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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 46 MediKids or Healthy Kids, depending on their age. CMSN care coordinators will explain the benefits of CMSN enrollment invite providers, if they meet CMSN’s credentialing requirements, to join the CMS Network, if opting out to keep a provider not in the CMS Network. Families opting out of CMSN will sign the Voluntary Opt Out form. There are no limits to the number of times a clinically eligible child can enroll in CMSN and opt out.

PIC Services: CMSN enrolled children who are or have been diagnosed with life threatening conditions, with or without complex psychosocial and familial problems, who are at risk of a death event prior to reaching 21 years of age will be eligible for participation in PIC. The CMS care coordinator will include in the medical, developmental, psychosocial assessments, additional assessment information to determine eligibility for PIC services. PIC services are only available to children enrolled in CMSN. Clinically eligible children opting out of CMSN cannot receive PIC services.

Since the CMSN is a PCCM model, each child has a primary care physician who provides or authorizes all services for the child. The CMSN care coordinator works in collaboration with the family/caregiver and the primary care physician as well as specialists. The CMSN care coordinator, after determining eligibility for PIC services, will contact the child’s physician for his/her medical determination that the child is at risk for a death event prior to age 21 and could benefit from PIC services. Families will be offered the choice of participating in PIC. Upon receiving physician approval, the family/caregiver will be contacted by professional hospice staff that work with PIC to assess the child’s needs for PIC services.

The enrollment goal for the Title XXI pilot program is to have approximately 150 children enrolled based on the following criteria: 50 will be newly diagnosed, 50 will be in the mid-stage of their life-threatening illness, and 50 will be at the end-of-their life. The CMSN is responsible for referring children for PIC services through a coordinated effort that includes the child’s primary physician, specialist physicians and the family/caregiver. The