Diagnostic and Treatment Programs

About the CCS Diagnostic Program

The CCS Diagnostic Program refers and pays for evaluations by medical specialists and diagnostic tests when a child (birth to 21 years of age) is suspected to have a serious medical condition. This program is available to families who have no health insurance, families who have Medi-Cal insurance and all families whose health insurance denies in writing a CCS covered diagnostic service. Not all medical conditions or diseases are eligible.

Medical Eligibility Criteria for the CCS Diagnostic Program

A child who may have a serious, potentially life-threatening or physically disabling illness or condition is most likely medically eligible. CCS has medical eligibility guidelines for diagnostic services. CCS encourages referrals even when there is doubt regarding medical eligibility.

Requirements for the CCS Diagnostic Program

A client must be:

  • Less than 21 years old
  • A resident of Santa Barbara County
  • Able to meet financial eligiblity requirements

Steps to Obtain CCS Diagnostic Services

  1. Initial CCS Referral by hospital, physician, community organization or family.
  2. Family submits a CCS Family Application.
  3. Medical records are required from hospital and/or physician to CCS.
  4. CCS reviews and determines medical eligibility.
  5. CCS communicates by phone or letter with the family to complete the application.

About the CCS Treatment Program

The CCS Treatment Program provides comprehensive case management for children (birth to 21 years) with serious, potentially life threatening or disabling physical conditions or diseases. A child who is eligible is assigned to a Case Management Team consisting of a Nurse Case Manager and a Case Worker. The Case Management Teams help families, health professionals and community organizations access specialty care for children with special health care needs. The CCS Medical Director and Program Manager assist the teams as needed. Children and families must meet medical, financial, and residential eligibility requirements. Children who qualify receive all services free of charge or with minimal fees. CCS may pay for medical services from physicians, nurses, audiologists or other health professionals. CCS may also cover medications, medical equipment, medical supplies, laboratory tests, x-rays, etc.

Medical Eligibility Criteria for the CCS Treatment Program

A child who may have a serious, potentially life-threatening or physically disabling illness or condition is most likely medically eligible. CCS has medical eligibility guidelines for treatment services. CCS encourages referrals even when there is doubt regarding medical eligibility.

Requirements for the CCS Treatment Program

A client must be:

  • Less than 21 years old
  • A resident of Santa Barbara County
  • Able to meet financial eligibility requirements

Note:
The child's family must be earning less than $40,000 per year at the time of application and annual renewal of eligibility (adjusted gross income on California tax return). The exception is when the medical expenses of the family for treatment of a CCS Medically Eligible condition exceed 20% of the family's adjusted annual income. The family must provide sufficient documentation to verify the cost of the planned treatment and their income.

Steps to Obtain CCS Treatment Services

  1. Initial CCS Referral by hospital, physician, community organization or family.
  2. Family submits CCS Family Application.
  3. Medical records are required from hospital and/or physician to CCS.
  4. CCS reviews and determines medical, financial and residential eligibility. This may require the family to come to CCS for an interview and/or to apply for Medi-Cal insurance coverage.
  5. CCS contacts physician(s) with a letter(s) regarding eligibility.
  6. CCS sends a letter to the family regarding eligibility.
  7. Family completes and returns all CCS documents including a Program Services Agreement.
  8. Treating physician(s) submits prescriptions for care to CCS for authorization.
  9. CCS issues authorizations for services to providers if eligible.

How the CCS Treatment Program Works

Once a child is determined to be eligible, he or she can receive authorized services related to the eligible medical condition for the next year. Eligibility must be renewed annually. The family, the child's health professionals and CCS become a team that works together to assure the child's optimal treatment and access to health care. The CCS team includes a Nurse Case Manager, Case Worker, Clerical Support, Program Manager, and Medical Director.

Who CCS Can Authorize and Pay

CCS will authorize a CCS Paneled Specialist. These are health professionals who have demonstrated special training and skills in the diagnosis and treatment of childhood conditions and diseases. CCS will help the child's physician and family through the process of application, referral, appointment authorization, and follow up.

Important facts about the CCS Diagnostic and Treatment Programs

CCS encourages referrals. If a child is not eligible for the program, CCS will give advice to the family or medical provider on alternate resources.

CCS needs collaboration from the child's family and medical providers. In order to determine medical eligibility and authorize services, CCS must receive current medical reports and prescriptions from the child's specialist.

If CCS Does Not Authorize a Service Requested by the Family or Health Professionals

There are services that CCS expressly does not cover. However, there are times when there are questions about the necessity or appropriateness of a request. If CCS denies a request, the family can appeal the decision through the CCS Due Process. The family will receive a formal letter called a Notice of Action when a prescribed service is denied. The letter includes the steps a family must take to appeal the decision.