Payment of Copays, Coinsurance, and Deductibles for Service through Insurance by Regional Centers

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#F102.01

Payment of Copays, Coinsurance, and Deductibles for Service through Insurance by Regional Centers

This pub tells you when the regional center can pay for insurance payments. It tells you the type of payments it can pay for. It tells you what to do if the regional center will not make the payments.

The Department of Developmental Services (DDS) through its Budget Trailer Bill (TBL) changed the laws related to funding of copays, coinsurance, and deductibles by regional centers. The specific changes are described below.

Can the regional center pay for my copays, coinsurance, and/or deductibles under the Lanterman Act?

Yes. For minors, the regional center may pay for insurance copays, coinsurance, and/or deductibles if the service is included in the child’s individual program plan or individual family services plan and is needed to ensure that your child receives the service.1 The following criteria must also be met:

  1. The child is covered by a health care service plan or health insurance policy under his or her parent/guardian/caregiver.
  2. The family’s annual gross income is at or below 400 percent of the federal poverty level.
  3. There is no other third-party responsible for the cost.

For adult consumers, the regional center may pay for insurance copays, coinsurance, and/or deductibles if the service is included in the individual program plan (IPP) and needed to ensure that the service is received. The following criteria must also be met:

  1. The consumer has an annual gross income of 400 percent of the federal poverty level of less.
  2. There is no other third-party responsible for the cost.2

What if our family has an income over 400 percent of the federal poverty level?

For families that have an annual income above 400 percent of the federal poverty level, the regional center may pay copays or coinsurance if needed to maintain the child in the home and one or more of the following applies:

  1. An extraordinary event occurred that impacts the ability of the parent/guardian/caregiver to pay the copay or coinsurance or to meet the care and supervision needs of the child.
  2. A catastrophic loss (things like natural disasters or accidents) that temporarily impacts the ability of the parent/guardian/caregiver or adult consumer to pay copays or coinsurance.
  3. Significant unreimbursed medical costs associated with the child or another child who is a regional center consumer.3

How does the regional center know what my gross annual income is?

You should provide the regional center with a copy of the W-2 Wage Earner Statement, payroll stubs, state income tax return, or other proof of income.4 You should notify the regional center when a change in your income occurs that could result in a change in eligibility.5

What is the federal poverty level for 2014?

Persons in Family 48 Contiguous States and D.C. 400% of Poverty Level
1 $11,670 $46,680
2 15,730 62,920
3 19,790 79,160
4 23,850 95,400
5 27,910 111,640
6 31,970 127,880
7 36,030 144,120
8 40,090 160,360
For each additional person, add 4,060  

How can I find the federal poverty level for future years?

You can go to this website for information about the federal poverty level: http://aspe.hhs.gov/poverty/index.cfm. 400% of the federal poverty level is the federal poverty level multiplied by 4.

Can the regional center help pay for my deductibles under the Lanterman Act?

Yes, as of June 20, 2014, the law was changed to allow the regional center to pay for deductibles as outlined above.6

Written Notice of Action Required to Be Given By the Regional Center

If you request a service or support, like funding of a copay, the regional center has 15 days to make a decision about whether or not to authorize that service or support.7 The regional center then has 5 days to send you a notice of action if they are denying your request.8 If you and your regional center do not agree on a change to your current services, the regional center must give you a notice 30 days before the change begins.9 The notice must give you the following information:

  • the action the regional center is taking;
  • the basic facts about why the regional center is making its decision;
  • the reason for the action;
  • the effective date; and
  • the specific law, regulation or policy that supports the action.10

Filing for Hearing

If you are already receiving the service and you disagree with the regional center’s decision and want to continue to receive the service, you must request a fair hearing within 10 days of receiving the notice.11 Otherwise, the request must be made within 30 days.12

Your Rights During the Hearing Process

You have a right to:

  • See your regional center records;
  • Be present and give evidence by speaking or writing.
  • Have your own family, friends, therapists or doctors be present and speak on your behalf.
  • Have a lawyer or advocate present.
  • Have an interpreter if your primary language is other than English.

Prepare for Your Hearing

  • Gather information that shows that you need the services that the regional center wants to change. Make sure the information you use is accurate and explains your needs in detail. Also, find people who are willing to go to your hearing and tell the judge why you need the services. Make sure these people know your needs.
  • At the hearing, you can argue that you have the right to have your needs met to fulfill your IPP or IFSP goals and objectives or explain why you meet an exception or exemption to the law.

For more important information on how to appeal decisions by the regional center, read our publication, Regional Center Hearing Packet, at http://www.disabilityrightsca.org/pubs/548401.pdf

1 Welfare and Institutions Code Sec. 4659.1(a).– (Return to main document)

2 Welfare and Institutions Code Sec. 4659.1(b).– (Return to main document)

3 Welfare and Institutions Code Sec. 4659.1(c).– (Return to main document)

4 Welfare and Institutions Code Sec. 4659.1(d).– (Return to main document)

5 Welfare and Institutions Code Sec. 4659.1(e).– (Return to main document)

6 Welfare and Institutions Code Sec. 4659.1(a).– (Return to main document)

7 Welfare & Institutions Code Section 4646(f).– (Return to main document)

8 Welfare & Institutions Code Section 4710(b).– (Return to main document)

9 Welfare & Institutions Code Section 4710.– (Return to main document)

10 Welfare & Institutions Code Section 4701. The information must also be in the language you understand.– (Return to main document)

11 Welfare & Institutions Code Section 4715.– (Return to main document)

12 Welfare & Institutions Code Section 4710.5 (a).– (Return to main document)

 

 

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