The Children’s Special Health Care Services (CSHCS) Program helps families of children with serious chronic medical conditions get treatment related to their child’s medical condition. CSHCS serves as a type of supplemental insurance and is the payer of last resort. This means that the program may pay only after your primary health insurance has been billed and has either paid or denied the claim. This program is federally and state funded, and features care coordination services that help children and their families get medical care.
There are four conditions that must be met to be eligible for the Children’s Special Health Care Services program. The individual must be between 0-21 years of age, a resident of Indiana, and meet certain medical eligibility criteria. The family also must meet certain financial eligibility criteria. There is one exception to these four conditions being met. If a person has cystic fibrosis, is a resident of Indiana and continues to be financially eligible, then they are covered for life.
New financial eligibility guidelines are effective each year when the federal poverty level guidelines are established. A family with a gross income (before taxes) no greater than 250% of the poverty level may be eligible for the program. As of January 2021, for example, a family of four could qualify with a gross income of up to $66,250. For each additional member add $11,350.
All services processed and paid by this program are based on Indiana Medicaid allowed rates. This means the program may not pay the total amount your provider bills to CSHCS. If CSHCS approves the charge for services, you will not be billed for any balance.
Conditions that meet medical eligibility are listed below. Additionally, the eligible condition must last, or be expected to last, at least two years. The severity of the condition must have caused, or be expected to cause, disability or disfigurement, limitations of ability to function, or require a special diet or dependence on an assistive device. Also, the condition without treatment, would lead to a chronic, disabling physical condition.
The twenty-three medical conditions that are eligible include:
- Asthma; Severe
- Cerebral Palsy
- Chronic Anemia
- Chromosomal Disorders
- Chronic Pulmonary Disease
- Cleft Lip and/or Palate
- Congential or Acquired Developmental Deformities
- Congenital Heart Disease or Arrhythmias
- Cystic Fibrosis (life-time medical eligibility)
- Endocrine Deficiencies
- Hemophilia; Severe
- Inflammatory Bowel Disease
- Inborn Errors of Metabolism
- Myelodysplasia or Spinal cord Dysfunction
- Neuromuscular Dysfunction
- Oncologic Disorders
- Profound Bilateral Hearing Loss
- Renal Disease
- Seizure Disorder
Applications for the Children’s Special Health Care Services (CSHCS) program can be downloaded from the CSHCS website: https://www.in.gov/isdh/19613.htm. You can also call 800-475-1355 and have an application sent to you. Riley Children’s Hospital (room 1669), in Indianapolis, is a site for applying to the program. You can apply 8:30 am- 3:30 pm Mondays- Fridays, at Riley Hospital, and no appointment is needed. The number at Riley Hospital to call for more information is 317-944-4603. In addition, if your child is already enrolled in First Steps, you can ask your Service Coordinator for an application for the CSHCS program.
To complete an application, you are required to have your child’s birth certificate and social security number. You also need proof of residency (e.g., utility bills or rental or property payment receipts) and proof of household income (e.g., recent federal income tax form or three consecutive check stubs).
This program requires that families also access any private health insurance and/or the Hoosier Healthwise/Medicaid Program. You must bring information on your child’s private or public medical insurance when applying for the CSHCS Program. Always remember, the Children’s Special Health Care Services program is set up as a supplemental insurance company and is always the payer of last resort. Primary private insurance or Hoosier Healthwise/Medicaid must be billed first.
Depending on the child’s needs and medical condition, the CSHCS program services available can include:
- Community Referrals and Information
- Diagnostic Evaluation
- Comprehensive Primary Care Visits with primary care physician
- Specialty Care Visits that are related to the eligible medical condition
- Prescription Drugs that are necessary for treatment
- Routine and Specialized Dental Care as eligible
- Mileage reimbursement for non-Medicaid covered participants, travel to and from medical appointments (if travel exceeds 50 miles total)
- Other services related to the eligible medical conditions, such as therapies, durable medical equipment, and inpatient hospitalization may also be accessed.
Once enrolled, most services must receive prior authorization or be provided by a “linked provider” enrolled in the CSHCS program. Services provided by a “linked provider” do not require prior authorization. Before making your first appointment with a healthcare provider or when changing your primary or specialty care physician, you must work with CSHCS to make sure your provider is linked to the CSHCS program. If not using a “linked provider,” you will need to obtain a prior authorization, or your bills may not be paid.
If your child does not already have Medicaid insurance, an application for Medicaid will have to be completed at the same time as you make an application for CSHCS. Your family may be over the income guidelines for Medicaid, but you still need to apply. You will receive a denial letter that states your child was denied because you are over income and that is okay. A copy of that denial letter needs to be sent to CSHCS; if you do not send it, they will ask you to send it. If you are within the income guidelines for the CSHCS program, your child is still financially eligible for the CSHCS program, even though not financially eligible for Medicaid.
Each year, participants of the program are re-evaluated to determine if they continue to be eligible both medically and financially. For more information about the CSHCS program, call the toll-free statewide phone number which is 1-800-475-1355. You may also call 317-233-1351 or email email@example.com. Again, the web site to access information is: https://www.in.gov/isdh/19613.htm.
Wheeler, M. (2021). Children's special health care services program of Indiana. Retrieved from https://www.iidc.indiana.edu/irca/articles/childrens-special-health-care-services-program-of-indiana.html .