Transcript Healthcare Systems for Children

Healthcare Systems
for Children
37
Medicaid (Medi-Cal)


California’s
Medicaid program
Health insurance for
low-income families
and individuals
38
Fee for Service Medi-Cal

Go to any doctor who accepts
Medi-Cal


Don’t need a referral to see a
specialist
Eligibility – children who



receive SSI
are in foster care
Most children aren’t eligible for
this
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Medi-Cal Managed Care
HMO
 Most common kind of
Medi-Cal
 Only choice for most
children
 Primary care provider

• gatekeeper
• need referral to see a
specialist
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Medi-Cal Managed Care

Different Plans

Los Angeles
• LA Care
• HealthNet

Orange County
• Cal Optima
• All Medi-Cal
programs are
managed care
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Automatically Qualify for
Medi-Cal if you are in…

SSI/SSP (Supplemental Security
Income/State Supplemental Program)

CalWORKs (California Work
Opportunity and Responsibility to Kids).

Refugee Assistance
 Foster Care or Adoption
Assistance Program
 TANF (Temporary Assistance to
Needy Families)
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Medi-Cal for Children with
Disabilities

Medi-Cal even
if families make
too much to
qualify
Share of cost
 Waiver

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Share of Cost Medi-Cal


For people with disabilities who
make too much money for
regular Medi-Cal
pay a certain amount (share of
cost) each month that you
receive medical care before
Medi-Cal begins to pay
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Waiver

For some children who



are medically fragile or
have developmental
disabilities
Does not count parents’
income in deciding eligibility
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Eligibility for Medi-Cal

Income

Few resources

United States
Citizen or
documented
resident
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Important Points about
Medi-Cal

Many ways to qualify for MediCal


a child with a disability may qualify
even if the rest of the family
doesn’t
It can be very confusing to figure
out if you or your child qualifies

Eligibility is different depending on
the age of the child and whether
he/she has a disability
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Important Points about
Medi-Cal

You can get help with things
like



finding out if your child is eligible,
filling out applications or
problems
at places like the Consumer
Health Center of Los Angeles
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Denti-Cal
Program for dental care.
 Provides

regular cleaning and
check-ups
 needed dental work
 Orthodontia

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Eligibility for Denti-Cal

Eligible for MediCal

Over age 3
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Important points about
Denti-Cal

List of dentists who
accept Denti-Cal
from CHDP

Covers orthodontia
for children
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Healthy Families

Insurance program for
children 0 to 19 years of
working families
• Income too high for Medi-Cal
• Under 250% FPL
• No health insurance
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Paying for Healthy Families

Monthly premium





family size,
income and
amount of services you need
Different plans cost between
$4 - $15 a month (per child)
The most you can pay is $45
per month.
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Paying for Healthy Families

co-pay each time you receive
services


Usually $5
No charge for preventive
services, like yearly check-ups
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Eligibility for Healthy
Families





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Children age 0 – 19
Working families
Under 250% FPL
($3,928 for a family
of 4).
United States
Citizen or
documented
resident
California resident
Important Points about
Healthy Families


Comprehensive health care
Several choices of Healthy Families
plans

look at each plan and pick the one that
bests meets your child’s needs
• Check to see which doctors belong to
which plans
• Look at what medications are covered
• Decide if you need vision coverage as well
as health care
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Healthy Kids Los Angeles

Comprehensive health
insurance for children
0 to 19
 who don’t qualify for Medi-Cal
or Healthy Families


Free or low-cost
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Paying for Healthy Kids

Premium ranges
from 0 - $12 per
child a month


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Maximum of $24
a month
Co-pay for some
services
Eligibility for Healthy Kids

Children ages 0 to
19

Living at or below
300% FPL

Living in Los
Angeles County
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Eligibility for Healthy Kids

Ineligible for




no-cost, full-scope Medi-Cal,
Healthy Families,
Access for Infants and Mothers
(AIM) or
job-based health insurance
program, and not covered by
Kaiser Child Health Plan.
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Important Points About
Healthy Kids



Insurance can be used by children
who are undocumented
Includes dental and vision
There is a maximum enrollment


waiting list if full
Healthy Kids programs in other
counties
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Other publicly funded
insurance for children

KP Child Health Plan
 Low-cost health care for children 0 – 19.
 up to 300% FPL
 for children who don’t qualify for
• Medi-Cal
• Healthy Families or
• insurance paid in any part by an employer
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Other publicly funded
insurance for children

California Kids



Comprehensive primary health care
services to children ages 2 through
18.
Provides insurance for kids who don’t
qualify for Healthy Families, up to
300% FPL
Not taking applications at this time
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Child Health and Disability Prevention
Program (CHDP)



Early Periodic Screening
Diagnosis and Treatment
(EPSDT)
A well-child screening program
for infants, children and teens
Well child exams


diagnosis and treatment
Free services
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Eligibility for CHDP
Children with Medi-Cal from birth to
age 21
 Children from low-income families
birth to age 19


not eligible for Medi-Cal
• below 200% FPL

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Children in Head Start and State
Preschool programs (generally ages
3-5).
Important points about
CHDP

CHDP can pay for services like



Sports and camp physicals
Mental health services
Expanded dental services
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Children’s Programs for Special
Populations
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California Children’s Services
(CCS)
Program for children
and youth


serious and/or chronic
medical conditions

0 – 21
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CCS

pays for services that are
provided at special care
centers

pays for special equipment

only pays for services for
child’s CCS eligible condition
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CCS

Medical Therapy Program
(MTP)
provides therapy services,
such a physical therapy, or
occupational therapy
 Medical Therapy Units
(MTUs) are at schools


No income requirement
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Eligibility for CCS



Birth – age 21
CCS eligible condition
For general CCS



Family income under $40,000 or
Expect to pay over 20% of income for
treatment of CCS eligible condition
For MTP only

No income eligibility
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Eligibility for CCS

Permanent resident of
California


Do not need to be documented
Parents live in the county
where you apply
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Important Points about CCS

Anyone can make a referral

Can pay for diagnostic services

Some children may qualify for
MTP services but not general
CCS.
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County Department of
Mental Health (DMH)
For children with Serious
Emotional Disturbance
(SED) such as

severe depression or bi-polar
disorder.


not for people with
developmental disabilities or
substance abuse

unless they also have an SED.
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Mental Health Programs

Care can
include
• therapy,
• medication,
• hospitalization
and
• other services
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AB 3632 (school aged
children)

For students receiving
special education

Who need more mental
health services than
provided by special
education
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Eligibility

For general DMH services

0 – 18

Financially eligible for Medi-Cal

Diagnosed with or thought to have
an SED
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Eligibility

AB3632


Receiving or thought eligible for
special education services
Needs higher level of mental
health services than typically
provided by special education
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Mental Health Programs

Mental Health
services for
children who don’t
have a SED




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Medi-Cal,
Healthy Families,
EPSDT or
private pay
Other related programs for
children
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In Home Supportive
Services (IHSS)

An alternative to out-ofhome care,


nursing homes or board
and care facilities
Two Types


Residual program
Personal Care Services
Program (PCSP)
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Residual Program
helps pay for services to help children
remain safely in their own home
 For children

with disabilities (including blindness)
 Who don’t need personal care or
paramedical services


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Must meet SSI/SSP disability criteria
Personal Care Services
Program (PCSP)
helps pay for services to help children
remain safely in their own home
 Covers similar services

• Provides personal care and/or
• Paramedical services
• Doesn’t fund protective services

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Must receive SSI to qualify
IHSS

Services can be provided by


A hired care provider
A parent can be the provider for a
child with a severe disability only if
the parent is can’t work full-time
because of the child’s needs and
there isn’t an appropriate caregiver
available.
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IHSS

Services include







housecleaning,
preparing meals,
laundry,
grocery shopping,
personal care services
taking people to medical
appointments, and
protective supervision for
people with cognitive
disabilities
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Eligibility for IHSS




United States citizens or qualified aliens;
and California residents.
Live at home
Current recipients of SSI/SSP (PCSP) or
Current recipients of SSI/SSP (Residual)
• Are eligible for SSI/SSP but their family
income is too high
• May have share of cost
• are eligible for SSI/SSP, including income,
but don’t get SSI
• Get Medi-Cal and meet SSI/SSP disability
criteria.

Limited resources
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IHSS

You can qualify for both
Residual and PSCP

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If service is covered by both
programs, it will be funded by
PSCP
Supplemental Security
Income (SSI)



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not a healthcare
system provider
federal program
that gives a
monthly payment
automatically
eligible for fee for
service Medi-Cal
Eligibility for SSI

SSI for Children

Under age 18
or
• Under age 22
and still
receiving
special
education
services
Low income
 Limited
resources

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Eligibility for SSI
Citizen or documented
resident
 Diagnosis on the eligible list
or

• Has marked or severe
functional limitations
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Important Points about SSI



There are different
requirements for children
and adults
You must meet financial
eligibility
SSI provides a cash
payment and
makes you eligible for fee
for service Medi-Cal
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Regional Center & Health
Care Services

Serves people with
developmental disabilities

Not a healthcare provider

Can help their clients get some
of the healthcare services they
need.
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Important Points about
Regional Center & Health
Care Services

May fund healthcare
services related to the
developmental disability,

They are the payer of
last resort
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