Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

List of Medicaid and CHIP Benefitsm

Bundle: (GenIC 1) Sec. 1915(b)(4) Waiver Application - Fee For Service Selective Contracting Program & (GenIC 2) Sec. 1115 Demo and Waiver Application

OMB: 0938-1148

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List of Medicaid and CHIP Benefits


Medicaid Benefits

Benefit

Reference

Inpatient Hospital Services

Mandatory 1905(a)(1)

Outpatient Hospital Services

Mandatory 1905(a)(2)

Rural Health Clinic Services

Mandatory 1905(a)(2)

FQHC Services

Mandatory 1905(a)(2)

Laboratory and X-Ray Services

Mandatory 1905(a)(3)

Nursing Facility Services for Age 21 & Older

Mandatory 1905(a)(4)

EPSDT

Mandatory 1905(a)(4)

Family Planning Services

Mandatory 1905(a)(4)

Tobacco Cessation for Pregnant Women

Mandatory 1905(a)(4)

Physicians’ Services

Mandatory 1905(a)(5)

Medical or Surgical Services by a Dentist

Mandatory 1905(a)(5)

Medical Care and any type of remedial care recognized under State Law - Podiatrists’ Services

Optional 1905(a)(6)

Medical Care and any type of remedial care recognized under State Law - Optometrists’ Services

Optional 1906(a)(6)

Medical Care and any type of remedial care recognized under State Law - Chiropractors’ Services

Optional 1905(a)(6)

Medical Care and any type of remedial care recognized under State Law - Other Practitioners’ Services

Optional 1905(a)(6)

Home Health Services - Intermittent or part-time nursing services provided by a home health agency

Mandatory for certain individuals -1905(a)(7)

Home Health Services - Home health aide services provided by a home health agency

Mandatory for certain individuals -1905(a)(7)

Home Health Services - Medical supplies, equipment and appliances

Mandatory for certain individuals-1905(a)(7)

Home Health Services - Physical therapy, occupational therapy, speech pathology, audiology provided by a home health agency

Optional-1905(a)(7), 1902(a)(10)(D), 42CFR 440.70

Private duty nursing services

Optional 1905(a)(8)

Clinic Services

Optional 1905(a)(9)

Dental Services

Optional 1905(a)(10)

Physical Therapy

Optional 1905(a)(11)

Occupational Therapy

Optional 1905(a)(11)

Services for individuals with speech, hearing and language disorders

Optional 1905(a)(11)

Prescribed Drugs

Optional 1905(a)(12)

Dentures

Optional 1905(a)(12)

Prosthetic Devices

Optional 1905(a)(12)

Eyeglasses

Optional 1905(a)(12)

Diagnostic Services

Optional 1905(a)(13)

Screening Services

Optional 1905(a)(13)

Preventive Services

Optional 1905(a)(13)

Rehabilitative Services

Optional 1905(a)(13)

Services for Individuals over 65 in IMDs -Inpatient hospital services

Optional 1905(a)(14)

Services for Individuals over 65 in IMDs -Nursing facility services

Optional 1905(a)(14)

Intermediate Care Facility services for individuals in a public institution for the mentally retarded or persons with related conditions

Optional 1905(a)(15)

Inpatient psychiatric services for under 22

Optional 1905(a)(16)

Nurse-midwife services

Mandatory 1905(a)(17)

Hospice Care

Optional 1905(a)(18)

Case management services 1915(g)

Optional 1905(a)(19), 1915(g)

Special TB related services

Optional 1905(a)(19), 1902(z)(2)

Respiratory care services under 1902(e )(9)(A) through (C )

Optional 1905(a)(20)

Certified pediatric or family nurse practitioners’ services

Mandatory 1905(a)(21)

Home and Community Care for Functionally Disabled Elderly Individuals

Optional 1905(a)(22)

Personal Care Services in the beneficiary’s home

Optional 1905(a)(24), 42CFR 440.170

Primary care case management services

Optional 1905(a)(25)

PACE Services

Optional 1905(a)(26)

Special Sickle-Cell Anemia-Related Services

Optional 1905(a)(27)

Licensed or Otherwise State-Approved Free-Standing Birthing Centers

Optional 1905(a)(28)

Transportation

Optional benefit – 1905(a)(29) – 42CFR 440.170, Required as an administrative function – 42CFR 431.53

Services provided in religious non-medical health care facilities

Optional 1905(a)(29), 42CFR 440.170(b)

Nursing facility services for patients under 21

Optional 1905(a)(29), 42CFR 440.170(d)

Emergency Hospital services

Optional 1905(a)(29), 42CFR 440.170(e)

Expanded Services for Pregnant Women - Additional Pregnancy-related and postpartum services for a 60-day period after the pregnancy ends

Optional 1902(e)(5)

Expanded Services for Pregnant Women - Additional Services for any other medical conditions that may complicate pregnancy

Optional 1902(e)(5)

Emergency services for certain legalized aliens and undocumented aliens

Mandatory 1903(v)(2)(A)

Home and Community-Based Services for Elderly or Disabled Individuals

Optional 1915(i)

Self-Directed Personal Assistance Services

Optional 1915(j)

Community First Choice

Optional 1915(k)

Other (describe in benefit chart)

Optional 1905(a)(29)


CHIP Benefits


Benefit

Reference

Well-baby and well-child care, including age appropriate immunizations

Mandatory 2103(c)(1)(D)

457.410(b)

Emergency services

Mandatory

457.410(b)

Dental benefits

Mandatory 2105(c)(5)

Inpatient and Outpatient Hospital Services

Mandatory for benchmark equivalent 2103(c)(1)(A)

Physicians surgical and medical services

Mandatory for benchmark equivalent 2103(c)(1)(B)

Laboratory and x-ray services

Mandatory for benchmark equivalent 2103(c)(1)(C)

Clinic services (including health center services) and other ambulatory health care services)

Optional

2110(a)(5)

Prenatal care and pre-pregnancy family services and supplies

Optional

2110(a)(9)

Inpatient mental health services

Optional 2110(a)(10)

Outpatient mental health services

Optional

2110(a)(11)

Durable medical equipment

Optional

2110(a)(12)

Disposable medical supplies

Optional

2110(a)(13)

Home and community-based health care services

Optional

2110(a)(14)

Nursing care services

Optional

2110(a)(15)

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

Optional

2110(a)(16)

Inpatient substance abuse treatment services

Optional

2110(a)(18)

Outpatient substance abuse treatment services

Optional

2110(a)(19)

Case management services

Optional

2110(a)(20)

Care coordination services

Optional

2110(a)(21)

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders

Optional

2110(a)(22)

Hospice care

Optional

2110(a)(23)

Any other medical, diagnostic, screening, preventative, restorative, remedial, therapeutic, or rehabilitative services

Optional

2110(a)(24)

Premiums for private health insurance coverage

Optional

2110(a)(25)

Medical transportation

Optional

2110(a)(26)

Enabling services

Optional

2110(a)(27)

Any other health care services or items specified by the Secretary

Optional

2110(a)(28)




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