IDAPA 16.02.26
The Children’s Special Health Program (CSHP) provides financial assistance and care coordination for medical and rehabilitative services to persons age birth to eighteen (18) years who meet the diagnostic eligibility criteria in these rules.
The rules define the scope of activities provided by CSHP contractors and private providers such as diagnosis, case management, and treatment. The types of services for which reimbursement is made are related directly to program fiscal resources. Funds available for CSHP are limited in amount. Changes in the scope of services and in rates of reimbursement may be made by administrative decision should budgetary reductions or cost overruns occur.
This rule implements the following statute passed by the Idaho Legislature:
Public Assistance and Welfare -
Administrative appeals and contested cases are governed by the provisions of the Idaho Administrative Procedures Act, Chapter 52, Title 67, Idaho Code, and IDAPA 62.01.01, “Idaho Rules of Administrative Procedure.”
Unless exempted, all public records are subject to disclosure by the Department that will comply with Title 74, Chapter 1, Idaho Code, upon requests. Confidential information may be restricted by state or federal law, federal regulation, and IDAPA 16.05.01, “Use and Disclosure of Department Records.”
Idaho Department of Health and Welfare Bureau of Clinical & Preventive Services – Maternal & Child Health Section 450 West State Street Boise, ID 83702
P.O. Box 83720
Boise, ID 83720-0036
Phone: (208) 334-4993 or 1-877-887-3075
Fax: (208) 334-4946
Email: IdahoMCH@dhw.idaho.gov
Webpage: https://healthandwelfare.idaho.gov/services-programs/about-childrens-special-health-program
This rule chapter will be reviewed in compliance with Section 67-5292, Idaho Code, and in accordance with the 8-year rule review schedule linked here.
16.02.26 – Children’s Special Health Program
000. Legal Authority. ... 3
001. Scope. ... 3
002. Written Interpretation. ... 3
003. -- 009. (Reserved) ... 3
010. Definitions. ... 3
011. -- 050. (Reserved) ... 3
051. Diagnostic/Consultative Services. ... 3
052. Treatment Services. ... 3
053. Follow Up And Case Management. ... 3
054. Hospital In-Patient Services. ... 4
055. -- 099. (Reserved) ... 4
100. Diagnostic Categories. ... 4
101. Cardiac. ... 4
102. Cleft Lip And Palate. ... 4
103. Craniofacial. ... 4
104. Cystic Fibrosis. ... 4
105. Neurologic. ... 5
106. Orthopedic. ... 5
107. Phenylketonuria (PKU). ... 5
108. Plastic/Burn. ... 6
109. -- 148. (Reserved) ... 6
149. Program Eligibility. ... 6
150. -- 156. (Reserved) ... 6
157. Sliding Fee Scale. ... 6
158. Application For Other Resources. ... 7
159. -- 199. (Reserved) ... 7
200. Applications. ... 7
201. -- 249. (Reserved) ... 7
250. Payments To Providers. ... 7
251. Prior Authorization. ... 7
252. Maximum On Hospital In-Patient Payments. ... 7
253. Billing Third Parties First. ... 7
254. Third Party Payments In Excess Of CSHP Limits. ... 8
255. Medicaid Eligibility. ... 8
256. Out-Of-State-Care. ... 8
257. Durable Medical Equipment. ... 8
258. -- 999. (Reserved) ... 8
Section 56-1003, Idaho Code, authorizes the Director of Health and Welfare to adopt rules related to personal health. (3-15-22)
The Children's Special Health Program (CSHP) provides medical and rehabilitative services to persons age birth to eighteen (18) years who meet the diagnostic eligibility criteria defined in Sections 101 through 108 of these rules. The scope of activities provided by CSHP contractors and private providers such as diagnosis, case management, and treatment. The types of services for which reimbursement is made are related directly to program fiscal resources. Funds available for CSHP are limited in amount. Changes in the scope of services and in rates of reimbursement may be made by administrative decision should budgetary reductions or cost overruns occur. (3-15-22)
This agency has written statements that pertain to the interpretation of the rules of this chapter, or to the documentation of compliance with the rules of this chapter. These documents are available for public inspection and copying at cost in the main office and each regional or district office of this agency. (3-15-22)
For the purposes of these rules, the following terms are used: (3-15-22)
01. Applicant. A person under age eighteen (18) seeking services provided by CSHP. (3-15-22)
02. Care Coordinator. A Department employee or contractor responsible for receiving and processing CSHP applications and supporting documentation from current and potential CSHP clients. A care coordinator issues authorization memos for services authorized by CSHP. (3-15-22)
03. Children's Special Health Program (CSHP). The program section within the Department's Division of Health, which is responsible for the administration of services leading to the identification, diagnosis, and aftercare of children with special health care needs. (3-15-22)
04. Client. A person under age eighteen (18) with a chronic physically disabling condition which meets one (1) of the diagnostic categories of CSHP. (3-15-22)
05. Department. The Idaho Department of Health and Welfare. (3-15-22)
06. Diagnosis. The act of identifying a disease from its signs or symptoms. (3-15-22)
07. Medical Food. A food which is formulated to be consumed or administered enterally (i.e., passing through the stomach and digested in the intestine), under the supervision of a physician and metabolic nutritionist, and which is intended for the specific dietary management of PKU. (3-15-22)
08. Patient. The term 'patient' is synonymous with the term 'client.' (3-15-22)
Clinical examination of a CSHP client to confirm or determine the extent of their condition and recommend treatment options. Physician specialists under contract to CSHP may continue to serve in consultative roles to clients' primary care physicians following clinical examination. (3-15-22)
Following the diagnostic process, individuals may be closed to further service as having 'no eligible condition found.' Program-eligible clients are accepted for continuing service coordination under CSHP. Care is provided through clinics where treatment schedules are planned and periodic review of cases are conducted, and through private medical providers. An individual client's treatment plan may cover a variety of related services. (3-15-22)
CSHP will contract with care coordinators to follow-up on CSHP clients receiving treatment through the program to assure that a treatment plan is outlined. These staff will also implement timely scheduling of medical habilitative and rehabilitative services. (3-15-22)
If diagnostic evaluation requires hospitalization, a maximum of three (3) days inpatient care may be authorized. No inpatient hospital services are paid for emergency, acute or chronic medical care. (3-15-22)
CSHP will serve clients in eight (8) general diagnostic categories: Cardiac, Cleft Lip and Palate, Craniofacial, Cystic Fibrosis, Neurological, Orthopedic, Phenylketonuria (PKU) and Plastic/Burn. (3-15-22)
01. Eligible Conditions. Eligible conditions include congenital heart disease or defects, acquired heart disease, and dysrhythmia. (3-15-22)
02. Excluded Conditions. The following conditions are excluded from care under CSHP: patent ductus arteriosus (PDA) in premature neonates, inpatient care for non-diagnostic and non-surgical admissions, and acute care, despite its potential relationship to an underlying covered condition. (3-15-22)
03. Spending Limit. Services provided to eligible patients under the Cardiac Program are subject to a per patient, annual spending limit of twenty five thousand dollars ($25,000) for each state fiscal year. (3-15-22)
01. Eligible Conditions. Eligible conditions include cleft lip, cleft palate, cleft palate with cleft lip, cleft nose, Pierre Robin syndrome, choanal atresia, palatal incompetence, severe malocclusions resulting from disease or trauma, severe structural deformities involving the growth, and development of the mandible or maxilla. (3-15-22)
02. Excluded Conditions. The following conditions are specifically excluded from care under the CSHP Cleft Lip/Palate Program: isolated hyper/hyponasality, non-cleft-related malocclusions, and mild familial malocclusions. (3-15-22)
03. Spending Limits. Services provided to eligible patients under the CSHP Cleft Lip and Palate program are subject to a per patient, annual spending limit of fifteen thousand dollars ($15,000) for each state fiscal year. (3-15-22)
01. Eligible Conditions. Eligible conditions include congenital anomalies of the skull and face, acrocephalosyndactyly, craniosynostosis, Crouzon’s Disease, hyperterrorism (severe), platybasia, and hemifacial microsomia, including associated microtia. (3-15-22)
02. Excluded Conditions. The following conditions are excluded from care under the Idaho CSHP Craniofacial Program: isolated microtia, temporal mandibular joint disease (TMJ), and simple hemangioma not affecting other organ systems. (3-15-22)
03. Spending Limits. Services provided to eligible patients under the CSHP Craniofacial Program are subject to a per patient, annual spending limit of eighteen thousand dollars ($18,000) for each state fiscal year. (3-15-22)
01. Eligible Conditions. In addition to cystic fibrosis, services are also provided under this program to clients eighteen (18) years of age and under who have Kartagener’s Syndrome or immotile cilia. (3-15-22)
02. Services Provided. Services available include Physician’s office or clinic visits, laboratory, x-ray and other tests ordered by physician, medications and drugs prescribed in connection with treatment of cystic fibrosis, transportation to out-of-state medical centers based on physician referral, and home therapy equipment prescribed by the physician. Genetic counseling clinics are available through the state or contractors, and cystic fibrosis patients and their families are encouraged to make use of this service. (3-15-22)
03. Excluded Services. Inpatient hospital care is not paid for under the CSHP Cystic Fibrosis Program, consistent with CSHP policy of not paying for emergency, acute, or chronic medical care. (3-15-22)
04. Spending Limit. Services provided to eligible patients under the CSHP Cystic Fibrosis Program are subject to a per patient, annual spending limit of eighteen thousand dollars ($18,000) for each state fiscal year. (3-15-22)
01. Eligible Conditions. Eligible conditions include cerebral palsy, seizures/epilepsy, metabolic and storage diseases, central nervous system (CNS) degenerative disorders, congenital CNS anomalies, chronic encephalopathy and CNS injury (near drowning, birth asphyxia), neurocutaneous and neuromuscular syndromes, chronic residua of CNS infections, neuromuscular disorders, attention deficit hyperactive disorder (ADHD) (limited to two (2) visits per year after diagnosis), Tourette’s Syndrome, rehabilitation services associated with tumors, infections, trauma, and cerebral vascular disease (CVD). (3-15-22)
02. Excluded Conditions. The following conditions are excluded from care under the CSHP Neurologic Program: speech problems without associated CSHP eligibility, primary intellectual disabilities, autism, acute head and spinal cord injuries, primary psychiatric and emotional disorders, headache, and night terrors. (3-15-22)
03. Spending Limit. Services for eligible patients under the CSHP Neurologic Program are subject to a per patient, annual spending limit of twelve thousand dollars ($12,000) for each state fiscal year. (3-15-22)
01. Eligible Conditions. Eligible conditions include juvenile rheumatoid arthritis (JRA), developmental dysplasia of the hip, cerebral palsy, neuromuscular dystrophies and atrophies, spinal column defects and deformities causing functional impairment, congenital anomalies of the extremities causing functional impairment, chronic conditions resulting from trauma, limb deficiencies and length discrepancies, chronic infections and inflammations of bones and joints, congenital developmental hip conditions, skeletal dysplasia and other forms of dwarfism, fractures associated with bracing or other long-term care, rehabilitation services associated with tumors and malignancies, metatarsus varus and adductus, and polydactyly. (3-15-22)
02. Excluded Conditions. The following conditions are excluded from care: simple fractures and other trauma without handicapping residual, acute infections of bone or joint, simple flat feet (painless), acute care for amputations, acute care for fractures or other injuries, benign genu valgum (knock knee), benign genu varum (bow legs), tibial torsion/femoral version, and growth hormone therapy for short stature. (3-15-22)
03. Spending Limits. Services provided to eligible patients under the CSHP Orthopedic Program are subject to a per patient, annual spending limit of fifteen thousand dollars ($15,000) for each state fiscal year. (3-15-22)
Under this program eligible patients are provided treatment services that include nutritional assessment, dietary counseling, and provision of medical foods, including formula, in compliance with the patient’s treatment plan. PKU patients under eighteen (18) years of age may purchase medical foods from CSHP or CSHP’s contractor(s) by pre-paying the appropriate percentage, if any, of CSHP’s cost. The percentage of cost is based on the sliding fee scale in Section 157 of these rules. (3-15-22)
01. PKU Patients Under Eighteen Years of Age. PKU patients under eighteen (18) years of age may purchase medical foods from CSHP or CSHP’s contractor(s) by pre-paying the appropriate percentage, if any, of
CSHP's cost. The percentage of cost is based on the sliding fee scale in Section 157 of these rules. (3-15-22)
01. Eligible Conditions. Eligible conditions include hemangioma and lymphangioma depending on severity, location, and effect on function; cystic hygroma; and hemifacial microsomia, including associated microtia. (3-15-22)
02. Excluded Conditions. The following conditions are excluded from care under the Idaho CSHP Plastic/Burn program: acute burn care, cosmetic surgery, and hemangioma, including port wine stain, not affecting physical function. (3-15-22)
03. Spending Limit. Services provided to eligible patients under the CSHP Plastic/Burn Program are subject to a per patient, annual spending limit of fifteen thousand dollars ($15,000) for each state fiscal year. (3-15-22)
Eligibility for participation in CSHP is based on the following: (3-15-22)
01. Insurance Status. Any person with creditable medical insurance as determined by the Department is not eligible for this program, except for CF and PKU participants. Creditable insurance is determined by using IDAPA 16.03.01, 'Eligibility For Health Care Assistance For Families and Children.' (3-15-22)
02. Age. Applications may be accepted on persons up to age eighteen (18). CSHP will pay for no services after the patient's 18th birthday unless the person is receiving active inpatient treatment at the time of the birthday. In that case CSHP will pay for services until discharge if they fall within the guidelines described in Section 054 of these rules. (3-15-22)
03. Diagnosis. Eligible persons are those born with or who acquire physical disabilities or special health care needs as defined under Sections 101 through 108 of these rules and who require long-term multi-disciplinary care to improve their ability to function. (3-15-22)
04. Residence. Applicants must be legal residents of the state of Idaho to receive services from CSHP. Legal residents of neighboring states are not eligible for services. Non-citizens who are legal residents of Idaho are eligible to receive services, but undocumented aliens are not. (3-15-22)
05. Income. Income for a family is defined as 'adjusted taxable income' from the family's most recent tax return. Financial eligibility is redetermined annually and may be redetermined more often if family circumstances change during the year. (3-15-22)
06. Family Size. Family is defined as a 'group of related or non-related individuals who are not residents of an institution, but who are living together as one (1) economic unit.' Family size is the number of individuals included in that unit. (3-15-22)
The sliding fee scale in this rule is used to determine the family's percentage of financial participation for a CSHP client's treatment. Each percentage category includes an annual per-client maximum for which a family would be responsible in any given year. The percentage amount applies to all costs incurred for services provided to the client up to the annual maximum indicated.
| TABLE 157 - SLIDING FEE SCALE FOR CSHP SERVICES | ||
|---|---|---|
| Percent of Federal Poverty Level | Percentage of Cost Sharing Responsibility for Responsible Party | Annual Maximum Responsibility Per Client |
| 0% - 185% | 0% | $0 |
| 186% -199% | 10% | $1,800 |
| 200% - 224% | 20% | $3,600 |
| 225% -249% | 30% | $5,400 |
| 250% -274% | 50% | $9,000 |
| 275% -299% | 75% | $13,500 |
| 300% and above | 100% | $18,000 |
(3-15-22)
CSHP applicants are required to apply for benefits from other programs for which they may be eligible and which reduces the costs to CSHP. The use of all available other resources is required in order to supplement program dollars to the greatest degree possible. For new applicants and during redetermination there will be a review for possible eligibility for other programs and appropriate referrals will be made. Families who refuse to obtain benefits for which they are eligible or do not complete the application process will be closed to the program. (3-15-22)
An application for services from CSHP must, at a minimum, consist of a completed Application Form and verification statement from medical provider confirming eligible diagnosis. A copy of the family’s most recent tax return will also be required in order to determine financial eligibility. CSHP may require additional forms such as a Request for Services, Consent for the Release of Information and an Authorization to Release Information. Applications are processed by CSHP staff and contractors. Applicants are notified as to their acceptance or denial by a CSHP Care Coordinator. (3-15-22)
CSHP payments are made on the basis of fee schedules or set allowances; where applicable, Idaho Medicaid rates are used. (3-15-22)
To qualify for payment by CSHP, services other than diagnostic/consultative and follow-up/case management must be preauthorized by the CSHP Care Coordinator or designee. A CSHP Authorization Memo, obtained from the District CSHP Care Coordinator, must be issued for any service authorized under CSHP. (3-15-22)
There is a twelve thousand dollar ($12,000) maximum payment, per hospitalization, for inpatient hospital expenses, exclusive of surgeon, anesthesiologist or other physician costs related to the hospitalization. These costs are applied toward the annual program cap. (3-15-22)
Providers and parents or legal guardians must bill all other sources of direct third party payment before submitting their claims to CSHP for payment. Private insurance must be billed and benefits, or the denial of benefits, ascertained
before the CSHP will consider payment. Typically either an Explanation of Benefits (EOB) from the third party payor or a letter stating that the service is not covered will be required before CSHP payment will be made. (3-15-22)
CSHP will not reimburse providers for services rendered when the amount received by the provider from the third party payor is equal to or exceeds the level of reimbursement allowed by CSHP for those particular services. (3-15-22)
Any person who may be eligible for Medicaid is required to apply before CSHP services are authorized. CSHP is always last payor to Medicaid. (3-15-22)
CSHP will not pay for care out-of-state that is available in-state. Any exceptions to this rule will be determined by the state office of the CSHP. All out-of-state care must be preauthorized through a CSHP clinic or other regular program mechanism. (3-15-22)
The CSHP will always be payor of last resort for all durable medical equipment provided to clients. (3-15-22)
258. -- 999. (RESERVED)