Prepared by Area Board 10 — Summary of Trailer Bills that directly impact people with developmental disabilities for 2012 / 2013 budget
Insurance coverage for behavioral services for children with autism and PDD
While this law was passed a year ago, full implementation began July 1, 2012.
This law requires most private health insurance companies to provide coverage of medically necessary behavioral services (such as ABA therapy) to children with autism and pervasive developmental disorder. Medi-Cal is excluded from this provision.
In practice there are no clear requirements on issues such as what determines medical necessity, how much therapy insurance providers must cover, and if regional centers will cover co-pays. However there are some things you need to know:
- If you refuse to pursue therapy through your insurer, regional center is not obligated to pay
- If denied by your insurer, you do not have to exhaust every appeal before regional center becomes responsible
- While you await a decision from your insurer either on your initial request or on appeal, regional center is permitted to pay for services.
Some strategies to get behavioral services:
- Make sure these services are identified in your child’s IPP.
- Request therapy from your health insurer by getting a prescription for it from your child’s doctor.
- Ask the regional center to fund the services until your health insurance provider makes a determination.
- If denied by your insurer, be prepared to go through at least one level of appeal.
- Keep your documentation in good order in anticipation of appeals and/or hearings.
Early Start and insurance
While families may voluntarily ask their private health insurers to cover the cost of various therapies for their young children in Early Start, the use of private health insurance to pay for early intervention services may not result in any of the following:
- The loss of benefits for the child or family
- Difficulty in obtaining health coverage
- Increased premiums for health insurance for the child and/or family
The bottom line is that your child’s or family’s health insurance may only be used to pay for early intervention services if it will not create a negative impact on your health insurance situation.
Supported Living – a new assessment process
The assessment process for supported living has changed. As always, the agency that will provide the service will conduct a needs assessment. However, DDS has developed a standard questionnaire for the regional center to use at a team meeting in order to maximize the use of generic resources and ensure an accurate assessment of the person’s needs. This is applicable to all SLS recipients. The questionnaire is posted on the DDS website.
The requirement introduced in 2011 to obtain an outside assessment for individuals who receive high cost SLS services has been rescinded.
The state legislature has replaced the term “Mental retardation” with “developmental disability.”
In-Home Supportive Services
IHSS recipients currently have a 3.6% reduction in IHSS hours that was intended to expire in June 2012. This cut has been extended for the next year; there will be no further reduction in hours.
Rate reduction and Regional Center caseloads
For the last two years regional center service providers had their rate reduced by 4.25%. Regional Center operations budget also saw a 4.25% reduction. Starting July 2012 those reductions will be a 1.25% cut instead.
Because of the continued funding reduction, the requirements limiting service coordinator caseloads continue to be suspended. This means that caseloads are unlikely to change in the foreseeable future.
Healthcare coordination – Medi-Cal, Medicare, IHSS, and long term care
In an attempt to make healthcare more efficient and cost-effective, there is a phased in shift of Medi-Cal and Medicare recipients from fee-for-service to managed care health plans. There are multiple factors that determine when an individual will shift to managed care. This year most people who have both (called Dual-Eligibles) will be assigned to a managed care plan. Regional Center dual-eligible consumers will not be required to shift to managed care this year but will in the future. Additionally, management of long term care and IHSS hours will be taken on by these managed care health plans.
DDS and Regional Centers – transparency in use of funds
In order to increase transparency and identify discrepancies on how DDS funds are being spent, DDS and each regional center are required to compile data on how their purchase of services money has been spent. This data must be posted on the regional centers’ and DDS’ websites by March 31, 2013. This information will include data on persons served, in the following categories:
- primary language
- disability types
Additionally, each regional center must hold a public meeting explaining the data within three months of compiling it.
Developmental center admissions, use of mental health facilities and out-of-state placements.
DDS and the regional centers have great difficulty in serving individuals with complex and severe challenges. They have often resorted to placements in Developmental Centers (DC), locked mental health facilities and out-of-state facilities to meet the immediate needs of these individuals. Beginning July 2012 the use of such facilities will be discontinued or severely limited. Only Fairview DC will be used for acute crises and only if court ordered. Such a placement will be for a short term until stabilization and community supports are in place. Individuals with forensic issues will be managed using a different set of criteria. If this is an area of concern for you, the following document is recommended:
If state revenues are not what they are projected to be halfway through the budget year, the developmental services system will take another 50 million dollar cut.