What is the CCS Program?

The California Children's Services (CCS) program was created in 1927 to provide pediatric medical care, case management, and other services for children with the most serious, sometimes life-threatening, conditions and illnesses. It is vital that children with CCS conditions receive the most expert pediatric care available as quickly as possible. CCS, California's version of the federal Title V Program for Children with Special Health Care Needs, currently serves approximately 170,000 children with an annual total budget of $1.3 billion in combined federal, state and county funds, for an average of about $7,650 per child per year.

Who Are the Children in the CCS Program?

The CCS program was specifically designed to manage the care of children with special health care needs, such as leukemia and other cancers, cleft palate, congenital heart disease, HIV, spina bifida, diabetes, cerebral palsy, sickle cell anemia, muscular dystrophy, premature birth, and other serious, often life-threatening, conditions. As these children have extremely complex health care needs, they need timely access to the multi-disciplinary, specialized pediatric services of CCS providers, all of whom must meet rigorous state regulations in order to become certified as CCS providers.

Who Qualifies for the CCS Program?

The CCS program is open to any child who:

• has or may have a serious medical condition that is covered by CCS;
• is under 21 years old;
• is a resident of California; and
• has a family income of less than $40,000 as reported as the adjusted gross income on the state tax form; or
• the out-of-pocket medical expenses for a child who qualifies are expected to be more than 20 percent of family income; or
• has full-scope Medi-Cal or Healthy Families coverage.

• need diagnostic services to confirm a CCS eligible medical condition; or
• were adopted with a known CCS eligible medical condition; or
• are applying only for services through the Medical Therapy Program.

• CCS maintains high pediatric program standards for credentialing institutions and providers to ensure their pediatric expertise. These standards include such factors as the volume of children seen or procedures performed by paneled providers, a critical criterion for conditions that may be rare in children but have deadly consequences.
• Within the context of a CCS treatment plan, CCS ensures access to all appropriate pediatric care including pediatric sub-specialists, regional pediatric programs and institutions, special care centers with multi-disciplinary teams, pediatric durable medical equipment, and other care.
• As a statewide program with a statewide provider network, CCS ensures access to appropriate care without regard to the child's county of residence, i.e. the statewide network of credentialed providers ensures that children can receive expert care for their specific condition regardless of that provider's location, from treatment of rare cancers to quick transfer to regional neonatal intensive care units.
• County-based CCS physicians and nurses develop treatment plans, authorize all care provided under the program, and provide comprehensive case management for CCS children.

CCS providers are paid on a fee-for-service basis directly by the State and county, ensuring payments that match the level of services needed and cost-effective use of dollars for treatment rather than administrative overhead. Under traditional managed care, as much as 30 percent of the current treatment dollars could be diverted to administrative costs-- to the State, the managed care plans, and the Independent Practice Associations (IPAs) which contract with plans on behalf of many physicians.

Expenditure of CCS Treatment Dollars
Expenditure in Current System: 100 percent of Funds to Treatment	Expenditure Under Managed Care: 20-30 percent of Funds to Administration

What Safeguards Must be in Place for CSHCN under Managed Care?

Studies in the pediatric literature indicate that there are basic standards that must be met for the most vulnerable children to be enrolled in managed care plans:

• First and foremost, there is no evidence that traditional managed care plans, designed for a routine, healthy population, are equipped to serve children with complex, multi-system, and expensive needs. The lessons from the literature and experience indicate that managed care plans seeking to enroll CSHCN should be designed specifically for this population.
• All health care delivery to CSHCN should flow from their medical and related needs. The medical necessity definition and standards of care for these children should reflect sound pediatric principles and address children's health, developmental, social and behavioral needs.
• Children should have access to comprehensive medically and developmentally appropriate care regardless of their geographic region. County-based systems of care that limit access to pediatric or other appropriate providers are not acceptable for CSHCN. Children should retain access to regionalized pediatric health care systems for CCS-approved neonatal care, pediatric intensive care, and other pediatric care.
• CSHCN should have clearly identified medical homes including primary care providers, pediatric sub-specialists, and care coordination. Families should have the ability to exercise choice in selecting providers from the pool of those meeting pediatric credentialing standards.
• Provider networks should include all pediatric sub-specialties, pediatric hospitals, child-appropriate DME and other supply vendors, and other pediatric-appropriate services. Providers should meet clearly established pediatric standards for credentialing that reflect pediatric training and experience.
• The benefit package for children should be comprehensive and include medical, dental, developmental, behavioral, and rehabilitative services; pharmaceuticals; DME and medical supplies; and ancillary services. Care coordination should be a recognized component of service delivery to CSHCN.
• Quality assurance and evaluation activities should include indicators specific to children and to CSHCN and should include measures of family satisfaction.
• Financing of health care delivery to CSHCN should recognize their special needs through fee-for-service rates that reflect actual costs of care and include the capacity to cover pediatric services beyond typical medical care (e.g. office visits) such as care coordination, or capitation rates that are risk-adjusted to reflect actual costs of care and additional services such as care coordination. Capitated systems should not include risk to providers (thus removing financial disincentives to the provision of necessary care) and should avoid full risk to plans through strategies such as reinsurance or risk-sharing with the State (such as the current CCS carve-out).