Health Insurance for People with Developmental Disabilities Feda Almaliti Teresa R. Campbell, Esq. Karen Fessel, DrPH Lisa Kleinbub, RN, MSN Sherrie Lowenstein, Esq. Disclosures: None Notes:
Getting Services for People with Autism and other DDs through Medi Cal Karen Fessel, Dr PH www.autismhealthinsurance.org UCSF Conference Who we are and what we do. Non profit public charity Formed by parents coming together and realizing that health care systems were not providing adequate care for ASDs. Mission: To help families, professionals, and people with ASDs get necessary health services through insurance, so that they can reach their full potential. Expanding to include Mental health and DDs. :
What we offer: Families and People with DDs Direct advocacy Writing appeals and grievances with health plans Requesting single case agreements with preferred specialists at in network rates. Requesting and managing regulatory intervention, including independent medical review requests Advising families on the best course of action, including teaching them how to do it themselves. Free advice Sliding scale based on income Medi Cal families, through grants. What we offer: Providers Credentialing: Getting in network with plans, contract negotiations. General guidance and strategizing on how to appeal. Denials of specific cases Advice on coding, billing, and what to include in reports to maximize payment and the likelihood of getting funded through insurance. Recovery of money, if and when health plans do not follow the contract.
What we offer: The public Through our website and quarterly newsletters: How to info, including tools, info about relevant laws and legal protections Changes in the laws, recent developments, useful links. Educational seminars in the community At conferences With Regional Centers, family resource networks Clinics including direct advocacy, by appointment. Policy Development We are in a unique position to identify gaps in the system. Work closely with regulators to inform them of systemic problems. Work closely with legislators to develop relevant policies to address problems.
Medicaid/Medi Cal, 1 Federal Entitlement Medi Cal serves low income families, seniors, persons with disabilities, children in foster care, pregnant women, and, now, due to ACA, low income adults without employment related insurance. Early Periodic Screening, Diagnosis, and Treatment: Federal law, available for low income kids (under 21) with special needs. Covers specialty mental health through county mental health departments. must correct or ameliorate defects and physical or mental conditions. Must treat existing illness and prevent development of worsening of condition. Medi Cal, Speech and OT Speech, OT, PT, some referrals to specialists. In managed care Medi Cal, must go through PCP. As needed, not limited to 2 sessions/month. Cannot be carved out to school district (SD must offer appropriate program, not prevent worsening of condition). SD s often offer pushins, in groups. Medi Cal often inappropriately denies, we ve had several successful overturns. Medi Cal Managed Care offers appeal through Fair Hearing (ALJ) or DMHC (IMR).
Medi Cal, Mental Health Issues Specialty MH is carved out to County MH Depts. Did not treat autism. Effective 1/1/2014, some MH to be provided within medical home. Due to ACA, autism can no longer be excluded or referred to RCs for MH treatment. All DSM conditions must be treated either in the medical home or in the MH carve out. (Most RCs only take on kids at the more severe end of the spectrum. Last year, many low income kids could not get MH treatment. BIG PROBLEM!!!) Medi Cal, Problems Network insufficiency. Most DD specialists are in high demand. Medi Cal does not pay competitively. We refer families to hospital based clinics. Long wait lists. Not enough providers. Community based clinics, grants, other funding streams.
Medicaid Waivers People with DDs may also qualify for Medicaid through the waiver process. The income requirements (or parental income) are waived for many with DDs. May be through Regional Centers, SSI, or other entities (many paths to Medicaid). Acertain level of disability must be demonstrated beyond diagnosis. Can be used as secondary insurance, will cover co pays for medication and treatments if the provider takes Medi Cal. Works best if primary and Medi Cal plan are in the same network. If You Can t Beat Em SUE Em! KG vs Dudek, Florida case, children with autism on Medicaid sued the state of FL and HCFA for failing to provide ABA through Federal EPSDT and won!! Was upheld on appeal. Has national implications, including in CA.
National Health Care Reform/ Covered CA Exchanges If your household earns less than 400% of FPL and your employer does not offer an affordable plan, you can purchase a plan on the exchange with tax credits and possibly subsidies. Families with children on Medi Cal can purchase a plan on the exchange. This way, they can get ABA. But $$$. Changes Due to ACA No exclusions or inflated costs due pre existing conditions. Young people can stay on parents plan until age 26. Self insured plans must offer external review for medical necessity denials and procedural violations, protections of Federal MH parity, though not held to 10 EHBs. People can buy plans on the exchange which offer state protections (ABA mandate, state MH parity, habilitative therapies). No charge for screenings for developmental disabilities. Shortcomings: habilitative therapies in parity with rehab, not enough. DME, typically only 50% coverage, no subsidies if on the waiver.
Possible Upcoming CA Legislation Intensive behavioral therapy for Medi Cal enrollees will be addressed again this year through the Trailer Bill. The RC co pay bill may be modified to be less restrictive. Insurance reform: Bill which requires plans to track co pays and co insurance towards the out of pocket maximum, inform families, and pay 100% when it has been hit. Medi Cal reform: aid paid pending for those that use the DMHC IMR for dispute resolution. Medi Cal reform: Allowing those in county mental health carve outs to use the IMR process for dispute resolution.
FAQs FUNDING OF COPAYMENTS/COINSURANCE FOR SERVICES COVERED BY PRIVATE HEALTH INSURANCE What was the status of regarding copayments/coinsurance prior to July 1, 2013? California Senate Bill 946 authored by Senator Steinberg and supported by many parent advocates was signed into law by the Governor on October 9, 2011. This bill required private health insurance regulated by the State of California to provide coverage for behavioral health treatment for persons with pervasive developmental disorder or autism. It went into effect on July 1, 2012. Many individuals have transitioned from regional center to health insurance funding for these services over the last year. Some families were required to meet deductibles and to pay copayments and coinsurance for these services. Reginal Center of the East Bay (RCEB) was able to assist families with copayments/coinsurance. The Legislature provided monies for regional center funding of these payments through June 30, 2013. What changed? Effective July 1, 2013, new legislation (AB 89) added Section 4659.1 to the Lanterman Act (California Welfare and Institutions Code). This change in the law limits regional centers ability to fund copayments and coinsurance for services or supports identified in the individual program plan or individual family service plan (IPP/IFSP) that the individual or family is accessing through private insurance. The governor proposed this change in law and the legislature approved Assembly Bill 89 that contained this change. Assembly Bill 89 is posted on our web site.
Although RCEB, other regional centers, and many advocates were opposed to these changes to the law, the state of California enacted them. New legislation would be required to change them. Under what circumstances can the regional center fund co pays/coinsurance? The following language describes the circumstances under which regional centers may pay copayments or coinsurance. Regional centers may pay copayments or coinsurance for minors whose gross family income is less than 400 percent of the Federal Poverty Level. Regional centers may pay copayments or coinsurance for adults whose gross personal income is less than 400 percent of the Federal Poverty Level Are there any circumstances when an exception can be made? The law specifies that in some cases when gross income exceeds 400 percent of the Federal Poverty Level but an extraordinary event, a catastrophic loss, or significant unreimbursed medical costs prevent the family from funding copayments or coinsurance, an exception may be made. If our family income is just a small amount above the 400 % of federal poverty level, can the regional center fund some part of my co pays? No, the law does not allow this Can the regional center fund my child s health insurance deductible? No, this law prohibits regional centers from paying health insurance deductibles. How can I find out what 400% of the federal; poverty level is for my family? A chart detailing 400% of federal poverty for different family sizes is on our web site. If I believe that our income does not exceed 400% of the federal poverty level and we need assistance with copayments/insurance, what do we need to do?
You will need to provide your case manager with a complete copy of your most recent Federal Tax Form 1040. It is best if you can send this to the case manager electronically. You can redact social security numbers. These documents will be kept confidential. Fiscal staff will review the documentation to determine if RCEB can fund co pays/coinsurance. If we can, you will submit additional documentation on your actual copayments/coinsurance. If our income exceeds 400% of the federal poverty level but I believe we would qualify for an exception, what do we do? Contact your case manager to discuss your specific situation. Each situation will be different and may require different information. Where can I find additional information and help with this process? Your case manager has been trained on the procedures to follow within the regional center review family/individual income level to determine whether we can help with copayments/coinsurance. They will be your best source of information and have resources to help them with this process. RCEB is committed to providing you with ongoing support. We will also maintain current information on our web site at www.rceb.org.
August 12, 2013 RE: CHANGE IN REGIONAL CENTER OF THE EAST BAY S FUNDING OF COPAYMENTS/COINSURANCE FOR SERVICES COVERED BY PRIVATE HEALTH INSURANCE Dear Regional Center of the East Bay (RCEB) Consumers and Families: In July 2012, a new law went into effect in California. It required that many private health insurers in California pay for behavioral health treatment for persons with pervasive developmental disorder or autism. Heath insurers started to pay for services previously funded by regional centers. Some families had to pay copayments for these services and RCEB was able to help families with these co pays. Another change in law occurred effective July 1, 2013. A new law (AB 89) was passed that changed the Lanterman Act (California Welfare and Institutions Code) and it limited when regional centers could help with co pays or coinsurance. Now regional centers can only help when the family or individual income is below 400% of the federal poverty level. A chart is attached so you can see what this means based on family size. The law allows for some exceptions for people who have faced catastrophic or extraordinary circumstances and those with extraordinary medical expenses. The law also states that we shall not pay insurance deductibles. Although RCEB, other regional centers, and many advocates were opposed to these changes to the law, the State of California enacted them. As these rules are now in law, new legislation would be required to change them. These changes to the law mean RCEB will need information on family or individual income before we know if we can help with co pays and coinsurance. We need to know if your income is above or below 400% of the federal poverty level. Your case manager will tell you what documents are needed. We understand that these changes to the law may be difficult for you and your family. We do want to provide you with ongoing support. Your case manager is your most important resource but we will also have up to date information on our web site (www.rceb.org). San Leandro (Main Office): 500 Davis Street, Suite 100 San Leandro CA 94577 Tel: 510 618 6100 Fax: 510.678.4100 Concord: 2151 Salvio Street, Suite 365 Concord CA 94520 Tel: 925 691.2300 Fax: 925 674.8001 Website: www.rceb.org