Thank you to Autism Speaks, Family Services Department, for a generous grant supporting the creation of this webpage and the funds to advocate with policy makers and provide individual assistance to families on Medi-Cal.
Medi-Cal, the CA version of Medicaid, is free or low-cost health insurance for California residents who qualify. It is administered by the CA Department of Health Care Services (DHCS). Most Medi-Cal plans now run through a managed care plan administered by your county. Managed Care Medi-Cal is regulated by the Department of Managed Health Care (DMHC). Medi-Cal was excluded from SB 946 and California’s Mental Health Parity Act, (these laws require insurance companies to provide behavioral health therapies for children with autism).
ABA is finally available for children with ASDs on Medi-Cal! Beginning September 15, 2014 low-income families on Medi-Cal may call their health plan and their child's primary care physician and request an assessment for ABA therapy.
In July 2014, the Centers for Medicaid & Medicare Services issued federal guidance to the states indicating that ABA is a covered benefit for children under 21-years-old. This benefit was hard fought for by families, advocates and supportive public officials.
How to get Behavioral Intervention Therapy (ABA)
In order to be eligible, children will need to have a diagnostic assessment of autism spectrum disorder, and a prescription for ABA therapy from either a psychologist or treating physician. The prescribing professional will need to explain why ABA therapy is medically necessary for a child. More information.
Speech and Occupational Therapies
Medi-Cal managed care plans are governed by the Knox Keene Act, and must meet the requirement to provide “Basic Health Care Services” as described in Health & Safety code §1367(i) and further elaborated in 28 CCR §1300.67 (a) (1). Speech and occupational therapies are considered basic health care services, and you can argue that you are entitled to these medically necessary services if you are in a Medi-Cal managed care plan and they attempt to deny or limit the number of sessions that you receive. We encourage you to obtain a letter from your child’s physician attesting to the medical necessity of these treatments.
How to Request Speech or OT
If you are in a Medi-Cal managed care plan the first step to requesting speech or OT is to visit your child's primary care doctor and request a speech or OT evaluation. Your doctor can make the request to the health plan on your behalf. Unfortunately physician requests are sometimes denied by the health plan, so it is in your interest to request a letter of medical necessity from your doctor, in the event that you have to appeal. Here is a sample letter that you can give to your doctor or psychologist for him or her to edit.
What if my doctor says no?
If your doctor tells you that this is not a covered benefit, or that you need to obtain speech or OT through your school district, they are wrong! Ask them to put this denial in writing for you so that you can appeal it to the health plan and the Department of Managed Health Care. You should also send a formal written request for services to your health plan. We have created a sample letter to request service.
What if my doctor says yes, but I never hear from the health plan?
If your doctor orders a speech or OT assessment from you, mark the date of their request on your calendar. It would also be helpful for them to put in writing for you that they made the request on a particular date. If you do not hear back from your health plan within 30 days, visit the www.dmhc.ca.gov and file a complaint against your health plan. The DMHC will contact you, and contact your health plan, and force them to respond.
What if my health plan responds within 30 days and says no?
If your health plan responds with a no, you can appeal. If they deny based on medical necessity, use the letter of medical necessity that you requested from your child's MD when you requested the service.
You are going to want to carefully review the plan’s reason for denial and address that in your appeal letter. The health plan cannot simply refer you to your school district for treatment, as this violates federal EPSDT statutes. EPSDT is a federal law which stands for Early Periodic Screening Diagnosis and Treatment and requires Medi-Cal to screen for, diagnose, and treat disabilities in low-income children. The program must “correct or ameliorate defects, physical and mental illnesses, and conditions discovered by screening services, whether or not such services are covered under the Medicaid State Plan." For a thorough discussion of what can be provided under EPSDT statutes, read this article.
Speech Therapy Denials
FALSE: Only Two Visits Allowed Per Month In 2013 and 2014 many Medi-Cal patients received notice that their child's speech therapy visits were cut to twice monthly. Denial letters stated that two visits per month is the maximum amount allowed by the law. This is not true! The law in questions AB X3 5 (Evans, Chapter 20, Statutes of 2009) specifies that additional speech therapy is available to individuals under 21 through Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Services where medically necessary. We have created a sample appeal letter that you may use to appeal the denial to your health plan. Be sure to attach this document about the law AB X3 5.
FALSE: Please Contact Your School District for Speech Families often report being denied speech therapy with the explanation that this is a service they should seek from their local, public school districct. This is an inadequate explanation, and if you have received this type of letter, you should appeal. We have created a sample letter that you may use to appeal the denial to your health plan.
If you are having difficulty with your health plan and are not sure what your rights are, the Medi-Cal Ombudsman’s office may be able to help.
No Available Providers/Timely Access to Care & Evaluation
The DMHC will get involved if families are having difficulty accessing autism specialists, including speech therapists, occupational therapists, and others such as psychologists and developmental pediatricians, after you have filed an appeal or grievance with your plan. While in some counties there are qualified autism professionals that are in the plan network, in many counties, Medi-Cal plans have inadequate autism networks. The only way to get these treatments is to follow through and insist on single case agreements. A single case agreement is a special contract that the health plan sets up with a specialist, just for your child, because they don’t have an adequate network. The plan must make up the difference in cost between their usual rate and the rate that the provider requests if they do not have an adequate network. If your Medi-Cal managed care plan does not have providers, please contact the DMHC for assistance: 1-888-466-2219.
In some counties, families wishing to have their child evaluated for autism must wait 6-12 months. This is too long! Under the law, patients should be able to schedule with a specialist within three weeks. We have created a sample appeal letter that you may customize to request a single-case agreement with another qualified autism evaluator.
Other Mental Health Services
Sometimes children with autistic spectrum disorders need other mental health treatments, besides or in addition to ABA, such as weekly or more frequent psychotherapy. Sometimes it may be for the treatment of anxiety, depression, or something else, or it may be for symptoms related to autism. Recently, all mental health services within Medi-Cal have been carved out to the county mental health departments. In 2014, DHCS says that some people will be able to get treatment within the main managed care plan, and some will be referred out to the county system. We are not clear where and how people with autism will get mental health treatment. Some county mental health programs have been turning away people with autism, saying that they are not equipped to handle their issues or they are not allowed to treat the symptoms of autism. We are very concerned about this type of discrimination, and are very interested in hearing from you if you have been told this. Please contact us and let us know if this has happened to you. This information can help us correct a system that is not working right.
Appeals, grievance, and your rights
In the Managed Care Medi-Cal system, if you do not agree with the decision of the health plan, there are usually instructions on how to file an appeal in the denial letter. If they try to tell you on the phone that services are not covered, ask for the letter in writing (they have to provide this). If you are currently getting services, and the plan notifies that you that they will be terminating or cutting back on services, you have the right to aid paid pending (that means they continue the services until you go to fair hearing), but you have to fill out and return the form within ten days. You would then file an appeal letter with your health plan (you can do this by phone or in writing, if you do it in writing, you will have a copy for your records). If the plan continues to deny your request, you can choose to go to fair hearing or to an independent medical review with the DMHC. If you apply for aid paid pending, you have to go to fair hearing. A fair hearing is a small trial in front of an administrative law judge. If you have health professionals that support your child getting the care, it is a good idea to get one of them to come or at least submit a written statement. The independent medical review process is often a better option, especially if your child has a good medical reason to get care, because all the information goes out to a medical expert to decide. Overall, rates of success are higher in IMR than in fair hearing. Currently, you do not have the option to get aid paid pending when you go through DMHC, but this is something that we would like to see changed.
The county mental health system does not allow the option of independent medical review. Your only dispute resolution option is fair hearing. If you can get your mental health care within the HMO, however, we believe you will be able to use the IMR process for disputes.
Medi-Cal waivers are special programs that are available to those with certain types of disabilities. They allow the person with the disability to “waive” or bypass the income requirements that people without disabilities are subjected to. The most common Medi-cal waiver that children with developmental disabilities get is the Home and Community Based waiver, which they typically get through the regional center system. Some regional centers try to put all of their clients on the waiver, as they get a greater contribution from the federal government, while others do not. The idea behind this waiver is that it is much less expensive for someone to live in their home and community than in an institution, and so the government waives the income requirements for people that are at risk for being institutionalized. It is also possible to get on Medi-Cal through SSI, this may involve considering family income, but the family can have a higher income than Medi-Cal beneficiaries who are not disabled.
Options under Covered California
Under Covered California, the new health exchange, if your household income is less than 400% of the federal poverty level, and you do not have another offer for a health plan (i.e. you or your spouse or parents does not have a plan through work), you will likely be eligible for tax credits and possibly subsidies on co-pays and deductibles. If the person with a disability is on Medi-Cal through the waiver, however, this counts as an offer of insurance, and that person will not
qualify for tax credits or subsidies. At certain income levels, the parents will not qualify for Medi-Cal, but the children will (children qualify for Medi-Cal if they are within 250% of the FPL.) Because ABA is not covered under Medi-Cal, but it is covered under Covered CA, some families, especially those who do not qualify for regional center, may want to consider buying a plan for their ASD child. It will be important to consider the out of pocket costs if you choose to do this. The platinum plan may be the best option, because the out-of-pocket costs are the lowest. Costs range from $190 - $250 (unsubsidized) for monthly premiums. There are no deductibles, and co-pays cannot exceed $4,000 total for the year. Assistance for co-pays may be provided through grants from charitable foundations.
Kaiser Permanente special plan for children
Kaiser offers a special, subsidized plan only for children, that is available to those who do not qualify for Medi-cal or a health plan through the parent’s work. The family must earn less than 300% of the Federal Poverty Level. This option offers ABA to those with autism, has low out of pocket costs, and premiums range from 0 - $20 monthly. Information can be found here.
CoPays, CoInsurance & Deductibles
Senate Bill 856, which went into effect June 2014, authorizes a regional center to reimburse a consumer's insurance deductible on any given service if it is in their individual program plan (IPP). Prior law authorized regional centers to reimburse copayments and coinsurance on services paid for by health plans, but it explicitly excluded the deductible. Now RCs are authorized to cover deductibles too! Eligible families must earn less than 400 percent of the federal poverty level, or $95,400 for a family of four.