Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule defines the medical conditions for
which MCCS will provide service and funding.
(1) Category I shall include those eligible
applicants whose medical conditions require immediate life-saving medical
treatment. The conditions include, but are not necessarily limited to:
(A) Burn care-any burns requiring seven (7)
days or more inpatient care and burns requiring skin grafting;
(B) Cardiac care-congenital heart disease
requiring surgical intervention or presenting with congestive heart failure;
and acute rheumatic fever with congestive heart failure or requiring cardiac
surgery;
(C) Cleft lip and palate
care-initial lip or palate closure or both;
(D) Genito-urinary (GU) care-bladder
extrophy, vesico-ureteral reflux and uretero-pelvic junction
obstruction;
(E) Myelomeningocele
care (spina bifi-da)-surgical closure of myelocele;
(F) Neurology care-depressed skull fracture,
subdural hematoma and uncontrolled seizures;
(G) Neurosurgery care-shunting
procedures;
(H) Orthopedic
care-acquired amputations, fractures and fracture dislocations of the vertebral
column with or without associated spinal cord injury except for closed
coc-cygeal fractures, open fractures, osteogenesis imperfecta, osteomyelitis or
pyarthrosis presenting with sepsis; and
(I) Pediatric surgery care-diaphragmatic
hernia with accompanying respiratory distress; Hirschsprung's disease; multiple
surgically-staged imperforate anus; duodenal atre-sia; jejunal atresia;
tracheoesophageal fistula; gastroschisis; omphalocele; intestinal obstruction
in neonates; lacerated tendons; electrical burns to the mouth; surgical
procedures for subglottic stenosis; laryngeal webs; choanal atresia; and
ingestion burns; and
(J) The
following are not covered under Category I: arthritis care; cerebral palsy
care; ear; nose and throat (ENT)/hearing care; ENT/surgical care; and physical,
medical and rehabilitation (PM&R) care.
(2) Category II shall include those medical
conditions which, if not treated, could grow worse or cause a crippling
disability. A limited term of hospitalization and a good prognosis should be
expected. The conditions may include, but are not necessarily limited to:
(A) Arthritis care-acute juvenile rheumatoid
arthritis;
(B) Burn care-follow-up
and rehabilitation services;
(C)
Cardiac care-congenital heart disease (CHD) not requiring immediate surgical
intervention and CHD not presenting with congestive heart failure;
(D) Cerebral palsy care-surgical procedures
and bracing;
(E) Cleft lip and
palate care-surgical procedures;
(F) Ear, nose and throat (ENT) surgical
care-surgical procedures for chronic otitis media, tympanic membrane
perforation, cholesteatoma and other otologic conditions requiring specialty
care;
(G) Genito-urinary
care-bladder exstrophy, vesicoureteral reflux, utreteropelvic junction
obstruction, hypospadias and ambiguous genitalia;
(H) Myelomeningocele care (spinal
bifi-da)-follow-up and rehabilitation services:
(I) Neurology care-residuals of meningitis,
Guillain-Barre syndrome, Reye's syndrome, poliomyelitis, seizure disorders and
stalic encephalopathies;
(J)
Neurosurgery care-hydrocephanlus, diastematomyelia, enecephalocele and vascular
lesions affecting the central nervous system;
(K) Orthopedic care-congenital deformities;
arthrogryposis congenital dysplasia of the hip; complicated fractures of the
limbs, pelvis and shoulder girdle; scoliosis and kyphosis; surgical treatment
of late effects of epiphyseal injury; osteomyelitis; closed spinal fracture
without neurologic deficit, excluding coccygeal fractures; rickets;
Legg-Calve-Perthes disease; club feet; nonmalig-nant bone tumors and acquired
injury to limbs;
(L) Pediatric
surgery care-benign tumors, hemangiomas, lymphangiomas and neurofi-bromas which
cause functional impairment or disfigurement and surgical correction of
laryngeal papillomas;
(M) Physical,
medical and rehabilitation (PM&R) care-rehabilitation for spinal cord
injuries; and
(N) The following are
not covered under Category II: ear, nose and throat (ENT)/hear-ing
care.
(3) Category III
shall include those eligible applicants whose conditions may require prolonged
outpatient care and may require hos-pitalization at some time. The conditions
have a fair prognosis if treated and may include, but are not necessarily
limited to:
(A) Arthritis care-juvenile
sheumatoid arthritis follow-up as needed;
(B) Burn care-covered under Category I and
II;
(C) Cardiac care-congenital
heart disease follow-up and resistant dysrhythmias;
(D) Cerebral palsy care-rehabilitation
services;
(E) Cleft lip and palate
care-surgical revisions, dental care and speech therapy;
(F) Ear, nose and throat (ENT)/hearing
care-all eligible services;
(G)
Ear, nose and throat (ENT)/surgical care-surgical care follow-up;
(H) Genito-urinary care-follow-up care as
needed;
(I) Myelomeningocele
care-covered under Categories I and II;
(J) Neurology care-residuals of meningitis,
seizure disorders, Guillain-Barre syndrome, Reye's syndrome, poliomyelitis and
stalic encephalopathies;
(K)
Neurosurgery care-hydrocephalus, diastematomyelia, encephalocele and vascular
lesions affecting the central nervous system;
(L) Orthopedic care-claw foot,
calcaneo-valgus and other acquired congenital deformities and rehabilitation
services;
(M) Pediatric surgery
care-follow-up care as needed; and
(N) Physical, medical and rehabilitation
(PM&R) care-covered under Category II.
(4) Category IV shall include those eligible
applicants whose medical conditions have a poor to fair prognosis or uncertain
restoration to a useful or productive life regardless of the treatment
provided. The conditions are considered to be maintained by the services that
are provided for them and thus are put in this category of maintenance. This is
primarily a category of case management and covers the entire spectrum of
CCS-eligible conditions.
(5)
Category V shall include all those eligible applicants whose medical conditions
have variable prognosis; enhancement allows improvements in activities of daily
living (ADL), physical appearance for psychological reasons, with plastic
surgical procedures, etc. This also includes exotic conditions such as
craniofacial anomalies which are not ordinarily eligible for CCS services due
to budgetary limitations; if funding allows, these conditions would be included
under this category. Cosmesis, inborn errors of metabolism, exotic drugs and
special counseling are some of the miscellaneous items that would be funded in
this category.
(6) The categories
in sections (1)-(5) of this rule may have funding ceilings or limitations
imposed on them or may be categorically suspended, as stipulated in
19 CSR
40-1.060(1)(B).
*Original authority: 192.005, RSMo 1985 and 201.060, RSMo
1959.
