Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.94-002 - Changes to the Medical Services Policy Manual to Explain the Purpose, Current, Activities, and Operating Procedures of Children's medical Services (CMS)

Children's Medical Services (CMS) is limited to Children with S$feg£aji[LESS THAN]4tealth Care Needs (CSHCN) under the age of 18 years, who will benefit from itfrgw&* Jfl medical intervention or require extensive case coordination (Age/Exception -m 4105)

Services

Children's Medical Services recognizes the importance of early identification of children in need of health care services to correct or ameliorate defects or chronic conditions that would lead to a disabling condition. An informative pamphlet describing the services available through CMS has been distributed throughout the state.

Specific case finding activities are accomplished through CMS Community Based Offices and referrals from private physicians, the local health department, schools, and EPSDT screening.

The legal basis for the operation of the Children's Medical Services Program is vested in the Ark. Stat. Ann. 83-109 (Act 280 of 1939).

The Director of the Department of Human Services has designated the Division of Medical Services to assume the responsibility for the administration of Children's Medical Services. Within the Division, the Children's Medical Services Section is charged with the administration of all such services to children with disabilities.

CMS is funded by state and federal funds. Federal funds are provided under Title V and other grants. The state funds are appropriated by the Arkansas Legislature and used to provide direct medical services for eligible children and administration expenses.

Any interested person or organization may refer a child for diagnosis and recommendation for treatment.

Referrals for Children's Medical Services' application will be made to the DHS County Office of the child's county of residence.

Applications for Children's Medical Services may be taken by a Service Representative in the DHS County Office of the child's county of residence, by a hospital social worker who has received instruction on completion of the forms, by any CMS staff member, or any person trained and authorized by. CMS to take applications.

Applications will be made in duplicate on Form EMS-800.

The parent, legal guardian, or emancipated individual under 18 years of age must supply information to complete the EMS-800. The signature of the parent, guardian* or emancipated individual under 18 constitutes authority for the Division'to determine eligibility and to arrange for any recommended services or treatment within the scope of the program.

In addition to the EMS-800, two (2) signed DHS-81's (Consent for Release of Information), and an EMS-97 (Earnings Statement for each employed parent) will be completed.

The Service Representative will sign as witness on the EMS-800.

If the application is taken anywhere other than the DHS County Office, the name of the agency or institution where the application is made will be written beneath the representative's signature. Applications may be sent to the CMS Central Office or directly to the CMS Community Based Office serving the county where the applicant resides.

If the child is a Medicaid recipient at the time a CMS application is made, the child's Medicaid ID number must be entered on the EMS-800.

To ensure compliance with Children's Medical Services' policies, the following information is required to process a CMS application. To assist in helping the applicant understand what he/she must furnish in order to qualify for CMS, the Service Representative will supply the applicant with Form EMS-882, which lists the information to be provided to CMS. The Service Representative will review the EMS-882 with the applicant to ensure adequate understanding of what is needed to process the CMS application. The following information is required:

Income Verification - Each employed Member of the family unit (Re. MS 4120) will have an EMS-97 completed by his/her employer and returned to CMS. Self-employed persons will provide a copy of last year's Federal Income Tax Return. Parents of Children with Special Health Care Needs who are on SSI or TEFRA and under the age of 16 who only wish service coordination, transportation, or CMS clinics do not have to furnish income verification. Children with Special Health Care Needs may be placed directly in a special category by CMS, as CMS is mandated to serve this population. If however, they wish to be evaluated for additional services they must supply income verification.

Birth Certificate - CMS requires a birth certificate (may be a copy but must be of the official birth certificate) to assure that the child's legal name is entered into CMS records for matching with Medicaid, AFDC, medical and other records and to assure that the person making the application is the parent.

Checking and Savings Accounts - Verification of all account balances are required by CMS.

Hospital Insurance - The applicant is required to furnish the name of any health insurance company covering his/her child, the company's address and policy number. All available insurance benefits will be utilized prior to CMS coverage of medical charges. Insurance payments must be applied to the cost of services received. Failure to apply insurance payments to the cost of services received will result in termination of the CMS case, and further CMS services will not be available until the money has been repaid.

Medicaid - CMS will not pay for services that can be covered by Medicaid. The CMS program has limited resources and must require parents to access all available payment resources (i.e. Medicaid, insurance,.etc.) in order to be able to offer assistance. The CMS applicant will be screened for Medicaid eligibility and a Medicaid application taken when it appears, based on income, resources, medical expenses, and other requirements, that the family or child would be eligible for Medically Needy, U-18, TEFRA, or the categories for Pregnant Women, Infants and Children.

The CMS applicant will be informed of his/her potential eligibility for Medically Needy Spend Down. Often a parent applies prior to the child's hospitalization/surgery and, at this time, is not eligible for Spend Down because there are no outstanding medical bills. The Service Representative will explain that, when the child's medical bills have been received, the parent should return to apply for Medicaid under the Medically Needy Spend Down Program if the CMS applicant does not meet the eligibility requirements for any other Medicaid category.

A chi1d may need CMS and Medi caid (or other medi cal coverage) simultaneously for maximum coverage, since each program has exclusions that a second program may provide. CMS will not pay any portion of the family's Spend Down liability used to qualify for Medicaid.

An applicant who refuses to complete a Medicaid application when eligibility appears likely, or who fails to provide necessary information or documentation to determine Medicaid eligibility, will not be accepted for CMS coverage.

Social Security Enumeration - As with other benefit programs, CMS requires a Social Security number or a completed SS-5 for the applicant child (Re. MS 1358). When possible, the Service Representative will view the SSN card to assure that the number is recorded correctly.

The County Office Service Representative will forward the original EMS-800, EMS-97(s), and both DHS-81's to Children's Medical Services within five (5) working days from the date of initial application, regardless of whether all necessary information has been provided or whether there is a pending application for

Medicaid. (CMS will be notified of the filial disposition of the Medicaid application). The copy of the EMS-800 will be retained for the County file. Children's Medical Services will conduct follow-up to secure necessary information that has not been provided to the Service Representative, and will make the!eligibility determination for CMS.

Cases involving the need for emergency treatment should be forwarded immediately to Children's Medical Services. A copy may be faxed to the CMS office, but must be followed by the original application.

Occasionally the EMS-800 or the DHS-81 will be returned to the County Office to secure a signature of the parent, legal guardian, spouse, or the Service Representative who witnessed the signature; or to obtain additional information.

When the EMS-800 or the DHS-81 has been returned to the County Office, the Service Representative will contact the applicant to secure the needed signature and/or information for immediate resubmission to CMS.

If the applicant fails to supply the requested information within thirty (30) days of the contact, a memorandum will be forwarded to Children's Medical Services giving the status of the application. The application will be placed in a special category for coordination only until financial eligibility can be determined.

A child must be under eighteen (18) years of age to be eligible for CMS. All expenditures by Children's Medical Services on behalf of a child must be for services received prior to his/her eighteenth birthday.

EXCEPTION:

All children eligible for Children's Medical Services must be residents of Arkansas. Patients moving into the state from out-of-state where they have been eligible for Children's Medical Services will be accepted by transfer of the record from the previous program, if they meet the financial eligibility requirements currently effective in this state and are medically eligible within the scope of the Arkansas Program.

All children potentially eligible for CMS who are not United States citizens must have resided in the U.S. for one year prior to applying for CMS services.

Marital status is not a condition of eligibility for Children's Medical Services.

A child is considered needy for CMS if the child or his/her parent(s), spouse, legal guardian or family unit meets the financial criteria under CMS' sliding income eligibility scale. Those counted in the family unit in addition to the client and his/her parents are all persons under age 18 living in the household who are members of the client's immediate family.

Consideration is given to available income as compared with recognized standards of need and the extent to which available resources can be used to meet the current cost of medical care. The probable cost of treatment will be a significant factor in determining financial eligibility.

A sliding scale established by CMS and updated periodically will be the basis for financial eligibility. The sliding scale will also determine the level of CMS participation. In some situations, CMS will require the family to pay for specific portions of the child's treatment or care.

It is required that financial need be reviewed yearly, or at any time there is a change in income, resources, or county of residence (Re. MS 4165 for reevaluations). The applicant will be informed by the Service Representative to notify CMS promptly when changes occur.

To qualify medically for services under the auspices of Children's Medical Services, a patient must meet the criteria of having a special health care need which can be benefited by surgical or medical intervention or requires coordination of services. In addition, his medical need must be that which requires the services of a physician or surgeon with specialized skills beyond the level of care provided by the family physician. If the available information indicates that the applicant may be eligible for medical services within the scope of the Program, an invitation will be sent for the child to secure a diagnostic examination at an appointed time and place in the geographic area in which he/she lives, or an invitation will be issued to a specialized clinic. Medical eligibility Will be determined following receipt of the examination report. Determination of eligibility for treatment through CMS will be made after a final diagnosis has been established. Acceptance of a patient for diagnostic coverage and treatment coverage are considered separately. Scaled financial criteria considering projected treatment cost and criteria for the degree of medical severity must be satisfied to establish treatment coverage after the diagnostic requirements are met.

The medically eligible patient will be treated by CMS only for his/her eligible condition and periodic pediatric examinations. Directly related medical or surgical services may be approved when necessary to prepare the patient to receive the authorized CMS treatment or when such services may enhance or preserve the recommended treatment.

An unrelated medical condition not classified as eligible in its own right does not become eligible because the patient is accepted for treatment of another eligible condition.

CMS will not pay for organ transplants, but coordination of services will be provided for Medicaid recipients. All SSI recipients under the age of sixteen (16) will be considered eligible for coordination of services.

An application will be denied if:

A CMS case will be closed or placed in a Special Category when:

(devaluation of CMS cases will be completed every 12 months for review of financial and social information. The CMS Central Office will mail the EMS-804 to the parent, guardian or emancipated recipient for completion and return to CMS. The County Office may be contacted, by CMS or the recipient, for assistance in completion of the revaluation.

If a recipient moves to another county, reevaluation must be completed within one month of the move. When income or resources change, verification of the change must be provided to CMS within two months of the change.

If the reevaluation is not submitted and completed within the time limits allowed by CMS, the case record will be closed and the individual must reapply on Form EMS-800 at the County Office to reopen the CMS case.

In areas where CMS does not have transport vans, County Office staff will be responsible for authorizing needed transportation to CMS clinics and subsequent recommended treatment facilities for Medicaid eligible recipients. Bank Funds will be utilized from Medicaid funds.

CMS provides limited travel to Medical appointments in areas where vans and drivers have been obtained.

In emergency cases needing referral to CMS but not previously known to the agency, the attending physician and/or the hospital will be responsible for contacting CMS immediately for tentative oral approval, If .the available information indicates possible eligibility. Final approval will be given only upon receipt of the application form EMS-800 and the medical report. Form EMS-800 should be received by CMS within five (5) working days from the time the emergency request is made.

The County Office, or hospital Social Worker, is responsible for transmitting the EMS-800 and two DHS-81's to the CMS Central Office within five (5) working days from date of application. Authorization for medical service will originate in any Children's Medical Services' Office, after eligibility has been established and before any payment can be made for the service. When found eligible, children may be approved for hospitalization by contractual agreement for any eligible condition.

Outpatient Services are provided by CMS. Care for eligible conditions for authorized patients will be provided in various clinical settings as deemed appropriate by the CMS Central Office. The site of care is made on the basis of need and local availability.

There are no specific diagnostic criteria other than CMS provides services for Children with Special Health Care Needs.

CMS Multidisciplinary Community Based Clinics are held in communities where specialized pediatric services are unavailable or where a large population of CMS clients with similar diagnosis are located in one area. The Multidiscipline team consists of CMS Staff Nurses, Social Worker, Nutritionists and Equipment Specialists, as well as Surgeons and Medical Specialists from various fields.

CMS attempts to furnish equipment, appliances and prosthetics on an individual basis, with the biggest consideration being the medical need of the child. Parent participation is required on all such purchases and repairs. Limitations are set as fiscal restraints dictate and when necessary equipment is placed on a waiting list.

X-ray and Laboratory services are authorized to health care providers providing these services upon the recommendation of the client's attending or examining physician. The services must be preauthorized by CMS.

Therapy services (speech, physical, & occupational) can be provided after a prescription is received from the attending physician specialist for specific diagnoses. The service must be preauthorized.

Medication, nutritional formulas, and supplies necessary for the treatment of a disease or condition may be provided by CMS. All drugs and supplies will be preauthorized by CMS.

Community Based Offices have been established in accordance with the Omnibus Budget Reconciliation Act of 1989 (OBRA 89). The location of these offices is determined by the number of CMS clients in the area, accessibility to medical services and potential clients in the area. New care coordination teams are formed as conditions warrant and funds become available.

Each coordination team consists of a Registered Nurse, Medical Secretary and, when possible, a Licensed Social Worker and CMS parent.

Family centered, service coordination is provided to all CMS recipients. This involves working closely with other Departments, other Divisions in DHS, and community organizations to provide Children with Special Health Care Needs whatever services are needed to appropriately meet their needs.

Periodic record reviews are completed on a random basis by supervisory staff to assure clients receive all the services they are entitled to, are informed of services available from other agencies, and to identify training needs.

Quarterly analysis of specified data from each area will be compiled by the Central Office administrative staff to comply with federal and state regulations and assure the provision of client services.