Common use of Nursing Facility Waiver Services for Clause in Contracts

Nursing Facility Waiver Services for. those Members who qualify for such services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the 1915 (c) Nursing Facility Waiver Services. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies o Physical Therapy, Occupational Therapy, Speech Therapy o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) Subject: Attachment B-2.2 - CHIP Perinatal Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. Revision 1.2 September 1, 2006 Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs. Revision 1.3 September 1, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.5 January 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.6 February 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.7 July 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.8 September 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.9 December 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.10 March 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.11 September 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.12 March 1, 2009 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services.

Nursing Facility Waiver Services for. those Members who qualify for such services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the 1915 (c) Nursing Facility Waiver Services. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Self Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies o Physical Therapy, Occupational Therapy, Speech Therapy o Adult Xxxxxx Care o Assisted Living Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-2.1 – STAR+PLUS Covered Services Version 1.7 o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-2.2 - – CHIP Perinatal Covered Services Version 1.7 DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. Revision 1.2 September 1, 2006 Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs. Revision 1.3 September 1, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.5 January 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.6 February 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.7 July June 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.8 September 11 Status should be represented as “Baseline” for initial issuances, 2007 Contract Amendment did not revise “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision. 3 Brief description of the changes to the document made in the revision. Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-2.2- B-2.2 – CHIP Perinatal Covered Services. Revision 1.9 December 1, 2007 Contract Amendment did not revise Attachment B-2.2- Services Version 1.7 CHIP Perinatal Program Covered Services. Revision 1.10 March 1, 2008 Contract Amendment did not revise Attachment B-2.2- Services Covered CHIP Perinatal Program services must meet the definition of Medically Necessary Covered ServicesServices as defined in this Contract. Revision 1.11 September 1There is no lifetime maximum on benefits; however, 2008 Contract Amendment did 12-month enrollment period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays do not revise Attachment B-2.2- apply to CHIP Perinatal Covered ServicesProgram Members. Revision 1.12 March 1, 2009 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Program Members are eligible for 12-months continuous coverage following enrollment in the program. Covered Services.Benefit CHIP Perinate Newborn CHIP Perinate

Nursing Facility Waiver Services for. those Members who qualify for such services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the 1915 (c) Nursing Facility Waiver Services. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies o Physical Therapy, Occupational Therapy, Speech Therapy o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) Subject: Attachment B-2.2 - CHIP Perinatal Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. Revision 1.2 September 1, 2006 Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs. Revision 1.3 September 1, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.5 January 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.6 February 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.7 July 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.8 September 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.9 December 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.10 March 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.11 September 11 Status should be represented as “Baseline” for initial issuances, 2008 Contract Amendment did not revise Attachment B-2.2- “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision. 3 Brief description of the changes to the document made in the revision. CHIP Perinatal Program Covered Services. Revision 1.12 March 1, 2009 Contract Amendment did not revise Attachment B-2.2- Services Covered CHIP Perinatal Program services must meet the definition of Medically Necessary Covered ServicesServices as defined in this Contract. There is no lifetime maximum on benefits; however, 12-month enrollment period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays do not apply to CHIP Perinatal Program Members. CHIP Perinatal Program Members are eligible for 12-months continuous coverage following enrollment in the program.

Nursing Facility Waiver Services for. those Members who qualify for such services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the 1915 (c) Nursing Facility Waiver Services. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies o Physical Therapy, Occupational Therapy, Speech Therapy o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) Subject: Attachment B-2.2 - CHIP Perinatal Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. Revision 1.2 September 1, 2006 Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs. Revision 1.3 September 1, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.5 January 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.6 February 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.7 July 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.8 September 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.9 December 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.10 March 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.11 September 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.12 March 1, 2009 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. 1 Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision. 3 Brief description of the changes to the document made in the revision. CHIP Perinatal Program Covered Services Covered CHIP Perinatal Program services must meet the definition of Medically Necessary Covered Services as defined in this Contract. There is no lifetime maximum on benefits; however, 12-month enrollment period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays do not apply to CHIP Perinatal Program Members. CHIP Perinatal Program Members are eligible for 12-months continuous coverage following enrollment in the program.

Nursing Facility Waiver Services for. those Members who qualify for such services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the 1915 (c) Nursing Facility Waiver Services. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies o Physical Therapy, Occupational Therapy, Speech Therapy o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-2.2 - CHIP Perinatal Covered Services Version 1.6 DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. Revision 1.2 September 1, 2006 Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs. Revision 1.3 September 1, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.5 January 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.6 February 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.7 July 11 Status should be represented as “Baseline” for initial issuances, 2007 Contract Amendment did not revise Attachment B-2.2- “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision. 3 Brief description of the changes to the document made in the revision. CHIP Perinatal Program Covered Services. Revision 1.8 September 1, 2007 Contract Amendment did not revise Attachment B-2.2- Services Covered CHIP Perinatal Program services must meet the definition of Medically Necessary Covered ServicesServices as defined in this Contract. Revision 1.9 December 1There is no lifetime maximum on benefits; however, 2007 Contract Amendment did 12-month enrollment period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays do not revise Attachment B-2.2- apply to CHIP Perinatal Covered ServicesProgram Members. Revision 1.10 March 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.11 September 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.12 March 1, 2009 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered ServicesProgram Members are eligible for 12-months continuous coverage following enrollment in the program.

Nursing Facility Waiver Services for. those Members who qualify for such services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the 1915 (c) Nursing Facility Waiver Services. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies o Physical Therapy, Occupational Therapy, Speech Therapy o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) Subject: Attachment B-2.2 - CHIP Perinatal Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. Revision 1.2 September 1, 2006 Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs. Revision 1.3 September 1, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.5 January 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.6 February 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.7 July 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.8 September 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.9 December 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.10 March 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.11 September 1, 2008 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.12 March 11 Status should be represented as “Baseline” for initial issuances, 2009 Contract Amendment did not revise Attachment B-2.2- “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision. 3 Brief description of the changes to the document made in the revision. CHIP Perinatal Program Covered ServicesServices Covered CHIP Perinatal Program services must meet the definition of Medically Necessary Covered Services as defined in this Contract. There is no lifetime maximum on benefits; however, 12-month enrollment period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays do not apply to CHIP Perinatal Program Members. CHIP Perinatal Program Members are eligible for 12-months continuous coverage following enrollment in the program.

Nursing Facility Waiver Services for. those Members who qualify for such services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS HMO must also provide the services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the 1915 (c) Nursing Facility Waiver Services. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies o Physical Therapy, Occupational Therapy, Speech Therapy o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the HMO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the HMO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) Subject: Attachment B-2.2 - CHIP Perinatal Covered Services DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-2, Covered Services Revision 1.1 June 30, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS Covered Services. Revision 1.2 September 1, 2006 Revised Attachment B-2, Covered Services, by updating provisions applicable to MCOs participating in the STAR and CHIP Programs. Revision 1.3 September 1, 2006 Revised Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP Perinatal Covered Services. This is the initial version of Attachment B-2.2, which lists the CHIP Perinatal Covered Services, exclusions and DME/Supplies. Revision 1.4 September 1, 2006 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.5 January 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.6 February 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.7 July 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.8 September 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.9 December 1, 2007 Contract Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered Services. Revision 1.10 March 11 Status should be represented as “Baseline” for initial issuances, 2008 Contract Amendment did not revise Attachment B-2.2- “Revision” for changes to the Baseline version, and “Cancellation” for withdrawn versions 2 Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g., “1.2” refers to the first version of the document and the second revision. 3 Brief description of the changes to the document made in the revision. CHIP Perinatal Program Covered Services. Revision 1.11 September 1, 2008 Contract Amendment did not revise Attachment B-2.2- Services Covered CHIP Perinatal Program services must meet the definition of Medically Necessary Covered ServicesServices as defined in this Contract. Revision 1.12 March 1There is no lifetime maximum on benefits; however, 2009 Contract Amendment did 12-month enrollment period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays do not revise Attachment B-2.2- apply to CHIP Perinatal Covered ServicesProgram Members. CHIP Perinatal Program Members are eligible for 12-months continuous coverage following enrollment in the program.