KIDSfirst benefits

We want to make sure you get the covered services you need

Look at this information carefully. It will help you understand what is covered by your plan, and how you can find the right care when you need it. Some services need prior approval before you can get them. If you don't know if something needs approval, check with your doctor or call Member Services at 1-888-814-2352.

Covered services for CHIP Members and CHIP Perinate Newborn Members must meet the CHIP definition of "medically necessary." A CHIP Perinate Member is an unborn child.

 Medically Necessary means:

  1. Health care services that are:
    1. Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life;
    2. Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions;
    3. Consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;
    4. Consistent with the member’s diagnoses;
    5. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
    6. Not experimental or investigative; and
    7. Not primarily for the convenience of the member or provider; and
  2. Behavioral Health Services that are:
    1. Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;
    2. In accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;
    3. Are furnished in the most appropriate and least restrictive setting in which services can be safely provided;
    4. Are the most appropriate level or supply of service that can safely be provided;
    5. Could not be omitted without adversely affecting the member’s mental and/or physical health or the quality of care rendered;
    6. Not experimental or investigative; and
    7. Not primarily for the convenience of the member or provider. 

There is no lifetime maximum on benefits; however, 12-month period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays apply until a family reaches its specific cost-sharing maximum. Co-pays do not apply to the Parkland CHIP Perinate Newborn members.

Some services need a prior authorization. Prior authorization is an approval that Aetna Better Health of Texas requires for certain services and medications. Some services need approval before they are given. The provider who is treating your child should get this approval. You can ask your doctor or us if an approval is needed for a service or treatment.

For Prior authorizations: Allow at least 3 business days for a response if medically appropriate. Urgent requests for medically non-urgent services will be handled within the timeframes for a routine request.