 2110(a)(17)) State Specific Dental Benefit Package. The state adopted the Washington Medicaid dental benefit package for CHIP. This includes EPSDT coverage. The state assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefit. A comprehensive description of covered services and schedules can be found at http://maa.dshs.wa.gov/Download/Billing_Instructions/Dental_Thr u_20/Dental_Program_Through_20_BI.pdf. 1. Diagnostic (i.e., clinical exams, x-rays)(CDT codes: D0100- D0999)(must follow periodicity schedule) 2. Preventative (i.e., dental prophylaxis, topical fluoride treatments)(CDT codes: D1000-D1999)(must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns)(CDT codes: D2000-D2999) 4. Endontic (i.e., root canals)(CDT codes: D3000-D3999)