What Is CCS Insurance & Who Is Eligible for Coverage?

California Children’s Services (CCS) is a state program providing specialized medical care and rehabilitative services for children and young adults with chronic, severe, or physically disabling medical conditions. CCS ensures eligible children receive necessary treatment, equipment, and therapies to improve health outcomes.

Understanding CCS Insurance

California Children’s Services (CCS) is a state program, not a traditional insurance plan, that facilitates and funds specialized medical care for eligible children in California.

Eligibility for the CCS program rests on four primary criteria. First, the child must be under 21 years of age. Second, the child must be a permanent resident of the California county where the application is submitted. The child’s residence is where the parent or guardian lives.

Third, the child must possess a CCS-eligible medical condition. Examples of covered conditions include cleft lip/palate, spina bifida, cystic fibrosis, cerebral palsy, severe burns, specific genetic disorders, certain cancers, and complex congenital heart diseases. CCS specifically targets conditions that are physically disabling or require ongoing, specialized care.

Fourth, financial eligibility is a determining factor for most services. Children enrolled in Medi-Cal are automatically considered financially eligible for CCS services. For families without Medi-Cal, financial eligibility is assessed based on family income, with an adjusted gross income (AGI) of $40,000 or less generally qualifying. Families with an AGI exceeding $40,000 may still qualify if their child’s medical expenses for the CCS condition are expected to be more than 20 percent of their family income.

Families who do not meet the income criteria for full financial eligibility may be subject to an annual assessment fee, which is $20, and an enrollment fee based on a sliding scale. This enrollment fee varies depending on family size and income. Families can request to waive or reduce these fees if they demonstrate financial hardship.

Services covered by CCS include specialized medical care, surgical procedures, diagnostic tests, medical equipment, and orthopedic appliances. Rehabilitation therapies, such as physical, occupational, and speech therapy, are also covered. CCS also provides medical case management to help coordinate care with specialists and other agencies.

CCS works in coordination with any other health insurance a family may possess, including private insurance or Medi-Cal. CCS functions as a “payer of last resort,” meaning primary insurance benefits are generally utilized first. The program then covers medically necessary services related to the eligible condition that are not fully paid for by the family’s primary insurance.

Applying for CCS Services

Initiating an application for California Children’s Services begins with a referral. A child’s healthcare provider, such as a doctor or hospital, can make a referral to the local county CCS office. Parents, guardians, or others can also directly contact their county CCS office.

To complete the application, families must gather specific documentation:
Personal identifying information for the child and parents or guardians (names, dates of birth, residency details).
Medical records related to the child’s suspected eligible condition (diagnosis reports, treatment history, physician’s notes, test results).
Financial documentation (proof of income, tax returns, pay stubs) to assess financial eligibility, unless the child has full-scope Medi-Cal.
Proof of California residency, usually through the parent’s address.

Official application forms can be obtained from the local county CCS office or downloaded from the county health department’s website. These forms require accurate and complete information based on the gathered documents.

Once the complete application package is submitted, a review process begins. The county CCS office reviews the submission, which includes both a medical eligibility review by CCS medical staff and a financial eligibility review by specialized personnel. A nurse case manager reviews medical reports to determine if the child’s condition meets CCS criteria. Concurrently, human services specialists assess financial and residential eligibility.

Families are formally notified of the eligibility decision, whether approved or denied, through written communication. This notification outlines the basis for the decision. If the application is denied, families have the right to appeal the decision. An appeal can be filed with the Department of Health Care Services (DHCS) and/or the local CCS program within 30 calendar days of receiving the written denial notice. Families can also request a state hearing to challenge the decision, which can be done without first filing a local appeal.

Managing CCS Approved Care

Once a child receives approval for California Children’s Services, families can access authorized medical services. Accessing care under CCS requires specific authorizations for treatments, specialist visits, medical equipment, or therapies. CCS provides service authorization requests (SARs) that enable payment for approved services related to the child’s eligible condition.

CCS works with a network of approved providers and facilities, referred to as “paneled providers” or “special care centers”. These are specialized hospitals, clinics, and individual healthcare professionals who meet specific requirements to treat CCS clients. Families can obtain lists of these approved providers from their local CCS office or the Department of Health Care Services website.

Maintaining eligibility and continuity of care involves ongoing family responsibilities. Children enrolled in CCS undergo annual reviews to re-evaluate medical and financial eligibility. During these reviews, the child’s medical condition is reassessed, and financial information is updated. Families must report changes in income, other health insurance, or residency status to their CCS case manager. Regular communication with the case manager or care coordinator is important for coordinating appointments and understanding treatment plans.