Based solely upon annual appropriations, the CYSHCN Program will consider payment for medically necessary diagnostic and treatment services when directly related to the participant’s CYSHCN eligible diagnosis. This section provides information for some of the covered services. This is not an all-inclusive listing. Requests for services not included in this section or outside the prescribed purview below may be sent to the Program Manager, through the Service Coordinator, and will be clinically reviewed on a case by case basis.

Some services require prior authorization to be considered for payment. Please refer to the Prior Authorization section of this Manual or contact the Service Coordinator for information on the prior authorization process. For additional information on prior authorization requirements and reimbursement information, please refer to the CYSHCN Reimbursement Rate Schedule below.

Covered services include but are not limited to:

• Audiology
• Augmentative Communication Devices (including Evaluation, Purchase and Repair)
• Consultation: CYSHCN approved physician may request a consultation from another SHCN approved physician whose opinion or advice is desired for the evaluation and/or management of the CYSHCN participant's care.
• Dental Care: Only active participants who have a medical diagnosis of Cleft Lip and/or Palate, Seizure Disorder, and/or Velopharyngeal Incompetency (VPI) may be eligible for dental care. Prior approval must be obtained from the Service Coordinator for all dental care except routine dental checkups.
• Participants with a diagnosis of Cleft Lip & Palate are eligible to receive:
  • Dental Care - A maximum of two (2) routine dental checkups may be approved annually WITHOUT prior approval. A routine dental check-up consists of:
    • Examination
    • Fluoride treatment
    • Prophylaxis
    • Restorations (up to and including three (3) fillings - need not be on same day as the check up)
    • Sealants - need not be on same day as check up
    • X-rays
  • Additional preventive or restorative dentistry, endodontics, periodontics, oral surgery, orthodontics, prosthodontics, and adjunctive treatments require a written prior approved dental plan.
• Participants with a diagnosis of Seizure Disorder may be eligible to receive:
  • Gingivectomy for participants on anticonvulsant therapy. This service requires prior approval through the Program Manager.
• Participants with a diagnosis of Velopharyngeal Incompetency (VPI) are eligible to receive:
  • Dental Care - only as it relates to prosthetic management.
• Durable Medical Equipment/Supplies (including Purchase, Rental, and Repair)
• Emergency Care Centers:
  • When emergency care is necessary to stabilize the participant
  • When severe harm would be caused if emergency care was not received

It is the responsibility of the provider to notify CYSHCN within three (3) business days of the provision of emergency care. Neither CYSHCN nor the participant/family will be responsible for payment for a service when the provider fails to notify CYSHCN within three (3) business days.

• Emergency Transportation:
  • When emergency transportation is necessary to stabilize the participant
  • When severe harm would be caused if emergency transportation was not received
• Hearing Aid/Ear Molds/Repairs: When recommended by the evaluating Audiologist and Otolaryngologist, the following care and/or equipment may be considered for reimbursement:
  • Audiological Evaluation - Includes all testing performed by the audiologist to determine if a hearing impairment is present.
  • Cochlear Implants or Implanted Hearing Aids - The following care may also be considered for payment:
    • Equipment
    • Post-surgical aural rehabilitation
    • Pre-surgical evaluation
    • Surgical implantation and hospitalization costs
  • Earmolds
  • FM System/Auditory Training Unit - CYSHCN will cover the cost of a personal FM System/Auditory Trainer for home use. CYSHCN will not purchase FM Systems to be used by multiple students in a school/classroom. CYSHCN will cover the cost of accessories to a personal hearing aid that will allow the use of a school/classroom FM System.
  • Hearing Aid Batteries
  • Hearing Aid Evaluation
  • Hearing Aid Purchase - Hearing aid(s) selection is not restricted. Hearing aid requests are subject to prior approval by the Program Manager. The audiologist shall assure and include as part of their written report that the hearing aid selected is the least expensive of the appropriate hearing aids tested during the hearing aid evaluation. If only one model hearing aid is appropriate, this should also be stated in the hearing aid evaluation report.
  • Hearing Aid Repair - The cost of repair of a hearing aid worn by a participant may be billed to CYSHCN. It is the responsibility of the Audiologist to utilize existing warranties and to consider the cost of repair to an "old" hearing aid in comparison to the purchase price of a new hearing aid. Consultation with the participant's Service Coordinator is recommended if there is question of the appropriate action. Abuse to the hearing aid or the need for frequent repair should be reported to the participant's Service Coordinator.
  • Postage and Handling
• Hemophilia Factor
• Inpatient Care: The provider will notify CYSHCN within three (3) business days of admission in order for CYSHCN to consider payment. Neither CYSHCN nor the participant/family will be responsible for inpatient care service charges when the three (3) business days’ notification is not received.
• Interpreter Fees: When the provision of service coordination is not possible due to the inability to communicate.
  • In-Home Interpretation – The provider must bill CYSHCN with service code ‘0105H’ when services are provided in the participant’s/family’s home.
  • Telephone Interpretation – The provider must bill CYSHCN with service code ‘0105’ when interpreter services are delivered by telephone or at the provider/agency location.
• Medical Record Fees: Only if the provider is not enrolled with SHCN.
• Office Visits
• Out-of-State Coverage: Only in cases of emergency or when the service is not available in the State of Missouri.
  
  The provider will notify CYSHCN within three (3) business days of the emergency service in order for CYSHCN to consider payment. Neither CYSHCN nor the participant/family will be responsible for emergency care service charges when the three (3) business days’ notification is not received.
• Outpatient Care
• Prescription Medications: Generic and brand name prescription medications are considered for coverage; however, over-the-counter medications are not covered.
• Professional Fees – Inpatient/Outpatient
• Specialized Formula/Feeding Supplies
• Therapies (including Evaluation and Treatment): In-home evaluation/therapy services are not covered.