016.05.20 Ark. Code R. 001

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.05.20-001 - Children with Chronic Health Conditions (CHC)

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

016.05.20 Ark. Code R. 001

Adopted by Arkansas Register Volume MMXX Number 13, Effective 7/1/2020