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General Laws

Section 10F. (a) There is hereby established a program of managed care to provide primary and preventive health care services for uninsured dependent and adopted youths from birth through age eighteen; provided, however, that only said youths who are ineligible for medical benefits pursuant to this chapter shall be eligible for the services defined in this section. Said program shall be administered by the division subject to appropriation from the Children’s and Seniors’ Health Care Assistance Fund established pursuant to the provisions of section 2FF of chapter 29 and other appropriated funds. The comptroller shall transfer amounts appropriated from the General Fund or any other fiscal resource of the commonwealth designated for health care services provided to said youths from birth to age 12, inclusive, to said Children’s and Seniors’ Health Care Assistance Fund. Services available from the program shall include the following:-

(1) preventive pediatric care in a participating doctor’s office, community health center, health maintenance organization or school-based clinic, including not less than one well-child visit a year, immunizations, tuberculin testing, hematocrit, hemoglobin and other appropriate blood testing, urinalysis, and routine tests to screen for lead poisoning, and such services as are periodically recommended by the American Academy of Pediatrics; provided that services provided by a participating independent laboratory for diagnostic laboratory tests shall be reimbursed by said program;

(2) unlimited sick visits in a participating doctor’s office, community health center, health maintenance organization, school-based clinic or a patient’s home;

(3) first-aid treatment and follow up care, including the changing or removal of casts, burn dressings or structures, in a participating doctor’s office, community health center, health maintenance organization or school-based clinic;

(4) the provision of smoking prevention educational information and materials to the parent, guardian or person with whom an enrollee resides.

(b) Services made optionally available under said program may include the following:

(1) prescription drugs up to $200 per year; provided, however, that enrollees shall be responsible for a copayment of $3 for each interchangeable drug prescription and $4 for each brand name drug prescription; provided, further, that the division may authorize a higher prescription benefit level for any person enrolled in said program for which said higher benefit will prevent hospitalization.

(2) urgent care visits in the outpatient department of a participating hospital when an enrollee’s primary care practitioner is not available to provide such services, and emergency care in the outpatient department or emergency department of a participating hospital of up to $1,000 per year, including related laboratory and diagnostic radiology services for said urgent and emergency care, provided that rates of reimbursement for such urgent care and emergency services are negotiated by participating hospitals with the department or its designated vendor;

(3) outpatient surgery and anesthesia which is medically necessary for the treatment of inguinal hernia and ear tubes, but not including the professional component for related radiology or pathology services; provided that rates of reimbursement for such urgent care and emergency services are negotiated by participating hospitals with the division or its designated vendor;

(4) annual and medically necessary eye examinations;

(5) medically necessary outpatient mental health services not to exceed 13 visits per year; provided, however, an additional 7 outpatient visits may be approved by the division when clinically necessary according to program guidelines; provided further, that no such mental health services shall be provided by the division that would substitute for mental health services required pursuant to chapter 71B;

(6) dental health services, including preventive dental care; provided, however, that no funds shall be expended for cosmetic or surgical dentistry;

(7) durable medical equipment up to $200 per year; provided, however, the division may authorize up to $500 per year to prevent unnecessary hospitalization for children with chronic medical conditions, so-called, when clinically necessary according to program guidelines; and

(8) auditory screening.

(c) The division shall establish cost-containment measures designed to ensure that only medically necessary services are reimbursed by said program. Should costs of said program exceed the appropriated funds, the division shall limit enrollment rather than reducing benefits.

(d) The cost of the program shall be funded in part by premiums contributed by enrollees. The premiums shall be set forth in regulations of the executive office of health and human services; but, enrollees in households earning less than 200 per cent of the federal poverty level shall not be responsible for contributing to program premium costs.

(e) Notwithstanding the premium contribution requirements established by this section, no enrollee shall be exempt from the co-payment requirements established herein or by the division. Said co-payments shall be designed to encourage the cost-effective and cost conscious use of said services.

(f) The division shall promulgate regulations necessary to implement the requirements of this section and shall maximize federal financial participation for state expenditures made on behalf of program enrollees.

(g) The division shall report quarterly to the house and senate committees on ways and means and to the joint committee on health care on enrollment demographics, claims expenditures and the annualized costs of said program. The division shall file notice with said committees and the secretary of the executive office of administration not less than thirty days before modifying program benefits and eligibility standards that are intended to ensure that program costs are limited to the funds appropriated therefore.

(h) The program established by this section shall not give rise to enforceable legal rights in any party or an enforceable entitlement to the services funded herein and nothing stated herein shall be construed as giving rise to such enforceable legal rights or such enforceable entitlement.

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