Defining serious conditions is difficult and depends on the institution (e.g., employer, broker, insurer) that hosts the program for their beneficiaries.
A number of criteria can be used to describe medical conditions as serious and complex, including severity of the illness, degree of impairment or disability, and level of need for comprehensive care management.
Regarding the following examples of descriptive criteria for serious and complex medical conditions, it is important to recognize that such conditions might be serious and complex for some patients only at some points during the course of their disease or disability.
- Conditions that are life threatening: Cancer, heart disease, stroke, and HIV/AIDS
- Conditions that cause serious disability without necessarily being life threatening: Stroke, closed head or spinal cord injuries, mental retardation, and congenital malformations
- Conditions that cause significant pain or discomfort that can cause serious interruptions to life activities: Allergies, migraine, arthritis, and sickle cell anemia
- Conditions that require major commitments of time and effort from caregivers for a substantial period: Mobility disorders, blindness, Alzheimer’s disease and other dementias, chronic obstructive pulmonary disease, paraplegia or quadriplegia, Down syndrome, and depression
- Conditions whose management requires the coordination of multiple specialties: Most cancers, multiple sclerosis, and cerebral palsy
- Conditions whose treatment poses a risk of serious complications: Most cancers and conditions requiring complex surgery