Current through Register Vol. 49, No. 9, September, 2024
1.
Purpose. To
establish the eligibility criteria and covered services under the Children with
Chronic Health Conditions (CHC) program of the Department of Human Services,
Division of Developmental Disabilities Services (DDS).
2.
Mission. CHC is
committed to ensuring that Children with Special Health Care Needs (CSHCN) in
Arkansas receive the services and support necessary to achieve their greatest
potential. CHC will work together with families and health care providers to
promote assessment, intervention, education, and coordination of
services.
3.
Authority. Title V of the Social Security Act,
codified at 42 USC §§
701 et seq.
4.
Definitions. For
purposes of this policy, the following definitions apply:
A.
Activities of Daily Living
(ADLs)- The basic tasks of everyday life, including eating,
communication, dressing, mobility, bathing, and toileting.
B.
Children with Chronic Health
Conditions Program (CHC) - Arkansas's program for CSHCN funded by the
Maternal and Child Health Services Block Grant. The CHC program is housed
within the Division of Developmental Disabilities Services (DDS) in the
Department of Human Services (DHS).
C.
Children with Special Health Care
Needs (CSHCN) - The Maternal and Child Health Bureau (MCHB) broadly
defines CSHCN as those that "have or are at increased risk for chronic
physical, developmental, behavioral, or emotional conditions and who also
require health and related services of a type or amount beyond that required by
children generally."
5.
Referrals. Any person or organization may refer a
child for diagnosis or treatment of an eligible condition.
Referrals must be made to DDS Centralized Intake and Referral
Unit. Contact information can be found here.
6.
Eligibility
Criteria. Eligibility must be determined on an annual basis.
A.
Residency Requirement.
1) The child and his or her family must be
current residents of Arkansas at the time services are provided. Proof of
residency will be required.
2) If
the child is not a naturalized citizen (e.g., the parent has a work visa), the
family must provide proof the child has been in the United States for twelve
(12) consecutive months and current residency in Arkansas.
3) The individual applying for services on
behalf of the child must:
a. Be the parent or
guardian of the child; and
b. Be a
current resident of the state of Arkansas.
B.
Medical eligibility. A
child diagnosed with a condition that causes chronic illness or disability may
be eligible for CHC services when the illness or disability results in the need
for periodic pediatric specialty treatment and follow-up. The family must
provide medical documentation of the illness or disability and the continued
need for periodic treatment and follow-up by a specialty physician.
C.
Age Restrictions. A child
is eligible to receive CHC services if they are under eighteen (18) years of
age and meet all other eligibility criteria.
D.
Financial eligibility.
The family's annual household gross income cannot exceed 350% of the Federal
Poverty Level (FPL).
1) The "household"
includes: the parents, step-parents, the child, all siblings, half-siblings,
and step-siblings. The household does not include any siblings over eighteen
(18) years of age, a significant other or the significant other's child(ren),
and other relatives.
2)
Income.
a. Income includes
regular salary (including military income and income from self-employment) and
overtime, as well as:
* cost of employer furnished housing or utilities,
* per diem for travel to and from work,
* bonuses,
* tips,
* educational stipends, grants, scholarships, and fellowships
to the extent they cover living expenses
* unemployment benefits,
* stock and bond dividends,
* charitable contributions,
* Social Security Benefits,
* adoption subsidy, and
* royalties.
b. Income does NOT include:
* Income from those not counted in the household;
* Income from the siblings, half-sibling, and
step-siblings;
* Grants, Scholarships, and fellowships to the extent they
cover educational expenses (tuition, books, etc.);
* Foster Care Board Payments; and
* Income from the child, unless emancipated.
c. If parents have joint custody, income is
determined based on the parent who has primary physical custody of the
child.
3) Failure to
truthfully disclose the following may result in denial of the CHC application:
* All sources of income
* Pending litigation
* Other sources of payment, such as awards and settlements for
medically necessary services.
7.
Exclusions.
The following are not eligible to receive CHC Services:
A. Children who are eligible to receive case
management services through another program (i.e., children enrolled in a
Provider-Led Arkansas Shared Savings Entity (PASSE)).
B. Recipients of the 1915(c) Autism
Waiver.
C. Recipients receiving
Hospice Care without concurrent disease modifying treatment.
D. Children living in a residential care
setting, such as a skilled nursing facility or intermediate care facility. This
includes residential treatment facilities for children with behavioral health
diagnoses.
8.
Assistance Categories:
CHC may provide assistance with the following categories of
services and supports, up to the applicable service and support limits. Service
limits are subject to change based on available funding and are published
here.
A.
Medically Necessary
Item or Equipment. A medically necessary item or piece of equipment
that is prescribed by a primary care physician (PCP), Specialty Physician,
Physician's Assistant, or Advance Practice Registered Nurse that addresses the
eligible condition(s)
and is not otherwise covered by
insurance, including Medicaid State Plan or Medicaid Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT).
The following will not be covered by CHC:
* Continuous Positive Airway Pressure (CPAP Machines)/Bilevel
Positive Airway Pressure (BiPAP Machines)
* Intrapulmonary Percussive Ventilator (IPV)
* Insufflator/Exsufflator (Cough Assist Machines) Machines,
unless the child is not eligible for Medicaid coverage.
* Prescription or over-the-counter medication.
B.
Parent
Education. Fees and necessary expenses associated with parents
attending conferences and workshops related to the needs of an eligible child.
Parent education may also include purchase of books, tapes, or other
educational materials. The activity or material must assist the parent in
acquiring knowledge of their eligible child's CHC qualifying disability or
delay.
C.
Medical Camps.
Camps specifically designed to provide opportunities for children
with medical needs or developmental delays to increase independence and learn
from social interactions with peers. The camp must be designed to meet that
child's specific medical or developmental needs.
D.
Adaptive Equipment. Any
assistive technology device, equipment, or product system that is used to
increase, maintain, or improve the performance of ADLs for an eligible child.
This excludes any environmental modifications. Adaptive equipment may be
purchased off-the-shelf, modified, or custom made. All adaptive equipment must
be prescribed by an appropriate, licensed clinician.
E.
Respite Services. Respite
services provide temporary relief, allowing the primary caregiver of a child
with a disability or special health care needs to have an occasional break from
caring for the child.
1. The primary
caregiver must be the guardian of the child.
2. To qualify for respite services, the child
must have deficits in at least two (2) ADLs or must have recently had an
emergency or crisis that requires respite to allow the situation to
de-escalate.
Note: An example of an emergency or crisis would be
when the primary caregiver of the child is scheduled for surgery and will need
assistance.
3.
Approved respite funding must be paid to a Medicaid enrolled provider of
respite, supportive living, or personal care services.
F.
Vehicle Modification.
Modification to a vehicle that allows the vehicle to be accessible to an
eligible child and increase the eligible child's mobility or access to
services. The vehicle must be owned by the family or the eligible individual.
Examples of allowed vehicle modifications include lift installation or
wheelchair carrier. The modification must be in accordance with Americans with
Disabilities Act (ADA) Requirements and necessary to maintain the individual in
the community. Vehicle modifications will only be provided once to each
eligible child or his or her family.
9.
CHC Providers and
Billing:
A.
Enrollment. To receive payment for CHC services, the
individual or entity must be enrolled as a Medicaid Provider or enrolled as a
CHC provider and be willing to accept Electronic Funds Transfer
(EFT).
B.
Prohibition on
Balance Billing. Providers must agree that payment from CHC will be
considered payment in full and the eligible child and his or her family may not
be billed the balance.
C.
Prior Authorization. All covered services for eligible
children must be prior authorized prior to billing. A request for prior
authorization can be submitted through the Medicaid Management Information
System (MMIS) portal.
D.
Deductibles and Coinsurance. For covered services paid for by
private insurance, CHC may assist with the deductible or coinsurance amount up
to one (1) month of household gross monthly, provided it does not exceed the
service limit.
E.
Payor of
last resort. CHC will not pay for covered services before all other
funding sources have been exhausted.
1) CHC
cannot pay for any service that would be covered by medical insurance,
including Medicaid or Medicare.
2)
If it appears that the family or child would be eligible for Medicaid (ARKids,
TEFRA, or SSI) or for insurance through the Affordable Care Act (ACA) the
family must apply for coverage before they can be eligible for CHC
services.
3) CHC will not cover
services for a child who is TEFRA Medicaid eligible but has lost TEFRA Medicaid
due to failure to pay the required premium.
10.
Appeals. If the
parent or guardian feels their child's case has been denied unfairly, they may
appeal in writing to the CHC Program Director within ten (10) business days
from the date of notification.
Reconsideration Requests/Appeals should be mailed to:
DDS Director's Office
P.O. Box 1437, Slot N501
Little Rock, AR 72201-1437
