Enrollees and Children with Special Health Care Needs

The term “Enrollee with Special Health Care Needs (ESHCN)” means a person having chronic and disabling condition(s) as defined in WAC 388-538-050. These enrollees must meet all of the following conditions:

  • Have a biologic, psychological or cognitive basis
  • Have lasted or are virtually certain to last for at least one year
  • Produce one or more of the following conditions stemming from a disease:
  • Significant limitation in areas of physical, cognitive, or emotional function
  • Dependency on medical or assistive devices to minimize limitations of function or activities
  • For children, any of the following:
    1. Significant limitation in social growth or developmental function
    2. Need for psychological, educational, medical or related services over and above the usual for the child's age
    3. Special ongoing treatments, such as medication, special diet, interventions or accommodations at home or school (WAC 388-538-050)

Children with Special Health Care Needs

The Children with Special Health Care Needs (CSHCN) program exists for health plans to develop a comprehensive program that will enable the Plan to identify appropriate members through a variety of methods including State identified Title V children, and program referrals from our Primary Care sites. Current CSHCN mandates are for Title V children.

Those members who score “high” risk will be referred for Case Management at Community Health Plan and will follow established Case Management processes. Outreach may include case management activities such as assisting the family in coordination of care, completing necessary “open” referrals, allowing seamless access to necessary care, and connecting the family to community resources that are available to them. For those members who may already be benefiting from case management at the Primary Care Provider's office, Community Health Plan interventions may include regular follow up with the family to ensure that current care needs are being met, periodic assessment for any anticipated health care needs, and targeted member health education material mailings.

Community Health Plan must ensure that clients have choice in healthcare providers, including PCP, to prevent any limitation or restriction to specialist care, and to ensure that the PCP has an individualized care plan for each child that includes all relevant bio-psycho-social factors. The goals of the Community Health Plan CHSCN program are to:

  • Help families through the maze of Managed Care,
  • Provide quality Case Management for complex and chronic special needs children,
  • Include, but not be limited to, providing support services to PCPs to assist with Coordination of Care and providing resource information of medical and community services,
  • Improve health outcomes whenever possible, and
  • Contain costs.