What you need to know about changes to
MediCal and Healthy Families for Children
with Special Health Care Needs.
Renee C. Wachtel MD FAAP
Developmental-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 lowincome 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 MediCal. 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 MediCal 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 MediCal.

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.

A description of the action proposed by the LEA, in this case the
change in related services.


The prior written notice is required to include:
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
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:

2.

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