under age 21 Covered Covered with limitations 
Intermediate care facility for 
intellectual disabilities 
(ICF-IDD) Covered Not Covered 
Intermediate care facility 
services for individuals with 
intellectual disabilities  Covered Covered with limitations 14 Summary of Benefits H5619075000SB23 H5619075000 
BENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT 
Mental health services 
(outpatient group therapy and 
individual therapy visit)  Covered Covered 
Nursing facility services, other