Sec. 10.11.03.06. Medical Eligibility

A. Children with special health care needs may be eligible for services covered by the CMS Program.

B. Chronic medical conditions which may render an applicant medically eligible include, but are not limited to, the following:

(1) Chronic asthma;

(2) Chronic renal disease;

(3) Cystic fibrosis;

(4) Diabetes and other endocrine disorders;

(5) Hemophilia;

(6) Immune deficiencies;

(7) Juvenile rheumatoid arthritis;

(8) Leukemia and other childhood cancers;

(9) Phenylketonuria and other inborn errors of metabolism; and

(10) Sickle cell anemia and other chronic anemia.

C. Other medical and surgical conditions which may render an applicant medically eligible include, but are not limited to, the following:

(1) Biliary atresia;

(2) Bronchopulmonary dysplasia;

(3) Tracheal esophogeal fistula; and

(4) Ulcerative colitis.

D. Neurodevelopmental conditions which may render an applicant medically eligible include, but are not limited to, the following:

(1) Brain tumors;

(2) Cerebral palsy and other central nervous system disorders;

(3) Certain high risk neonates;

(4) Closed head injury with residual defects;

(5) Down's syndrome and other genetic and chromosomal anomalies;

(6) Hydrocephalus;

(7) Medical aspects of learning disabilities and attention deficit disorders;

(8) Medical aspects of intellectual disability and developmental delay;

(9) Muscular atrophies and dystrophies;

(10) Spina bifida, myelomeningocele, and the spinal cord dysfunctions;

(11) Other neurologic damage;

(12) Peripheral neuromuscular disease; and

(13) Seizure disorder.

E. Orthopedic conditions which may render an applicant medically eligible include, but are not limited to, the following:

(1) Chronic conditions resulting from trauma;

(2) Chronic infections of bones and joints;

(3) Club foot and other foot deformities;

(4) Congenital developmental hip conditions such as congenital hip dislocation;

(5) Limb deficiencies and length discrepancies;

(6) Skeletal dysplasias and other forms of dwarfism; and

(7) Spinal column defects and deformities.

F. Cardiac conditions which may render an applicant medically eligible include, but are not limited to, the following:

(1) Arrhythmias;

(2) Congenital heart defects;

(3) Hypertension; and

(4) Rheumatic heart disease.

G. Craniofacial and dental conditions which may render an applicant medically eligible include, but are not limited to, the following:

(1) Cleft lip and palate, orofacial defects;

(2) Handicapping malocclusions; and

(3) Medically necessary dental care related to eligible medical conditions.

H. Vision, hearing and speech-language conditions, which may render an applicant medically eligible include, but are not limited to, the following:

(1) Amblyopia;

(2) Cataract;

(3) Cholesteatoma;

(4) Chronic otitis media;

(5) Conductive and sensory-neural hearing loss;

(6) Otosclerosis;

(7) Speech-language disorders;

(8) Strabismus; and

(9) Velopharyngeal incompetence.

I. The following are excluded from CMS Program medically eligible services:

(1) Well child care;

(2) Mental health;

(3) Emergency care; and

(4) Urgent care.

J. Care excluded from CMS Program medically eligible conditions unless the services are medically necessary due to the underlying chronic condition includes:

(1) Dermatology;

(2) Gynecology; and

(3) Dental services.