Michigan Department of Health and Human Services
Children’s Special Health Care Services
Guidance Manual for Local Health Departments
Table of Contents
INTRODUCTION 1
SECTION 1: CSHCS MISSION STATEMENT 3
SECTION 2: CSHCS PROGRAM OVERVIEW 5
2.1 General Program Description 5
2.2 Family-Centered Care 6
2.3 Maternal and Child Health Bureau (MCHB) Core Outcomes 7
2.4 Medical Home 8
2.5 Transition 9
SECTION 3: HISTORY OF CSHCS 12
SECTION 4: CSHCS ORGANIZATIONAL STRUCTURE 15
4.1 CSHCS Program Sections and Responsibilities 15
4.1.A Customer Support Section (CSS) 15
4.1.B Policy and Program Development 15
4.1.C Quality and Program Services 16
4.1.D Family Center for Children and Youth with Special Health Care Needs (the Family Center) 16
4.2 Office of Medical Affairs 17
SECTION 5: FAMILY CENTER FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS-CYSHCN (commonly known as the Family Center) 19
5.1 Description 19
5.2 Program Services and Support 19
5.3 Purpose of the Family Center 20
SECTION 6: ROLE OF THE LOCAL HEALTH DEPARTMENT (LHD) 23
6.1 LHD Resources 24
6.1-A Linguistica International 24
6.1-B Mihealth Training 25
SECTION 7: MINIMUM PROGRAM REQUIREMENTS (MPR) 27
7.1 Background 27
7.2 Funding 27
7.3 Fiscal Year MPR 27
SECTION 8: CSHCS PROGRAM ELIGIBILITY 31
8.1 Medical Eligibility 31
8.2 Release of Information 33
8.3 Diagnostic Evaluations 34
8.4 Other Eligibility Considerations 37
8.4-A Citizenship Status 37
8.4-B Residency 38
8.4-C Long Term Care Facility 38
SECTION 9: CSHCS APPLICATION PROCESS 42
9.1 General Information 42
9.2 Financial Determination 43
9.3 Financial Determination Process 43
9.4 Verification of Income 45
9.5 Payment Agreement 45
9.6 Chronological Summary of CSHCS Application Process 47
9.7 Exceptional Circumstances Payment Agreement Work Sheet: 51
9.8 How to Reimburse Children’s Special Health Care Services 55
SECTION 10: CSHCS COVERAGE PERIODS 57
10.1 Effective Date 57
10.2 Coverage Period 57
10.2-A MIChild/Healthy Kids 57
10.3 Partial Month Coverage 58
10.4 Incarceration or Juvenile Detention Facility 58
10.5 Service Delivery 58
10.6 Renewal of Coverage 59
10.7 Medical Renewal Period 59
10.8 CSHCS Annual Review Process 60
10.8-A Chronological Description of the CSHCS Annual Review Process 60
10.9 Termination of Coverage 62
SECTION 11: PAPER VERIFICATION OF CSHCS ENROLLMENT 65
11.1 The mihealth Card 65
11.2 Client Eligibility Notice (CEN) 65
SECTION 12: CSHCS MEDICAL SERVICES COVERAGE 68
12.1 Dental Benefits 69
12.1-A General Dental Benefits 69
12.1-B Specialty Dental Benefits 69
12.2 Pharmacy Contractor (Magellan Medicaid Administration, Inc.) 70
12.3 Diaper and Incontinence Supplies Contractor (J & B Medical) 70
12.4 Vision Contractor (Classic Optical) 71
12.5 Commonly Requested Non-Covered Services 71
Some of the commonly requested services that are not covered by CSHCS are as follows: 71
SECTION 13: CARE COORDINATION 73
13.1 Care Coordination after the Death of the CSHCS Client 77
SECTION 14: CASE MANAGEMENT 80
SECTION 15: 93
SECTION 16: HOSPICE 95
SECTION 17: RESPITE BENEFIT 98
SECTION 18: INSURANCE PREMIUM PAYMENT BENEFIT 103
18.1 COBRA 103
18.2 Medicare Part B Buy-In 104
18.3 Insurance Premium Payment Application Process 105
18.4 Effective Date of Insurance Premium Payment Assistance 105
18.5 Annual Review for Renewal of Eligibility 106
18.6 Requirement to Repay CSHCS for Funds Expended on Terminated Policies 106
SECTION 19: OUT-OF-STATE MEDICAL CARE 107
19.1 Pre-Planned Medical Services 108
19.2 Provider Enrollment 108
19.3 Renewal of Out-of-State Providers 109
19.4 Borderland Providers 109
SECTION 20: TRAVEL ASSISTANCE 111
20.1 In-State Travel 111
20.1-A In-State Travel Assistance Requests 114
20.2 Out-Of-State Travel 114
20.2-A Out-of-State Travel Assistance Requests 115
20.3 Travel Reimbursement Process 116
20.3-A Transportation 117
20.3-B Air Travel 117
20.3-C Lodging 117
20.4 Clarification of Common Transportation Errors 118
20.5 Travel Advances and Reconciliation 119
20.6 Non-Emergency Medical Transportation (Non-Ambulance) 120
20.7 Non-Emergency Ambulance Transportation 121
20.8 Special Transportation Coverage 122
20.8-A Special Transportation Requests 122
20.9 Emergency Transportation Coverage 123
20.10 Non-Medical Transportation 123
20.11 Inappropriate Use of Transportation Benefits 123
SECTION 21: CHILDREN’S MULTI-DISCIPLINARY SPECIALTY (CMDS) CLINICS 125
21.1 CMDS Clinic Enrollment 125
21.2 Explanation of Services 126
21.3 CMDS Clinic Staff Requirements 126
21.4 CMDS Clinic Visit Types 127
21.4.A Initial Comprehensive Evaluation 128
21.4.B Basic and Ongoing Comprehensive Evaluation 129
21.4.C Management/Follow-up Visits 130
21.4.D Support Service Visits 130
21.5 Additional Responsibilities 131
21.6 CMDS Clinic Fee Billing Instructions 131
SECTION 22: PROVIDER PARTICIPATION WITH CSHCS 133
22.1 CHAMPS On-Line Provider Enrollment 133
22.2 Approved/Authorized Providers 133
22.3 CSHCS Approved Providers 134
22.3-A Physicians 134
22.3-B Hospitals 134
22.4 CSHCS Authorized Providers 135
22.4-A Providers Requiring Authorization 135
22.4-B Providers Not Requiring Authorization 135
22.5 Verifying Provider Authorization and Diagnosis Information 135
22.6 Adding Providers to a CSHCS Client’s Authorized Provider List 136
22.6-A Adding Physicians and Other Providers 136
22.6-B Adding Hospitals 137
22.7 Eligibility Verification 137
22.7-A Eligibility Verification System (EVS) 137
22.7-B Other Billing Contractors (Netwerkes) 138
22.7-C Web-DENIS 138
22.8 Prior Authorization 139
22.9 Provider Reimbursement 139
22.10 LHD Guide to Problem Solving for Families Prior to Sending to Lansing Office 140
SECTION 23: CSHCS COORDINATION WITH OTHER HEALTH CARE COVERAGE 145
23.1 Medicaid 145
23.2 MIChild 145
23.3 Transitional Medical Assistance (TMA) 145
23.4 Maternity Outpatient Medical Services (MOMS) 145
23.5 Healthy Michigan Plan 145
23.6 Medicare 145
23.7 Other Insurance 145
23.7-A Insurance Co-Payments 146
23.7-B Co-Insurance and Deductibles 147
23.7-C Services Not Covered by Another Insurance 147
23.7-D Private Insurance Mail Order Pharmacy COB Contractor (Magellan Medicaid Administration, Inc.) 147
23.7-E Changes in Other Insurance Coverage 147
23.8 Court-Ordered Medical Insurance 149
23.9 Co-Pay Coverage RE: Diabetic Supplies Using A DME Provider 149
SECTION 24: CHILDREN WITH SPECIAL NEEDS (CSN) FUND 152
24.1 History and Mission 152
24.2 CSN Fund Application Page and Brochure 152
24.3 CSN Fund Grant Eligibility Criteria 153
24.3-A Medical Eligibility 153
24.3-B Income Eligibility 153
24.4 CSN Fund Covered Items 154
24.4-A Van Lifts & Wheelchair Tie-Down Systems 154
24.4-B Home Wheelchair Ramps & Platform Lifts 155
24.4-C Air Conditioners & Central Air 155
24.4-D Electrical Service Upgrades 156
24.4-E Therapeutic Tricycles and Other Adaptive Recreation Equipment 157
24.4-F Summer Camp Scholarship Program 157
24.4-G Other Requests 157
24.5 CSN Fund Non-Covered Items 158
24.5-A Vehicle Modification 158
24.5-B Home Modification 158
24.5-C Assistive Technology 159
24.5-D Specialty Services 159
24.5-E Personal Care/Household Items 159
24.5-F Reimbursement/Replacement of Equipment 160
24.6 Processing CSN Fund Applications 160
24.7 Notification of Decisions 160
24.8 Appeal Decisions 161
SECTION 25: LEGAL MATTERS 163
25.1 Appeals 163
25.1-A Department Reviews 163
25.1-B Administrative Hearings 163
25.1-C Failure to Appear 164
25.1-D Withdrawal of Appeals 164
25.2 Subpoenas 164
25.3 Court Originated Liability Cases 164
25.4 HIPAA: Confidentiality of Protected Health Information (PHI) 165
SECTION 26: TRANSITION ASSISTANCE 167
SECTION 27: BEREAVEMENT 169
27.1 LHD Bereavement Procedure 169
27.2 Family Center Bereavement Procedure 169
27.3 CSHCS Analyst Procedure 169
27.4 Bereavement Letter 171
APPENDIX A Who to Call List 173
APPENDIX B Medicaid Provider Manual Directory 175
APPENDIX C Contacts at a Glance List 177
APPENDIX D Forms and Forms Reference List 179
APPENDIX E CSHCS Diagnosis Listing 181
APPENDIX F Acronym List 183
APPENDIX G Medicaid Provider Manual Navigation Instructions 185
APPENDIX H Record Retention and Disposal Schedule 187
APPENDIX I CSHCS Medical Diagnoses and Possible Related Specialties 189
APPENDIX J WHAT TO DO IF…. 191
APPENDIX K Plan of Care (Sample) 193
APPENDIX L Consultant Reason Codes 195
APPENDIX M Family Rights and Responsibilities 197
APPENDIX N Minimum Program Requirements 199
APPENDIX O Medicaid Health Plan Carve-Out Information 201
INDEX 203
Version: August 2016 Page II
Michigan Department of Health and Human Services
Children’s Special Health Care Services
Guidance Manual for Local Health Departments
INTRODUCTION
Children’s Special Health Care Services (CSHCS) has developed the Guidance Manual (GM) for Local Health Departments (LHDs) as a resource document. It contains CSHCS program policy in addition to procedural and guidance information that assists a LHD serving CSHCS clients as well as serving to enhance communication between state and local offices.
CSHCS will send updated information to the Guidance Manual as it becomes available and/or as policies change. Sections within the manual, as well as some subsections, are designed so that entire replacement documents can be inserted without disturbing the continuity of the manual.
When using the manual, keep in mind the following:
· “MDHHS” is interchangeably used referencing the Michigan Department of Health and Human Services and the CSHCS program.
· With the exception of headings and sub-headings, text that appears in blue-bold reflects CSHCS policy as published in the Children’s Special Health Care Services Chapter of the Medicaid Provider Manual and the Minimum Program Requirements (MPR).
· Additional information and procedures appear in regular text.
· Yellow highlighted information reflects changes that have been incorporated since the update.
· Specific information related to covered services, prior authorization requirements, etc. should be obtained from the Medicaid Provider Manual, which is updated quarterly. The Medicaid Provider Manual can be accessed on the MDHHS website at www.michigan.gov/mdch. Click on “Providers.”
· Medicaid related policy bulletins, draft policy, fee screens, and other pertinent information can be accessed on the website.
· Contact information does not appear throughout the manual. All contact information can be found in Appendix A (Who to Call List) and Appendix B (Medicaid Provider Manual Directory Appendix).
· Official forms (published by MDHHS) related to CSHCS or referred to in the Guidance Manual are contained in Appendix D. Forms and informational sheets created by CSHCS for internal use are found at the end of the section that references their use.
SECTION 1: CSHCS MISSION STATEMENT
Children’s Special Health Care Services (CSHCS) Program Mission:
CSHCS strives to enable individuals with special health care needs to have improved health outcomes and an enhanced quality of life through the appropriate use of the CSHCS system of care.
CSHCS program goals are to:
· Assist individuals with special health care needs in accessing the broadest possible range of appropriate medical care, health education, and supports
· Assure delivery of these services and supports in an accessible, family-centered, culturally competent, community-based, and coordinated manner
· Promote and incorporate parent/professional collaboration in all aspects of the program
· Remove barriers that prevent individuals with special health care needs from achieving these goals
SECTION 2: CSHCS PROGRAM OVERVIEW
2.1 General Program Description
Children’s Special Health Care Services (CSHCS) is mandated by the Michigan Public Health Code, Public Act 368 of 1978, Part 58, children and youth with special health care needs (MCL 333.5801 – 333.5879), in cooperation with the federal government under Title V of the Social Security Act, Sec.501. [42 U.S.C. 701] (a) 1 (D) and the annual Michigan Department of Health and Human Services (MDHHS) Appropriations Act. This makes CSHCS a separate program from Medicaid.
However, CSHCS partners closely with the Medicaid program regarding the use of the Medicaid system. This allows for greater efficiency in administering the two programs and allows both programs to collaborate on the care of a beneficiary so there is no duplication of services. CSHCS does not pay for Medicaid-covered services that have been denied by Medicaid. The system and areas of the department that make those decisions are the same for CSHCS and Medicaid. (NOTE: See below for more information about the CSHCS interface with Medicaid).
CSHCS is charged by the Social Security Act, Title V, Maternal and Child Health office with promoting the development of systems of care that are family-centered, community-based, coordinated, and culturally-competent with a focus on health equity. CSHCS strives for having the most appropriate pediatric subspecialists and services that are identified by combining the family’s expertise regarding their child and the condition, the medical services provider, the department’s medical expertise and CSHCS policy and program intent.
CSHCS increases access to resources and supports for the families and beneficiaries. Services occur in partnership recognizing the family as the constant in the child’s life. The goal is to reduce or eliminate barriers that are inherent to the condition. This in turn is intended to increase the quality of life for the beneficiary and the family. This family-centered approach impacts the level of independence most beneficiaries are able to achieve.
CSHCS identifies children with special health care needs. The child’s pediatric subspecialist submits medical reports to CSHCS for determination of medical eligibility. When the child does not have a pediatric subspecialist and there is no other way to obtain a medical report (i.e. private insurance, Medicaid, etc.), the program pays for a diagnostic evaluation of medical conditions that are likely to be covered by CSHCS. The beneficiary may be diagnosed with a CSHCS covered condition, which is the first step toward CSHCS eligibility but is not the only criterion. The condition must also meet chronicity, medical severity criteria and the need for treatment by a pediatric subspecialist before the beneficiary can be determined medically eligible for the program. Unlike other programs, there are no financial criteria that would limit eligibility for CSHCS. Eligibility is determined based upon medical circumstances and not on financial circumstances. Medical eligibility (and allowable citizenship/permanent residency status) must be established by the department before the beneficiary can enroll in CSHCS.
Once enrolled, CSHCS covers pediatric specialty medical treatment (adult specialty for the few enrolled adults) related to the qualifying condition. Care is limited to the qualifying diagnosis and related conditions. The limitation occurs by authorizing particular specialty providers for each child and having the authorized provider(s) order additional services such as therapies, lab tests, etc., as needed as related to their specialty. Providers who are not CSHCS-authorized are not eligible for reimbursement. CSHCS does not cover primary care or condition-related care delivered by a primary care provider.
NOTE: CSHCS and Medicaid interface – CSHCS follows Medicaid policy except where specified in this chapter. Many of the CSHCS processes (e.g. prior authorization, medical determinations, claims, etc.) are integrated into the Medicaid system and processes for CSHCS beneficiaries.
CSHCS strives to enroll CSHCS beneficiaries into Medicaid when they are eligible for Medicaid. This is primarily because Medicaid covers a broader range of medical services and conditions whereas CSHCS covers only specialty health care for the specific conditions CSHCS covers.
CSHCS also partners with Medicaid when beneficiaries have both CSHCS and Medicaid. Most beneficiaries who also have Medicaid are required to enroll with a Medicaid Health Plan. Under this situation, medical coverage is subject to the Medicaid rules. CSHCS can at times, provide additional services beyond what is available through the Medicaid benefit package. These services include care coordination, the development of a plan of care in which the family participates, referral to appropriate medical providers, and assistance with locating, accessing, and navigating community support services, etc.
The CSHCS Program does not issue “Emergency Services Only” coverage. The program issues coverage for services related to the CSHCS qualifying diagnosis(es) to those who are medically eligible, meet all of the program requirements, and complete the application process.
2.2 Family-Centered Care
The CSHCS program (and every state’s program legislated by Title V of the Social Security Act) has a strong commitment to family-centered care. The Institute for Family-Centered Care defines the term as follows: