California Children Services: CCS

Medical Eligibility

How does CCS determine Medical Eligibility?
Based on the medical records provided by physicians and health professionals who have examined the referred child, CCS determines the child's suspected or confirmed medical diagnosis. CCS then determines if that diagnosis is one of the diseases or conditions defined by the State of California CCS office as medically eligible.

Who makes the determination for CCS?
A specially trained Public Health Nurse performs the initial review of the child's medical records. The CCS Medical Director (a physician) makes the final decision for uncertain cases.

What if a family or the referring person disagrees with the Medical Eligibility decision?
This can be discussed directly with the CCS Medical Director. Sometimes, a little more information about the child will clarify the situation. In addition, the Director may refer the case to the CCS Regional Office for consultation. If the family receives a denial from CCS, it is a formal letter called a Notice of Action and includes the steps that a family can take to appeal the decision. (Click on Due Process.)

Are the criteria presented here the official State guidelines?
No, they are a summary because the State guidelines are quite long. Santa Barbara CCS encourages referrals; so, if a child's condition may fit in one of these general categories, please refer the child. If you have a question about a specific diagnosis and its medical eligibility, please contact CCS.

SUMMARY OF CCS MEDICALLY ELIGIBLE CONDITIONS

1. Infectious Diseases
Those infections that involve the central nervous system (brain & spinal cord), bone or eye and lead to physical disabilities or blindness. Also, congenital infections (Infections of the child during the mother's pregnancy) that require post-natal (after birth) medical or surgical treatment.

2. Neoplasms
All malignant neoplasms (cancer) and any neoplasm (tumor) that causes significant disability, deformity or functional impairment.

3. Endocrine, Nutritional and Metabolic Diseases and Immune Disorders
When a disease or disorder of these systems is chronic, affects the general health of the child and requires substantial, long term treatment, it is CCS Medically Eligible. Examples include cystic fibrosis, PKU, growth hormone deficiency and IgG deficiency. Diabetes is usually covered.

4. Diseases of the Blood and Blood Forming Organs
These conditions are usually eligible. Examples include hemophilia, sickle cell disease and aplastic anemia.

5. Diseases of the Nervous System
If a disease or condition results in a significant physical disability, it is likely to be eligible. Cerebral palsy is the most common condition in this category. Seizures that are intractable (cannot be controlled with two or more medications/treatments) may be eligible.

6. Diseases of the Eye
Any disease or condition that could lead to one or two sided blindness is eligible, such as strabismus (the eyes do not work together) if surgery is necessary or retinitis (Inflamation of the Retina).

7. Diseases of the Ear
Hearing loss of moderate or higher degree is covered. A perforation of the ear drum requiring surgery, a cholesteatoma (a tumor of the ear drum) and mastoiditis (an infection of the mastoid) are eligible. Chronic, recurrent ear infections without documented hearing loss are not eligible.

8. Diseases of the Circulatory System
Any serious condition or disease of the heart, blood vessels and lymphatic system is generally eligible.

9. Diseases of the Respiratory System
Diseases and conditions of the lung are eligible if they are chronic, result in significant disability and require complex treatment. Asthma is usually not eligible; but, in severe cases, it may qualify.

10. Diseases of the Digestive System
Diseases and conditions of the stomach, intestines and liver are eligible if they are chronic, result in significant disability and require complex treatment. Appendicitis and hernias are not eligible.

11. Diseases of the Genitourinary System
Chronic problems of the kidneys, collecting system and bladder that require long term medical or surgical treatment are eligible. An acute (sudden) condition may be eligible if it presents a risk of permanent injury to the kidneys.

12. Disease of the Skin and Subcutaneous Tissues
Skin disease and conditions are eligible if they are disfiguring, disabling and require plastic or reconstructive surgery and/or prolonged & frequent multidisciplinary management.

13. Congenital Anomalies
If a child is born with a physical abnormality that is disabling, deforming or limiting of function and can be cured, corrected or ameliorated, it is a medically eligible condition.

14. Perinatal Morbidity and Mortality
A newborn child who has a CCS medically eligible condition or disease who is treated in a CCS-approved Neonatal Intensive Care Unit is covered. Newborn infants who are critically ill or need special NICU care may be eligible. This is determined by special review of the child's hospitalization.

15. Accidents, Poisonings, Violence and Immunization Reactions
In these areas, a child's case is reviewed to determine if the event has led or could lead to permanent, physical disability if not treated. Serious burns, lead poisoning and fractures of the spine, skull, pelvis or femurs are examples of eligible conditions.

Special Conditions

• Children who have a CCS medically eligible condition may receive services for other, non-CCS medically eligible conditions if that other condition is related to the CCS condition. For example, if a child has moderate hearing loss, a CCS condition, CCS would cover treatment for recurrent otitis media which is not a CCS condition but is related to the hearing loss.
• Children with learning disabilities are not medically eligible generally; these children are referred to the County School's Special Education Office or local school district.
• Children with mental retardation or another developmental disability are not medically eligible for treatment of their developmental disorder; they are referred to the Tri-Counties Regional Center and the County Schools Special Education Office. However, these children frequently do have CCS medically eligible conditions such as cerebral palsy, intractable seizures or heart conditions.