LAC 48:V.5903. Reference Material

A. Table I CSHS Medical Category CSHS Medical Category | Treatment Phase | Number 1 = High Cost - Active treatment/Medically Fragile/Surgery 5 = Moderate Cost-Routine treatment/ Medically stable 10 = Least Cost-Follow-up/Observation 1. Arthritis | Active treatment/Medically fragile/surgery Active treatment/Medically stable Inactive - Remission | 1 5 10 2. Audiology | Diagnosis Testing Audiology Appliances and Molds Follow-up | 5 5 10 3. Cardiology | Surgery/Hospitalization Diagnostic Tests(inpatient) Active treatment/Medically stable Observation (includes routine clinic test) | 1 1 5 10 4. Cleft Palate And/Or Lip | Surgery/Hospitalization Orthodontic Treatment Routine treatment/Medically stable Follow-up/Observation (No surgery or orthodontia anticipated) | 1 1 5 10 5. Cystic Fibrosis | Treatment | 1 6. Nephrology | Active treatment/Medically fragile Routine treatment/medically stable Inactive -Remission | 1 5 10 7. Neurology | Hospitalization/Active treatment/Medically fragile Routine treatment/Medically stable Inactive - Remission | 1 5 10 8. Neurosurgery | Surgery/Hospitalization Active treatment/Medically fragile Routine treatment /Medically stable Follow-up (No surgery or therapy anticipated) | 1 1 5 10 9. Ophthalmology | Surgery/Hospitalization Active treatment Follow-up (No medication or treatment anticipated) | 1 5 10 10. Orthopedic Amputee Cerebral Palsy Hand Scoliosis Spinal Cord | Surgery/Hospitalization Active treatment/Wheelchair/Bracing Active treatment (No bracing) Follow-up (No surgery or treatment anticipated) | 1 1 5 10 11. Otology | Surgery/Hospitalization Active treatment Follow-up (No surgery or treatment anticipated) | 1 5 10 12. Reconstructive Surgery (Other Than Cleft Lip And Palate) | Surgery/Hospitalization Active treatment/Therapy Follow-up (No surgery or therapy anticipated) | 1 5 10 16. Urology | Surgery/Hospitalization Active treatment /Medically fragile Active treatment /Medically stable Follow-up (No surgery or hospitalization anticipated) | 1 1 5 10 If a child has multiple conditions in mixed levels of activity, the lowest value shall be chosen. If two or more children in a family are applying for services, each child will be considered separately for medical eligibility. B. Exhibit I PATIENT’S NAME:__________________ PID Number ___________ DOB:__________________ CHILDREN’S SPECIAL HEALTH SERVICES FAMILY INCOME AND RESOURCE WORKSHEET Please fill out this form. You are responsible for its accuracy. A social services worker or Eligibility Determination Examiner will review the form with you and determine your eligibility for CSHS. CSHS requires eligibility to be determined when your child is a new patient, on an annual basis and when a major expenditure is anticipated. FAMILY INCOME Person(s) Employed Yes No Total Monthly For CSHS Staff Gross Income Use Only Father _____ _____ $_____________ ______________ Mother _____ _____ $_____________ ______________ Other _____ _____ $_____________ ______________ Sources of Other Income: A.F.D.C.____ _____ _____________ ______________ S.S.I. ____ _____ _____________ ______________ Refugee Cash Assistance ____ _____ _____________ ______________ Social Security ____ _____ _____________ ______________ Veterans Benefits ____ _____ _____________ ______________ Pension or Retirement ____ _____ _____________ ______________ Unemployment Benefits ____ _____ _____________ ______________ Workman’s Compensation ____ _____ _____________ ______________ Child Support ____ _____ _____________ ______________ Military Family Allotment ____ _____ _____________ ______________ Alimony ____ _____ _____________ ______________ Interest and Dividends from ______________ Savings, Stocks, Bonds, etc. ____ _____ _____________ ______________ TOTAL FAMILY INCOME $_____________ $_____________ Less Deductions: Child support payments for children Living outside of your home $_____________ $_____________ Yearly medical insurance premiums _____________ _____________ Medical payments other than insurance reimbursement for 12 months _____________ _____________ TOTAL DEDUCTIONS $_____________ $ ____________ ——————————————————————————————-----------------------FOR CSHS STAFF USE------------------------------------- Total Family Income $______________________ Less Total Deductions (-)_____________________ Adjusted Family Income $______________________ Less Size of Family (-)_____________________ Plus Medical Category Number (+)_____________________ ELIGIBILITY DETERMINATION VALUE ____________________ Income Eligible Yes ______ NO_______ FAMILY RESOURCE FOR CSHS Savings Accounts Yes No Value or Equity STAFF USE ONLY Individual ____ _____ $_____________ ________________ Joint ____ _____ _____________ ________________ Both ____ _____ _____________ ________________ ________________ Promissory Note ____ _____ _____________ ________________ ________________ Time Deposit ________________ (i.e., certificate of deposit) ____ _____ _____________ ____ _______________________ Family-held Mortgage ____ _____ ___________ ___________ Mutual Fund Shares ____ _____ _____________ ___________ Municipal, Corporate and/or _________________ Government Bonds/stocks ____ _____ ___________ ___________ Property (other than home) ____ ____ _________ __________ Share in Estate(undivided estate) _________________ (when in control of family) ____ _____ ________ _________ Trust (have access to trust) ____ _____ __________ _________ Mineral Rights ____ _____ ____________ _____________ Vehicles (other than 2 family cars) ___ ____ _______ _______ (Description include boats, campers, motor homes, motorcycles, 4 wheelers) Settlements (structured or lump sum) or winnings ____ _____ _____________ _________________ Crops in Storage ____ _____ ____________ ______________ IRA (when other retirement benefits are available) ____ _____ ____________ _________________ Keogh (same as above) ____ _____ __________ _____________ -------------------------FOR CSHS STAFF USE ONLY------------------------ Total Family Resources $ ________________________ Less Resource Allowance (-) Total Adjusted Resource $_________________________ Resource Eligible Yes ______ No_______ The information I have given is true and correct to the best of my knowledge. I understand that verification of income and/or resources may be requested. I understand that my application will be reviewed for eligibility purposes and that I have the right to appeal if my child is denied acceptance or if I feel my civil rights have been violated. If verification of family income and resources are requested, the requested items must be returned within fifteen (15) days of this date to the CSHS Regional Office or the case will be closed and services terminated. I agree to notify the CSHS Regional Office of any lawsuit filed on behalf of the applicant pertaining to his disability and for which the CSHS is providing medical services. Failure to sign necessary documents (i.e., SSI, Medical Needy, Medicaid, etc,) will cause the patient to be discharged from CSHS. _____________________________________________________ Parent/Applicant or Appropriate Representative Date Relationship _____________________________________________________ Witness Date ________________________________________________________ CSHS Eligible ______ CSHS Ineligible _______ Pending _______ ______________________________________________________ ___ Reviewed by Title Date C. EXHIBIT II ASSIGNMENT OF INSURANCE BENEFITS NAME OF INSURANCE COMPANY: ADDRESS OF INSURANCE COMPANY: NAME OF INSURED: ADDRESS OF INSURED: POLICY Number: I/We,_________________________________________________, am/are the parent(s) and/or guardian(s) of _______________________________, who has been enrolled in CHILDREN’S SPECIAL HEALTH SERVICES of the Office of Public Health of the Department of Health and Hospitals. I/We hereby authorize and direct CHILDREN’S SPECIAL HEALTH SERVICES to prepare and submit claims for the medical or hospital expense incurred by _________________ to the captioned insurance company. I/We hereby authorize and direct the said insurance company to honor and recognized this instrument wherein I/we assign, transfer, set over and deliver to the said CHILDREN’S SPECIAL HEALTH SERVICES of the Office of Public Health of the Department of Health and Hospitals, as assignee herein, all money, checks, drafts or payments now due and payable to me/us, and to become due and payable to me/us, for the medical care and treatment of _________________________, under the terms and conditions of the above numbered insurance policy. The insurance company is further directed to forward all such payment directly to CHILDREN’S SPECIAL HEALTH SERVICES at the address indicated on the papers submitting the claim(s). In witness whereof I/we have executed this assignment at _____________, the __________day of________________, _______. WITNESSED BY: _________________________ ___________________________ Signature of insured _________________________ ___________________________ NOTE: Two witnesses are required who are age 21 or older. D. EXHIBIT III INTERVENTION AND SUBROGATION AGREEMENT STATE OF LOUISIANA PARISH OF ________________________ BEFORE ME, a Notary Public, duly commissioned and qualified, in and for the Parish of___________________, State of Louisiana, on this ____________________day of _______________, ____ in the presence of the witnesses hereinafter named and undersigned, personally came and appeared: WHO DECLARED that they are the parents or guardians of ____________________, who has received and/or is now under medical treatment and care provided by Children’s Special Health Services of the Office of Public Health of the Department of Health and Hospitals, as the result of accidental injuries sustained by the said child on or about _______________________. AND THE SAID APPEARERS FURTHER DECLARED that they hereby assign transfer, set over and deliver unto Children’s Special Health Services of the Office of Public Health of the Department of Health and Hospitals, its successors and assigns, to its proper use and benefit forever, any and all sum or sums now due or owing said assignors, and all claims, demands and cause or causes of action of whatever kind and nature which said assignors had or now have or may have against __________________________________, arising out of or as a result of the accidental injuries sustained by the said child on or about_____________. This assignment, however, is EXPRESSLY LIMITED to the value of the said medical treatment and care provided, furnished or obtained by Children’s Special Health Services of the Office of Public Health of the Department of Health and Hospitals on behalf of the said child as the result of accidental injuries sustained by the said child on or about_____________________. Nothing herein shall prevent the said appearers from presenting claims or claims, if any they had or have or may have against ______________________ for damages in an amount in excess of the assigned value of medical treatment and care described and referred to hereinabove; however, the said appearers do hereby further agree, consent and promise to duly notify Children’s Special Health Services of the Office of Public Health of the Department of Health and Hospitals of any legal steps, if any, they may have taken or are now taking or may take against the said ____________________________, as a result of the accidental injuries sustained by the said child as described and referred to hereinabove. APPEARERS FURTHER hereby authorize and direct and empower said Children’s Special Health Services of the Office of Public Health of the Department of Health and Hospitals to intervene in any legal cause of action of proceeding that appearers may have taken or are now taking or may take against _________________________ as a result of the accidental injuries sustained by the said child as described and referred to hereinabove, such intervention-power EXPRESSLY LIMITED to the value of the said medical care and treatment. THUS DONE AND PASSED AS AN AUTHENTIC ACT BEFORE ME,__________________, a Notary Public, duly commissioned and qualified in and for the Parish of ___________________, State of Louisiana in the presence of the undersigned witnesses and sworn to by the said appearers ________________and______________this_____day of _________, _____. APPEARERS: _________________________ _________________________ WITNESSES: (address)_________________________ ___ ________________________(address)______________________ _____________________________ __________________________ NOTARY PUBLIC and (affix seal) _____________________________ (address)___________________ (address)_______________ _______________________ _____________________________ __________________________ DHH/Secretary