Neb. Admin. Code tit. 467 — Medically Handicapped Children’s Program

Chapter 1 Administration

Neb. Admin. Code tit. 467, ch. 1 Administration {#sec-467-nac-1 omnilex-key=us-ne-regs-official--title-467--467 NAC 1}

001. SCOPE AND AUTHORITY . The Medically Handicapped Children’s Program includes Title V Services for Medically Handicapped Children’s Program, Genetically Handicapped Persons Program, and Disabled Children’s Program.

001.01 PURPOSE. The purpose of the Medically Handicapped Children’s Program is to develop, improve, and strengthen standards and services for children with special health care needs and:

(A) To promote systems development to improve the organization and delivery of high quality services for children with special health care needs and their families with an emphasis on community-based services;

(B) To promote coordinated comprehensive care within a medical home;

(C) To provide culturally competent services and support by assisting families of children with special health care needs within a community and to identify and meet their needs through coordination of informal and formal supports;

(D) To develop, promote, and improve the standards of care for children with special health care needs;

(E) To promote efforts that emphasize early evaluation and treatment, health-related education and advocacy in order that children with special health care needs and their families may maximize their full potentials; and

(F) To increase public awareness through the establishment of outreach efforts.

001.02 LEGAL BASIS. Title V Services for the Medically Handicapped Children’s Program is administered under Public Law 97-35, Subtitle D, 42 United States Code (U.S.C.) §§ 701-713, “Title V Maternal and Child Health Services Block Grant”, and Nebraska Revised Statute (Neb. Rev. Stat.) §§ 43-522, 68-309, and 68-717. The Genetically Handicapped Persons Program is a program for adults with cystic fibrosis, hemophilia, and sickle cell disease established by Neb. Rev. Stat. §§ 68-1401 to 68-1406. The Disabled Children’s Program is administered by the Department as part of the Title V Maternal and Child Health Services Block Grant.

001.03 FUNDING. The Medically Handicapped Children’s Program and Disabled Children’s Program are funded by a federal block grant and state funds appropriated by the legislature. The Genetically Handicapped Persons Program is funded by state funds appropriated by the legislature. The Department has the authority to set priorities of services and service components based on available funding. Donations may be accepted.

002. APPLICANT AND RECIPIENT RIGHTS . Applicants and recipients applying for or receiving services have the right to confidentiality, non-discrimination, grievance and fair hearing.

002.01 CONFIDENTIALITY. Applicants and recipients have the right to have their information treated confidentially.

002.02 NON-DISCRIMINATION. No individual may be subjected to discrimination on the grounds of his or her race, color, national origin, sex, age, disability, religion, or political belief.

002.03 GRIEVANCE AND FAIR HEARING. Applicants and recipients have the right to a Fair Hearing on any action or inaction with regard to an application, the amount of assistance, or failure to act with reasonable promptness. The appeal must be filed in writing within 90 days of the Department’s action or inaction.

002.04 APPLICANT AND RECIPIENT RESPONSIBILITIES. Applicants, recipients, parents, and legal guardians must comply with the following:

(A) Report accurate financial information;

(B) Report accurate information about the applicant’s or recipient’s needs;

(C) Report a change of address, household size, or income within ten days following the change;

(D) Participate in any financial or medical eligibility review;

(E) Notify the Department before receiving services at scheduled appointments and tests;

(F) Keep all appointments for care and services related to the special health care need;

(G) Follow the individual medical treatment plan;

(H) Notify the Department of any emergency care or hospitalizations within five working days;

(I) Obligate payment for any part of treatment which has been determined to be the recipient’s responsibility;

(J) Assume responsibility for the general health care of the recipient; and

(K) Ensure the Department and medical providers have any third party liability information prior to care, if applicable, and supply necessary documentation for filing claims before the Medically Handicapped Children’s Program, Genetically Handicapped Persons Program, and Disabled Children’s Program pays for any service.

History

• Effective 2022-05-17

Chapter 2 Referral, Application, and Eligibility for the Medically Handicapped Children’s Program and the Genetically Handicapped Persons Program

Neb. Admin. Code tit. 467, ch. 2 Referral, Application, and Eligibility for the Medically Handicapped Children’s Program and the Genetically Handicapped Persons Program {#sec-467-nac-2 omnilex-key=us-ne-regs-official--title-467--467 NAC 2}

001. REFERRAL . Any individual, health care professional, or agency may refer a potential applicant to the Medically Handicapped Children’s Program or Genetically Handicapped Persons Program.

001.01 INITIATING A REFERRAL. A referral for services is made by the applicant, any individual, health care professional, or agency. A referral is made by completion of the application or, at a minimum, providing the Department with the potential applicant’s following information:

(1) Name;

(2) Date of birth;

(3) Parent or legal guardian’s name;

(4) Address;

(5) Phone number;

(6) Diagnosis or medical condition; and

(7) Reason for referral.

001.01(A) EMERGENCY REFERRAL. A hospital emergency department who wishes to refer potential applicants must make the referral within five days of admission to the hospital.

002. APPLICATIONS . Upon receiving a referral, the Department will mail the potential applicant an application form and a release of information form. The Department must receive the completed application and signed release from the applicant within 30 days after the Department mails the forms. A legally responsible adult age 19 or older must complete the application.

002.01 RESIDENT OF NEBRASKA. Applicants and recipients must reside in Nebraska.

002.02 CITIZENSHIP. The applicant must be a citizen of the United States of America or a qualified alien and be lawfully present in the United States of America as required by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 4-108 to 4-112. The applicant must sign an attestation required by Nebraska Revised Statute (Neb. Rev. Stat.) § 4-111. The applicant’s citizenship or alien status must be verifiable by the Department.

002.03 AGE REQUIREMENT. The age requirement for the Medically Handicapped Children’s Program is birth through 20 years. The age requirement for the Genetically Handicapped Persons Program is 21 years and older.

002.04 WITHDRAWAL. The applicant may voluntarily withdraw an application.

003. MEDICAL AND FINANCIAL ELIGIBILITY . Eligibility for the Medically Handicapped Children’s Program and Genetically Handicapped Persons Program is based on medical eligibility and financial qualifications. Current medical and financial information must be provided.

003.01 MEDICAL ELIGIBILITY DETERMINATION. Medical eligibility is determined by either the Department or Department designated medical reviewer. If an applicant is seen by a Department designated clinic team, medical eligibility can be determined without going through the medical reviewer. Eligibility is specific to one or more diagnosis and each diagnosis must meet the qualifications in Chapter 3. To determine eligibility, the medical records must include the diagnosis and a current individual medical treatment plan developed by a physician, physician assistant, or nurse practitioner. Medical records submitted must have a date of service less than six months prior to the determination request date.

003.02 MEDICAL ELIGIBILITY REVIEWS. Current medical specialty reports must be received for the eligible diagnosis at the time of review annually. Department designated clinic team reports may take the place of a specialty report. Medical eligibility for reviews are not determined by a medical consultant.

003.03 FINANCIAL ELIGIBILITY DETERMINATION. Financial eligibility is determined based on the probable cost of specialized medical care and the income and resources available to the applicant, parents, or legal guardians. The recipient’s income must be at or below 185 percent of the federal poverty level for the appropriate family size after countable income is figured minus deductions. If the family’s income minus deductions exceeds the requirement, a financial margin must be calculated. Countable income includes all income not listed as exclusions in the Title.

003.03(A) INCOME EXCLUSIONS. The following are excluded as sources of income:

(i) Withdrawals of bank deposits;

(ii) Money borrowed;

(iii) Tax refunds;

(iv) Cash gifts under $500;

(v) Earnings of all children age 18 years and younger;

(vi) Child or spousal support;

(vii) Subsidized adoption or subsidized guardianship payments from Title IV-E or child welfare funds;

(viii) Value of United States Department of Agriculture donated foods;

(ix) Any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;

(x) Loans, grants, and scholarships obtained and used under conditions that prohibit the use for current living costs;

(xi) Alaska Native Claims Settlement Act payments to the extent the payments are exempt from taxation under section 21(a) of the Act;

(xii) Value of Supplemental Nutrition Assistance Program and the special food service program for children under the National School Lunch Program Child Nutrition Act of 1966, as amended;

(xiii) Money awarded by the Indian Claims Commission or the Court of Claims;

(xiv) Reimbursement of expenses or payments for services from the Senior Companion Program, AmeriCorps, Senior Corps, Foster Grandparents, Service Corps of Retired Executives, Experience Works, and any other programs under Title II and III of Public Law 93-113;

(xv) Payments to an individual participating in training or school attendance subsidized Vocational Rehabilitation within the Nebraska Department of Education; and

(xvi) Low Income Energy Assistance funds.

003.03(B) FINANCIAL DEDUCTIONS. The following are deducted from the countable income:

(1) Child support paid;

(2) Spousal support or alimony paid;

(3) Child care necessary for employment or education if both parents are employed or receiving education or if one parent is unavailable to care for the child due to absence or incapacity. This excludes students pursuing second undergraduate degrees and certificates or any post-graduate schooling;

(4) Tuition and books for family members attending school. This excludes students pursuing second undergraduate degrees and certificates or any post-graduate schooling; and

(5) Medical expenses for the entire family, including medical insurance premiums, paid within the 12 months preceding the date of application.

003.03(B)(i) MEDICAL EXPENSE DEDUCTION REDETERMINATION. Medical expenses allowed for the previous year’s financial margin are not counted for the current year’s medical expenses. The medical expenses deducted and allowed on the previous year’s application must be deducted at the time of redetermination.

003.03(C) RESOURCE LIMITS. There are no resource limits for these programs.

003.03(D) FINANCIAL MARGIN. The financial margin is the recipient’s responsibility that must be paid annually, after any third party, on the recipient’s specialized health care prior to the Department making any payments. If the family’s income minus deductions exceeds the income requirement, a financial margin must be calculated. The financial margin is 25 percent of the amount which exceeds the income requirements minus the financial margin deductions.

003.03(D)(i) FINANCIAL MARGIN DEDUCTIONS. The following are deducted from the financial margin:

(1) Unpaid medical bills for the applicant or recipient, not included in previous year’s medical allowance;

(2) Projected travel and lodging costs using state employee rates for specialized medical care; and

(3) Projected costs of child care for siblings while the client is hospitalized or receiving medical services.

003.04 FINANCIAL ELIGIBILITY REVIEWS. Financial eligibility redetermination must be completed annually or at the time of any changes in income or family size.

003.05 MEDICAID ELIGIBLE WITH SHARE OF COST. Applicants and recipients must apply for Medicaid if a referral is appropriate. If the applicant or recipient is eligible or denied Medicaid with a high share of cost, the Department may request Medicaid be open with the share of cost based on the cost savings for the program and benefit to the applicant or recipient. Funds may be used towards medical care not to exceed the Medicaid share of cost. The applicant or recipient is considered Medicaid eligible once the share of cost is met.

004. NOTICES FROM DEPARTMENT . A notice is sent to applicants and recipients in the following instances:

(A) An applicant is determined eligible or ineligible for the program;

(B) A recipient is determined eligible or ineligible at time of redetermination; or

(C) Services are reduced or terminated.

005. NOTICES NOT REQUIRED BY DEPARTMENT . A notice is not sent to applicants or recipients in the following instances:

(A) Services are no longer needed and applicant or recipient requests the closure;

(B) Applicant or recipient has died;

(C) Applicant or recipient becomes institutionalized;

(D) Applicant or recipient whereabouts are unknown; or

(E) Failure to act upon request for redetermination.

History

• Effective 2022-05-17

Chapter 3 Diagnoses and Services for the Medically Handicapped Children’s Program

Neb. Admin. Code tit. 467, ch. 3 Diagnoses and Services for the Medically Handicapped Children’s Program {#sec-467-nac-3 omnilex-key=us-ne-regs-official--title-467--467 NAC 3}

001. SPECIALIZED MEDICAL CARE . Specialized medical care is covered, according to each diagnoses’ service components, for eligible recipients. The medical care must be outlined in the individual medical treatment plan that is developed and signed by a health care professional. The specialized medical care must be directly related to the medically eligible diagnosis. Routine, general health care is not a covered service.

001.01 LOCATION OF SERVICES. Recipients are encouraged to use medical providers and facilities closest to their place of residence. If a medical provider or facility is available closer to the residence and the recipient chooses one further away, the Department is not obligated to pay for services.

001.02 SERVICES PROVIDED OUTSIDE NEBRASKA. Specialized medical care received from Nebraska medical providers is covered by the Program. The recipient, parent, or legal guardian must obtain prior approval from the Department for all non-emergency services outside of Nebraska. In the following situations, the Department may approve specialized medical care to be provided outside Nebraska:

(A) A medical service is not available in Nebraska but is available in another state. Written documentation must be provided by the medical provider to explain the medical service requested and that the service is not available in Nebraska;

(B) Emergency situations that arise while the recipient is visiting in another state and the recipient’s health would be jeopardized if care was postponed until the recipient returned to Nebraska. Medical services are covered as if it were provided in Nebraska. Emergency services may be reviewed by the medical consultant. Emergency services will be covered up to five days; or

(C) The medical service is more accessible in another state.

001.03 NON COVERED SERVICES. Services and care of recipients residing in an institution setting are not covered. Funds are not used to cover fees for long term care facilities, including skilled nursing facilities or intermediate care facilities.

002. ASTHMA DIAGNOSIS AND SERVICES . This service provides treatment for severe, persistent asthma in recipients.

002.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Applicants and recipients must meet specific criteria to establish eligibility factors. Persistent asthma is having more than two episodes of asthma symptoms per week. Severe asthma is continual daily symptoms and frequent nightly symptoms prior to treatment. Daily symptoms or more per month nightly symptoms fall into the more moderate category. Life threatening episodes, frequent hospitalizations, evidence of chronic lung disease, evidence of the disease adversely affecting every day functioning, including psychological disturbances secondary to the disease will all be taken into account.

002.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for asthma.

002.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

002.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

003. BURNS DIAGNOSIS AND SERVICES . This service provides treatment for serious burn injuries through the burn centers in the metro-area.

003.01 MEDICAL ELIGIBILITY CONSIDERATIONS. When determining eligibility, the medical consultant takes into account the referring physician’s report of the burn injury, the degree of the burn, percentage of body surface burned, and the physical location of the burn.

003.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for burns.

003.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

003.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

004. CEREBRAL PALSY DIAGNOSIS AND SERVICES . This service provides screening and treatment for applicants or recipients who have residual alterations in motor function as a result of brain or brain stem damage or spinal cord injury from any cause.

004.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The most common diagnoses covered are quadriplegia, hemiplegia, diplegia, and paraplegia. Other applicants and recipients with motor difficulties may be eligible as authorized by the medical consultant or clinic team.

004.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for cerebral palsy. If a Department sponsored medical clinic is available in the applicant or recipient’s community, the clinic evaluation may take the place of the medical consultant review for eligibility determination.

004.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met. If applicant is utilizing a Department sponsored medical clinic for medical eligibility, the certification date is the date the applicant was first seen at the medical clinic.

004.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

005. CRANIOFACIAL DIAGNOSIS AND SERVICES . This service provides treatment for recipients with craniofacial anomalies.

005.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Eligible diagnosis include bilateral, unilateral, complete, and incomplete cleft lip and cleft palate. Other craniofacial anomalies may be considered. Department sponsored medical clinics may be offered in the applicant or recipient’s community to provide diagnostic evaluations.

005.01(A) MEDICAL ELIGIBILITY DETERMINATION. The Department determines medical eligibility for craniofacial diagnosis. The medical consultant only determines eligibility for craniofacial diagnosis which falls under the “other craniofacial anomalies”.

005.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

005.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

006. CYSTIC FIBROSIS DIAGNOSIS AND SERVICES . This service provides treatment for cystic fibrosis which is commonly associated with the pancreas, respiratory system, and sweat glands.

006.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The only eligible diagnosis is cystic fibrosis, fibrocystic disease. Cystic fibrosis is an inherited disease of the exocrine glands.

006.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for cystic fibrosis.

006.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

006.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

007. DIABETES DIAGNOSIS AND SERVICES . This service provides treatment for diabetes mellitus.

007.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The only eligible diagnosis is diabetes mellitus, Type I or Type II.

007.01(A) MEDICAL ELIGIBILITY DETERMINATION. The Department determines medical eligibility for diabetes diagnosis. Medical consultant does not determine medical eligibility.

007.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

007.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

008. EYE DIAGNOSIS AND SERVICES . This service provides treatment for eye defects which include the need for surgeries.

008.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The most common diagnoses covered are ptosis, exotropia, congenital cataracts, glaucoma, and blocked tear ducts. Medical eligibility is dependent upon the need for surgery.

008.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for eye diagnosis.

008.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

008.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

009. HEARING DIAGNOSIS AND SERVICES . This service provides treatment for recipients with significant hearing loss requiring amplification or a condition which may result in a hearing loss. The purpose is to improve hearing acuity and prevent further hearing loss.

009.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The hearing diagnosis may be used to fill the service gaps for infants that need additional diagnostic, medical treatment planning, and medical treatment services beyond the newborn hearing screening phase, subject to local school system’s responsibilities. Eligibility for hearing services must be evidenced by a permanent hearing loss or a medical condition resulting in a permanent hearing loss. Medical conditions which include hearing loss but respond to medication and placement of tube, myringotomy, and usually result in normal hearing are considered acute conditions which are not medically eligible.

009.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for hearing.

009.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

009.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

010. HEART DIAGNOSIS AND SERVICES . This service provides treatment for congenital and acquired heart disease.

010.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The most common diagnoses covered are Tetralogy of Fallot, transposition of the great vessels, and coarctation of the aorta, mitral/aortic valve stenosis, ventricular septal defect, and atrial septal defect. Other chronic heart conditions may be considered.

010.01(A) MEDICAL ELIGIBILITY DETERMINATION. The Department determines medical eligibility for heart diagnosis. The medical consultant only determines eligibility for heart diagnosis which falls under the “other diagnoses may be considered” category.

010.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

010.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

011. HEMOPHILIA DIAGNOSIS AND SERVICES . This service provides treatment for hemophilia and certain bleeding disorders.

011.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Hemophilia is a genetically transmitted disease caused by deficiency of an antihemophilic globulin, Factor VIII. Bleeding episodes may occur due to minor injuries, surgeries, dental work, and other procedures and may require extensive treatment. Medically eligible diagnoses are congenital Factor VII and severe Factor IX disorders, such as hemophilia and Christmas disease.

011.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for hemophilia diagnosis.

011.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

011.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

012. MAJOR MEDICAL DIAGNOSIS AND SERVICES . This service provides treatment for diagnoses determined to be congenital, chronic, or prolonged, and in need of active treatment. If the applicant or recipient’s diagnosis does not meet criteria for other services, the applicant or recipient may be considered for this service.

012.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Common diagnoses covered are Addison’s disease, Turner’s syndrome, hypothyroidism, esophageal strictures, imperforate anus, tracheoesophageal fistula, choanal atresia, enterocolitis, Hirschsprung’s disease, aplastic anemia, gastroschisis, growth hormone deficiency, phenylketonuria, and duodenal atresia. Medically eligible immunological deficiencies are congenital hypogammaglobinemia, acquired hypogammaglobinemia, DiGeorge’s syndrome, severe combined immunodeficiency, ataxia-telangiectasia syndrome, Wiskott-Aldrich syndrome, chronic granulomatous disease, Chediak-Higashi syndrome, and Kostmann’s syndrome. Complement deficiencies may be considered. Not covered are growth hormone transplants of bone marrow and thymus or selective IgA deficiency, chronic mucocutaneous candidiasis, hyper IgE syndrome, and Quie-Hill syndrome.

012.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for major medical.

012.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

012.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

013. MIDLINE NEUROLOGICAL DEFECT DIAGNOSIS AND SERVICES . This service provides treatment for spina bifida, meningomyelocele, or other central nervous system neurological defects.

013.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Common diagnoses covered are spina bifida aperta with hydrocephalus, spina bifida aperta without hydrocephalus, spina bifida occulta, congenital hydrocephalus, encephalocele, obstructive hydrocephalus – acquired, hydranencephaly, spinal cord lesion, and craniosynostosis requiring surgery. Other central nervous system neurological defects may be considered.

013.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for midline neurological defect.

013.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

013.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

014. NEOPLASM DIAGNOSIS AND SERVICES . This service provides treatment for neoplastic (cancerous) diseases or non-malignant tumors when the tumor is potentially disabling.

014.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Common diagnoses covered are leukemia, lymphoma, Ewing’s sarcoma, Wilm’s tumor, rhabdomyosarcoma, neuroblastoma, astrocytoma, and osteogenic sarcoma. Other brain tumors that are potentially disabling may be considered.

014.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for neoplasm.

014.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

014.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

015. NEUROLOGICAL DIAGNOSIS AND SERVICES . This service provides treatment for neurological conditions.

015.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Common diagnoses covered are seizures, subdural hematoma, encephalocele, and Guillain-Barre syndrome. Seizures are not a covered diagnosis during a newborn’s initial hospitalization at birth. Other chronic neurological conditions may be considered.

015.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for neurological.

015.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

015.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

016. ORTHOPEDIC DIAGNOSIS AND SERVICES . This service provides treatment for general orthopedic problems, congenital or acquired, excluding recent fractures.

016.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Common diagnoses covered are talipes equinovarus, arthrogryposis, Legg-Calve-Perthes disease, congenital dislocation of the hip, and the need for prostheses. Spinal cord injuries may be considered for rehabilitative care. Additional diagnoses that may be considered are tibial torsion, bowed legs, torn medial meniscus, leg length discrepancy, and fractures that have not healed properly. Other severe and chronic orthopedic conditions may be considered.

016.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for orthopedic.

016.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

016.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

017. PREMATURE BIRTHS DIAGNOSIS AND SERVICES . This service provides treatment for certain premature infants with medical complications and must be referred to other available resources or programs that assist with this population.

017.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Medical eligibility is based on seriousness of the condition for each applicant or recipient. Covered diagnoses may include bronchopulmonary dysplasia and hyaline membrane disease or respiratory distress syndrome when the infant has been on mechanical ventilation for more than five days. Certain other conditions associated with prematurity may be considered. Diagnoses not covered are meconium aspiration, neonatal sepsis, hypoglycemia, and neonatal meningitis. Low birth weight and gestational age alone are not medically eligible. Hospitalizations for acute care or weight gain are not medically eligible.

017.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for premature births. All inpatient hospitalization discharge summaries are required.

017.01(B) CERTIFICATION DATE. The certification date is the date of birth, if referred within 30 days of the date of birth, once medical and financial eligibility is met. If the referral is not made within the 30 days of birth, the certification date is the date of referral, once medical and financial eligibility is met.

017.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

018. RHEUMATOID ARTHRITIS DIAGNOSIS AND SERVICES . This service provides treatment for juvenile rheumatoid arthritis and related conditions.

018.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The covered diagnosis is juvenile rheumatoid arthritis. Other related conditions may be considered.

018.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for rheumatoid arthritis.

018.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

018.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

019. SCOLIOSIS DIAGNOSIS AND SERVICES . This service provides treatment for anomalies of the spine.

019.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Eligible diagnoses are congenital scoliosis, spondylolisthesis, and congenital absence of vertebra, hemivertebra, and congenital fusion of the spine. Other conditions of the spine may be considered.

019.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for scoliosis.

019.01(B) CERTIFICATION DATE. The certification date is the referral date, once medical and financial eligibility is met.

019.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

020. UROLOGY DIAGNOSIS AND SERVICES . This service provides treatment for kidney, urinary, and genital anomalies determined to be chronic and disabling or potentially disabling and active treatment is necessary.

020.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Covered diagnoses are exstrophy of the bladder, bilateral ureteral reflux, extensive hypospadias, ambiguous genitalia, and hydronephrosis. Other related diagnoses may be considered. Eligibility ends when dialysis or transplant is required – other public programs are available for this stage of disease.

020.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for urology.

020.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

020.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

History

• Effective 2022-05-17

Chapter 4 Diagnoses and Services for the Genetically Handicapped Persons Program

Neb. Admin. Code tit. 467, ch. 4 Diagnoses and Services for the Genetically Handicapped Persons Program {#sec-467-nac-4 omnilex-key=us-ne-regs-official--title-467--467 NAC 4}

001. SPECIALIZED MEDICAL CARE . Specialized medical care is covered, according to the diagnosis of each service component, for eligible recipients age 21 years and older. The medical care must be outlined in the individual medical treatment plan that is developed and signed by a health care professional. The specialized medical care must be directly related to the medically eligible diagnosis. Routine, general health care is not a covered service.

001.01 LOCATION OF SERVICES. Recipients are encouraged to use medical providers and facilities closest to their place of residence. If a medical provider or facility is available closer to the residence and the recipient chooses one further away, the Department is not obligated to pay for services.

001.02 SERVICES PROVIDED OUTSIDE NEBRASKA. Specialized medical care received from Nebraska medical providers is covered by the Program. The recipient, parent, or legal guardian must obtain prior approval from the Department for all non-emergency services outside of Nebraska. In the following situations, the Department may approve specialized medical care to be provided outside Nebraska:

(A) A medical service is not available in Nebraska but is available in another state. Written documentation must be provided by the medical provider to explain the medical service requested and that the service is not available in Nebraska;

(B) Emergency situations that arise while the recipient is visiting in another state and the recipient’s health would be jeopardized if care was postponed until the recipient returned to Nebraska. Medical services are covered as if it were provided in Nebraska. Emergency services may be reviewed by the medical consultant. Emergency services will be covered up to five days; or

(C) The medical service is more accessible in another state.

001.03 NON COVERED SERVICES. Services and care of recipients residing in an institution setting are not covered. Funds are not used to cover fees for long term care facilities, including skilled nursing facilities, and intermediate care facilities.

002. CYSTIC FIBROSIS DIAGNOSIS AND SERVICES . This service provides treatment for cystic fibrosis which is commonly associated with pancreas, respiratory system and sweat glands.

002.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The only eligible diagnosis is cystic fibrosis fibrocystic disease. Cystic fibrosis is an inherited disease of the exocrine glands.

002.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for cystic fibrosis.

002.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

002.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

003. HEMOPHILIA DIAGNOSIS AND SERVICES . This service provides treatment for hemophilia and certain bleeding disorders.

003.01 MEDICAL ELIGIBILITY CONSIDERATIONS. Hemophilia is a genetically transmitted disease caused by deficiency of an antihemophilic globulin, Factor VIII. Bleeding episodes may occur due to minor injuries, surgeries, dental work, and other procedures and may require extensive treatment. Medically eligible diagnoses are congenital Factor VII and severe Factor IX disorders, such as hemophilia and Christmas disease.

003.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for hemophilia diagnosis.

003.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

003.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

004. SICKLE CELL DISEASE DIAGNOSIS AND SERVICES . These services provide treatment for sickle cell disease – sickle cell anemia.

004.01 MEDICAL ELIGIBILITY CONSIDERATIONS. The only eligible diagnosis is sickle cell disease.

004.01(A) MEDICAL ELIGIBILITY DETERMINATION. The medical consultant determines medical eligibility for sickle cell disease.

004.01(B) CERTIFICATION DATE. The certification date is the date of referral, once medical and financial eligibility is met.

004.02 SERVICE COMPONENTS. Service components may be covered if recommended in the individual medical treatment plan and funds are available.

History

• Effective 2022-05-17

Chapter 5 Medical Providers and Payments for the Medically Handicapped Children’s Program and Genetically Handicapped Persons Program

Neb. Admin. Code tit. 467, ch. 5 Medical Providers and Payments for the Medically Handicapped Children’s Program and Genetically Handicapped Persons Program {#sec-467-nac-5 omnilex-key=us-ne-regs-official--title-467--467 NAC 5}

001. MEDICAL PROVIDERS . Medical providers provide services and treatment to recipients with special health care needs and receive payment for prior authorized services.

001.01 PROVIDER ENROLLMENT. Prior to services being authorized for payment, providers must sign a Department form which requires the following:

(A) The Provider must follow the Program regulations and other applicable laws;

(B) The Provider must maintain current licensing and certifications required by state law;

(C) The Provider must be screened for abuse and neglect on the child and adult central registry and must have criminal background checks completed; and

(D) The Provider must maintain records on services provided for a minimum of six years after the date of service.

002. MEDICAL PAYMENTS . Medical payments are made to medical providers for authorized services after the Department reviews the billings for compliance with requirements.

002.01 BILLING REQUIREMENTS. The Department only considers payment for claims when the following billing requirements are met:

002.01(A) THIRD PARTY. All third party sources must be exhausted before payment may be considered.

002.01(B) REQUIRED DETAIL ON CLAIMS. The detail required on claims is dependent upon the type of medical claim being submitted. All medical claims submitted to the Department for payment must be completed in its entirety by the provider. Additional supporting documentation may be requested in order to process the claim. Failure to submit additional documentation timely will result in the claim being denied payment.

002.01(C) ACCEPT PAYMENT IN FULL. Medical providers must accept the Department’s payment as payment in full. Any balance remaining on a claim after payment has been made cannot be billed to the recipient. If the Department does not make payment due to third party sources paying more than the Department’s rate, the remaining balance must not be billed to the recipient. Recipients must not be billed for claims denied by the Department for untimely filing.

002.01(D) TIMELY FILING. Medical providers must bill within six months from the date of service for payment to be considered by the Department. Claims received beyond six months from the date of service will be denied.

002.01(E) REFUNDS. Medical providers have 45 days to refund any overages or erroneous payments or to show that the refunds have already been made or that the refund requests were made in error.

003. PAYMENT RATES FOR MEDICAL SERVICES . The Department follows the rates below for medical services provided while allowing the Department the discretion to negotiate rates when excessive costs are billed.

003.01 PHARMACY RATES. Pharmacy rates are as billed.

003.02 DURABLE MEDICAL EQUIPMENT. Durable medical equipment rates follow the Medicaid fee schedules.

003.03 PHYSICIAN RATES. Physician rates follow the Medicaid fee schedules.

003.04 HOSPITAL RATES. Hospital rates follow the Medicaid fee schedules.

003.05 DENTAL RATES. Dental rates follow the Medicaid fee schedules.

003.06 UNKNOWN RATES. Certain medical services do not have available Medicaid pricing. Rates that are unknown are determined by the Department on a negotiated basis until pricing becomes available.

History

• Effective 2022-05-17

Chapter 6 Referral, Application, Eligibility, and Services for the Disabled Children’s Program

Neb. Admin. Code tit. 467, ch. 6 Referral, Application, Eligibility, and Services for the Disabled Children’s Program {#sec-467-nac-6 omnilex-key=us-ne-regs-official--title-467--467 NAC 6}

001. INTRODUCTION . The Disabled Children’s Program serves eligible children with special health care needs and their families by providing medical support services. Family needs are assessed to determine the support services that may be covered based on available funding.

002. REFERRALS . Any individual or agency may refer children who are determined to be eligible for Supplemental Security Income benefits.

003. APPLICATIONS . Upon receiving a referral, the Department verifies Supplemental Security Income current pay status prior to applications being mailed to potential applicants. The Department must receive the completed application within 30 days after the Department mails the application. A legally responsible adult age 19 or older must complete the application. A referral is not a requirement for completing an application.

003.01 WITHDRAWAL. The applicant may voluntarily withdraw an application.

003.02 ELIGIBILITY REQUIREMENTS. The following are the eligibility requirements:

003.02(A) RESIDENT OF NEBRASKA. Applicants and recipients must reside in Nebraska.

003.02(B) CITIZENSHIP OR ALIEN STATUS. Applicants and recipients must be United States citizens or qualified aliens as required by Nebraska Revised Statute §§4-108 to 4-112. Applicants and recipients must sign an attestation form verifying lawful presence in the United States. The Department must be able to verify the status of applicants and recipients.

003.02(C) AGE REQUIREMENT. Applicants and recipients must be age 15 years or younger.

003.02(D) SUPPLEMENTAL SECURITY INCOME. Applicants and recipients must be in current pay status with Supplemental Security Income benefits.

003.02(E) NEED FOR SERVICES. Applicants and recipients must have an identified disability-related need for services.

003.03 CERTIFICATION DATE. The certification date is the date the completed application is received by the Department.

003.04 ELIGIBILITY REVIEWS. Eligibility reviews are completed annually.

004. NOTICES FROM DEPARTMENT . A notice is sent to applicants and recipients in the following instances:

(A) An applicant is determined eligible or ineligible for the program;

(B) A recipient is determined eligible or ineligible at time of redetermination; or

(C) Services are reduced or terminated.

005. NOTICES NOT REQUIRED BY DEPARTMENT . A notice is not sent to applicants or recipients in the following instances:

(A) Services are no longer needed and applicant or recipient requests the closure;

(B) Applicant or recipient has died;

(C) Applicant or recipient becomes institutionalized;

(D) Applicant or recipient whereabouts are unknown; or

(E) Failure to act upon request for redetermination.

006. NEEDS ASSESSMENT . Once the applicant or recipient is determined eligible, a needs assessment is completed to identify the disability-related needs of the family.

007. INDIVIDUAL SERVICE PLAN . An individual service plan is developed for each recipient based upon their needs assessment, service components of the program, and available funds. The plan details the services available to the recipient which are prior approved by the Department.

007.01 LOCATION OF SERVICES. Recipients are encouraged to use medical providers and facilities closest to their place of residence. If a medical provider or facility is available closer to the residence and the recipient chooses one further away, the Department is not obligated to pay for supportive services for that care or treatment.

007.02 SERVICE COMPONENTS. Service components may be covered based on identified needs and available funds.

007.02(A) MEDICAL MILEAGE. Medical mileage reimbursement is a covered service for families who transport recipients to disability-related medical care or treatment. Mileage for routine, general health care is not a covered service. The reimbursement rate for medical mileage follows the annual Internal Revenue Service standard mileage rate per mile driven for medical purposes.

007.02(B) LODGING. Lodging is a covered service for families who travel long distances for disability-related care or treatment for the recipient. If lodging is available through another program at no cost or minimal cost, this service may not be available. The reimbursement rate for lodging follows the annual United States General Services Administration Per Diem Rates based on the location of the lodging. Additional lodging for leisure is optional and not covered.

007.02(C) RESPITE CARE. Respite care is a covered service to provide caregivers a short break from taking care of the recipient with special health care needs. The Department determines the maximum dollar amount of respite care for each recipient based on the needs of the family and available funds, not to exceed $125 per month, which is then included in the individual service plan. Respite care may not be used as child care when a caregiver is working or going to school.

007.02(C)(i) RESPITE PROVIDERS. Parents and legal guardians of recipients are responsible for locating respite providers to care for the recipients. The following are required of all respite providers:

(1) The provider must undergo a child and an adult registry check at least once every twelve (12) months to be enrolled as a provider. The Department may require additional registry checks when the circumstances warrant further investigation. The Department may in its discretion accept a child and an adult registry check completed by another Department program within the previous twelve (12) months. Funds cannot be used to pay providers identified on the Department’s child or adult registries as a substantiated perpetrator of abuse or neglect.

(2) The provider must be age 19 years or older.

(3) The provider must not reside in the household with the recipient.

(4) Non-relative providers are encouraged. The Department has the discretion to deny payment for relative providers so long as providers are available in the recipient’s residing area.

007.02(D) SPECIAL EQUIPMENT AND ACCESSIBILITY MODIFICATIONS. Special equipment and accessibility modifications are covered services based on the needs of each recipient, available funds, and individual service plans. The maximum dollar amount is $3,600 per recipient’s family per 12-month period. Medical necessity must be documented by a health care professional.

008. FRAUDULANT ACTIONS . The Department has the authority to terminate any relationship with a provider who has committed fraud in another government program. The Department has the authority to terminate provider relationships and deny payments to any provider that engages in fraudulent billing.

009. PAYMENTS . Payments are made to the parent or legal guardian of the recipient in specific situations and in other situations payments are made directly to the providers.

009.01 PAYMENTS TO THE PROVIDER. Payments are made directly to the provider for respite care services, special equipment, and accessibility modifications. Billing documents must be completed accurately and received by the Department timely, within 60 days from the date of service, in order to be considered for payment. Billings received by the Department after the 60 days from the date of service will be denied payment. One billing document must be completed for each month for each type of service authorized. Special equipment and accessibility modifications are paid once the purchase or project is complete to satisfaction of the family. Inaccurate or incomplete billing claims may be denied.

009.02 PAYMENTS TO THE RECIPIENT’S PARENT OR LEGAL GUARDIAN. Payments are made as reimbursement to the parent or legal guardian of the recipient for medical mileage and lodging services. Billing documents must be completed accurately and received by the Department timely, within 60 days from the date of service, in order to be considered for payment. Billings received by the Department after the 60 days from the date of service will be denied payment. One billing document must be completed for each month for each type of service authorized. Inaccurate or incomplete billing claims may be denied.

History

• Effective 2022-05-17