CMS-10448 EHB State Submission of State Mandates Template

EHB State Submission of State Mandates Template

Benefit

State Mandate Required?

Select "Yes" if the benefit is
Mandated by the State

Primary Care Visit to Treat an Injury
or Illness
Specialist Visit
Other Practitioner Office Visit (Nurse,
Physician Assistant)
Outpatient Facility Fee (e.g.,
Ambulatory Surgery Center)
Outpatient Surgery
Physician/Surgical Services
Hospice Services
Non-Emergency Care When Traveling
Outside the U.S.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home
Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Home Health Care Services
Emergency Room Services
Emergency
Transportation/Ambulance
Inpatient Hospital Services (e.g.,
Hospital Stay)
Inpatient Physician and Surgical
Services
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Prenatal and Postnatal Care
Delivery and All Inpatient Services for
Maternity Care
Mental/Behavioral Health Outpatient
Services
Mental/Behavioral Health Inpatient
Services
Substance Abuse Disorder
Outpatient Services
Substance Abuse Disorder Inpatient
Services
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Diagnostic Test (X-Ray and Lab
Work)
Imaging (CT/PET Scans, MRIs)
Preventive
Care/Screening/Immunization
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Eye Glasses for Children
Dental Check-Up for Children
Other

Name of Mandated
Benefit

Description of Benefit
Mandates

Market Applicability

Enacted prior to
12/31/2011?

Citation Number

Citation URL

Required if State Mandate is
"Yes":
Enter the Name of the Mandated
Benefit

Required if State Mandate is
"Yes":
Enter a Description of the
Mandated Benefit

Required if State Mandate is
"Yes":
Enter the Market Applicability
(such as Individual, Small
Group, Large Group)

Required if State Mandate is
"Yes":
Select "Yes" if the Mandate was
enacted prior to 12/31/2011

Required if State
Mandate is "Yes":
Enter Citation Number

Required if State Mandate is "Yes":
Enter the Citation URL