APPENDIX C Description of CHIP Benefits

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1 Inpatient General Acute and Inpatient Rehabilitation Hospital Unlimited. Includes: Hospital-provided physician services Semi-private room and board (or private if medically necessary as certified by attending) General nursing care ICU and services Patient meals and special diets Operating, recovery and other treatment rooms Anesthesia and administration Surgical dressings, trays, casts, splints Drugs, medications and biologicals X-rays, imaging and other radiological tests (technical Laboratory and pathology services (technical Machine diagnostic tests Oxygen services and inhalation therapy Radiation and chemotherapy Administration of blood products, if medically necessary Access to TDH-designated Level III perinatal centers or hospitals meeting equivalent levels of care for non-emergency care and following the first 24 hours of emergency care Does not cover blood or blood products Does not cover reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system $200 deductible for families with incomes between 186% - 200% of FPL Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Unlimited. Includes the following services provided in a hospital clinic or emergency room, a clinic or health center, or an ambulatory health care setting: X-ray, imaging, and radiological tests (technical Laboratory and pathology services (technical Machine diagnostic tests Ambulatory surgical facility services Drugs, medications and biologicals Casts, splints, dressings Preventive health services Physical occupational and speech therapy 1

2 Renal dialysis Radiation and chemotherapy Post-stabilization services $50 deductible for families with incomes between 186% - 200% of FPL Professional (Physician/Physician Extender) Unlimited. Includes: American Academy of Pediatrics recommended wellchild exams and preventive health services (including but not limited to vision and hearing screening and immunizations) Physician office visits Laboratory, x-rays, imaging and pathology services and professional interpretation Medications and materials administered in physician s office Allergy testing Professional component (in/outpatient) of surgical services, including: Surgeons and assistant surgeons for major and minor surgical procedures including appropriate follow-up care Administration of anesthesia by physician (other than surgeon) or CRNA Second surgical opinions Same-day surgery performed in a hospital without an over-night stay Invasive diagnostic procedures such as endoscopic examinations Does not cover infertility treatments and prostate and mammography screening Does not cover reproductive services other than prenatal care, labor and delivery, and care related to diseases, illnesses, or abnormalities related to the reproductive system Copayments required for members above 100% of FPL except for well-child visits, well-baby visits, and immunizations Prescription Drugs Includes unlimited drugs prescribed for the medical treatment of illness or injuries HMO may use a closed formulary but must provide a 2

3 process for consideration of drugs outside the formulary when medically necessary Excludes contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care Copayments required for members above 100% of FPL Inpatient Mental Health Includes services furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated mental hospitals.: 45 days annual limit inpatient 25 days of the inpatient benefit can be converted to residential treatment, therapeutic foster care or other 24-hour therapeutically planned and structured services or subacute outpatient (partial hospitalization or rehabilitative day treatment) mental health services on the basis of financial equivalence against the inpatient per diem cost. Twenty of the inpatient days must be held in reserve for inpatient use only. Outpatient Mental Health Outpatient services may require prior authorization but do not require physician prescription. Medication management visits do not count against the outpatient visit limit. 60 days annual limit rehabilitative day treatment 60 outpatient visits annual limit for crisis stabilization, evaluation and treatment, including office, school, in-home and outpatient hospital based services (includes, but is not limited to, serious mental illness) Limitations/Exclusions 60 rehabilitative day treatment days can be converted to outpatient visits on the basis of financial equivalence against the day treatment per diem cost. Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies Includes equipment, devices and supplies that are medically indicated to assist in the treatment of a medical condition, including but not limited to: : Orthotic braces and orthotics Prosthetic devices such as artificial eyes and limbs, braces, hearing aides, and eyeglasses Other artificial aides including surgical implants Disposable medical supplies 3

4 $20,000 annual limit for DME, prosthetics, devices and disposable medical supplies (diabetic supplies and equipment are not counted against this cap) Authorization for more than one pair of eyeglasses annually and/or for contact lenses when medically necessary. Home and Community Health Includes therapies provided in the home and community: Speech, physical and occupational therapy Home infusion Respiratory therapy Visits for private duty nursing Skilled nursing visits Does not include custodial care Inpatient/Residential and Outpatient Substance Abuse Treatment Residential rehabilitation and outpatient substance abuse treatment services do not require physician prescription. Prevention and intervention services, screening, assessment and referral for chemical dependency disorders, hospital inpatient/residential services 14 days annual limit detox/crisis stabilization 24 hour residential rehabilitation program up to 60 days per episode. 30 days must be held in reserve but 30 days (in addition to benefits below) may be converted to 60 days partial hospitalization, 90 days intensive outpatient rehabilitation or 90 days of outpatient services Maximum of three inpatient/residential episodes per lifetime Intensive outpatient program (up to 12 weeks per episode) Outpatient services (up to six months per episode) Maximum of three outpatient episodes per lifetime of nonemergent services Case Management for Children with Complex Special Health Care Needs Covered services are beyond the scope normally provided and include (Refer to Section X, Item B): Outreach and informing 4

5 (CCSHCN) Enhanced care coordination Intensive case management Community Referral Rehabilitation Hospice Care Includes unlimited habilitation and rehabilitation services: Physical, occupational and speech therapy Developmental assessment Includes: Unlimited hospice care for terminally ill children Skilled Nursing Facilities (Includes Rehabilitation Hospitals) Semi-private room and board Regular nursing services Rehabilitation services Medical supplies and use of appliances and equipment furnished by the facility 60 day annual limit Private duty nurses, television and custodial care are excluded Smoking Cessation Programs Covered up to a $100 annual limit Emergency, including Emergency Hospitals, Physicians, and Ambulance Cannot require prior authorization as a condition for payment for emergency conditions or labor and delivery. Emergency services based on prudent lay person definition of emergency health condition Hospital emergency department room and ancillary services and physician services 24 hours a day, 7 days a week, both by in-network and out-of-network providers Medical screening examination Stabilization services Access to TDH designated Level 1 and Level II trauma centers or hospitals meeting equivalent levels of care 5

6 Member copayments are required for emergency room visits Emergency ground transportation Professional Vision Examination by an optometrist or ophthalmologist to determine the need for and prescription for corrective lenses and frames One routine eye exam annually Transplants All non-experimental human organ and tissue transplants and all forms of bone marrow transplants and peripheral stem cell transplants, including donor medical expenses Does not cover donor non-medical expenses May require prior authorization Chiropractic Covered services do not require physician prescription and include: Spinal subluxation as indicated by x-rays Maximum 12 treatments annually May require prior authorization for additional treatments Non-Emergency Transportation May be included as a value added service in areas without accessible public transportation when the family cannot provide the transportation 6