CCHILDREN’S

SSPECIAL

HHEALTH

CCARE

SSERVICES

Children’s Special Health Care Services (CSHCS) is a program within the Michigan Department of Community Health (MDCH) created to find, diagnose and treat children in Michigan with Chronic Illness and Disabling Conditions .

For more than 50 years, CSHCS was called the Division of Services for Crippled Children.

C S H C SC S H C S

In 1988, the program adopted the name Children’s Special Health Care Services. The name change was done to better reflect the more than 2,600 health care problems covered by the program. The new name describes the children CSHCS serves in a positive, respectful way.

C S H C SC S H C S

CSHCS is funded by both state and federal dollars. Each year, Michigan lawmakers fund CSHCS through the MDCH Appropriations Act.

The Michigan law that governs children with special health care needs is Part 58 of the Public Health Code (Act 368 of 1978).

C S H C SC S H C S

C S H C SC S H C S

Federally, CSHCS receives funding from Title V of the Social Security Act. Each year, federal lawmakers fund all Title V programs in every state through the Maternal and Child Health Block Grant.

CSHCS is a specialty medical care program. Conditions eligible for CSHCS coverage require care by medical specialist at least once a year.

CSHCS usually does not cover care that is managed only by internists, pediatricians, or family doctors. An exception may be made for medical service directly related to the medically eligible condition

WHAT IS CSHCS ?

Factors Related to CSHCS Coverage

Residency – A person must be a Michigan resident to receive CSHCS through MDCH. A resident is defined as a person who:

Lives in Michigan and Plans to reside in Michigan for a period of time, or Is in Michigan to work or to look for a job

Factors Related to CSHCS Coverage

Migrant Workers- Children of migrant workers may receive CSHCS coverage if their parent(s) are working or looking for work in the state.

The citizenship requirements do not apply to the children of migrant workers who are otherwise eligible for CSHCS

Factors Related to CSHCS Coverage

Citizenship – U.S. citizens and some non-citizens may qualify for CSHCS coverage. If a non-citizen qualifies for and uses CSHCS, that will not affect his or her chances of receiving a green card.

Factors Related to CSHCS Coverage

Non-citizens Who Qualify for CSHCS –

Non-citizens may be eligible for CSHCS if they, a parent, or a legal guardian are citizens of the United States or are non-citizens lawfully admitted for permanent residence.

A child born in the United States, or a child of a migrant worker who meets all other program eligibility criteria, is eligible regardless of the parent/legal guardian’s citizenship

Factors Related to CSHCS CoverageFinancial Factors- It is important to note that

financial factors do not count in determining CSHCS eligibility.

It is incorrectly believed that CSHCS only accepts families with little or no income. In fact, families at every income level are in the CSHCS program.

Families that have private health insurance are also eligible for CSHCS. In those cases CSHCS provides additional help to families.

Client Rights & Responsibilities

To guarantee CSHCS families receive the best care and treatment possible, MDCH has established rights and responsibilities.

The rights and responsibilities established by MDCH are rules and regulations CSHCS and CSHCS families must follow.

The rights and responsibilities are designed to ensure quality care and treatment.

Client Rights

Receive quality health care

Be treated with respect

Be seen by providers who will arrange the care needed Get all the facts about their health and treatment procedures

Client Rights

Know if co-payment is required

Say “no” to any medical treatment you disagree with

Be told what CSHCS covers

Be told in writing when and why benefits are being reduced or stopped

Get a second medical opinion

Client Responsibility

Keep all scheduled appointments

Provide complete information about current medical history and problems

Ask questions about the care

Make prompt payment for services not covered by CSHCS

Report other insurance benefits when eligible

Follow the provider’s medical advice

Report any changes that may affect the coverage

Client Responsibility

TO BE ELIGIBLE FOR CSHCS

THE CHILD MUST HAVE A

QUALIFYING MEDICAL

CONDITION THAT REQUIRES

TREATMENT BY A

SPECIALIST AT LEAST ONCE

A YEAR.

CSHCS Eligibility

There are over 2,600 qualifying health conditions and 9,000 medical diagnoses that are covered by CSHCS . Some conditions / diagnosis allow for life-time coverage such as Cystic Fibrosis and certain Blood Disorders. A child can be covered by CSHCS for more than one qualifying diagnosis.

Medical Conditions Covered by CSHCS

Four Factors determine if a condition is covered by CSHCS.

Determining CSHCS Eligibility

Diagnosis

Need for treatment by a physician specialist

Chronicity

Severity

Determining CSHCS Eligibility

Diagnosis – To qualify for CSHCS, an individual must have a CSHCS covered diagnosis where activity is or may become so restricted by disease or deformity as to reduce normal capacity for education and self-support

Determining CSHCS Eligibility

Chronicity – A condition is considered to be chronic when it is determined to require specialty medical care for not less than 12 months.

Determining CSHCS Eligibility

Severity – When the MDCH medical consultant determines that specialty medical care is needed to prevent, delay or significantly reduce the risk of activity becoming so restricted by disease or deformity as to reduce the individuals’ normal capacity for education and self-support.

Severity – Based on severity, some persons will receive CSHCS coverage for certain conditions while others will not. Assessment of severity may include:

Determining CSHCS Eligibility

An evaluation of the frequency of hospitalizations or emergency visits

The complexity of the treatment schedule

The natural history of the condition

Examples of How Severity Affects Eligibility

Asthma – Conditions covered if the asthma classification is moderately severe to severe

Burns – Condition covered if burns require hospitalization or treatments by a special burn team

Seizures – Condition covered if seizures are difficult to manage

Determining CSHCS Eligibility

Determining CSHCS Eligibility

Need for Treatment by a Physician Specialist – The condition must require the services of medical and/or surgical sub-specialist at least annually, as opposed to being managed exclusively by primary care physicians.

Medically Eligible Conditions

Examples of medically eligible conditions are:

Cerebral Palsy

Sensoneural Hearing Loss

Asthma

Diabetes

Medically Eligible Conditions

Convulsive Epilepsy

Respiratory Distress Syndrome

Sickle Cell Anemia

Cleft Lip and Palate

Conditions Typically Covered

CSHCS covers about 2, 600 health problems, such as:

Chronic conditions peculiar to newborns

Congenital anomalies

Disease of blood and blood-forming organs

Endocrine, nutritional and metabolic diseases

Diseases of the nervous system and the sense organs

Disease of the circulatory, respiratory, digestive and genitourinary systems

Conditions Typically Covered

Fee-For Service (FFS) System

FFS is how services rendered are covered by CSHCS.

Under the FFS system, families go to the CSHCS providers listed on the Eligibility Notice that each client receives.

FFS means the doctor gets paid a fee by CSHCS for each service the doctor provides to the client. Families do not pay those fees.

CSHCS and Medicaid Coverage

CSHCS and Medicaid are often confused with each other because they both use the Medicaid billing system. It is important to understand how they differ:

CSHCS - only covers treatment related to the qualifying diagnosis.

Medicaid - is comprehensive health care coverage.

Covered CSHCS Services

CSHCS only covers those services or treatments directly related to the client’s qualifying diagnosis(es). What is covered depends on the client’s medical condition or family circumstance.

CSHCS as Secondary Coverage:

In cases where CSHCS is combined with other coverage, CSHCS by law, is the “payer of last resort.” That means CSHCS coverage is always secondary to other insurance.

CSHCS and Other Coverage:

Some clients have CSHCS plus Medicaid or private health insurance. In some cases CSHCS may pay the private insurance premiums.

Covered CSHCS Services

Covered CSHCS ServicesBased on the individual needs, services covered may include:

Hearing

Dental

Vision

Specialized Hone Care

Therapies

Office Visits

Hospital Stays

Pharmacy

Covered CSHCS Services

Physical Therapy

Speech/Language Therapy

Medical Equipment

Medical Supplies

Genetic Counseling

Laboratory Tests

Nutrition Counseling

Occupational Therapy

Based on the individual needs, services covered may include:

Services Not Covered by CSHCS

Primary Care – CSHCS does not cover primary care. That means common colds or childhood illnesses like mumps or measles.

CSHCS does not cover acute situations like broken bones and fevers unrelated to a qualifying diagnoses.

A child may become CSHCS eligible as a result of an accident or traumatic event.

Well-Child Care – CSHCS does not cover well-child care . Families should check for well-child care under their private health plan or their Medicaid coverage.

Services Not Covered by CSHCS

Mental Health – CSHCS does not cover any mental health diagnoses. A person could have a mental disability plus some medical problem and be eligible for CSHCS.

Services Not Covered by CSHCS

This means that the following Mental Health Conditions are not CSHCS qualifying diagnosis:

ADD (Attention Deficit Disorder)

ADHD (Attention Deficit Hyperactive Disorder)

Developmental Delays

Mental Deficits

CSHCS works with families to ensure the best care for the child.

CSHCS can help with paying medical bills, learning about specialty providers, coordinating health insurance benefits and covering co-pays and deductibles.

What Does CSHCS Do?

CSHCS works within Local Health Departments (LHD) to provide local services for eligible members. Those services include:

Linking child/provider to Community Resources

Home Assessments

A Plan of Care (POC) annually in some cases

Care Coordination is a service provided to families to assist with the linking of service providers and specialist by:

Care CoordinationCare Coordination can be provided by any member of the LHD’s CSHCS staff under the guidance of a Registered Nurse.

Care Coordination services can be provided in the home or the service can be provided by phone

Care Coordination’s Plan of Care can be developed by a Registered Nurse or a Social Worker

Plan of Care can b shared with the Primary Care Doctor if the family desires this.

Case management is a service provided by the LHD to families to assist with the care of children that require high-tech assistance to maintain optimum health.

CASE MANAGEMENT

Case management usually involves private duty nursing services.

A Plan is developed which is called the Plan of Care (POC). The POC is updated quarterly

The POC must be approved and signed by the parent/legal guardian

The POC is shared with the Physician

CASE MANAGEMENT

CASE MANAGEMENT

Case Management can only be provided by a Registered Nurse. It involves:

Home Visits Discharge Planning

Monitoring Private Duty Nursing Services

Consulting with physicians regarding treatment

Communicating with other service agencies

In-depth health family/client teaching

The Local CSHCS Office also assists families with:

Respite Care Applications

Children’s Special Needs Fund

Linkage with MI Child

Diagnostic Evaluation Referrals

Linkage with Healthy Kids

The Local CSHCS Office also assists families with:

Linkage with the Family Support Network (FSN)

Lodging Assistance

Transportation Assistance – In-State

Out-of-State Transportation Assistance

The Local Health Department provides MCH grant mandated services such as:

Home Visits

Application completion

Income Review and Payment Agreement

Medical Renewal Assistance

COBRA application

The Local Health Department provides MCH grant mandated services such as:

Linkage to MIChild & Healthy Kids

Linkage to Early On, WIC,

Community Resources

Community and Program Outreach

To learn more about CSHCS Contact your Local CSHCS Office at :

http:\\healthcare.mivu.org/cshcs.html

Detroit Health Department1151 Taylor Building 6 – Room 202Detroit, MI 48202Phone: 313 – 876-0180Fax: 313-876-0178

Or visit Michigan Virtual University at