California Children Services Program (CCS)
What is the California Children Services Program?
California Children Services (CCS) is a statewide program that arranges, directs, and pays for medical care, equipment, and rehabilitation, when these services are authorized by the program. Services can be authorized for children and young adults under 21 years of age who have eligible medical conditions and whose families are unable to pay for all or part of their care. CCS defines eligibility and selects the most qualified professionals to treat the child's CCS-eligible condition. However, it is important for you to know that CCS is not a health insurance program. It will not meet all of your child's health needs, only those related to the CCS-eligible condition.
Overview of California Children Services
California Children Services Benefits
What you Should Know About CCS Appeals
What does the CCS program offer children?
If your child's doctor thinks that your child may have a medical condition that might be CCS-eligible, CCS may pay for or provide a medical evaluation to find out if it is actually covered.
If your child is eligible, CCS may pay for or provide:
- Treatment, such as doctor services, hospital and surgical care, physical therapy (PT) and occupational therapy (CT), laboratory tests, X-rays, orthopedic appliances, and medical equipment.
- Medical case management to help get special doctors and care for your child when medically necessary, and referral to other agencies, including public health nursing and regional centers; or a
- Medical Therapy Program (MTP), which can provide PT, and/or OT in some public schools for children who are medically eligible for these special services.
How is the CCS program organized?
The California Department of Health Services manages the CCS program. The larger counties operate their own CCS program. Smaller counties share the operation of their program with state CCS regional offices in Sacramento, San Francisco, and Los Angeles.
How is the CCS program funded?
The program is financed from state, county, and federal tax monies, along with some fees paid by parents.
Who is eligible for CCS?
Your child may be eligible if he or she meets all four of the following requirements:
- Age -Your child must be under 21 years of age.
- Residence -Your child must be a permanent resident of the California county where you apply. (Your child's residence is usually where you live.)
- Income -Your family income must be less than $40,000 per year, according to the adjusted gross income on your California income taxes. A child may be eligible when the family income is more than $40,000 if medical care for the child's CCS condition is expected to cost the family more than 20 percent of the family's income. If your child is adopted your income will not matter. There is no financial eligibility requirement for diagnostic or therapy services.
- Medical Conditions - Only certain conditions are eligible for CCS. In general, CCS covers medical conditions that are physically disabling or require medical, surgical, or rehabilitative services. Categories of medical conditions that may be covered and some examples of each are shown on page 4. There also may be certain criteria that determine if your child's medical condition is eligible. Ask CCS if you have questions.
Eligible Medical Conditions
- Conditions involving the heart (congenital heart disease, rheumatic heart disease)
- Neoplasms (cancers, tumors)
- Diseases of the blood (hemophilia, sickle cell anemia)
- Diseases of the respiratory system (cystic fibrosis, chronic lung disease)
- Endocrine, nutritional, and metabolic diseases (thyroid problems, PKU, or diabetes that is hard to control)
- Diseases of the genito-urinary system (serious kidney problems)
- Diseases of the gastrointestinal system (liver problems such as biliary atresia)
- Serious birth defects (cleft lip/palate, spina bifida)
- Diseases of the sense organs (eye problems leading to loss of vision such as glaucoma and cataracts, and hearing loss)
- Diseases of nervous system(cerebral palsy, uncontrolled epilepsy/seizures)
- Diseases of the musculoskeletal system and connective tissue (rheumatoid arthritis, muscular dystrophy)
- Severe disorders of the immune system (HIV infection)
- Disabling injuries and poisonings requiring intensive care or rehabilitation (severe head, brain, or spinal cord injuries, and severe bums)
- Complications of premature birth requiring an intensive level of careDiseases of the the skin and subcutaneous tissue (severe hemangioma)
- Medically handicapping malocclusion (severely crooked teeth)
Steps to CCS Services
- Child's condition found
- Referral made
- Application completed (if your child does not have Medi-Cal, you must apply for it If your child has Medi-Cal he or she may be assigned to a "Managed Care"plan.)
- Eligibility determined: age • residency • financial • medical disagree with the decision you may appeal
- Services given:medically necessary • prior authorization
How can my child receive CCS services?
First, a referral and application must be made. Anyone can refer a child to CCS, including parents. Ask your child's doctor if your child has any of the medical conditions listed on page 4. If so, either you or the doctor can call the CCS office at your county health department to refer your child. The referral will work best if medical information is given to CCS at that time. If your child needs to be referred because he or she is in a hospital, ask the attending doctor or hospital social worker to refer your child within 24 hours after admission. After the referral to CCS, parents must still fill out an application and/or financial eligibility form and meet all four eligibility requirements. If CCS determines that your child is eligible, your child can then receive services.
What papers should I bring?
To help CCS determine if your child is eligible, you may need to bring papers to the county CCS office to show your child's age, where you live, and how much income you had in the past year. Examples of papers you might need are your social security card, driver's license, rent and utility receipts, paycheck stubs, birth or baptismal certificates, school enrollment forms, military ID, health insurance information or Medi-Cal card, and recent income tax forms. If you do not have some of these papers, ask CCS what other papers you may bring instead.
Are there any costs to me?
There are some fees for CCS clients who do not have Medi-Cal or who have Medi-Cal with a share of cost.The amount of the fees is based on family income and size. Ask CCS if you have any questions.
California Children Services Benefits
What are CCS benefits?
Benefits of CCS are medical services that the CCS program provides directly to eligible children or arranges to pay for their cost. This section explains these services.
Case Management
Case management is determining medical eligibility, deciding what your child needs, and helping you get special doctors and services to meet your child's special needs. This includes help to coordinate your child's medical care and referral to other agencies, such as the county health department, schools, and agencies that serve children and adults with disabilities. Every CCS client receives case management.
If your child has Medi-Cal and a CCS eligible condition, CCS can coordinate your child's medical care. This way, decisions about who will provide care and payment can be made faster by a person who is familiar with your child's needs. If you have Medi-Cal and are enrolled in a managed care plan, case management services may not be the same in all counties. In most counties, your child's CCS-eligible condition is still the responsibility of CCS, but in some counties it is the responsibility of the managed care plan. You should ask your CCS office if the case management of your child's CCS-eligible condition is covered by a managed care plan or the CCS program.
Diagnostic Services
If CCS thinks that your child might have an eligible condition, CCS will pay for diagnostic services. These include examinations, laboratory tests, and X-rays. Diagnostic services will be provided only until CCS finds out that your child has a condition that is eligible for CCS.
Treatment Services
Treatment services include medical services, medicines, equipment, or supplies that are medically necessary to treat your child's CCS- eligible condition. Treatment services are provided when they are a benefit of the CCS program, prescribed by a CCS-approved doctor, and authorized by CCS. Most of the time, these services can be provided in doctors' offices close to your home, but sometimes CCS might refer your child to a special care center if your child is eligible (see p. I 1). You should be sure to tell the doctor everything you know about your child's condition and ask the doctor about any services that might be available through CCS.
- Services From A Doctor
Doctor services may include consultations, office visits, surgery, anesthesiology, radiology, and other medical services needed to treat the CCS-eligible condition.
- Emergency Services
Emergency services, including doctor, lab, or hospital services to treat a CCS-eligible condition, may be a benefit of the CCS program. You, your doctor, or other hospital staff must ask CCS for authorization on the first working day after the service began. If your child is treated by a doctor or admitted to a hospital that is not approved by CCS, your child's treatment may be authorized for a short time, until treatment by a CCS-approved doctor or hospital can be arranged or your child is discharged.
- Hospital Services
Overnight hospital care can be authorized by CCS only if the doctor and hospital are approved by CCS and your child's condition is severe enough to require overnight hospital services. CCS must also authorize other services performed in the hospital.
- Home Health Care Services
In some cases, home health care services such as nursing, occupational therapy, physical therapy, or medical social services, may be provided to treat your child's CCS-eligible condition. If your child's CCS-authorized doctor prescribes the service and CCS agrees that your child needs the service, it can be authorized.
- High-Risk Infant Follow-Up Services
CCS provides high-risk infant follow-up services for eligible infants discharged from neonatal intensive care units (NICU). The purpose of these services is to prevent or reduce problems that may develop because of the child's medical condition. Benefits include case coordination, home visits by nurses, and other services that special care centers provide.
- Other Medical Services
Following are additional services that may be authorized only when CCS determines that they are medically necessary to treat your child's CCS-eligible condition. This list may not be complete. Ask CCS about other services.
- Medicines, including prescription drugs and special nutrition products
- Home infusion therapy
- Dental services
- Nutrition services
- Social work services
- Durable Medical Equipment (DME) such as wheelchairs and braces
- Medical supplies
- Eyeglasses, prostheses, and orthotics
- Dialysis
- Organ transplants and donor services
- Audiology services and hearing aid services
- Rehabilitation services, including OT, PT, and speech therapy
- Medical transportation
- Genetic counseling service
Special Care Centers
A special care center is where CCS can send your child to get the best medical care, using a team of specialists, such as doctors, social workers, nurses, therapists, and nutritionists. The team members will help you and your child manage your child's medical condition, and you are expected to bring your child in at least once a year. There will be evaluations to measure your child's progress and team meetings, which include you and your child (if your child is old enough) to discuss and/or change the treatments as your child's needs change.
- Eligibility
CCS special care centers are not for every child enrolled in CCS. These centers are only for children who have special medical conditions that require care from many specialists working together. The CCS program requires that children with certain medical conditions receive care through special care centers. Examples of these conditions include:
- Complex congenital heart diseases
- Inherited metabolic disorders
- Chronic renal diseases
- Chronic gastrointestinal diseases
- Chronic lung diseases
- Malignant neoplasms (cancers)
- Blood problems such as hemophilia, sickle cell disease Severe immunologic disorders
- Problems in the way the skull and face were formed
- Spina bifida
- Endocrine disorders including diabetes
If your child has any of the above conditions, ask your doctor to explain what it means.
Medical Therapy Program (MTP)
The Medical Therapy Program (MTP) is a coordinated program of medically necessary PT and OT services provided to medically eligible children. These services are provided in Medical Therapy Units (MTUs) located at certain public sites. PT and OT may help your child to be independent in such areas as getting around, getting in and out of a wheelchair, walking, feeding, dressing, staying clean and neat, and home skills.
There is a separate evaluation by the Medical Therapy Team (the doctors and therapists who specialize in treating children with physical disabilities). The team decides if your child would benefit from MTU services and meets with you to discuss which services would best meet your child's needs. The team can prescribe medically necessary PT or OT, as well as durable medical equipment and any other medical services. These services are often given in the MTU. However, they can also be provided by your child's health maintenance organization or your child's health insurance provider.
- Eligibility
Not every CCS client is eligible for MTP services. Eligibility for the MTP is different than for the CCS program. Residential eligibility for the MTP is the same, but medical eligibility is different and there is no financial eligibility. In other words, any child who is medically and residentially eligible for the MTP can receive PT and/or OT at no cost to the family. Two groups of children are served in the MTP:
- Children with a neuromuscular, musculoskeletal, or muscular disease. Examples include but are not limited to some types of cerebral palsy, poliomyelitis, myasthenias, muscular dystrophies, osteogenesis imperfecta, arthrogryposis, rheumatoid arthritis, amputation, and contractures resulting from burns.
- Children under 3 years old who have certain neurological findings that suggest a high chance that they may have a physical disability that is eligible for the MTP but who do not have diagnosis.
Ask CCS whether your child may be eligible for this program.
Click here for more information about the MTP program
Other Services to Help Parents and Children
The CCS program understands that you and your child may require more than just medical services. For instance, skilled nursing services in your home may be necessary for your child. Possibly you or your child could benefit from talking to someone about stress and worries. Or, you might need financial help in taking your child to a special care center. It is important to remember that these specialized services are only available on a limited basis. Some of the services you or your doctor may want to ask CCS about are listed below.
- Skilled Nursing Services in Your Home
CCS sometimes provides nursing services in the home by licensed nursing personnel. Since there are rules about when this can be provided, you should ask CCS whether it can be authorized.
- Counseling to Help With Stress and Worry
Being the parent of a child with special health care needs or being a child with special health care needs can cause anger, worry, or sadness. Sometimes the worry or sadness gets to be too stressful and you or your child might need help with these feelings. Talking to a professional trained to help with these problems can make you or your child feel better. This kind of help may be a CCS benefit when CCS agrees that the stress and worries are connected to the CCS-eligible condition and that they affect the child's treatment. If Medi-Cal or another insurance program covers your child, you should ask the other insurance program for the help first.
- Transportation, Lodging, and Meals
Services that provide the kind of special help that your child may need might not be available near your home. Sometimes, CCS may authorize help with travel expenses (mileage, bus transportation, food that you have to eat out, and the cost of staying at a motel) if you cannot afford them and no other resources are available. This help is available when the distance from your home to the provider that CCS authorized is so far that you cannot make the trip in one day or if you have to stay at the hospital to learn how to care for your child. To have CCS pay YOU back, you must have prior authorization and save all your receipts. CCS will usually authorize the closest appropriate provider. If you prefer to take your child to a provider farther away than the one CCS authorized, you may have to pay for the travel expenses.
What are the rules about CCS benefits?
Benefits may be authorized only from CCS-approved doctors, hospitals, OTs, PTs, etc. These people or groups are called "providers." Only services determined by CCS to be medically necessary to treat the CCS-eligible condition will be authorized. CCS must also have enough money to pay for the benefits.
- Services must be medically necessary ("Medically necessary benefits" means that the service, equipment, test, or drug)
- has been ordered by the doctor approved to provide care for your child;
- is a benefit of the CCS program; and,
- according to a CCS medical consultant, is the most effective way to treat the CCS-eligible condition.
Prior Authorization is Needed for CCS Services
Authorization by your local CCS program must happen before a service is given. Authorization means a written approval by the CCS program for a specific provider to give specific service(s). The authorization will name the service, the provider, and when the service must be provided. Each service requires a separate CCS authorization. For example, if CCS authorizes a provider to treat your child, the provider may decide that additional services are needed. You should be aware that other authorizations are required for the additional services. It is especially important to know this when your child is receiving services at a hospital. Additional authorizations are needed when your child is sent to different departments or doctors, even if it is in the same hospital. Before any service is given, you should ask if CCS has authorized the service. If a service is provided without authorization or it is not exactly the same as what was approved, CCS may not pay for it. You may then have to pay for the service yourself.
If the doctor or hospital cannot get authorization for emergency or urgent services because the CCS office is closed, CCS should be contacted for authorization on the next working day. Parents can call the doctor or CCS to be sure this was done.
You Must Use A CCS Provider
CCS wants to be sure that your child gets the best possible care. Therefore, hospitals and other medical providers must meet strict standards before they may treat CCS clients. Providers must be specialists in the care of children with special health care needs. Doctors must be experts in their specialty and members of the staff of a CCS-approved hospital. They must also agree to coordinate the care related to the CCS-eligible condition, to accept CCS payment as payment in full, and to keep the CCS program informed about your child's progress.
When CCS Will Not Pay For a Service
CCS will not pay for services for your child if any of the following things happen:
- The service was not authorized or the authorization has expired.
- You did not use a CCS-approved provider.
- It is not a CCS benefit.
- Your child is not or is no longer eligible for CCS.
- You or your child did not follow the treatment plans or keep scheduled appointments.
- The service is not for a CCS-eligible condition.
- You have not paid the required CCS fees.
- The medical treatment has been completed.
- The service your child needs is fully covered by your health insurance plan or Medi-Cal.
Family and CCS Program Expectations
What can our family expect from CCS program staff?
- All families and children should expect to be treated with respect and dignity,
- able to get information about other resources that may be helpful to them,
- assured of the confidentiality of their personal records and information,
- able to have their child's eligibility determined and authorizations processed in a timely way
What about confidentiality?
Confidentiality means that your records are private and can generally only be given to you or someone else with your permission. However, CCS program staff and other authorized see your records, but they must maintain confidentiality. The CCS program will also allow you to see your child's records. A copy of your child's records may be available for free or at little cost. You can see the record as long as you schedule a meeting in advance and when there is a person that the county CCS office believes can interpret the medical terms for you.
What is Family-centered care?
Family-centered care means that families are involved as equal partners in the care of their child with special health care needs are more likely to receive this type of care if they let ram know that they want to be involved.
Family-centered care is based on an equal relationship between family members and service providers. The following describes what all service providers should provide in the context of family-centered care.
- Service providers should recognize that you are the only ones who are there all the time in your child's life. The people who provide services are always changing, but your child is your responsibility all the time.
- Service providers should share all information with you about your child's treatment in a caring way. You have a right to know what the provider is recommending, what good will come of it what the possible risks are, and why the provider thinks it is the best choice. You also have the responsibility to ask questions until you understand what the provider is saying.
- They should respect different ways of dealing with health problems. When providers tell you what they think is best for your child, they should also listen to what you think, too.
- They should invite you to work together with doctors and other staff in the care of your child. This means that you should be included in planning the treatment for your child before decisions are made, not just be given a consent form to sign.
- Service providers should ask you what you liked and disliked about the care your child received and how to improve it.
- They should use their understanding of the special needs of children of different ages in how they provide health care. They should explain to you and your child what will happen and why. Your child should also be asked his or her opinion and feelings about their treatment. Your teen should generally receive the full explanation that you get. You have the right to ask the provider to talk to your child and the responsibility to do it if the provider is not able to do so.
- They should invite you to talk to other families of children with similar conditions. Parents can help other parents in a way that no doctor can. No one knows what you are going through better than another parent who has gone through it. Information should be available about how to contact other parents like you.
- And all service providers should try to make health care flexible, convenient, and meet the family's changing needs.
We hope that giving you this information will help you get family entered care for your child and to ask for it if you don't get it.
What does the CCS program expect from families?
Following is what the family, legal guardian, or emancipated minor must do to receive CCS services.
- Complete and sign CCS program forms, including the application form, program services agreement, the yearly financial eligibility redetermination, and medical Release of Information forms. (if you have difficulty filling out these forms, CCS staff will be happy to assist you.)
- Be determined eligible for CCS services and comply with program requirements, policies, and procedures.
- Notify CCS program representatives and providers of any health insurance at the time of application and agree to ask your insurance to pay for a service before asking CCS. Apply for and cooperate with Medi-Cal when asked to do so by the CCS program.
- Inform CCS within 15 days about any changes that might affect eligibility, such as health insurance/Medi-Cal coverage, residence, income, employment status, or a child's legal guardianship.
- Pay any required program fees.
- Keep appointments or call the provider if you need to change the appointment.
- Follow treatment plans.
- Notify the CCS program immediately about any financial settlements, payments, or awards received in connection with the child's CCS-eligible condition.
- Repay CCS for money spent for your child when required to do so.
- Promptly inform CCS of any emergency or nonscheduled hospitalization.
You should also remind the provider to request prior authorization for all services, to notify CCS of any changes in the treatment plan or termination of medical treatment, and to send reports of the services to CCS.
What you Should Know About CCS Appeals
General Rules About the CCS Appeals Process
Once you have applied for CCS services, you will get a written decision if your eligibility or a service has been denied, reduced, or stopped. This decision is called a "Notice of Action" (NOA). The NOA explains what action has been taken and why the action was necessary. If you do not agree with the decision, you have the right to appeal it. Before you ask for an appeal, you should call the CCS office at the number listed on the NOA to talk about your complaint. Often, complaints can be resolved without asking for an appeal. However, do not wait too long because there are time limits for appeals. If you decide to ask for an appeal, you must show that the decision by CCS was not right for your child.
The appeal process begins when a family requests an appeal of a decision. The process has two steps. Both steps give applicants or clients a way to share information and settle differences. The first step is the First Level Appeal. If you do not agree with the result, you may go to the second step and request a Fair Hearing. You must make a request in writing for each level of appeal.
What is the difference between a First Level Appeal and a Fair Hearing?
A First Level Appeal is an informal review of all information about your complaint by experienced health care professionals.
A Fair Hearing is a formal meeting where you are given a chance to present evidence to a hearing officer. A hearing officer is an attorney required by the state to make a fair decision about your complaint. To do this, the hearing officer will review your child's records and keep all information confidential.
Will services be continued during the appeal process?
Your child's services may continue during the appeal process if all the following things have taken place.
- The service was already authorized by CCS.
- You requested (in your written appeal) that the service continue.
- Your request was determined to be medically necessary by a CCS authorized physician.
- The length of time that services can be continued will vary, depending on the length of the appeal process.
Where can I get help with my appeal?
The best way to find out about getting help is to contact your local CCS program.
- CCS ASSISTANCE
CCS can help by explaining the complete appeal process and allowing you to review the information in your case file. Copies of your records and the regulations and policies upon which decisions are made will be made available to you upon request for little or no charge.
- OTHER RESOURCES
You are not required to have legal representation. However, help or representation may be available through private attorneys, legal clinics, and nonprofit legal organizations if you need it. You may also have an advocate from another organization that knows your child, such as a regional center for developmental disabilities, a family resource center, or an organization that gives information about your child's CCS-eligible condition. They may be listed in the white or yellow pages of your telephone book.
How do I ask for an appeal or a Fair Hearing?
If you must make either request in writing within 30 days of receiving an NOA. The appeal must tell CCS what your complaint is about, why you disagree with the decision, and what you want CCS to do about it. Your request for a Fair Hearing must be made within I 5 days of receiving the appeal decision and must include a copy of the First Level Appeal decision. Both types of requests must be signed by you and should provide enough information to show exactly why you disagree with the CCS decision. You may wish to write the appeal in a personal letter, get help with it, or have someone write it for you.
Can I have an interpreter at the Fair Hearing?
If you need an interpreter for the Fair Hearing, CCS will provide one for you at no cost. You must ask for an interpreter and tell CCS what language you speak when you make your Fair Hearing request.
Are there services that can’t be appealed?
Sometimes a CCS-approved doctor will not prescribe a service that you want for your child. Also, the doctor may refuse to continue prescribing a service. You cannot appeal either decision. For example, medical therapy services can be stopped by a private CCS-approved physician or by a physician in the Medical Therapy Program. If this happens and you disagree with the decision, there is a different process that you can use to settle the disagreement. You may request a second medical opinion from an expert physician. You will be able to choose the doctor from a list of three experts that CCS will give you. The opinion of that expert is final.
What are the laws relating to CCS?
California state law and regulations govern the CCS program. The state laws are found in the Health and Safety Code, Welfare and Institutions Code, and the Government Code. The regulations are found in the California Code of Regulations. These laws and regulations can be found in a county law library. All written decisions will tell you which laws and regulations apply to your child's case.
Is there more information about the appeal process?
The CCS appeals process has more requirements than described here. For a complete description of the appeal process, you may contact your local CCS program. A copy of the appeal regulations may be available for free or at little cost.