Since 1933, Texas has worked to improve the care of children with special health care needs through this program. Using state and federal funds, the Children with Special Health Care Needs (CSHCN) Services Program provides health benefits to qualified families with children with special health care needs. Under Title V of the Social Security Act, the state receives a block grant to provide direct services (e.g., health benefits), as well as enabling services (e.g., case management) and population-based services (e.g., newborn screening). Title V programs, including CSHCN Services Program Health Benefits, provide and promote family-centered, community based, culturally competent, and coordinated health care and family support services. The CSHCN Services Program recognizes the importance of the family as the focus of planning and service delivery, and promotes family choice and collaboration between parents and professionals. The CSHCN Services Program strives to deliver services that honor and respect cultural beliefs, traditions, values, interpersonal styles, attitudes and behaviors.
Goals and Services of the CSHCN Services Program
Authorization
The CSHCN Services Program covers the following:
Enrolling in the CSHCN Services Program
To participate in the Children with Special Health Care Needs (CSHCN) Services Program, providers must complete an enrollment application. Providers of medical services must be actively enrolled as a Texas Medicaid provider as a prerequisite to becoming a CSHCN Services Program provider. This requirement is waived for providers of non-medical program services such as family support providers, funeral homes, meals, lodging, or transportation providers.
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CSHCN Services Program Resources on the TMHP website
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CSHCN Services Program Forms
Prior Authorization Forms for:
Authorization Forms for:
Certification and Documentation Forms for:
Provider Forms for:
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CSHCN Services Program Contact Information
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Goals and Services
The CSHCN Services Program exists to achieve the following program goals:
- Early identification of children with special health care needs
- Diagnosis and evaluation to determine appropriate treatment
- Direct medical care and related services
TMHP processes claims for the following services:
- Ambulance
- Ambulatory or day surgery
- Augmentative communication devices (ACDs)
- Behavioral health
- Bone marrow or stem cell transplants
- Charges related to the transportation of deceased clients
- Dental and orthodontia
- Drug copays (except Children’s Health Insurance Program [CHIP] drug copays)
- Durable medical equipment and expendable medical supplies
- Eye prostheses
- Gastrostomy devices
- Genetic services
- Hemophilia blood factor products (pharmacy providers)
- Home health (skilled nursing care only)
- Hospice services
- Hospital outpatient services
- Independent laboratory services
- Inpatient hospital services
- Inpatient hospital rehabilitations services
- Insurance Premium Payment Assistance (IPPA) Program reimbursements
- Medical foods
- Medical nutritional services and products, and total parenteral nutrition (TPN)/hyperalimentation services
- Orthotics and prosthetics
- Outpatient physical and occupational therapy
- Outpatient speech-language pathology
- Physical medicine and rehabilitation
- Physician services, including physician services performed by advanced practice nurses (APNs) and telemedicine services
- Podiatry
- Prescription shoes
- Radiology and radiation therapy services
- Renal dialysis
- Renal transplants
- Respiratory care and equipment
- Sleep studies
- Telemedicine
- Vision care
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Ambulance
The CSHCN Services Program provides coverage for emergency ground, non-emergency ground, and air ambulance transportation for eligible clients. An emergency is defined as the sudden onset of a life-threatening situation in which a severe debilitating condition or death would result if immediate medical care were not provided. When the condition of the client is life-threatening and requires use of special equipment, life support systems, and close monitoring by trained attendants while en route to the nearest appropriate facility, the ambulance transport is an emergency service.
Emergency Ground Transportation: An emergency is defined as the sudden onset of a life-threatening situation in which a severe debilitating condition or death would result if immediate medical care were not provided. When the condition of the client is life-threatening and requires use of special equipment, life support systems, and close monitoring by trained attendants while en route to the nearest appropriate facility, the ambulance transport is an emergency service.
Non-emergency Ground Transportation: When the client has a medical problem requiring treatment in another location and he or she is so severely disabled that the use of an ambulance is the only appropriate means of transfer, the ambulance transport is considered a non-emergency service. A severely disabled client is defined as one whose physical handicap limits his mobility to the extent that he must be transported by litter or life support systems, and an ambulance is the most appropriate means of transport. To meet CSHCN Services Program requirements, the non-emergency transfer must be to or from a scheduled medical appointment at the nearest appropriate CSHCN Services Program facility for indicated care that is CSHCN Services Program approved.
Air Ambulance Services: CSHCN Services Program coverage for air ambulance transfers is limited to instances in which the client's pickup point is inaccessible by land, or when great distance interferes with the immediate admission to a medical treatment facility appropriate for the client's condition.
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Ambulatory Surgery
The CSHCN Services Program does not authorize procedures when the CSHCN Services Program client is eligible for Medicaid. If Medicaid requires the service or procedure to be authorized, requests for services for clients eligible for Medicaid must be sent to the Texas Medicaid Program.
All facility services in a freestanding surgical center and provided in conjunction with the surgery (for example, lab, radiology, anesthesia) are considered part of the inclusive charge and must not be itemized or billed separately. Only those procedures specified on the Centers for Medicare and Medicaid Services (CMS) approved list and selected DSHS-CSHCN Services Program procedures are payable to a freestanding surgical center.
To be considered for payment, all surgeries performed in a freestanding surgical center must be authorized. Certain procedures require prior authorization. See “TMHP-CSHCN Services Program Authorization Requirements” for more information. In addition to requiring prior authorization, certain services require that both the physician and facility be approved by DSHS-CSHCN Servces Program as a specialty team/center provider.
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Authorization
Authorization is a condition for reimbursement; it is not a guarantee of payment. It is the responsibility of each provider to verify client eligibility. Services provided to a client not eligible for services or provided beyond the limitations of the CSHCN Services Program are not reimbursed.
Authorization requests for services requiring authorization (not prior authorization) must be received by TMHP within the 90-day authorization deadline. This 90-day deadline is for all services. Requiring authorization (not prior authorization), including extensions and emergency situations. The surgery authorization request form can be found at “CSHCN Surgery Authorization Request Form.”
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Dental Care
The CSHCN Services Program provides coverage for dental services to program eligible clients. Coverage of dental services is limited to what is necessary to prevent, treat, or correct dental and oral complications.
Orthodontic procedures require prior authorization and may be reimbursed for the following diagnoses:
- Major anomalies of jaw size
- Anomalies of relationship of jaw to cranial base
- Cleft palate and cleft lip
- Certain congenital musculoskeletal deformities of skull, face, and jaw
- Acrocephalosyndactyly
- Anomalies of skull and face bones
Some dental services require prior authorization. Refer to the CSHCN Services Program Provider Manual - Part I for additional information. The CSHCN Services Program does not require the submission of X-rays, models, etc., for prior authorized services. All prior authorization requests must include specific rationale for the requested service. Reimbursement for appliance adjustments is limited to one per month, per client. Newborn appliances and surgical archwires do not require authorization and may be adjusted more than once per month.
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Equipment & Medical Supplies
The CSHCN Services Program may reimburse medically necessary and appropriate DME. DME is considered equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, that is generally not useful to a person in the absence of illness, injury or disability, and that is appropriate for use in the home or community setting. The item must be prescribed by a licensed physician, must be covered by the CSHCN Services Program, and may require authorization/prior authorization. Requests for authorization/prior authorization must be submitted in writing. Requests for equipment that require PRIOR authorization must be complete and received before the requested date of service. Written requests for prior authorization are required for custom, manual, or power wheelchairs and their seating systems, pediatric hospital cribs and their tops, and other specified DME. The CSHCN Services Program may reimburse both custom and non-custom DME.
The CSHCN Services Program considers requests for coverage for the following types of durable medical equipment and services:
- Rehab equipment – purchase, rental, modification and/or repair of such items as ambulation aids, wheelchairs (manual and power), standers, hospital beds, hygiene equipment, etc.
- Miscellaneous equipment – such as transcutaneous electric nerve stimulator (TENS), hydrocollator and paraffin units, and special needs car seats
The CSHCN Services Program provides coverage for expendable medical supplies for eligible clients. A medical supply is defined as an item necessary to carry out a medical procedure or to maintain the client's optimal level of health at home. Most medical supplies are “expendable,” meaning not reusable and will be discarded after use. Supplies are only covered for those clients residing at home.
Examples of Covered Supplies
The following categories of medical supplies are covered by the CSHCN Services Program; this list is not all-inclusive:
- Respiratory care supplies, such as tubing, suction catheters, oxygen masks, nasal cannulas, supplies for cleansing respiratory equipment, etc.
- Ostomy and Catheterization supplies, such as pouches, wafers, cleaning solutions, tape, syringes, skin disinfectants, catheters, etc.
- Feeding supplies, such as feeding bags for pumps, tubing, nasogastric tubes, etc. (Enteral feeding pumps are considered DME.)
- Dressings, such as tape, bandages, masks, eye patches, ace wraps, etc.
- Diabetic care, such as testing supplies, lancets, etc. (Glucose monitors are considered DME.)
- Incontinence supplies, such as urinary catheters, gloves, lubricants, skin disinfectants, etc.
- Diapers can be authorized only for those eligible clients who are 4 years old or older and who are incontinent as a direct complication of their medical condition. Diapers require authorization.
- Miscellaneous supplies used in treatment of a medical condition.
- Articles of daily living are not a CSHCN Services Program benefit.
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Home Health Nursing
The CSHCN Services Program provides coverage for skilled nursing services in the home when provided by a CSHCN Services Program enrolled HCSSA.
For reimbursement by the CSHCN Services Program, skilled nursing services must meet the following conditions:
- Services must be provided by a CSHCN Services Program enrolled HCSSA
- A physician must prescribe services
- Services must be medically necessary and appropriate
- A Registered or Licensed Vocational Nurse must provide services
- Services are provided according to an established Plan of Care
- Services are authorized
Requests for skilled nursing hours must be submitted in writing to TMHP using the CSHCN Services Program Home Health Plan of Care within 90 days of the date of service. Skilled nursing services are authorized and reimbursed by the hour. The number of skilled nursing hours that can be authorized/reimbursed is limited to 200 hours per calendar year per client. An additional 200 hours of service per client per calendar year may be authorized with documented justification of medical necessity.
Skilled nursing can include, but is not limited to, the following:
- Periodic nursing assessment of a client
- Skilled nursing visits for administration of medications including IV therapy
- Skilled nursing visits for acute illness, surgery, and/or transition to the home
- Education of the primary caregiver and the client about the disease/illness process and the skills needed to care for the client's medical needs
- Medical treatments that require the skills of a licensed nurse
Skilled nursing services intended for respite or child care are not a benefit. The CSHCN Services Program covers other services, therapies, supplies, and equipment that may be provided in the home.
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Hospice Care
Hospice care includes palliative care for clients with a presumed life expectancy of six months or less during the last weeks and months before death. Services apply to care for the hospice terminal diagnosis condition or illnesses. Treatment for conditions unrelated to the terminal condition or illness is unaffected. Hospice care must be prescribed by a practitioner licensed to do so who is also enrolled as a CSHCN Services Program provider.
Note: Claims for this service are processed by DSHS-CSHCN Services Program.
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Hospital Care
Inpatient hospital services include medically necessary items and services ordinarily furnished by a CSHCN Services Program enrolled hospital or by an approved, enrolled out-of-state hospital. Effective for dates of service on or after October 11, 2001 , inpatient hospital care will be limited to 60 days per calendar year. Bone marrow and stem cell transplant clients may receive an additional 60 days.
Hospital services must be medically necessary, prior authorized, and are subject to the utilization review requirements of the CSHCN Services Program. Inpatient hospital services are reimbursed up to a total of 60 days per year, which may accrue intermittently or consecutively.
Inpatient hospitalizations for behavioral health conditions are limited to a maximum of 5 days per calendar year. No extensions are granted.
Emergency admissions are not required to be prior authorized, but authorization must be requested the next working day after the admission date for coverage of the entire stay. Emergency admissions are defined as those that are medically necessary for the same day admission from the emergency room or from a provider's office or clinic. If authorization for the emergency admission is not requested, the CSHCN Services Program will pay only for the emergency care and stabilization services in the first 24 hours. If an authorization request is made later than the next business day and is approved, only the emergency care and stabilization services in the first 24 hours, the day of the authorization request and subsequent days that are approved will be paid.
Inpatient hospital services include the following items and services:
- Room and board in semi-private accommodations or in an intensive care or coronary care unit, including meals, special diets, and general nursing services. Room and board in private accommodations including meals, special diets and general nursing services are reimbursed up to the hospital's charge for the most prevalent semi-private accommodations. Private accommodations are not subject to the semi-private rate if documented by the physician as medically necessary. The hospital must keep this documentation in the client's record and document the information on the claim.
- Whole blood and packed red blood cells reasonable and necessary for the treatment of illness or injury provided they are available without cost.
- All medically necessary ancillary services/supplies ordered by a physician.
Note: Items for personal comfort/convenience such as telephone or television are not a benefit of the CSHCN Services Program even if ordered by a physician.
Outpatient Services:
An outpatient is an individual who is provided ambulatory services in a hospital but is not admitted for inpatient care. Benefits include those diagnostic, therapeutic, rehabilitative, or palliative items or services deemed medically necessary and provided by a CSHCN Services Program hospital or under the direction of a physician to an outpatient. Supplies provided by a hospital supply room for use in physician's offices in the treatment of clients are not reimbursable as outpatient services.
Outpatient hospital services include those services performed in the emergency room or clinic setting of a hospital. In instances of sudden illness or injury, the client may receive treatment in the emergency room and be discharged, admitted for observation, or may be admitted for further care as an inpatient. If the client is admitted as an inpatient within 24 hours of treatment in the emergency room or clinic, the emergency room or clinic charges must be billed on the inpatient hospital claim form as an ancillary charge.
The modifier “SH” must be entered on the outpatient claim detail to indicate oral medications or miscellaneous supplies which were administered or used at the hospital. Take-home drugs and supplies must be billed directly to the Vendor Drug Program.
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Inpatient Rehabilitation
The CSHCN Services Program may reimburse inpatient rehabilitation services when the client is:
- Over 4 years of age and sufficiently alert to respond to interventions and to participate with the rehabilitation team in setting own treatment goals as well as being an active participant in therapeutic activities, or
- Less than 4 years of age, sufficiently alert to respond to interventions and to participate with the rehabilitation team. Parent(s) or caregiver(s) actively participate in setting treatment goals and learning therapeutic management.
In addition, at least one of the following criteria must be met to be eligible for reimbursement of inpatient rehabilitation services:
- The client developed a recent onset of illness or trauma (within the last 12 months) without previous comprehensive rehabilitation efforts, or
- There is no documentation of previous inpatient comprehensive rehabilitation effort, or
- The client experiences a loss of previous level of functional independence through complications or recurrent illness and recovery of functional independence is feasible.
The following are examples of conditions that may be considered for coverage of inpatient rehabilitation:
- Spinal cord injuries
- Traumatic amputation of upper or lower extremities
- Rheumatoid arthritis and other inflammatory polyarthropathies
- Burns
- Post polio
- Neoplasms
- Head injuries
- Late effects of infections i.e., Guillain Barre Syndrome
- Cerebrovascular diseases
Congenital conditions e.g., spina bifida and cerebral palsy, may be considered when there have been recent changes in medical and functional status e.g., post spinal surgery.
The inpatient rehabilitation provider must be approved by the CSHCN Services Program as an Inpatient Rehabilitation Facility/Unit before a prior authorization may be approved.
Acute Medical Episodes: If a client develops an acute medical condition during his or her inpatient rehabilitation admission that prevents his or her participation in program activities, the CSHCN Services Program should not be billed for inpatient rehabilitation services. Acute care, inpatient or outpatient, that is covered by the CSHCN Services Program may require authorization and must be billed as acute care services.
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Mental Health Services
Inpatient psychiatric care: Coverage is limited to inpatient assessment and crisis stabilization and is to be followed by referral to the Texas
Department of State Health Services (DSHS)
programs or other appropriate mental health program. Admission must be prior authorized and is limited to five days. Services include those medically necessary and furnished by a Medicaid psychiatric hospital/facility under the direction of a psychiatrist.
Outpatient mental health services: Outpatient mental health services are limited to no more than 30 encounters by all professionals licensed to provide mental/behavioral health services, including psychiatrists, psychologists, licensed master social worker-advanced clinical practitioners, licensed marriage and family therapists, and licensed professional counselors, per eligible client per calendar year. Coverage includes, but is not limited to psychological or neuropsychological testing, psychotherapy, psychoanalysis, counseling, and narcosynthesis.
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Orthotics and Prosthetics
The CSHCN Services Program may provide coverage for orthotics and prosthetics when medically necessary. Items must be prescribed by a licensed physician or podiatrist (for conditions below the ankle) and supplied by an orthotist or prosthetist who meets CSHCN Services Program enrollment criteria. Non-custom commercial products may be supplied through a physician's office. Extremity splints and inhibitive casting may be provided by occupational therapists (OTs) or physical therapists (PTs) as appropriate. Training in the use of an orthotic/prosthetic device for a client who has not worn one previously, has not worn one for a prolonged time period, or is receiving a different type may be reimbursed when provided by a licensed physical or occupational therapist.
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Renal Dialysis/Renal Transplants
Renal dialysis is limited to the treatment of acute renal disease or chronic (end stage) renal disease through an outpatient renal dialysis facility. Renal transplants may be covered in approved renal transplant centers if the projected cost of the transplant and follow-up care is less than that of continuing renal dialysis. Renal transplants must be prior authorized.
Note: Requests for renal dialysis
are processed by DSHS-CSHCN Services Program. Requests for renal transplants are processed by TMHP-CSHCN Services Program.
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Physical & Occupational Therapy
The CSHCN Services Program may reimburse medically necessary and appropriate outpatient PT and OT for CSHCN Services Program clients. Service must be prescribed by a physician or podiatrist (for conditions below the ankle). PT and OT may be provided through or in a comprehensive outpatient rehabilitation center, a licensed hospital, a physician's office, or the office of an enrolled PT or OT therapists.
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Special Nutritional Products & Services
Medical Nutritional Products: The CSHCN Services Program will reimburse medical nutritional products for program eligible clients. Medical nutritional products are those nutritional products that serve as a therapeutic agent for life and health and are part of a treatment regimen. The CSHCN Services Program will not cover nutritional products for individuals who could be sustained on an age-appropriate diet. Nutritional products are not provided to infants younger than age 12 months unless medical necessity is documented.
Medical Nutrition Services: the CSHCN Services Program provides coverage for nutritional assessment and counseling to prevent, treat, or minimize the effects of illness, injury, or other impairments.
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Speech and Language Pathology
Speech Language Pathology services (SLP) for a client must be medically necessary and prescribed by a physician and provided by a speech-language pathologist licensed by the State of Texas. The CSHCN Services Program coverage of Speech Language Pathology services may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible. Speech-language services may be benefits when provided to clients experiencing speech-language difficulty because of a disease or trauma, developmental delay, oral motor problem, or congenital anomaly.
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Transportation, meals, and lodging
Transportation, meals, and lodging may be covered when a child must travel from his or her hometown for medical services.
Clients should contact the Medical Transportation Program at 877-633-8747 for additional information.
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Case Management
Case management services include the following:
- Coordination of medical services
- Marshaling of available resources
- Liaison among the child, family, and caregivers
- Management of institutional services, insurance carriers, and other services needed for improving the well-being of the child and family
A statewide network of regionally based Social Service Program Consultants facilitates these activities.
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