FAQ’s - Use of Private Insurance Copays, Coinsurance and Deductibles
Why am I being asked to utilize my child’s health insurance?
California Early Intervention Services Act (CEISA) Section 95004 indicates that direct services shall be provided pursuant to the existing regional center system under the Lanterman Developmental Disabilities Services Act, contained within the Welfare and Institutions Code (WIC) and 95004(b)(1) private health insurance for medical services identified in the Individual Family Service Plan (IFSP), other than for evaluation and assessment, shall be used. Many required early intervention services are considered medically necessary by various private health insurances. Welfare and Institutions Code Section 4659(c) states that regional centers shall not purchase any service that would otherwise be available from private insurance. When should I begin to access health services for my child? Immediately. You will need to inquire and access health services while the regional center is completing evaluations and assessments to determine eligibility for Early Start. There may be duplication of assessments between the regional center and your health plan in order to determine your child’s developmental needs. If your child is eligible for Early Start, your service coordinator will review your health plan benefits and coverage limitations at your initial Individual Family Service Plan (IFSP). The primary funding agency for each required service will be determined and included in your IFSP. Does the regional center assist with co-payments, co-insurance and deductibles? Yes, as of July 1, 2019, regardless of income, a family is eligible for co-payments, co-insurance and deductible reimbursement. For Behavioral Services after age 3 under the Lanterman Act, income requirements below must be met in order to qualify for reimbursement. Prior to July 1, 2019 for Early Start Service OR for ongoing Behavioral Health Service after age 3 under the Lanterman Act:, families whose yearly gross income is below 400% of the federal poverty level (FPL) are eligible to receive reimbursement for co-payments/co-insurance and deductibles when the service is provided by an in network provider. Families whose yearly income is above 400% of FPL may be eligible for reimbursement if criteria for exceptional circumstances are met: 1-The existence of an extraordinary event that impacts the ability of the parent to meet the care and supervision needs of the child to help maintain the child at home or in the least restrictive setting or impacts the ability of parent with a health care service plan or health insurance policy, to pay the copay or coinsurance. 2-The existence of catastrophic loss that temporarily limits the parent ability to pay the health care service plan or health insurance policy and creates a direct economic impact on the family. Catastrophic loss may include, but not limited to, natural disasters and accidents involving major injuries to an immediate family member. 3-Significant unreimbursed medical costs associated with the care of the consumer or another child who is also a regional center consumer. What information do I need to provide to my service coordinator? 1) Explanation of Coverage (EOC): This is required if your child has private insurance and will be receiving ongoing Occupational Therapy (OT), Physical Therapy (PT), or Speech Therapy (Speech). You can obtain
Supporting people with developmental disabilities in the San Fernando, Santa Clarita, and Antelope Valleys since 1974
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