What does the CCS program offer children?
If your child's doctor thinks that your child may have a medical condition that might be CCS-eligible, CCS may pay for or provide a medical evaluation to find out if it is actually covered.

Who is eligible for CCS?
Your child may be eligible if he or she meets all four of the following requirements:

1. Age -Your child must be under 21 years of age.

2. Residence -Your child must be a permanent resident of the California county where you apply. (Your child's residence is usually where you live.)

3. Income -Your family income must be less than $40,000 per year, according to the adjusted gross income on your California income taxes. A child may be eligible when the family income is more than $40,000 if medical care for the child's CCS condition is expected to cost the family more than 20 percent of the family's income. If your child is adopted your income will not matter. There is no financial eligibility requirement for diagnostic or therapy services.

4. Medical Conditions - Only certain conditions are eligible for CCS. In general, CCS covers medical conditions that are physically disabling or require medical, surgical, or rehabilitative services. Categories of medical conditions that may be covered and some examples of each are shown on page 4. There also may be certain criteria that determine if your child's medical condition is eligible. Ask CCS if you have questions.

• Conditions involving the heart (congenital heart disease, rheumatic heart disease)

• Neoplasms (cancers, tumors)

• Diseases of the blood (hemophilia, sickle cell anemia)

• Diseases of the respiratory system (cystic fibrosis, chronic lung disease)

• Endocrine, nutritional, and metabolic diseases (thyroid problems, PKU, or diabetes that is hard to control)

• Diseases of the genito-urinary system (serious kidney problems)

• Diseases of the gastrointestinal system (liver problems such as biliary atresia)

• Serious birth defects (cleft lip/palate, spina bifida)

• Diseases of the sense organs (eye problems leading to loss of vision such as glaucoma and cataracts, and hearing loss)

• Diseases of nervous system(cerebral palsy, uncontrolled epilepsy/seizures)

• Diseases of the musculoskeletal system and connective tissue (rheumatoid arthritis, muscular dystrophy)

• Severe disorders of the immune system (HIV infection)

• Disabling injuries and poisonings requiring intensive care or rehabilitation (severe head, brain, or spinal cord injuries, and severe bums)

• Complications of premature birth requiring an intensive level of care

• Diseases of the the skin and subcutaneous tissue (severe hemangioma)

• Medically handicapping malocclusion (severely crooked teeth)

Case Management
Case management is determining medical eligibility, deciding what your child needs, and helping you get special doctors and services to meet your child's special needs. This includes help to coordinate your child's medical care and referral to other agencies, such as the county health department, schools, and agencies that serve children and adults with disabilities. Every CCS client receives case management.

Diagnostic Services
If CCS thinks that your child might have an eligible condition, CCS will pay for diagnostic services. These include examinations, laboratory tests, and X-rays. Diagnostic services will be provided only until CCS finds out that your child has a condition that is eligible for CCS.

Treatment Services
Treatment services include medical services, medicines, equipment, or supplies that are medically necessary to treat your child's CCS- eligible condition. Treatment services are provided when they are a benefit of the CCS program, prescribed by a CCS-approved doctor, and authorized by CCS. Most of the time, these services can be provided in doctors' offices close to your home, but sometimes CCS might refer your child to a special care center if your child is eligible (see p. I 1). You should be sure to tell the doctor everything you know about your child's condition and ask the doctor about any services that might be available through CCS.

• Services From A Doctor
  Doctor services may include consultations, office visits, surgery, anesthesiology, radiology, and other medical services needed to treat the CCS-eligible condition.

• Emergency Services
  Emergency services, including doctor, lab, or hospital services to treat a CCS-eligible condition, may be a benefit of the CCS program. You, your doctor, or other hospital staff must ask CCS for authorization on the first working day after the service began. If your child is treated by a doctor or admitted to a hospital that is not approved by CCS, your child's treatment may be authorized for a short time, until treatment by a CCS-approved doctor or hospital can be arranged or your child is discharged.

• Hospital Services
  Overnight hospital care can be authorized by CCS only if the doctor and hospital are approved by CCS and your child's condition is severe enough to require overnight hospital services. CCS must also authorize other services performed in the hospital.

• Home Health Care Services
  In some cases, home health care services such as nursing, occupational therapy, physical therapy, or medical social services, may be provided to treat your child's CCS-eligible condition. If your child's CCS-authorized doctor prescribes the service and CCS agrees that your child needs the service, it can be authorized.

• High-Risk Infant Follow-Up Services
  CCS provides high-risk infant follow-up services for eligible infants discharged from neonatal intensive care units (NICU). The purpose of these services is to prevent or reduce problems that may develop because of the child's medical condition. Benefits include case coordination, home visits by nurses, and other services that special care centers provide.

• Other Medical Services
  Following are additional services that may be authorized only when CCS determines that they are medically necessary to treat your child's CCS-eligible condition. This list may not be complete. Ask CCS about other services.
  

  • Medicines, including prescription drugs and special nutrition products

  • Home infusion therapy

  • Dental services

  • Nutrition services

  • Social work services

  • Durable medical equipment (DME) such as wheelchairs and braces

  • Medical supplies

  • Eyeglasses, prostheses, and orthotics

  • Dialysis

  • Organ transplants and donor services

  • Audiology services and hearing aid services

  • Rehabilitation services, including OT, PT, and speech therapy

  • Medical transportation

  • Genetic counseling service

Special Care Centers
A special care center is where CCS can send your child to get the best medical care, using a team of specialists, such as doctors, social workers, nurses, therapists, and nutritionists. The team members will help you and your child manage your child's medical condition, and you are expected to bring your child in at least once a year. There will be evaluations to measure your child's progress and team meetings, which include you and your child (if your child is old enough) to discuss and/or change the treatments as your child's needs change.

• Eligibility
  CCS special care centers are not for every child enrolled in CCS. These centers are only for children who have special medical conditions that require care from many specialists working together. The CCS program requires that children with certain medical conditions receive care through special care centers. Examples of these conditions include:

  • Complex congenital heart diseases

  • Inherited metabolic disorders

  • Chronic renal diseases

  • Chronic gastrointestinal diseases

  • Chronic lung diseases

  • Malignant neoplasms (cancers)

  • Blood problems such as hemophilia, sickle cell disease Severe immunologic disorders

  • Problems in the way the skull and face were formed

  • Spina bifida

  • Endocrine disorders including diabetes

If your child has any of the above conditions, ask your doctor to explain what it means.

Medical Therapy Program (MTP) in Schools 
The Medical Therapy Program (MTP) is a coordinated program of medically necessary PT and OT services provided to medically eligible children. These services are provided in Medical Therapy Units (MTUS) located at certain public schools. PT and OT may help your child to be independent in such areas as getting around, getting in and out of a wheelchair, walking, feeding, dressing, staying clean and neat, and home skills.

There is a separate evaluation by the Medical Therapy Team (the doctors and therapists who specialize in treating children with physical disabilities). The team decides if your child would benefit from MTU services and meets with you to discuss which services would best meet your child's needs. The team can prescribe medically necessary PT or OT, as well as durable medical equipment and any other medical services. These services are often given in the MTU. However, they can also be provided by your child's health maintenance organization or your child's health insurance provider.

• Eligibility
  Not every CCS client is eligible for MTP services. Eligibility for the MTP is different than for the CCS program. Residential eligibility for the MTP is the same, but medical eligibility is different and there is no financial eligibility. In other words, any child who is medically and residentially eligible for the MTP can receive PT and/or OT at no cost to the family. Two groups of children are served in the MTP:

1. Children with a neuromuscular, musculoskeletal, or muscular disease. Examples include but are not limited to some types of cerebral palsy, poliomyelitis, myasthenias, muscular dystrophies, osteogenesis imperfecta, arthrogryposis, rheumatoid arthritis, amputation, and contractures resulting from burns.

2. Children under 2 years old who have certain neurological findings that suggest a high chance that they may have a physical disability that is eligible for the MTP but who do not have symptoms.

Ask CCS whether your child may be eligible for this program.

Click here for more information about the MTP program

Other Services to Help Parents and Children
The CCS program understands that you and your child may require more than just medical services. For instance, skilled nursing services in your home may be necessary for your child. Possibly you or your child could benefit from talking to someone about stress and worries. Or, you might need financial help in taking your child to a special care center. It is important to remember that these specialized services are only available on a limited basis. Some of the services you or your doctor may want to ask CCS about are listed below.

• Skilled Nursing Services in Your Home
  CCS sometimes provides nursing services in the home by licensed nursing personnel. Since there are rules about when this can be provided, you should ask CCS whether it can be authorized.

• Counseling to Help With Stress and Worry
  Being the parent of a child with special health care needs or being a child with special health care needs can cause anger, worry, or sadness. Sometimes the worry or sadness gets to be too stressful and you or your child might need help with these feelings. Talking to a professional trained to help with these problems can make you or your child feel better. This kind of help may be a CCS benefit when CCS agrees that the stress and worries are connected to the CCS-eligible condition and that they affect the child's treatment. If Medi-Cal or another insurance program covers your child, you should ask the other insurance program for the help first.

• Transportation, Lodging, and Meals
  Services that provide the kind of special help that your child may need might not be available near your home. Sometimes, CCS may authorize help with travel expenses (mileage, bus transportation, food that you have to eat out, and the cost of staying at a motel) if you cannot afford them and no other resources are available. This help is available when the distance from your home to the provider that CCS authorized is so far that you cannot make the trip in one day or if you have to stay at the hospital to learn how to care for your child. To have CCS pay YOU back, you must have prior authorization and save all your receipts. CCS will usually authorize the closest appropriate provider. If you prefer to take your child to a provider farther away than the one CCS authorized, you may have to pay for the travel expenses.

What are the rules about CCS benefits?
Benefits may be authorized only from CCS-approved doctors, hospitals, OTs, PTs, etc. These people or groups are called "providers." Only services determined by CCS to be medically necessary to treat the CCS-eligible condition will be authorized. CCS must also have enough money to pay for the benefits.

• Services must be medically necessary
  "Medically necessary benefits" means that the service, equipment, test, or drug

1. has been ordered by the doctor approved to provide care for your child;

2. is a benefit of the CCS program; and,

3. according to a CCS medical consultant, is the most effective way to treat the CCS-eligible condition.

Prior Authorization is Needed for CCS Services
Authorization by your local CCS program must happen before a service is given. Authorization means a written approval by the CCS program for a specific provider to give specific service(s). The authorization will name the service, the provider, and when the service must be provided. Each service requires a separate CCS authorization. For example, if CCS authorizes a provider to treat your child, the provider may decide that additional services are needed. You should be aware that other authorizations are required for the additional services. It is especially important to know this when your child is receiving services at a hospital. Additional authorizations are needed when your child is sent to different departments or doctors, even if it is in the same hospital. Before any service is given, you should ask if CCS has authorized the service. If a service is provided without authorization or it is not exactly the same as what was approved, CCS may not pay for it. You may then have to pay for the service yourself.

If the doctor or hospital cannot get authorization for emergency or urgent services because the CCS office is closed, CCS should be contacted for authorization on the next working day. Parents can call the doctor or CCS to be sure this was done.

You Must Use A CCS Provider
CCS wants to be sure that your child gets the best possible care. Therefore, hospitals and other medical providers must meet strict standards before they may treat CCS clients. Providers must be specialists in the care of children with special health care needs. Doctors must be experts in their specialty and members of the staff of a CCS-approved hospital. They must also agree to coordinate the care related to the CCS-eligible condition, to accept CCS payment as payment in full, and to keep the CCS program informed about your child's progress.

When CCS Will Not Pay For a Service
CCS will not pay for services for your child if any of the following things happen.

1. The service was not authorized or the authorization has expired.

2. You did not use a CCS-approved provider.

3. It is not a CCS benefit.

4. Your child is not or is no longer eligible for CCS.

5. You or your child did not follow the treatment plans or keep scheduled appointments.

6. The service is not for a CCS-eligible condition.

7. You have not paid the required CCS fees.

8. The medical treatment has been completed.

9. The service your child needs is fully covered by your health insurance plan or Medi-Cal.

What can our family expect from CCS program staff?

• All families and children should expect to be treated with respect and dignity,

• able to get information about other resources that may be helpful to them,

• assured of the confidentiality of their personal records and information, and able to have their child's eligibility determined and authorizations processed in a timely way.

• Able to have their child’s eligibility determined and authorizations processed in a timely way.