EmblemHealth Child Health Plus Coverage Update

Covered Services and Criteria (Pediatric, Inpatient, Behavioral Health, DME, Supplies)

Pediatric Health Promotion / Well-Child Visits

Covered when services are consistent with the AAP visitation schedule and ACIP immunization schedule:

ALL of the following

Well child visits per AAP visitation schedule
Immunizations per ACIP schedule; immunizations must be provided within 90 days from publication in MMWR
Includes tuberculin (Mantoux) testing, hearing testing, dental and developmental screening, clinical laboratory and radiologic tests, eye screening, lead screening, reproductive health services with direct access

Inpatient Hospital Care

Covered when ALL of the following are met:

ALL of the following

Patient is a registered bed patient for treatment of an illness, injury, or condition which cannot be treated on an outpatient basis
Hospital is a short-term acute care facility licensed by New York State
No benefits are provided if care could be provided out-of-hospital or inpatient care was not necessary; no benefits are provided after discharge
Benefits include semi-private accommodations (private if medically warranted), physician and professional services, supplies, laboratory and imaging services, therapies, blood products, radiation, chemotherapy, and other customary hospital services

Maternity Care

Covered maternal/newborn inpatient services:

ALL of the following

Inpatient coverage for at least 48 hours after vaginal delivery
Inpatient coverage for at least 96 hours after C-section
Parent education, breastfeeding assistance, and necessary maternal and newborn clinical assessments
Option for earlier discharge if at least one home care visit is covered post-discharge

Inpatient Mental Health and Substance Use Services

Covered services when provided in qualifying facilities:

ALL of the following

Services provided in an OMH-operated facility or a facility issued an operating certificate pursuant to Article 23 or Article 31 of the Mental Hygiene Law, or a general hospital as defined in Article 28 of the Public Health Law
Scope includes rehabilitation-level inpatient mental health and substance use services

Durable Medical Equipment, Prosthetics, Orthotics (DME/P&O)

Covered DME/P&O when ordered by a qualified practitioner for treatment of a specific medical condition:

ALL of the following

DME must withstand repeated use, be primarily medical, not useful in the absence of illness or injury, and are usually not custom-designed for a particular person unless specified
Examples covered include hospital beds and accessories, oxygen and oxygen supplies, ventilators, nebulizers, traction equipment, walkers, wheelchairs and accessories, commode chairs, toilet rails, apnea monitors, patient lifts, nutrition and ambulatory infusion pumps, fitted/customized leg braces, prosthetic arms, footplates, and crutches
No coverage for cranial prosthesis (wigs) and dental prosthesis except when made necessary by accidental injury to sound natural teeth provided within 12 months of the accident, or for congenital abnormality or reconstructive surgery
Orthotic devices are covered except devices prescribed solely for use during sports

Medical Supplies

Covered consumable medical supplies when ordered by a practitioner for treatment of a specific condition:

ANY of the following

Diabetic supplies and equipment: insulin; blood glucose monitors (including models for visually impaired); test strips; syringes; insulin pumps and appurtenances; cartridges; injection aids; oral agents as prescribed
Enteral formulas and supplies when ordered with a written order distinguishing them from nutritional supplements
Ostomy equipment and supplies when prescribed by a health care provider authorized to prescribe
Other consumable supplies such as wound dressings, airway clearance device filters, and disposable breast milk storage bags

Therapeutic Services

Covered therapeutic services when medically necessary and under physician supervision:

ALL of the following

Ambulatory radiation therapy, chemotherapy, injections and medications provided at time of therapy are covered
Short-term physical and occupational therapy covered when ordered by a physician
Physical and occupational therapy for children with autism covered when treatment is deemed habilitative or nonrestorative
Experimental procedures or services are not reimbursed
Hemodialysis covered with determination whether home-based or facility-based treatment is appropriate

Speech and Hearing Services

Covered when medically necessary:

ALL of the following

Hearing examinations by a physician, optometrist, or audiologist to determine need for corrective action; one hearing exam per calendar year (additional exams if required)
Hearing aids, batteries and repairs are covered; more than one hearing aid covered if medically necessary
Speech therapy covered for conditions amenable to significant clinical improvement within two months; for autism spectrum disorder, speech therapy may be covered when deemed habilitative or nonrestorative

Pre-Surgical and Second Opinions

Pre-surgical testing and second opinions are covered in specified conditions:

ALL of the following

Pre-surgical laboratory and x-ray testing covered when ordered by a physician and the surgery takes place within seven days; if surgery is canceled because of pre-surgical test findings or as a result of a second opinion, the cost of the tests will be covered
Second surgical opinions provided by a qualified physician; second medical opinions available for cancer diagnosis or treatment and related situations

Outpatient Mental Health and Substance Use Visits

Covered when provided by certified or licensed professionals:

ALL of the following

No limitations indicated on outpatient visits for diagnosis and treatment of mental health and substance use disorders
Family therapy is covered when it is directly related to the enrolled child's alcohol, drug and/or mental health treatment

Home Health Care Services

Covered when home care prevents need for hospitalization or skilled nursing facility:

ALL of the following

Must be under the care of a physician and a written plan established and provided by the physician
Provided by a certified home health agency possessing a valid certificate of approval; includes part-time or intermittent home health aide services, PT/OT/SLP when provided by the agency, medical supplies, and drugs to the extent they would have been covered if hospitalized
Contract must provide up to 40 such visits in any calendar year if medically necessary

Diabetic Education and Home Visits

Covered when medically necessary and prescribed or referred:

ALL of the following

Diabetes self-management education, reeducation or refresher, and home visits for monitoring/education are covered when a physician documents a significant change necessitating reeducation
Services may be provided by a physician, other licensed health care provider, certified diabetes nurse educator, certified nutritionist, certified dietitian, or registered dietitian upon physician referral

Prescription and Non-Prescription Drugs

Covered when medications are medically necessary and authorized:

ALL of the following

Medications must be prescribed by a professional licensed to write prescriptions and be medically necessary
Coverage is limited to generic medications where medically acceptable; vitamins are not covered except to treat a diagnosed illness or condition
Family planning and contraceptive medications or devices are covered
Enteral formulas for home use are covered when a written order is issued distinguishing them from nutritional supplements

Emergency Medical and Ambulance Services

Covered for emergency conditions defined by sudden onset and severity (prudent layperson standard):

ALL of the following

Emergency services in hospitals for emergency conditions are covered without limitations
Ambulance services for pre-hospital emergency medical care and non-airborne transport are covered when the prudent layperson standard is met
Certain ambulance transports are considered emergency and do not require prior authorization (e.g., ER to Psychiatric Center, ER to Trauma/Cardiac/Burn Center, ER to ER transfers)

Air Ambulance Services

Covered when criteria for air ambulance are met:

ALL of the following

Patient has a catastrophic or life-threatening condition
Origin hospital is unable to properly manage the condition and the destination is uniquely qualified; ground transport is not appropriate
Rapid transport is necessary to minimize risk of death or deterioration or life-support/advanced medical care is required during transport
Reimbursable charges include base fee, patient loaded mileage, physician (when ordered), respiratory therapist (when ordered and hospital unable to supply), and destination ground ambulance charge when out of state; helicopter charges include lift-off and patient occupied flight mileage

Vision Care

Covered vision examinations and corrective devices:

ALL of the following

Vision exams by a physician or optometrist to determine need for corrective lenses are covered; exam components include history, internal/external exam, ophthalmoscopic exam, refractive status, binocular balance, tonometry, gross visual fields, and color vision testing
Prescription lenses and standard frames covered at minimum once every 12 months unless more frequent with documentation
Contact lenses covered when medically necessary

Dental Care (Preventive, Routine, Emergency, Orthodontics)

Covered dental services with specified limitations and frequencies:

ALL of the following

Emergency dental care to alleviate pain or trauma is covered
Preventive dental care covered including prophylaxis every 6 months, professionally applied topical fluoride at specified intervals (physicians/nurse practitioners for ages 0–6; dentists/dental hygienists per CDT intervals; fluoride varnish reimbursable to physicians/nurse practitioners once per 3 months under CPT 99188) and sealants on unrestored permanent molars
Routine dental exams/consults once within a 6-month period; X-ray intervals include bitewing 6–12 months, full mouth/panoramic 36 months as necessary
Endodontics and removable prosthodontics (dentures) covered per specifications; fixed bridges limited to narrow clinical indications

Children and Family Treatment and Support Services (CFTSS) - Various Modalities

Community-based behavioral health services for children and youth with specified scope, providers, and limits:

ALL of the following

Other Licensed Practitioner (OLP) services: non-physician behavioral health practitioners providing prevention, assessment, diagnosis and treatment; must be licensed and operate within state scope of practice
Group limits: groups should not exceed eight participants (smaller groups may be appropriate for younger children)
Services must be trauma-informed, culturally and linguistically competent, part of the treatment plan, and reimbursed per government rate-setting methodology
Outpatient and Residential Crisis Intervention modalities include Mobile Crisis and Crisis Stabilization; excluded activities include financial management, supportive housing/employment, habilitative basic skill acquisition, primarily educational/vocational/recreational or custodial services; crisis services cannot be denied for substance use

General eligibility and documentation requirements for CFTSS and related services

Services are covered when the following documentation and clinical conditions are met:

ALL of the following

Member is a child or youth with behavioral health needs; services are designed for children/youth and families/caregivers
Services must be part of an individualized treatment plan that includes goals and activities necessary to correct or ameliorate conditions discovered during the initial assessment
Provider agency must perform an assessment prior to developing the treatment plan
Services must be rendered by qualified practitioners within their scope of practice and meet applicable state licensure, certification and programmatic requirements
Exclusions based on diagnosis

Group service limits and requirements

Group services have participant limits and clinician staffing considerations:

ALL of the following

Rehabilitative Supports and Rehabilitative Psychoeducation groups: maximum of 8 participants (regardless of payor).
Smaller group sizes may be appropriate for participants younger than eight; consider additional clinician based on purpose, participant characteristics, age, developmental level, severity, family inclusion, and clinician experience.
Psychosocial Rehabilitation (PSR) groups: maximum of 8 child/youth participants (regardless of payor).
Family Peer Support Services (FPSS) groups: maximum of 12 individuals in total.
Same clinician-staffing considerations apply as above.
Groups may include family/collaterals with or without the child present, provided contacts are directly related to the child/youth's treatment plan and goals.

Evidence-based practices and approvals

Evidence-based practices (EBPs) used in CFTSS require formal oversight:

ALL of the following

EBP designation, prior approval, and ongoing fidelity reviews are required as determined necessary by New York State
EBPs should align with the Institute of Medicine definition: best research evidence, best clinical experience, and consistent with patient values

29-1 Health Facility Core Limited Health-Related Services requirements

Core services and documentation standards for Article 29-1 health facilities:

ALL of the following

Core services include: Skill Building (by LBHPs per Article 29-1 VFCA Health Facilities License Guidelines), Nursing Services, Treatment and Discharge Planning, Clinical Consultation/Supervision, and VFCA Child Health Plus Liaison/Administrator
Records (health/behavioral health record, treatment plan, service plan or plan of care) must reflect that services were medically necessary, appropriate, and rendered by qualified practitioners within their scope of practice, including supervision requirements
Services must meet state-determined standards of health practice and any state-mandated licensure/certification/programmatic requirements

Coverage for Autism Spectrum Disorder (ASD) services

Covered services for individuals diagnosed with ASD when prescribed or ordered by a licensed physician or psychologist:

ALL of the following

Behavioral health treatment, psychiatric care, psychological care, medical care by a licensed health care provider, and therapeutic care (including habilitative/non-restorative) are covered
Applied Behavior Analysis (ABA) is covered
Assistive communication devices are covered when ordered/prescribed for members unable to communicate through normal means; dedicated communication devices are covered while general-purpose devices are not covered unless software/apps enable speech-generation
Assistive devices may be rented or purchased, subject to prior approval.

Not covered items and services

The following list identifies services explicitly excluded from coverage:

ANY of the following

Experimental drugs
Prescription drugs used for erectile dysfunction
Over-the-counter drugs (except as defined elsewhere)
Drugs or biologicals furnished to cause or assist in causing death, suicide, euthanasia or mercy killing
Home health care, except as defined elsewhere

Numeric and Timing Thresholds

Key Thresholds

Immunization publication-to-provision windowImmunizations must be provided within 90 days from publication in the Morbidity and Mortality Weekly Report (MMWR)

Postpartum inpatient stay minimum>= 48 hours after vaginal delivery; >= 96 hours after C-section

Home health visits annual maximumContract must provide up to 40 visits in any calendar year if medically necessary

Group participant limit — general CFTSS groupsMaximum of 8 participants per group (smaller groups may be appropriate for younger children)

Group participant limit — Family Peer Support Services (FPSS)Maximum of 12 individuals per group

365

Codes and Coding Guidance

Referenced CPT/HCPCS/CDT guidance (examples)mixed

99188	Example cited: application of topical fluoride varnish by physician or qualified health care professional (physician/nurse practitioners reimbursable once per 3 months)
D1206	CDT example: Professionally applied fluoride varnish (dentists/dental hygienists benefit interval rules apply)
D1208	CDT example: Topical application of fluoride excluding varnish
D8210	Removable appliance therapy (orthodontics) — exception noted for provider types
D8220	Fixed appliance therapy (orthodontics)
D8999	Unspecified orthodontic procedure, by report

No explicit CPT/HCPCS/ICD-10 codes in this partmixed

No codes listed

Prior Authorizations, Documentation, and Operational Requirements

Documentation Required

Immunization timing documentation

Document that immunizations are provided within 90 days of their publication in the Morbidity and Mortality Weekly Report (MMWR) when applicable; include the date of MMWR publication and the actual administration date in the medical record.

Prior Authorization

Orthodontics prior approval

Obtain prior approval for orthodontia coverage for severe physically handicapping malocclusions before active therapy will be reimbursed; ensure authorization is in place prior to appliance placement and activation and observe the once‑in‑a‑lifetime limit (maximum three years active treatment plus one year retention).

Affected CDT codes called out: D8210, D8220, D8999
Treatment must be approved and active therapy begun by the member's 19th birthday

Key Definitions

Definitions

Prudent layperson standardAn emergency condition is defined by symptoms that a prudent layperson, with an average knowledge of medicine and health, would reasonably expect to result in serious jeopardy or impairment without immediate medical attention.

Durable Medical Equipment (DME)Devices ordered by a practitioner to treat a specific medical condition that can withstand repeated use, are primarily medical, not useful in the absence of illness/injury, and are usually not fitted/designed for a particular person unless custom-made.

CFTSSChildren and Family Treatment and Support Services — a set of community-based rehabilitative and support services for children/youth with behavioral health needs.

CPSTCommunity Psychiatric Supports and Treatment — component of CFTSS including rehabilitative psychoeducation, intensive interventions, rehabilitative supports, crisis avoidance and intermediate term crisis management.

PSRPsychosocial Rehabilitation — services to restore, rehabilitate, and support a child/youth's functional level for community and family integration.

Clinical and Administrative Context

This section describes the scope and level of coverage for Child Health Plus pediatric and related services in New York State. Covered services include preventive care (well-child visits), inpatient medical and surgical care, maternity services, behavioral health and substance use services, durable medical equipment (DME), prosthetics and orthotics, medical supplies, therapeutic services, and vision and dental care as summarized below. Inpatient hospital services are covered for 365 days per year when the patient is a registered bed patient in a New York State short-term acute care facility and inpatient care is medically necessary; benefits include accommodations, physician and professional services, supplies, labs, imaging, therapies, blood products, radiation and chemotherapy, and customary hospital services (including special and intensive care) (see inpatient coverage scope and level).

Preventive pediatric care follows the American Academy of Pediatrics (AAP) visitation schedule for well-child visits and incorporates the ACIP recommended immunization schedule. Immunizations must be administered within 90 days of publication in the Morbidity and Mortality Weekly Report (MMWR). Well-child visit services include immunizations, tuberculin (Mantoux) testing, hearing testing, dental and developmental screening, clinical laboratory and radiologic tests, eye screening, lead screening and direct-access reproductive health services for eligible members.

Maternity benefits provide inpatient coverage of at least 48 hours after vaginal delivery and at least 96 hours after a C-section, and include parent education, breastfeeding assistance and necessary maternal and newborn clinical assessments. Mothers may elect earlier discharge provided that at least one home care visit is covered post-discharge. Home health care is covered when it prevents the need for hospitalization and is provided under a written physician plan by a certified home health agency; the contract provides up to 40 visits per calendar year if medically necessary.

Behavioral health services include inpatient mental health and substance use services in appropriately certified facilities, Assertive Community Treatment (ACT) delivered by a mobile multidisciplinary team for individuals meeting specified clinical and referral criteria, and a broad set of community-based Children and Family Treatment and Support Services (CFTSS) including Other Licensed Practitioner (OLP) services, CPST, PSR, FPSS and YPS. Group-based rehabilitative services generally must not exceed 8 participants (with FPSS groups limited to 12 individuals), must be trauma-informed and culturally competent, and require assessment and individualized treatment planning prior to service delivery. Evidence-based practices used in CFTSS require prior approval/designation and ongoing fidelity review as determined by New York State.

Policy Dates and Updates

Effective April 1, 2023Policy effective dateLatest

Policy provisions for Child Health Plus pediatric, inpatient, maternity, behavioral health, DME, and related services became effective.

OpenPayer

Child Health Plus / Pediatric and Related Preventive, Inpatient, and Behavioral Health Services coverage (Part 1)

Covered Services and Criteria (Pediatric, Inpatient, Behavioral Health, DME, Supplies)

Numeric and Timing Thresholds

Codes and Coding Guidance

Prior Authorizations, Documentation, and Operational Requirements

Key Definitions

Clinical and Administrative Context

Policy Dates and Updates