C CS. California Children Services Alameda County

Transcription

1 C CS California Children Services Alameda County

2 The California Children Services (CCS) Program strives to assure access to medical services essential to the health and well-being of children with catastrophic or chronic illnesses and injuries. The CCS Program is a vital part of the larger Family Health Services Division within the Alameda County Health Care Services Agency, Public Health Department. The Family Health Services Division focuses upon: Maximizing opportunities for mothers and fathers to have healthy babies Assisting families to grow and nurture health children Helping families meet the special health care needs of their children We will do everything within our capacity to assure health care access for all children, including access to the full continuum of essential, quality health care services from preventive and primary care through all levels of specialty care. We believe that, in partnership with the families we serve, we can help assure the health of California s children. California Children Services (CCS) is a statewide program that assists children under the age of 21 who have a serious medical condition and require specialty medical care. A staff of physicians, nurse case managers, and social workers assures that clients receive appropriate, comprehensive care. CCS strives to ensure that children receive a high standard of medical care. Authorized physicians are either board certified or eligible for certification in their specialty. Other providers must meet specific requirements as determined by CCS. INTRODUCTION Children with complex conditions must be followed by CCS-approved Special Care Centers. At these centers, teams of health care professionals participate in the care of child and family. 2010

3 Medical Eligibility The California Code of Regulations, implementing state law, has defined medical eligibility for the CCS program. In general, conditions that are lifethreatening, chronic or potentially disabling are usually CCS eligible. While not exhaustive or authoritative, the following summary of eligible conditions can be used when considering whether to refer a child to CCS. 1. Infections if congenitally acquired; of bone; the eye (when leading to blindness) 2. Malignant neoplasms; benign neoplasms in some circumstances. 3. Endocrine, metabolic and immune system disorders. 4. Most diseases of blood and blood-forming organs. 5. Disabling nervous system disorders; some seizure disorders. 6. Diseases of the eye when they may lead to blindness. Strabismus when surgery is required. 7. Hearing loss as defined; cholesteatoma. 8. Most diseases of the heart, blood vessels and lymphatic system. 9. Respiratory diseases if they are chronic, cause significant disability or complicate the management of another eligible condition. 10. Chronic, inflammatory diseases of the liver and intestines and chronic intestinal failure. 11. Chronic renal disease. 12. Skin disorders if they are disfiguring or disabling. 13. Chronic musculoskeletal and connective tissue diseases. 14. Congenital anomalies if disfiguring or disabling and amenable to amelioration as per regulation. 15. Newborns requiring certain interventions in a NICU. 16. Accidents, poisonings, violence and immunization reactions which, if left untreated, can result in permanent physical disability, loss of function, disfigurement or death. Fractures of the spine, pelvis and femur. Other fractures if treated with ORIF or which involve joints or growth plates. MEDICAL ELIGIBILITY DEFINITIONS

4 Types of Services Each eligible child is assigned a nurse case manager who will coordinate care and authorize: Diagnostic Services for children when there is a reason to suspect a serious medical problem High Risk Infant Follow Up Program for certain medically fragile infants Treatment Services for the CCS Medically Eligible Condition These services may include: - Hospital and physician care - Laboratory and x-ray services - Durable medical equipment - Pharmacy - Home health - Home infusion - Interdisciplinary center care Orthodontic Services for children with severe malocclusion Confidential HIV Testing and Monitoring Program for children who are at-risk for AIDS Medical Therapy Unit (MTU) services for medically eligible children who require occupational and/or physical therapy All services, except emergencies, must receive prior authorization. TYPES OF SERVICES

5 Eligibility A CCS application signed by the child s parent or legal guardian is necessary for all services not covered by Medi-Cal. Health insurance must be used to its full extent. Children with private HMOs which cover the cost of care are not eligible. Medical The child must have a CCS medically eligible condition as determined by the CCS medical consultant. Residential Residential eligibility is based on the county where the parent or legal guardian resides. The parent or legal guardian needs to apply for CCS in the county in which they reside. Full scope Medi-Cal children are eligible. Financial Children with full-scope Medi-Cal and/or Healthy Families are eligible. Families with adjusted gross income under $40,000 as shown on their latest California Income Tax return or equivalent document are eligible. This includes families with shareof-cost or restricted Medi-Cal for their children. Financial eligibility is determined annually. Families with an income over $40,000 may be eligible if the anticipated cost of medical care for the CCS condition (after payment from insurance), is over 20% of the family s California Adjusted Gross Income. ELIGIBILITY Diagnostic and MTU services do not require a financial review.

6 How to Refer The provider must furnish the following information to CCS by mail or fax: 1. Child s name, date of birth, address and phone number HOW TO REFER 2. Social Security or Medi-Cal number 3. Written medical report 4. Name of preferred specialist, if known Mail or fax your referral to: California Children Services 1000 Broadway, Suite 500 Oakland, CA Tel: (510) Fax: (510) For patients without full-scope Medi-Cal, advising the family to complete a CCS application will expedite the referral process. Upon request, CCS will provide you with information about the status of your referral.

7 Medical Therapy Units (MTU) CCS Medical Therapy Units provide occupational and physical therapy at school-based clinics. Physicians and therapists develop and implement individual rehabilitation plans to promote the optimal functioning of each medically eligible child. There is no financial eligibility requirement for MTU services. A CCS application is required and must be submitted to: California Children Services 1000 Broadway, Suite 500 Oakland, CA Medical Therapy Units are located at several sites throughout Alameda County. Please call the CCS main number at (510) for your nearest MTU location. MTU Services Eligibility A. CCS applicants with at least one of the following conditions may be medically eligible for participation in the CCS Medical Therapy Program: 1. Cerebral palsy with symptoms of spasticity, ataxia, athetosis, or dystonia. 2. Neuromuscular conditions that produce muscle weakness and atrophy, such as poliomyelitis, myasthenias, and muscular dystrophies. 3. Chronic musculoskeletal and connective tissue diseases or deformities such as osteogenesis imperfecta, arthrogryposis, rheumatoid arthritis, amputations, and contractures resulting from burns. 4. Other conditions such as ataxias, degenerative neurological diseases, or other intracranial processes that manifest abnormal neurological signs and symptoms. B. CCS applicants under three years of age may be eligible when two or more of the following neurological findings are present: 1. Exaggerations of or persistence of primitive reflexts beyond the normal age (corrected for prematurity). 2. Increased Deep Tendon Reflexes (DTRs) that are 3+ or greater. 3. Abnormal posturing as characterized by the arms, legs, head, or trunk turned or twisted into an abnormal position. 4. Hypotonicity with normal or increased DTRs in infants below one year of age. (Infants above one year must meet criteria described in A.1.) 5. Asymmetry of neurologic motor findings of trunk or extremities. MEDICAL THERAPY UNITS (MTU) For more information, please refer to CCS regulations, Title 22, Section