by LA County CCS Department of Public Health CCS Outreach Presentation: CCS Background CCS Medical Eligibility Last update: 08.2016 by LA County CCS Department of Public Health

Presenters Section I: Dr. Edward Bloch, Medical Director History, Background, General information, and Disclaimers for CCS Medical Eligibility Section II: Dr. Karen Streeter, Assistant Medical Director Sections: Infectious Diseases to Diseases of the Ear and Mastoid Process. Section III: Dr. Sunthorn Sumethasorn, Assistant Medical Director Sections: Circulatory System to Accidents, and NICU criteria

Dr. Edward Bloch Section I: Medical Director Topics: History, Background, General information, and Disclaimers for CCS Medical Eligibility

Learning Objectives Goals Know CCS history and background Understand CCS Carved-Out and related Managed Care responsibility. Know CCS medical eligibility. Guide appropriate CCS referral. When in doubt, err on the side of referral. Improve care coordination for CCS clients.

History 1927: the California Crippled Children’s Act by Gov. Clement Young, established the program to meet the surgical needs of children with physical disabilities. 1935: Social Security Act by President F.D. Roosevelt, mandated that each state establish & fiscally support a program that provided services for children with special health care needs. 1978: Robert W. Crown Act Established State-run program, administered by Counties.

Overview CCS arranges and pays for all or part of the medical care and therapy services for children under 21 years of age with certain healthcare needs.

Organization Structure State level Department of Health Care Services System of Care Division. County level Department of Public Health, Children’s Medical Services

4 CCS Eligibilities Age: 0 - 21 years of age Residential: Los Angeles County Financial: -income <$40,000, or -expected to spend 20% or more of the family’s AGI on the CCS medical condition, or -have full scope Medi-Cal coverage, or -adopted with a CCS eligible medical condition Medical

Professional Case Management Teams: Case management activities: Nursing (primary) Medical (consultative) Eligibility determination SAR review/authorization: Care plan development Whole child approach for “complex” cases. Coordination of authorized services Identification of resources Ongoing case review/consultation Transition

Standards CCS paneling of providers Physician OT, PT, ST Nutritionist Special Care Center (SCC) Hospital All CCS providers must be Medi-Cal providers in order to receive reimbursement. State sets standards State reviews and panels or approves providers or hospitals State provides periodic site visits to special care centers and hospitals Mandated outcome report systems for HRIF, NICU, PICU centers Care to be provided by the provider or facility most appropriate for the condition and the level of complexity

Why CCS Standards Adapted from Family Voice of CA slides presented by Laurie Soman Children with serious and/or rare medical conditions have better outcomes when treated by providers and hospitals with pediatric expertise. Only specialized pediatric centers see the number of many children’s conditions needed to reach volume thresholds for quality. Children are not small adults; they and their families need access to physically, developmentally, and socially appropriate services and facilities. State CCS standards help to enforce and maintain the statewide system of care that ensures access to pediatric expertise, quality outcomes, and child-and family-centered care.

Medi-Cal Managed Care and CCS Carve-Out State Medi-Cal Managed Care Roll-Out Began in 1994. CCS Carve-Out from Medi-Cal Managed Care via SB 1371 (Bergeson), 1994. CCS Carve-in Counties, permitted under SB 1371 or added shortly after: Marin, Napa, San Mateo, Santa Barbara, Solano, and Yolo CCS Carve-out Counties: rest of State including counties new to Medi-Cal Managed Care. Governer Brown has just signed AB 187 (Bonta), extending CCS Carve-out till December 31, 2016. Adapted from Families Voice of CA slides by Laurie Soman

CCS Carve-Out (MMCD Letter No 96-10) Welfare and Institutional Code, Section 14094.3 (a), CCS covered services are excluded from the Medi-Cal managed care contracts entered into after 08/01/94. Plan is responsible for the care, primary and specialty, until the CCS program eligibility is determined and established. CCS services are covered only from the time the referral is made to County Office, except for emergency services or services rendered after office hours (referral to made the next business day).

CCS Carve-Out: Responsibilities Medi-Cal Managed Care Primary care Immunization Specialty care for non-CCS eligible condition Timely referral to County CCS for medical eligibility determination Training Identification and Tracking Coordination CCS Prompt eligibility determination Specialty care for CCS eligible condition Primary care as pertained to CCS condition Training and Resources Coordination Transition

CCS Medically Eligible Conditions Mandated by State Legislation: CA Code of Regulations, Title 22, Division 2, Part 2 Subdivision 7, Chapter 3, Article 2, Sections 41515.1 – 41518.9. http://www.dhcs.ca.gov/services/ccs/Documents/ccsnl050500.pdf http://www.dhcs.ca.gov/formsandpubs/publications/Documents/CMS/cmsin/cmsin0902.pdf

Disclaimers (1) The following is intended to be a general guideline for providers, managed care plans, and/or their staffs to help identify and appropriately refer patients with suspected or confirmed CCS conditions to CCS office. Expeditious CCS medical eligibility determination depends on timely submission of medical reports in support of such diagnoses. Same principles apply for ongoing requests of services and benefits for an already established CCS case.

Disclaimers (2) DHCS System of Care issues communications, such as numbered letters, to guide Counties with interpreting medical eligibility, and evaluating new benefits. Statewide CCS medical consultants meet regularly to improve consistency in eligibility interpretation. Conditions not well defined in the Regulations are reviewed case by case by LA CCS Medical Director or the designee(s).

Disclaimers (3) Disagreement is resolved through administrative avenues with provider(s) and/or plan partner (s), or formal due process with CCS client/family.

CCS Medically Eligible Conditions In general: most chronic, physically disabling, severely disfiguring, or life threatening conditions that require complex medical intervention, surgical, or rehabilitative services are eligible. Most acute, simple, self-limiting, or primarily mental, developmental conditions are NOT eligible.

Medical Eligibility Determination Medical eligibility for the CCS program, as specified in Sections 41515.2 through 41518.9 shall be determined by the CCS program medical consultant or designee through the review of medical records that document the applicant's medical history, results of a physical examination by a physician, laboratory test results, radiologic findings, or other tests or examinations that support the diagnosis of the eligible condition.

Definitions 41423. Disability. a limitation of a body function which includes both of the following: (a) Compromises the ability to perform the usual and customary activities that a child of comparable age would be expected to perform; and (b) Can be identified or quantified by a medical examination and standard tests for that body function.

Definitions 41445. Life Threatening. means an injury or illness that could lead to death

End of CCS Background & CCS Medical Eligibility Module Thank You