GenIC #10 (Extension w/o change): Section 1115 Demonstration and Waiver Application

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)

6