Mo. Code Regs. tit. 19 § 40-1.020

Current through Register Vol. 49, No. 23, December 2, 2024

Section 19 CSR 40-1.020 - Program Eligibility

PURPOSE: This rule establishes the criteria by which CCS accepts clients for service.

(1) Conditions of eligibility for Crippled Children's Service (CCS) services include:

(A) A client must be under twenty-one (21) years of age. All expenditures by CCS on behalf of a child must be for services received prior to his/her twenty-first birthday;

(B) A client must be a resident of Missouri;

(C) A client must be financially eligible for CCS;

(D) A client must be medically eligible for CCS;

(E) Marital status is not a condition of eligibility; and

(F) Each client shall have a parent or an appointed guardian as a condition of eligibility, unless the client is legally emancipated and may sign on his/her own behalf.

(2) To qualify medically for services under the auspices of CCS, a client must meet the definition of a physically-handicapped child in 19 CSR 40-1.010(16) and have a medical condition which is included in 19 CSR 40-1.030.

(A) The following factors shall be considered in establishing categories of conditions eligible under CCS: severity; complexity; extent of significant dysfunction or disability that is present or expected; duration of the disorder; potential for habilitation or rehabilitation and also a reasonable expected longevity; amenability to limited standard medical intervention; and a strong likelihood the treatment will have a major impact upon the physically handicapping condition(s). There must be reasonable expectation or improvement to be eligible for CCS coverage.

(B) CCS may assist any child under twenty-one (21) years of age who resides in Missouri in obtaining a diagnostic evaluation if that child is possibly afflicted with a CCS-eligible condition.

(C) The medically-eligible client will be treated only for the eligible condition and for directly related conditions necessary to prepare the client for treatment of the eligible condition and to preserve the benefits derived from the treatment. An unrelated medical condition which is ineligible does not become eligible when the client is accepted for treatment of an eligible condition.

(D) On emergency cases that need to be referred to CCS but not previously known to the agency, it will be the responsibility of the attending physician or the hospital to contact CCS within seventy-two (72) hours for tentative oral approval for treatment at an approved CCS hospital. Final approval will be given only upon receipt of an official CCS application form and the medical report for establishing eligibility. The application process must be initiated no later than seven (7) calendar days after the time of admission.

(E) The client's medical condition shall be reviewed on a periodic basis by CCS to insure the continuing CCS eligibility.

(3) To receive medical or surgical services, the client must be medically eligible and the client's family must meet the current financial eligibility criteria which are included in 19 CSR 40-1.040. An applicant shall agree to participate in any cost-sharing that may be required.

(A) CCS is the last resource after all other available sources of payment have been exhausted.

(B) The financial situation of the client and of his/her family shall be reviewed on a periodic basis by CCS to insure the continuing CCS eligibility.

19 CSR 40-1.020

AUTHORITY: sections 192.005.2 and 201.060, RSMo 1986.* This rule was previously filed 13 CSR 50-160.020. Emergency rule filed Dec. 12, 1984, effective Dec. 22, 1984, expired April 20, 1985. Original rule filed Dec. 12, 1984, effective April 11, 1985. Amended: Filed June 2, 1987, effective Aug. 13, 1987.

*Original authority: 192.005, RSMo 1985 and 201.060, RSMo 1959.