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)

Current through Register Vol. 49, No. 6, June, 2024
4000
CHILDREN'S MEDICAL SERVICES
4001
Eligible
			 Children
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)
4005
Earlv
			 Identification of Children in Nee'd-QJLHealth Ca'fe
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.
4010
Legal Basis for
			 Children's Medical Services
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).
4015
Responsibility for Children's Medical
			 Services
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.
4020
Funding for Children's
			 Medical Services
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.
4025
Referrals for
			 Children's Medical Services
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.
4030
Application for Children's Medical
			 Services
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.
4035
Information Required to Process the CMS
			 Application
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.
4045
County Office
			 Disposition
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.
4050
Return of EMS-800 to County Office
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.
4100
Eligibility
			 Requirements for CMS
4105
Age
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:
1.
Individuals with a diagnosis of
			 Cystic Fibrosis (CF) who are
financially eligible will be accepted for limited care up
				to age 21 if they are on CMS prior to their eighteenth birthday. If funds are
				available, additional limited services may be provided to those age 21 and
				older.
2.
Individuals who have regularly attended a CMS Community Based Clinic previous
			 to their 18th birthday may receive continued coverage for clinic service only
			 until they reach age 21.
4110
Residence
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.
4115
Marital
			 Status
Marital status is not a condition of eligibility for
				Children's Medical Services.
4120
Financial
			 Need
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.
4125
Medical Eligibility
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.
4150
Denials and Closures
4155
Denials
An application will be denied if:
(1)
the applicant does not meet the
			 eligibility requirements for the requested service;
(2)
the child has reached eighteen (18)
			 years of age (Exception: Cystic Fibrosis cases); or
(3)
no treatment is recommended by the
			 evaluating physician. Applicants who fail to furnish the needed information to
			 complete the application process and determine financial eligibility will
			 automatically be placed in a special category for up to one year from the date
			 of application. No services will be authorized for payment until all
			 information is received. Full eligibility will begin from the date the required
			 information is received and will not be retroactive to the date of
			 application.
4160
Closures
A CMS case will be closed or placed in a Special Category
				when:
(1)
maximum
			 improvement is reached;
(2)
the client is no longer eligible
			 due to age, financial or diagnostic condition;
(3)
residence is established out of
			 state;
(4)
other
			 resources are covering the services CMS would provide;
(5)
scheduled appointments are not
			 kept, and/or CMS correspondence is not answered;
(6)
the family fails to reapply or
			 submit information within the time limit set; or
(7)
the family requests voluntary
			 withdrawal.
4165
Reevaluations
(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.