(1) A child who is receiving Medicaid or is presumptively eligible for Medicaid is eligible for targeted case management services for children and youth with special health care needs if the child meets one of the requirements in (a) or (b) and meets one of the requirements in (c).
(a) The child is under the age of one and meets one of the following:
(i) was born to a mother who abused drugs or alcohol during her pregnancy;
(ii) was born prior to 37 weeks gestation;
(iii) was born at a birth weight of less than 2500 grams; or
(iv) the department has care and placement authority, a voluntary services agreement, an in-home service agreement or a voluntary placement agreement with the parent/guardians.
(b) The child is birth through 18 years of age and meets one of the following:
(i) is infected with the human immunodeficiency virus (HIV), as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS;
(ii) has been diagnosed with a congenital heart condition;
(iii) has been diagnosed with a neurological disorder or brain injury;
(iv) has been diagnosed with a condition that requires use of a ventilator;
(v) has been diagnosed with a condition that causes paraplegia or quadriplegia;
(vi) has been diagnosed with another chronic physical health condition that is expected to last at least 12 months and causes difficulty performing activities of daily living; or
(vii) has been diagnosed with failure to thrive in the past year.
(c) The child is at high risk for medical compromise due to one of the following:
(i) failure to take advantage of necessary health care services;
(ii) noncompliance with their prescribed medication regime; or
(iii) an inability to coordinate multiple medical, social, and other services.
(2) Initial assessment of children covered by these special health care needs targeted case management services may occur in the hospital following the infant's birth. This assessment must be followed by a referral to appropriate service providers in the community. Assessments by all professionals will be accepted, shared, and integrated into planning for all children covered by these services.