Louisiana Administrative Code › Title 48 - PUBLIC HEALTH-GENERAL › Part V - Preventive Health Services › Subpart 17 - Children's Special Health Services (CSHS) › Chapter 59 - Supplemental Security Income/Disabled Children's Program › Section V-5903 - Reference Material

Current through Register Vol. 50, No. 6, June 20, 2024
A. Table I CSHS
				  Medical Category
CSHS Medical Category
Treatment Phase
Number
1=High Cost - Active treatment/Medically
								Fragile/Surgery
5=Moderate Cost-Routine treatment/ Medically
								stable
10=Least Cost-Follow-up/Observation
1. Arthritis
Active treatment/Medically fragile/surgery
Active treatment/Medically stable
Inactive - Remission
1
5
10
2. Audiology
Diagnosis Testing
Audiology Appliances and Molds
Follow-up
5
5
10
3. Cardiology
Surgery/Hospitalization
Diagnostic Tests(inpatient)
Active treatment/Medically stable
Observation (includes routine clinic test)
1
1
5
10
4. Cleft Palate And/Or Lip
Surgery/Hospitalization
Orthodontic Treatment
Routine treatment/Medically stable
Follow-up/Observation (No surgery or orthodontia
								anticipated)
1
1
5
10
5. Cystic Fibrosis
Treatment
1
6. Nephrology
Active treatment/Medically fragile
Routine treatment/medically stable
Inactive -Remission
1
5
10
7. Neurology
Hospitalization/Active treatment/Medically fragile
Routine treatment/Medically stable
Inactive - Remission
1
5
10
8. Neurosurgery
Surgery/Hospitalization
Active treatment/Medically fragile
Routine treatment /Medically stable
Follow-up (No surgery or therapy anticipated)
1
1
5
10
9. Ophthalmology
Surgery/Hospitalization
Active treatment
Follow-up (No medication or treatment
anticipated)
1
5
10
10. Orthopedic
Amputee
Cerebral Palsy
Hand
Scoliosis
Spinal Cord
Surgery/Hospitalization
Active treatment/Wheelchair/Bracing
Active treatment (No bracing)
Follow-up (No surgery or treatment
anticipated)
1
1
5
10
11. Otology
Surgery/Hospitalization
Active treatment
Follow-up (No surgery or treatment
anticipated)
1
5
10
12. Reconstructive Surgery
(Other Than Cleft Lip And Palate)
Surgery/Hospitalization
Active treatment/Therapy
Follow-up (No surgery or therapy
anticipated)
1
5
10
16. Urology
Surgery/Hospitalization
Active treatment /Medically fragile
Active treatment /Medically stable
Follow-up (No surgery or hospitalization
anticipated)
1
1
5
10
If a child has multiple conditions in mixed levels
								of activity, the lowest value shall be chosen.
If two or more children in a family are applying
								for services, each child will be considered separately for medical eligibility.
B.
				  Exhibit I
PATIENT'S NAME:__________________ PID Number
					 ___________
DOB:__________________
CHILDREN'S SPECIAL HEALTH SERVICES
FAMILY INCOME AND RESOURCE WORKSHEET
Please fill out this form. You are responsible for its
					 accuracy. A social services worker or Eligibility Determination Examiner will
					 review the form with you and determine your eligibility for CSHS. CSHS requires
					 eligibility to be determined when your child is a new patient, on an annual
					 basis and when a major expenditure is anticipated.
FAMILY INCOME
Person(s) Employed Yes No Total Monthly For CSHS
					 Staff
Gross Income Use Only
Father _____ _____ $_____________ ______________
Mother _____ _____ $_____________ ______________
Other _____ _____ $_____________ ______________
Sources of Other Income:
A.F.D.C.____ _____ _____________ ______________
S.S.I. ____ _____ _____________ ______________
Refugee Cash Assistance
____ _____ _____________ ______________
Social Security
____ _____ _____________ ______________
Veterans Benefits
____ _____ _____________ ______________
Pension or Retirement
____ _____ _____________ ______________
Unemployment Benefits
____ _____ _____________ ______________
Workman's Compensation
____ _____ _____________ ______________
Child Support ____ _____ _____________
					 ______________
Military Family Allotment
____ _____ _____________ ______________
Alimony ____ _____ _____________ ______________
Interest and Dividends from ______________
Savings, Stocks, Bonds, etc.
____ _____ _____________ ______________
TOTAL FAMILY INCOME $_____________ $_____________
Less Deductions:
Child support payments for children
Living outside of your home $_____________
					 $_____________
Yearly medical insurance premiums _____________
					 _____________
Medical payments other than insurance
reimbursement for 12 months _____________
					 _____________
TOTAL DEDUCTIONS $_____________ $ ____________
-----------------------------------------------------FOR
					 CSHS STAFF USE-------------------------------------
Total Family Income $______________________
Less Total Deductions (-)_____________________
Adjusted Family Income $______________________
Less Size of Family (-)_____________________
Plus Medical Category Number
					 (+)_____________________
ELIGIBILITY DETERMINATION VALUE
					 ____________________
Income Eligible Yes ______ NO_______
FAMILY RESOURCE
FOR CSHS
Savings Accounts Yes No Value or Equity STAFF USE
					 ONLY
Individual ____ _____ $_____________
					 ________________
Joint ____ _____ _____________ ________________
Both ____ _____ _____________ ________________
________________
Promissory Note ____ _____ _____________
					 ________________
________________
Time Deposit ________________
(i.e., certificate of deposit)
____ _____ _____________ ____
					 _______________________
Family-held Mortgage ____ _____ ___________
					 ___________
Mutual Fund Shares ____ _____ _____________
					 ___________
Municipal, Corporate and/or _________________
Government Bonds/stocks ____ _____ ___________
					 ___________
Property (other than home) ____ ____ _________
					 __________
Share in Estate(undivided estate) _________________
(when in control of family) ____ _____ ________
					 _________
Trust (have access to trust) ____ _____ __________
					 _________
Mineral Rights ____ _____ ____________
					 _____________
Vehicles (other than 2 family cars) ___ ____ _______
					 _______
(Description include boats, campers, motor homes,
					 motorcycles, 4 wheelers)
Settlements (structured or lump sum) or winnings
____ _____ _____________ _________________
Crops in Storage ____ _____ ____________
					 ______________
IRA (when other retirement benefits are available)
____ _____ ____________ _________________
Keogh (same as above) ____ _____ __________
					 _____________
-------------------------FOR CSHS STAFF USE
					 ONLY------------------------
Total Family Resources $ ________________________
Less Resource Allowance (-)
Total Adjusted Resource $_________________________
Resource Eligible Yes ______ No_______
The information I have given is true and correct to the
					 best of my knowledge. I understand that verification of income and/or resources
					 may be requested.
I understand that my application will be reviewed for
					 eligibility purposes and that I have the right to appeal if my child is denied
					 acceptance or if I feel my civil rights have been violated.
If verification of family income and resources are
					 requested, the requested items must be returned within fifteen (15) days of
					 this date to the CSHS Regional Office or the case will be closed and services
					 terminated.
I agree to notify the CSHS Regional Office of any lawsuit
					 filed on behalf of the applicant pertaining to his disability and for which the
					 CSHS is providing medical services. Failure to sign necessary documents (i.e.,
					 SSI, Medical Needy, Medicaid, etc,) will cause the patient to be discharged
					 from CSHS.
_____________________________________________________
Parent/Applicant or Appropriate Representative Date
					 Relationship
_____________________________________________________
Witness Date
________________________________________________________
CSHS Eligible ______ CSHS Ineligible _______ Pending
					 _______
______________________________________________________
					 ___
Reviewed by Title Date
C. EXHIBIT II
ASSIGNMENT OF INSURANCE BENEFITS
NAME OF INSURANCE COMPANY:
ADDRESS OF INSURANCE COMPANY:
NAME OF INSURED:
ADDRESS OF INSURED:
POLICY Number:
I/We,_________________________________________________,
					 am/are the parent(s) and/or guardian(s) of
_______________________________, who has been enrolled in
					 CHILDREN'S SPECIAL HEALTH SERVICES of the Office of Public Health of the
					 Department of Health and Hospitals.
I/We hereby authorize and direct CHILDREN'S SPECIAL HEALTH
					 SERVICES to prepare and submit claims for the
medical or hospital expense incurred by _________________
					 to the captioned insurance company.
I/We hereby authorize and direct the said insurance
					 company to honor and recognized this instrument wherein I/we assign, transfer,
					 set over and deliver to the said CHILDREN'S SPECIAL HEALTH SERVICES of the
					 Office of Public Health of the Department of Health and Hospitals, as assignee
					 herein, all money, checks, drafts or payments now due and payable to me/us, and
					 to become due and payable to me/us, for the medical care and treatment
					 of
_________________________, under the terms and conditions
					 of the above numbered insurance policy. The insurance company is further
					 directed to forward all such payment directly to CHILDREN'S SPECIAL HEALTH
					 SERVICES at the address indicated on the papers submitting the claim(s).
In witness whereof I/we have executed this assignment at
					 _____________, the __________day of________________, _______.
WITNESSED BY:
_________________________
					 ___________________________
Signature of insured
_________________________
					 ___________________________
NOTE: Two witnesses are required who are age 21 or
					 older.
D. EXHIBIT III
INTERVENTION AND SUBROGATION AGREEMENT
STATE OF LOUISIANA PARISH OF
					 ________________________
BEFORE ME,
a Notary Public, duly commissioned and qualified, in and
					 for the Parish of___________________,
State of Louisiana, on this ____________________day of
					 _______________, ____ in the presence of the witnesses hereinafter named and
					 undersigned, personally came and appeared:
WHO DECLARED that they are the parents or guardians of
					 ____________________, who has received and/or is now under medical treatment
					 and care provided by Children's Special Health Services of the Office of Public
					 Health of the Department of Health and Hospitals, as the result of accidental
					 injuries sustained by the said child on or about
					 _______________________.
AND THE SAID APPEARERS FURTHER DECLARED that they hereby
					 assign transfer, set over and deliver unto Children's Special Health Services
					 of the Office of Public Health of the Department of Health and Hospitals, its
					 successors and assigns, to its proper use and benefit forever, any and all sum
					 or sums now due or owing said assignors, and all claims, demands and cause or
					 causes of action of whatever kind and nature which said assignors had or now
					 have or may have against __________________________________, arising out of or
					 as a result of the accidental injuries sustained by the said child on or
					 about_____________.
This assignment, however, is EXPRESSLY LIMITED to the
					 value of the said medical treatment and care provided, furnished or obtained by
					 Children's Special Health Services of the Office of Public Health of the
					 Department of Health and Hospitals on behalf of the said child as the result of
					 accidental injuries sustained by the said child on or
					 about_____________________.
Nothing herein shall prevent the said appearers from
					 presenting claims or claims, if any they had or have or may have against
					 ______________________ for damages in an amount in excess of the assigned value
					 of medical treatment and care described and referred to hereinabove; however,
					 the said appearers do hereby further agree, consent and promise to duly notify
					 Children's Special Health Services of the Office of Public Health of the
					 Department of Health and Hospitals of any legal steps, if any, they may have
					 taken or are now taking or may take against the said
					 ____________________________, as a result of the accidental injuries sustained
					 by the said child as described and referred to hereinabove.
APPEARERS FURTHER hereby authorize and direct and empower
					 said Children's Special Health Services of the Office of Public Health of the
					 Department of Health and Hospitals to intervene in any legal cause of action of
					 proceeding that appearers may have taken or are now taking or may take against
					 _________________________ as a result of the accidental injuries sustained by
					 the said child as described and referred to hereinabove, such
					 intervention-power EXPRESSLY LIMITED to the value of the said medical care and
					 treatment.
THUS DONE AND PASSED AS AN AUTHENTIC ACT BEFORE
					 ME,__________________, a Notary Public, duly commissioned and qualified in and
					 for the Parish of ___________________,
State of Louisiana in the presence of the undersigned
					 witnesses and sworn to by the said appearers
					 ________________and______________this_____day of _________, _____.
APPEARERS:
_________________________
_________________________
WITNESSES: (address)_________________________
___
					 ________________________(address)______________________
_____________________________
					 __________________________
NOTARY PUBLIC
and (affix seal)
_____________________________
					 (address)___________________
(address)_______________ _______________________
_____________________________
					 __________________________
DHH/Secretary
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S. 40:31.2,
					 and
					 R.S.
					 40:1299.111-120.