C HILDREN’S

1. CHILDREN’S SPECIAL HEALTH CARE SERVICES

2. C S H C S 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.

3. C 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.

4. C 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).

5. C 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.

6. WHAT IS CSHCS ? 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

7. 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

8. 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

9. 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.

10. 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

11. Factors Related to CSHCS Coverage Financial 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.

12. 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.

13. 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

14. 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

15. 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

16. Client Responsibility • Report other insurance benefits when eligible • Follow the provider’s medical advice • Report any changes that may affect the coverage

17. CSHCS Eligibility TO BE ELIGIBLE FOR CSHCS THE CHILD MUST HAVE A QUALIFYING MEDICAL CONDITION THAT REQUIRES TREATMENT BY A SPECIALIST AT LEAST ONCE A YEAR.

18. Medical Conditions Covered by CSHCS 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.

19. Determining CSHCS Eligibility Four Factors determine if a condition is covered by CSHCS. • Diagnosis • Chronicity • Severity • Need for treatment by a physician specialist

20. 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

21. 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.

22. 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.

23. Determining CSHCS Eligibility Severity – Based on severity, some persons will receive CSHCS coverage for certain conditions while others will not. Assessment of severity may include: • An evaluation of the frequency of hospitalizations or emergency visits • The complexity of the treatment schedule • The natural history of the condition

24. Determining CSHCS Eligibility 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

25. 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.

26. Medically Eligible Conditions Examples of medically eligible conditions are: • Cerebral Palsy • Sensoneural Hearing Loss • Asthma • Diabetes

27. Medically Eligible Conditions • Convulsive Epilepsy • Respiratory Distress Syndrome • Sickle Cell Anemia • Cleft Lip and Palate

28. 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

29. Conditions Typically Covered • Disease of the circulatory, respiratory, digestive and genitourinary systems • Diseases of the nervous system and the sense organs • Endocrine, nutritional and metabolic diseases

30. 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.

31. 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.

32. 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.

33. Covered CSHCS Services CSHCS and Other Coverage: Some clients have CSHCS plus Medicaid or private health insurance. In some cases CSHCS may pay the private insurance premiums. 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.

34. Covered CSHCS Services Based on the individual needs, services covered may include:

35. Covered CSHCS Services Based on the individual needs, services covered may include:

36. 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.

37. Services Not Covered by CSHCS 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. 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.

38. Services Not Covered by CSHCS This means that the following Mental Health Conditions are not CSHCS qualifying diagnosis: ADHD (Attention Deficit Hyperactive Disorder) ADD (Attention Deficit Disorder) Developmental Delays Mental Deficits

39. What Does CSHCS Do? 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.

40. CSHCS works within Local Health Departments (LHD) to provide local services for eligible members. Those services include: Care Coordination is a service provided to families to assist with the linking of service providers and specialist by: • Linking child/provider to Community Resources • Home Assessments • A Plan of Care (POC) annually in some cases

41. Care Coordination Care 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.

42. CASE MANAGEMENT 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.

43. 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

44. CASE MANAGEMENT Case Management can only be provided by a Registered Nurse. It involves: • Discharge Planning • Home Visits • Consulting with physicians regarding treatment • Monitoring Private Duty Nursing Services • Communicating with other service agencies • In-depth health family/client teaching

45. The Local CSHCS Office also assists families with: • Respite Care Applications • Children’s Special Needs Fund • Linkage with MI Child • Linkage with Healthy Kids • Diagnostic Evaluation Referrals

46. 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

47. The Local Health Department provides MCH grant mandated services such as: • Application completion • Income Review and Payment Agreement • Medical Renewal Assistance • COBRA application • Home Visits

48. The Local Health Department provides MCH grant mandated services such as: • Linkage to Early On, WIC, • Linkage to MIChild & Healthy Kids • Community Resources • Community and Program Outreach

49. To learn more about CSHCS Contact your Local CSHCS Office at : Detroit Health Department 1151 Taylor Building 6 – Room 202 Detroit, MI 48202 Phone: 313 – 876-0180 Fax: 313-876-0178 Or visit Michigan Virtual University at http:\\healthcare.mivu.org/cshcs.html