(1) To the extent department funding allows, and up to a maximum of $12,000 per eligibility year, the department will provide benefits as cited in (3) for the eligible conditions listed in (2) , subject to the exceptions to benefits and conditions in (4) and (5) .

(2) Eligible conditions are:

(a) genitourinary disorders;

(b) gastrointestinal disorders;

(c) metabolic disorders;

(d) neurological disorders;

(e) orthopedic disorders;

(f) craniofacial anomalies, including cleft lip and cleft palate;

(g) ophthalmic conditions;

(h) pulmonary disorders;

(i) endocrine disorders;

(j) juvenile rheumatoid arthritis, or similar arthritic disorders;

(k) cardiovascular disorders;

(l) chronic infectious disease;

(m) hematologic disorders; and

(n) dermatologic disorders.

(3) The following are covered benefits that may be provided to a CSHS eligible child or youth:

(a) evaluation, diagnosis and treatment, including surgical correction;

(b) evaluation and outcome management of developmental delay by a developmental pediatrician;

(c) appliances required for correction of a covered condition;

(d) medical foods for the treatment of a metabolic disorder, including prescriptive supplements for a child with inborn errors of metabolism;

(e) prosthetic devices, such as orthotics for a covered orthopedic condition;

(f) occupational, physical, nutrition and speech therapy for rehabilitation related to a covered service;

(g) allergy injections on the recommendation of a pediatric allergist after other preventive measures have been exhausted;

(h) hearing aids, up to a maximum of $1,500 per ear per year;

(i) one dental visit per eligibility year;

(j) one well child visit per eligibility year;

(k) breast pump purchase or rental (up to one year) to aid the mother of a newborn with a covered condition;

(l) eyeglasses for a child with a medical disorder-related condition, limited to a single pair of frames per eligibility year up to a maximum of $175 for frames, lenses and evaluation, plus an additional prescription lens change in six months as needed;

(m) disposable medical equipment for covered conditions;

(n) apnea monitor rental for a covered condition (up to one year) ;

(o) case management and care coordination;

(p) tonsillectomy and adenoidectomy in cases of obstructive sleep apnea or to protect hearing; and

(q) prescription medications related to the covered condition.

(4) No benefits are available for the following:

(a) acute care for illness or injury;

(b) insulin pumps;

(c) visual training therapy;

(d) home health and home nursing services for acute cases;

(e) legal services;

(f) psychological and psychiatric care and counseling;

(g) respite care;

(h) wheelchairs;

(i) transplants, including follow up care;

(j) transportation;

(k) growth hormone therapy, except for medically established hypothalamic/pituitary insufficiency;

(l) services provided outside of Montana, unless the required service is not available in-state or, due to the vast distances within Montana, the requirement to obtain in-state services places an undue hardship on a family;

(m) appliances, with the exception of orthopedic braces, prosthetic devices and appliances required for the correction of an orthodontic condition that affects an otherwise CSHS covered condition, such as that caused by the presence of a cleft palate or another syndrome-caused craniofacial anomaly;

(n) speech, occupational, nutritional, physical or respiratory therapy for a condition that is not CSHS-eligible;

(o) treatment for cleft/craniofacial conditions that are not planned and recommended by a multi-disciplinary cleft/ craniofacial team that meets American cleft palate-craniofacial association parameters.

(5) Conditions that are ineligible for financial assistance are:

(a) conditions which are usually non-remediable with no potential for long-term habilitation;

(b) behavioral, emotional, and learning disabilities;

(c) primary psychiatric diseases;

(d) injuries and illnesses; and

(e) catastrophic diseases, including neoplasms and other cancers.

(6) Standards for services that may be provided by CSHS are the following:

(a) to the extent CSHS funding allows and up to a maximum of $5,000 per person per federal fiscal year, the following services may be provided by the department to persons diagnosed with a CSHS-covered condition:

(i) resource and referral information;

(ii) transition information; and

(iii) nutritional counseling and management, medical formula or foods, and/or prescriptive medications not funded by other sources for a person identified with an inborn error of metabolism.

(b) services provided may not be covered by another payment source; and

(c) a person receiving services must:

(i) be a Montana resident; and

(ii) live in a household that meets CSHS income standards for benefit eligibility.