As of July 1, 2018, CenCal Health is now managing all the health care needs for its members under 21 years of age who are eligible for California Children’s Services (CCS). In order to better coordinate care for these children with complex medical needs, the California Department of Health Care Services authorized the change, called the Whole-Child Model, in order to improve the integration of services and overall outcomes for these children.
CenCal Health is now responsible for case management and authorizing medically necessary covered services of both CCS and non-CCS health conditions, including coordinating pediatric referrals, hospital stays, medications, supplies, and durable medical equipment for CCS-eligible Medi-Cal members. Care coordination of CCS clients who are not CenCal Health members will remain as the responsibility of the local County CCS offices.
The CCS program was designed to assist children with serious medical conditions requiring specialty medical care or rehabilitative services. Children with CCS-eligible conditions previously received services related to their CCS condition from the County in which they reside and CenCal Health coordinated the remaining services outside of their CCS condition. This model of care led to additional complexity for families trying to navigate access to care. The Whole-Child Model seeks to eliminate a bifurcated system and provide comprehensive treatment.
“CenCal Health has helped families obtain quality care for 34 years,” said Dr. Takashi Wada. “The Whole-Child Model will improve the function and quality of life for children with severe disabling conditions by simplifying the coordination of their care.”
To be eligible for CCS, a child must be under 21, meet residential and financial requirements, and must have a CCS eligible medical condition such as neoplasms (cancers, tumors), Cystic Fibrosis, chronic lung disease, congenital heart disease, rheumatic heart disease, Cerebral Palsy, Epilepsy or other severe conditions that fall under the CCS eligibility criteria.
The Whole-Child Model will eventually roll out to all 21 specified counties with a County Organized Health System or Regional Heath Authority. CenCal Health is among the first health plans to implement this change.
In preparation for this transition, CenCal Health formed a Family Advisory Committee comprised of CCS members and their families in order for CenCal Health to receive continuous feedback on the transition and ongoing program. CenCal Health also has a Pediatric Clinical Advisory Committee and encourages input from physicians.
Anyone can refer a child to CCS including family, school personnel, physicians and other providers. CenCal Health’s pediatric team requires medical documentation and prescriptions from providers to authorize services. Providers must be CCS paneled and approved for services to be authorized.
CenCal Health provides health insurance for approximately 20 percent of residents in Santa Barbara and San Luis Obispo counties, or nearly 180,000 members. For more information or questions about Whole-Child Model and California Children’s Services, please contact the CenCal Health Provider Services Department at (805) 562-1676 or email firstname.lastname@example.org.