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Expansion of Child Health Plus Benefits Effective January 1, 2023

Audience: Providers, Hospitals and Facilities

As part of the 2022-2023 New York state budget, Child Health Plus (CHP) benefits were expanded to include medical, behavioral health, dental, ambulance services, and medical supplies, to align with benefits received by children with Medicaid coverage effective January 1, 2023.

The Health Plan will reimburse these services at Medicaid fee-for-service benchmark rates.

The expanded CHP benefit package is extensive and includes the services covered as noted below:

Behavioral Health Services

  • Assertive Community Treatment Services (ACT), Young Adult ACT and Youth ACT
  • Children and Family Treatment and Support Services:
    • Other Licensed Practitioner
    • Outpatient and Residential Crisis Intervention
    • Community Psychiatric Supports and Treatment
    • Psychosocial Rehabilitation
    • Family Peer Support Services
    • Youth Peer Support
  • 29-I Health Facility Core Limited Health-Related Services
    • Please note that other health-related services (e.g., primary care, lab work, testing) are already a part of the CHP benefit package. If a 29-I provider already participates in our network, those services will be covered under the program effective January 1, 2023, if the provider is not currently contracted for the CHP line of business.

Medical Supplies

A list of medical supplies covered under the CHP benefit can be found in 4.1, 4.2 and 4.3 of the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Procedure Code Manual (PDF).
Examples include, but are not limited to:

  • Diabetic supplies
  • Enteral formulas and supplies
  • Wound dressings and disposable care accessories
  • Airway clearance device filters
  • Disposable collection and storage bags for breast milk
  • A fiscal order for medical supplies may be refilled when the prescriber has indicated on the order the number of refills and the member has requested the refill. All refills must be appropriately referenced to the original order by the dispenser.

Enhanced Ambulance Services

Land Ambulance Services

Transportation between hospitals:

  • When a CHP enrollee is admitted to a hospital licensed under Article 28 of the Public Health Law, reimbursement paid to the hospital includes all necessary transportation services for inpatient service. If the admitting hospital sends an inpatient round trip to another hospital to obtain a diagnostic test or therapeutic service, the original admitting hospital is responsible for the provision of the transportation services.
    • The following ambulance transports are considered emergency transports; therefore, preauthorization is not required:
      • Transport from an emergency room (ER) to a psychiatric center
      • Transport from an ER to a trauma/cardiac care/burn center
      • Transportation from an ER to another ER
      • Transportation from an ER to another facility

Air Ambulance Services

Air ambulance transportation must meet the following criteria:

  • The patient has a catastrophic, life-threatening illness or condition
  • The patient is at a hospital that is unable to properly manage the medical condition
  • The patient needs to be transported to a uniquely qualified hospital facility and ground transport is not appropriate for the patient
  • Rapid transport is necessary to minimize risk of death or deterioration of the patient’s condition; or
  • Life-support equipment and advanced medical care is necessary during transport
  • The following fixed wing air ambulance services are reimbursable when the transport physically occurs:
    • Base fee (lift-off/call-out)
    • Patient loaded mileage
    • Physician (when ordered by hospital)
    • Respiratory therapist (when ordered by the hospital, and only when the hospital is unable to supply) or
    • Destination ground ambulance charge (only when the destination is out of state).
    • The following helicopter (rotary wing) air ambulance services are reimbursable:
    • Lift off from base; or
    • Patient occupied flight mileage

Preventive Dental Care

  • Topical fluoride treatment: when professionally administered in accordance with
    • Physicians and nurse practitioners for members 0 through 6 years of age.
    • Dentists and dental hygienists (under general supervision of the dentist) in the dental office through age 19.
  • Fluoride varnish is reimbursable to physicians and nurse practitioners once per three (3) month intervals under CPT code 99188 (application of topical fluoride varnish by a physician or other qualified health care professional).
  • Fluoride treatments that are not reimbursable under the program include:
    • Treatment that incorporates fluoride with prophylaxis paste
    • Topical application of fluoride to the prepared portion of a tooth prior to restoration
    • Fluoride rinse or “swish”; and
    • Treatment for desensitization

Failure to provide notification and/or failure to comply with provider contract requirements and utilization management policies and procedures may result in claim denial or payment reduction. Please review the Authorizations section for notification and preauthorization requirements.

For questions related to this information, please contact your Provider Relations representative.

Please share this important information with all practice locations or corporate offices, and with anyone in your practice who should be aware.

Thank you for your partnership and collaboration as we continue our mission to provide access to quality, affordable health coverage to our members.

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