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
_____________________________________________________________________________________
National Health Care Reform/
Covered CA
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
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.
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.
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 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.
