What you need to know about changes to MediCal and Healthy Families for Children

with Special Health Care Needs.

Renee C. Wachtel MD FAAPDevelopmental-Behavioral Pediatrician

Overview

This webinar will present the important changes in access to health and mental health services that will affect children with special health care needs who have health insurance through MediCal and Healthy Families programs. These are issues that families need to know, since they may impact your child’s services.

Presenter

Presented by Dr. Renee Wachtel, Developmental-Behavioral Pediatrician . Dr. Wachtel has been caring for children with developmental disabilities and behavioral issues for many years, and serves as chair of the American Academy of Pediatrics (Chapter 1) Committee on Developmental and Behavioral Pediatrics and chair of the Bay Area Autism Consortium.

Outline

What are the programs-MediCal and Healthy Families

Changes in financial eligibility for MediCal Healthy Families to MediCal MediCal FFS to Managed Care Mental Health services and schools AB 3632 How to get more information How to get help Questions?

What are the programs?Medi-Cal

Medi-Cal is California's Medicaid program. This is a public health insurance program which provides needed health care services for low-income individuals including families with children, seniors, persons with disabilities, foster care, pregnant women, and low income people with specific diseases such as tuberculosis, breast cancer or HIV/AIDS.

Medi-Cal is financed equally by the State and federal government.

Medi-Cal is California’s version of the Federal Medicaid program, which is designed for low-income individuals, blind, and disabled.

Medi-Cal

California’s Medi-Cal program currently serves more than seven million people.

Nearly half of its beneficiaries are non-disabled children and another quarter are non-disabled adults; together these two groups account for 38 percent of expenditures.

The remaining quarter of Medi-Cal beneficiaries comprises seniors over age 65 (10%) and children and adults with disabilities (16%) who account for the bulk (62%) of spending in the program (California HealthCare Foundation, 2009.)

Services covered by Medi-Cal Medical and Surgical care Wheelchairs Wheelchair Repair Hearing Aids Battery for hearing aids and/or pace makers Eyeglasses Therapy Psychologist MRIs Chiropractic Care Acupuncture Care Non-emergency transportation for Dr. appointments Physical Therapy covered in LTC facility In-home services

Healthy Families Program

CA’s Healthy Families program is the state version of the federal Children’s Health Insurance program (CHIP)

It provides health insurance for the children of working families who have more income than would qualify for Medi-Cal and yet cannot afford private insurance.

In contrast to Medi-Cal, which is provided at no cost, families with children in Healthy Families pay a monthly premium and a co-pay for using services.

Healthy Families program: Eligibility

Children in Healthy Families must live in California and:

Be age 18 or younger.

Not be eligible for no-cost Medi-Cal.

Live in families with incomes within the Healthy Families Guidelines.

Live in families without health insurance from an employer for the past three months.

Meet citizenship or immigration requirements.

Healthy Families PREMIUMS: The monthly premium for a child is determined by income category.

The income category is based on family size, family income, and the health plan you choose. You pay a monthly premium between $4 and $24 for each child, up to a maximum of $72 for all children in a family enrolled in Healthy Families.

CO-PAYS: In addition to the monthly premiums, you pay a co-payment of $5 to $15 at the time of services for a child's benefits. Some services are free. No individual charge will exceed $15 for a child's benefits.

The maximum co-payment amount per benefit year that you pay for health care services is $250 per family. A benefit year is from October 1 through September 30.

Keep all your receipts for the co-payments you make at the time of receiving health care services. Let your health plan know if you reach the maximum $250 for the benefit year of coverage. Then you will not have to make any more $5-$15 co-payment for health care services until the next benefit year of coverage. If you can show that you paid more than $250 in copayments between October 1, and September 30, the plan will reimburse you for the amount over $250.

California Department of Health Care Services

California Department of Health Care Services (DHCS) finances and administers a number of individual health care service delivery programs, including the California Medical Assistance Program (Medi-Cal), Healthy Families, California Children’s Services program (CCS), Child Health and Disability Prevention (CHDP) program and the Genetically Handicapped Persons Program (GHPP).

DHCS also helps maintain the financial viability of critical specialized care services, such as burn centers, trauma centers and children’s specialty hospitals. In addition, DHCS funding helps hospitals and clinics located in underserved areas and those serving underserved populations.

California Health and Human Services Agency (CHHS)

The California Health and Human Services Agency (CHHS) oversees thirteen departments and one board that provide a range of health care services, social services, mental health services, alcohol and drug treatment services, income assistance and public health services to Californians from all walks of life.

Approximately 33,000 people work for departments in CHHS at state headquarters in Sacramento, regional offices throughout the state and residential facilities serving individuals with mental illness and people with developmental disabilities.

Major programs include no-cost and low-cost health care coverage for low-income Californians (Medi-Cal); income support for the aged, blind or disabled (SSI/SSP); income support for CalWORKs recipients, low-cost public health insurance (Healthy Families) for children from working families.

Other large programs administered by CHHS departments include food stamps, child welfare services, in-home supportive services, support for the developmentally disabled, foster care, mental health services, drug and alcohol treatment, and vocational rehabilitation.

What are the changes for families with children with special health care needs?

Changes to Medi-Cal eligibility

Changes in Medi-Cal from Fee for service to managed care

Changes in Healthy Families

Changes in school based mental health services

Potential Changes to Medi-Cal Eligibility

In March 2010, President Obama signed federal health care reform—the Affordable Care Act (ACA)—into law. The ACA will transform the way health care is provided and paid for in the United States, representing a major undertaking that, if implemented as planned, will be phased in over the next several years. Despite ongoing political debates over various provisions of the new law, California is already preparing for some of the major changes the ACA requires states to undertake as part of health care reform.

Beginning in 2014, all citizens and legally residing noncitizens who have been in the United States for at least five years and have family incomes below 139 percent of the federal poverty level (FPL)—about $31,000 annual income for a family of four—will be eligible for Medi-Cal. This includes low income adults without children.

In CA, more families will be eligible for Medi-Cal, including some now paying for health care through Healthy Families

Medi-Cal changes from fee for service (FFS) to Managed Care

New Requirement for Children and Youth with Disabilities on Medi-Cal:

Most children who have a disability and receive fee-for-service Medi-Cal-- e.g. children on SSI, the single most common disability-related category in Medi-Cal-- now are required to join a Medi-Cal managed care plan.

As of June 1, 2011, many adults and children with disabilities who have fee-for-service Medi-Cal are required to join a Medi-Cal managed care plan if they live in one of 16 counties: Alameda, Contra Costa, Fresno, Kern, Kings, Los Angeles, Madera, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, Santa Clara, Stanislaus, and Tulare.

Medi-Cal changes from fee for service (FFS) to Managed Care: Exceptions

Not everyone on Medi-Cal in these counties is affected: Children do not have to enroll in a managed care plan if they:

receive foster care or adoption assistance benefits;

are enrolled in a private health care plan (e.g. Kaiser);

are in a long-term care facility such as a nursing home or intermediate care facility;

have Medicare as well as Medi-Cal (e.g. have End-Stage Renal Disease); or

have a share-of-cost for Medi-Cal (i.e. must spend a certain amount of money on health care each month before Medi-Cal can be used).

Medi-Cal changes from fee for service (FFS) to Managed Care: Exceptions

Children with Medi-Cal in disability-related categories (known as SPD aid codes) who also are enrolled in the CCS program are not required to enroll in managed care plans if they reside in specific counties that are organizing CCS pilot projects. This includes Alameda County.

As of May 1, 2012, CCS/SPD children in all other counties must enroll in plans. CCS/SPD children in Contra Costa, Fresno, Kern, Kings, Madera, Riverside, Sacramento, San Bernardino, San Francisco, San Joaquin, Santa Clara, Stanislaus, and Tulare counties now are required to enroll in managed care plans.

Medi-Cal changes from fee for service (FFS) to Managed Care: Exceptions

Children or youth in the exempt categories above can be dis-enrolled if they are enrolled in a plan by mistake. Parents who wish to dis-enroll a child who is not required to enroll in Medi-Cal managed care can call Health Care Options at 1-800-430-4263 (toll-free) and press “0”. This will transfer the caller to an HCO staff person who will determine that the child does not have to enroll in a plan and will explain the process for dis-enrolling.

There is a separate process for dis-enrolling children in foster care who have been enrolled by mistake; disenrollment for these children is handled by the county foster care eligibility worker or foster care-public health nurse.

Changes to Healthy Families Starting January/March 2013, coverage will move from the Healthy

Families Program to the Medi-Cal Program. Health, dental, and vision care coverage will continue during this move

and the services will be the same. Your child will continue to receive their medical services through their

current health plan. Your child’s plan will be the same before and after the move. After the move, your child’s plan will also provide your child’s vision services.

Mental Health services will be provided through the county mental health system

Your child will receive their dental services through the Medi-Cal Dental Program. You will receive another notice about how your child will receive their dental services before your child moves.

You will get a letter with the date your child is being moved to Medi-Cal. You will get more letters before your child is moved to Medi-Cal.

Changes to Healthy Families

Important reminders before your child moves to Medi-Cal:

Pay your Healthy Families premiums every month.

Respond to letters about your Annual Eligibility Review.

Send Healthy Families your new address if you move and tell them if you change phone numbers.

Watch your mailbox for more letters about your child’s move to Medi-Cal.

Changes to Healthy Families

Is Healthy Families open today?

Yes, Healthy Families is open. You can use Health-e-App, the online Healthy Families Application, for your annual eligibility reviews or to add a child to Healthy Families. Visit Health-e-App at www.healtheapp.net.

Will I pay premiums for my child in Medi-Cal?

It depends on your income. Income eligibility for Medi-Cal may change and some families may not have to pay premiums to Medi-Cal. Some higher income families may pay premiums of $13 a month for each child, with a maximum of $39 a month, for all children in one family.

Changes to Mental Health Services in Schools

ASSEMBLY BILL 114:

On June 30, 2011, Assembly Bill 114, Chapter 43, Statutes of 2011, was signed into law. Under AB 114, several sections of Chapter 26.5 of the California Government Code (GC) were amended or rendered inoperative such as AB 3632, ending the state mandate on county mental health agencies to provide mental health services to students with disabilities in Special Education.

With the passage of AB 114, it is clear that local educational agencies (LEAs) are solely responsible for ensuring that students with disabilities receive special education and related services, including some services previously arranged for or provided by county mental health agencies.

Mental Health Services in Schools

As LEAs arrange for the provision of related services the California Department of Education (CDE) has sought input from a variety of stakeholders, including a survey of over 500 families.

Of the families who responded, 25-30 percent reported being told that services, including residential services, would not be provided or continued due to a change in law or funding. The survey authors also reported that several families responded that they had not received prior written notice with the reasons for terminating residential services.

Mental Health Services in Schools

The process for taking this course of action is described in EC § 56500.4 which covers the requirements for a prior written notice to be provided to parents when the LEA proposes a change of placement or related services as documented in an IEP. EC § 56400.4 includes:

1. Per Title 34, Code of Federal Regulations (CFR), § 300.503, prior written notice shall be given by the LEA to the parents when the LEA proposes to change the educational placement or the provision of a free appropriate public education of a child.

2. The prior written notice is required to include:

A description of the action proposed by the LEA, in this case the change in related services.

An explanation of why the LEA proposes to make this change.

A description of each assessment procedure, result, record, or report the LEA used as a basis for the change.

Mental Health Services in Schools

Respondent families reported using the following types of insurance: Private: 62.6%, Medi-Cal: 29.1%, Healthy Families: 5.1% , No insurance: 3.2%

Of the families who responded, 21 percent reported that services could only be provided if the parent would allow the LEA to bill insurance.

Of the families who responded, 18 percent reported that services were denied due to lack of Medi-Cal eligibility.

Mental Health Services in Schools

Of the families who responded, 24 percent had been asked to provide consent for the LEA to file for insurance services on an IEP. Of these respondents, a small number (N=9/94) volunteered that the district explained that consent could impact service caps, costs, or lifetime benefits from the use of their insurance.

Of the families who provided responses, 64 percent reported that IEP teams had not addressed changes to services to their satisfaction. (Satisfaction with school related mental health support/services increased slightly from 2010-11 to 2011-12.)

Of the families who provided responses, 48 percent reported encountering communication barriers with LEAs related to service planning.

Mental Health Services in Schools

Per CDE’s guidance letter from July 26, 2011:

As this transition unfolds, LEAs must ensure that students continue to receive all services delineated in their Individualized Education Programs (IEPs) without interruption and in compliance with all applicable federal timelines.

The provision of any related service must continue until an IEP team determines that the student no longer requires the service.

The IEP must then be amended with the consent of the parent, guardian, or other holder of the student’s educational rights (http://www.cde.ca.gov/sp/se/ac/ab114memo.asp).

Mental Health Services in Schools

A CDE guidance document on this topic, dated September 13, 2011, states: Some financial assistance in paying for certain health care-related services may be available from insurance sources (see also Education Code 56363.5). The Code of Federal Regulations (CFR) implementing the IDEA includes guidelines outlining when school districts may access insurance:

1. An LEA may access parents’ public or private health insurance benefits to pay for related services required for a free appropriate public education (FAPE) only if the parents provide informed consent (34 CFR 300.154[d][2][iv]; 34 CFR 300.154[e][2][i]; 34 CFR 300.9). The LEA may not require that parental consent is required for the child to receive FAPE.

Mental Health Services in Schools

2. An LEA may not use the child’s public insurance benefits (such as Medi-Cal) to pay for related services required for FAPE if the use would result in any of the following:

Out of pocket expenses, i.e., deductible or copayment amounts (although the LEA may pay the amount the parent would otherwise have to pay - see number four below)

Decrease in lifetime benefits coverage

Decrease in any other policy benefit

Increase in premiums

Cancellation or non-renewal of coverage

Risk of loss of eligibility for home and community-based waivers (34 CFR 300.154[d][2][iii])

Mental Health Services in Schools

3. If an LEA is unable to obtain parental consent for the use of a parent’s public or private insurance when the parent would incur a cost for a specified service required to ensure FAPE, the LEA may pay for the service (34 CFR 300.154 [f][1]).

4. To avoid financial cost to parents who otherwise would consent to use public or private insurance, if the parents incur a cost, the LEA may pay the cost that the parent would otherwise have to pay to use their benefits or insurance (e.g., deductible or co-pay amounts [34 CFR 300.154[f][2]).

Mental Health Services in Schools

These findings suggest that there may have been compliance issues with the provision of related services and use of private insurance to cover the cost of related services.

The CDE will utilize its complaint system and ongoing compliance monitoring process, including the newly revamped educational benefit process, to ensure that LEAs are complying with special education requirements, including the areas touched on by the survey

If you have any general questions regarding this subject, please contact the Policy and Program Services unit of the Special Education Division by phone at 916-323-2409.

Conclusions

1. More families may qualify for Medi-Cal under the ACA

2. The merger of Healthy Families into Medi-Cal will enable families to access a wider array of services, such as Early Childhood Mental Health

3. Schools must still provide mental health services to children with IEPs, and must get consent from parents to change the IEP services or to access health insurance

4. We must all keep informed as the programs change and identify service gaps and access problems.

Additional information or to report problems

Healthy Families, 1-866-848-9166, Monday to Friday, 8 a.m. to 8 p.m. or Saturday, 8 a.m. to 5 p.m. www.healthyfamilies.ca.gov

Medi-Cal 1-800-430-4263, Monday to Friday, 8 a.m. to 5 p.m.

Medi-Cal Ombudsperson 1-888-452-8609

CA Department of Insurance 1-800-927-4357

CA Department of Managed Care 1-800-466-2219