Who is Eligible for CSHCN Services?

Eligibility

Any child living in West Virginia who is under 21 years of age is eligible to receive a medical evaluation to establish a medical diagnosis, if necessary. If the child is enrolled in Medicaid, CHIP or has private insurance coverage, the cost of the evaluation will be billed to that coverage source.

Applicants

Applicants for Children with Special Health Care Needs (CSHCN) services must first apply for Medicaid and the West Virginia Children’s Health Insurance Program (CHIP) at their local Department of Health and Human Resources (DHHR) office. Information submitted to the local DHHR office during this process is used to determine financial eligibility for CSHCN services. An application for these services can be obtained by visiting www.wvinroads.org. 

Eligibility is based on the following factors:

	Must be a U.S. citizen.
	The child must be under 21 years of age.
	The child must reside within the State of West Virginia. (Exception: Children in custody of WVDHHR in out-of-state placements are eligible.)
	The child must have an eligible medical diagnosis.
	Income eligibility is determined according to the allowable percentage of Federal Poverty Level scale.

Insurance coverage does not preclude a child’s participation in the program.

	Benefits from other coverage sources (Medicaid, CHIP, or private insurance) must be used when available. Please note: CSHCN does not cover insurance co-pays or deductibles.
	Reimbursement of money paid by CSHCN for care is required if a legal or insurance settlement is received by the family/client.
	Children who have a diagnosis covered by CSHCN and receive WV Medicaid or Children’s Health Insurance Program (CHIP) are eligible to receive care management and/or limited services from the program.

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What medical conditions are covered by CSHCN?

Medical conditions eligible to receive CSHCN services may include:

	Conditions which involve bones, joints or muscles
	Heart Conditions
	Epilepsy and other convulsive conditions
	Neurological conditions such as cerebral palsy and spina bifida
	Certain operable eye conditions, such as crossed eyes and congenital cataracts
	Kidney and urological conditions, including those requiring dialysis
	Cleft lip/palate and other conditions requiring plastic surgery, such as burns
	Ear, nose and throat conditions requiring treatment by an otolaryngologist
	Hearing loss, including hearing aid placement and related services
	Other chronic conditions, such as cystic fibrosis and sickle cell anemia

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What services are provided by CSHCN?

Medical Care

Medical care is provided through CSHCN sponsored clinics located in various areas throughout West Virginia, or is arranged with participating medical specialists.

Treatment services may include:

	Laboratory tests and X-rays
	Medications
	Physical therapy
	Hearing aids
	Medical equipment and supplies
	Surgery/anesthesia
	Hospitalization
	Physician visits

Care coordinators

Care coordinators, comprised of registered nurses and licensed social workers, are available to coordinate and facilitate children’s participation in health care and social services. A Care Coordinator is assigned to each enrolled child at the time the Client/Family Assessment and Client Care Plan is completed.

                 CSHCN does not cover routine pediatric or primary care visits.

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Are children with private insurance eligible for CSHCN?

Insurance information:

	Having insurance coverage does not prohibit a child form being eligible for CSHCN Program services such as care coordination and transition services.
	Benefits from other coverage sources (i.e. Medicaid, CHIP or private insurance) must be used when available. CSHCN does not pay insurance co-pays, deductibles or co-insurance. This means that if another coverage source has paid for any part of the billed service(s), the CSHCN Program will not authorize any additional payment.
	Reimbursement of monies paid for care by CSHCN is required if a legal or insurance settlement is received by the family/client.
	Clients with no other funding source for CSHCN eligible medical diagnosis may have program-approved services/treatment paid for through Title V funds.
	For health maintenance organization (HMO) participants, referral from the client’s Primary Care Provider (PCP) is not needed for an evaluation to determine medical eligibility. However, a referral from the Primary Care Provider is needed for continued medical treatment under the CSHCN Program. mary Care Provider is needed for continued medical treatment under the CSHCN Program.

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How do I apply?

All applicants for the CSHCN program must first apply for Medicaid and CHIP through their local Department of Health and Human Resources Office.

Application for CSHCN may be made by clicking on the Systems Point of Entry, downloading the Specialty Care Intake Form, and returning the completed and signed application to: ning the completed and signed application to:

CHILDREN WITH SPECIAL HEALTH CARE NEEDS PROGRAM
SYSTEMS POINT OF ENTRY
 350 Capitol Street, Room 427
Charleston, WV 25301-3714
For additional information about the program call the Systems Point of Entry at:
Toll-free (in WV): 1-800-642-8522
Or (304) 558-5388

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