Medical Eligibility

Section 1200.110  Medical Eligibility a)         General In order to be eligible for DSCC Program benefits: 1)         An applicant child shall be suspected of having, and a recipient child shall have, one or more of the medically eligible conditions set forth in subsection (c); 2)         The medically eligible condition shall: A)        be chronic; B)        involve a physical limitation or restriction; or C)        necessitate long-term highly specialized medical care; 3)         The recipient child shall have an active plan of care for the medical treatment of the medically eligible condition from a provider that shall be periodically updated by the provider; and 4)         If care coordination services are sought, the applicant or recipient child must benefit from care coordination services. b)         Medical Reports 1)         Medical eligibility is determined following a review of medical reports, including current plans of care from a provider of the applicant or recipient child. 2)         If there is insufficient information to determine medical eligibility, DSCC may provide or pay for diagnostic services as set forth in Section 1200.90. c)         Medically Eligible Conditions 1)         "Blood Disorders" means both inherited and acquired hematologic conditions that are chronic and require management by a specialist.  Primary hematologic malignancies (i.e., leukemias) are excluded. 2)         "Cardiovascular Impairments" means impairments that primarily affect the heart and/or the larger blood vessels that are chronic and require management by a specialist. 3)         "Craniofacial and External Body Impairments" means significant defects affecting the skin and/or its underlying structures and defects of the mucosa and/or its underlying structures of the internal parts that may affect breathing, speech and eating, are chronic, and require management by a specialist. Internal parts include the oral and nasal structures with their extension into the mouth, pharynx, larynx, major bronchi, and esophageal structures. Defects of dentition and occlusion associated with severe oro-craniofacial structural deformities, or that are causative to impairment of intelligible speech and/or difficulty chewing food, are included. 4)         "Eye Impairments" means those that affect the eye and/or eye muscles, excluding isolated refractive errors, that lead to or cause a significant risk of loss of vision, are chronic, and require management by a specialist. 5)         "Gastrointestinal Impairments" means disabling conditions affecting the esophagus, stomach or intestines that are chronic and require management by a specialist. 6)         "Hearing Impairments" means loss of hearing or deafness of at least 30 decibels (dB) in two frequencies (500, 1000, 2000, 4000 and 8000 Hz) or a 35 dB loss in one speech frequency (500, 1000 and 2000 Hz) involving one or both ears, as determined by audiometric testing that are chronic and require otological intervention and management by a specialist. 7)         "Inborn Errors of Metabolism" means those newborn conditions leading to severe neurological, mental and/or physical deterioration that are chronic and require management by a specialist. 8)         "Nervous System Impairments" means those impairments that affect the brain, spinal cord or peripheral nerves, that present as persistent or recurring loss of function but not cognitive or emotional disability, and that are chronic and require management by a specialist. 9)         "Orthopedic Impairments" means those that affect bone, joint or muscle and that are chronic and require management by a specialist. 10)        "Pulmonary Impairments" means chronic disabling conditions affecting the lungs or breathing, such as cystic fibrosis or chronic lung disease, that are chronic and require management by a specialist.  Asthma, as an isolated condition, is excluded. 11)        "Urogenital Impairments" means organic impairments that affect the kidney, ureter, bladder, urethra and/or ano-genital structures and that are chronic and require management by a specialist.  Urinary tract infections and isolated ureteral urinary reflux are excluded unless associated with a persistent structural defect.