HEALTH CARE CONNECTIONS:

Transcription

1 HEALTH CARE CONNECTIONS: A Guide for Families of Children with Special Health Care Needs Produced by Bay Area Family Health Links Center for Access to Resources & Education (CARE) Family Resource Network Of Alameda County Matrix Parent Network and Resource Center Support for Families of Children With Disabilities This project has been funded by the California State Council on Developmental Disabilities, PDF Cycle XX, Contract #HD Updating and re-printing funded by California HealthCare Foundation, 2001.

2 FORWARD Health Care Connections: A Guide for Parents of Children with Special Health Care Needs is the product of a collaborative project of four Family Resource Centers: Center for Access to Resources & Education (CARE) 1350 Arnold Drive, Suite 203 Martinez, CA Phone: (925) Fax: (925) careofarc@aol.com Family Resource Network of Alameda 5232 Claremont Avenue Oakland, CA Phone: (510) Fax: (510) TDD: (510) o-frnoak@inreach.com Matrix Parent Network and Resource Center 94 Galli Drive, Suite C Novato, CA Phone: (415) Fax: (415) TDD: (415) matrix@matrixparents.org Website: matrixparents.org Support for Families of Children with Disabilities 1 Mission Street, San Francisco, CA 941 Phone: (415) Fax: (415) info@supportforfamilies.org While we have had this guide reviewed for accuracy by many people, the information contained herein is subject to change at any time. You should always ask anyone with whom you are working for copies of their current regulations, policies and guidelines should there be questions. ii

3 TABLE OF CONTENTS ACKNOWLEDGMENTS A. CORE VALUES FOR PROVIDING HEALTH CARE B. DESCRIPTION OF SERVICES A description of managed care plans, private health care and public programs for which families of children with special health care needs may be eligible Federal poverty chart C. CHOOSING A CARE PLAN AND PROVIDER Tips on choosing the right plan and health care provider for your child Worksheet: Choosing a Primary Care Provider D. WORKING IN PARTNERSHIP WITH YOUR PROVIDER Tips on communicating and working together with your child s care providers Worksheet: Questions and Concerns Keeping Track of Records Worksheet: Telephone Log Worksheet: Key People Chart Form: Authorization for Release of Medical Records E. MAKING CHANGES: ADVOCACY Tips on advocating for your child What to do When Things Go Wrong: Who to Contact, Grievance Procedures, Flow Chart of Services Helpful Hints for Writing Letters Sample Letter 1 Sample Letter 2 Monitoring agencies F. RESOURCES National Organizations State Resources Local Resources G. GLOSSARY Definitions of Health Care Terms H. REFERENCES iii

4 ACKNOWLEDGMENTS This Manual represents a collaborative effort of four Bay Area family resource centers: Center for Access to Resources & Education, Family Resource Network, Matrix Parent Network and Resource Center, and Support for Families of Children with Disabilities. We would like to acknowledge the California State Council on Developmental Disabilities (PDF Cycle XX, Contract #HD979050) for its support of this valuable tool for parents of children with special health care needs. The contributions of the following people are gratefully acknowledged: Anquanitte Barnes, MPH, Health Promotion Coordinator, Partnership HealthPlan of CA, Suisun, CA Barbara Bennett, MD, Director of Developmental Pediatrics, California Pacific Medical Center, San Francisco, CA Candida Brown, MD, Dept. of Pediatric Neurology, Kaiser Permanente, Walnut Creek, CA Patricia Bruno, JD, Bay Area Coordinator, Health Access Medi-Cal Community Assistance Project (MedCAP), San Francisco, CA Rokhsareh Charney, MD, California Children Services, San Mateo County, CA Lucy Crain, MD, MPH, Chairperson, California District, American Academy of Pediatrics; Clinical Professor of Pediatrics & Director of Pediatric Disabilities & Down Syndrome Clinics, University of California, San Francisco, CA Mildred Crear, RN, PHN, Maternal Child Health, San Francisco Health and Human Services, San Francisco, CA David Banda, Children s Medical Services Branch, State of California, Sacramento, CA Elissa Gershon, Attorney, Protection and Advocacy, Inc., Sacramento, CA Cindy Grace, Parent of a child with special health care needs, Martinez, CA Maridee Gregory, MD, Chief of Children s Medical Services Branch, State of California, Sacramento, CA Noeta Hester, RN, Manager of Utilization Review and Case Management, Alameda Alliance for Health, and parent of a child with special needs, Alameda, CA Patricia Jackson, RN, PHN, Department of Family Health Care Nursing, University of California, San Francisco, CA Gwendolyn Johnson, MD, Director of Newborn Nursery and Child Development Clinic, Contra Costa Regional Medical Center, Martinez, CA iv

5 Dorothy Jones, RN, Pediatric Rehabilitation, Parent of a child with special health care needs Juli Miletich, RN, Liaison for the Developmentally Delayed, Contra Costa Health Plan, and parent of a child with special needs, Martinez, CA Trish Rockeman, Parent of a child with special health care needs, Pinole, CA Pamm Shaw, California Child Care Health Program, California Early Intervention Technical Assistance Network (CEITAN), Sacramento, CA Rocio Smith, Executive Director, Area Board 5 for Developmental Disabilities, Oakland, CA Laurie Soman, Project Director, Children s Regional Integrated Service System, Center for the Vulnerable Child, Children s Hospital, Oakland, CA Diana Tang Duffy, MD, Pediatric and Adolescent Medicine, San Francisco, CA Andrea Youngdahl, MSW, School-Linked Services Coordinator, Alameda County Interagency Children s Policy Council, San Leandro, CA Julie Zumwalt, MSW, LCSW, Parent Liaison, Children s Medical Services Branch, State of California, Sacramento, CA v

6 CORE VALUES FOR PROVIDING HEALTH CARE The American Academy of Pediatrics has endorsed the core values defined below. The Academy believes that medical care should be accessible, continuous, comprehensive, family-centered, coordinated and compassionate, and delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of care. The Academy believes that the physician should be known to the child and family and should be able to develop a relationship of mutual responsibility and trust with them. (American Academy of Pediatrics, 1992) These values should form the basis for the development and evaluation of health care systems for families of children with special needs. Family-Centered Care. The system of care recognizes the importance of the family and reflects this in the way services are planned and delivered. It facilitates parent/professional collaboration, responds to family needs and the priorities that the family has set for itself, recognizes and builds on individual and family strengths, and respects the diversity of families. Informed Consumer Choice. The system of care provides families with complete and unbiased information about the health care financing options available to them. The structure, benefits, services and points of access are clearly explained in the primary language of the family. Consumer choice is achieved when family preference is supported in determining primary and specialty care providers, as well as health care facilities. Collaborative Care. The role of families as primary decision-makers and caregivers is acknowledged and supported when the health financing system pays for services that support this role. Family participation in the allocation of health resources is achieved when the parent is recognized as the primary decision-maker in the development of individualized plans of care. Information Sharing. The system of care should assure that information concerning diagnosis, treatment, prognosis and resources be shared with all members of the health care team, which includes the family. Community-Based. The system of care responds to the needs identified by the community and draws from the community to address needs. Services are provided in or near the home community to the extent possible. Culturally Competent. The system of care honors and respects the languages, culturally related beliefs, values, interpersonal styles, attitudes, and behaviors of families. Respect for those values is incorporated at all levels of policy, administration and practice. The Subcommittee on the Managed Care Initiative of Children s Special Health Care Services Advisory Committee wishes to acknowledge that it drew upon documents provided by the Maternal and Child Health Bureau, New England SERVE, Family Voices, and others in developing this list of values and definitions. Adapted from Managed Care for Children with Special Health Care Needs: Physician Care Management Model by Subcommittee on Managed Care Initiative of Children s Special Health Care Services Advisory Committee. 1

7 DESCRIPTION OF SERVICES CONTENTS Health care services in California are delivered to children with special health care needs through many different programs and/or agencies. This section describes: Things you need to know Private health insurance Fee-for-service Managed care plans Health Maintenance Organizations (HMOs) Point of Service Plans (POS) Preferred Provider Organizations (PPOs) Public Health Care Program Comparison Chart Medi-Cal Child Health and Disability Prevention (CHDP) Healthy Families CaliforniaKids Kaiser Permanente Cares for Kids Child Health Plan Early Start Under Individuals with Disabilities Education Act (IDEA) In-Home Supportive Services (IHSS) California Children Services (CCS) Genetically Handicapped Persons Program (GHPP) Women, Infants, Children Program (WIC) Regional Center Community Mental Health Federal Poverty Chart HOW TO USE THIS SECTION If you have private health insurance, review this section and compare it to your present coverage. Also take a look at Section C (Choosing a Managed Care Plan and Provider) to see if the health coverage you have answers your needs. If your child is currently served through any of the public programs you can review the narrative here and compare it with the services your child is receiving. If you think your child may be eligible for services through any of the public programs described, review the eligibility rules and call the state and/or local numbers listed in this section or in Section F (Resources). 2

8 Obtaining appropriate health care services for children can be an enormous challenge. Educating ourselves about the options available is a first step. Below is a description of the various kinds of private health insurance generally available. PRIVATE HEALTH INSURANCE PROGRAMS Private health insurance can be purchased either individually or through an employer as part of a group plan. Traditional Indemnity Plans (Fee-for-Service) These used to be the most familiar type of insurance plans. The insurance company covers some percent of the cost of the services with the remaining costs the responsibility of the family. The family s part is called a co-payment. Plans often have annual deductibles, an amount you pay before the plan pays, as well as co-payments. While traditional indemnity plans allow you the widest choice of providers, your out-of-pocket costs may be higher than some other plans require. Indemnity insurance covers large and/or unexpected health care expenses, but often not routine or preventive care like regular check-ups and wellchild visits. Managed Care Plans Managed care systems control costs by monitoring services and focusing on preventive health measures. Under managed care, health plans, also called managed care organizations, get a fixed monthly payment for each person enrolled in their plan. For that money, they must agree to manage the person s health services and provide health care. People who enroll in health plans must choose one personal doctor (or sometimes a nurse) [Primary Care Provider] to coordinate their health services. When enrollees need to see a specialist or need other services that their primary care provider cannot give them, they must first get a referral from their primary care provider. Managed care plans require payment of a monthly premium from the purchaser. Unlike indemnity insurance, you may have to make small co-payments for office visits, prescriptions and selected other services. Health Maintenance Organizations (HMOs) An example of a managed care organized health plan that offers health care coverage to its members primarily through selected networks of doctors, hospitals and other health care professionals. They operate under many different models: Staff Model HMOs typically own and operate their own health centers or clinics, where the doctors and other medical professionals are salaried employees. Many services under one roof allow for coordination of services. These types of HMOs can also closely monitor quality and costs of their physicians and services. Group Model HMOs are typically made up of one or more physician group practices that are not owned by the HMO. The HMO contracts with the group practice to provide or arrange covered services for each HMO member who is a patient of the group. Adapted from Paying the Bills: Tips for Families on Financing Health Care for Children with Special Needs from New England Serve and PASSPORT: For Children with Special Health Care Needs from University Affiliated Program, Child Development and Rehabilitation Center, Oregon Health Science University. 3

9 Independent Practice Associations (IPA) IPAs are now the fastest growing form of HMO in the United States. IPAs include individual private practice physicians who are paid a fee or a fixed amount per patient to take care of the IPA s members. One of the advantages of this type of HMO is that you will have the largest number of physicians to choose from. Point of Service (POS) Plans are somewhere between standard HMOs and traditional fee-for-service (or indemnity) insurance. A member of a POS plan can receive care from doctors and hospitals inside the HMO network or outside the network, with costs covered either way. This is a more expensive option and is not offered by all HMOs or employer. It can mean a higher co-pay or out-of-pocket expense for out-of-plan services. You may also have to fill out claim forms for outside visits. Preferred Provider Organizations (PPO) Networks of doctors and hospitals created by insurance companies or employers to provide care at a lower cost than traditional insurance. Because PPO is less managed than HMO care, the premiums are usually higher. They can also impose restrictions such as pre-existing conditions, exclusions and waiting periods. 4

10 Healthcare Coverage for Children Regular healthcare is important for a child s well being and physical development. Here are a few programs that provide no cost or low cost healthcare for children and pregnant women: Access for Infants and Mothers (AIM) provides health insurance for uninsured pregnant women up to 60 days post partum. To qualify, women must be no more than 30 weeks pregnant, California residents, not eligible for no cost Medi Cal, uninsured, and have incomes within AIM guidelines. Women with separate maternity deductibles or co payments over $500 may also qualify. For more information, call toll free Medi-Cal* provides no cost comprehensive health, dental and vision coverage for children and pregnant women. Eligibility is determined by family size, children s ages and family income. This program is available to eligible U.S. citizens, nationals and immigrants. For a mail in application, call toll free *A family whose income is higher than the allowable limits for no cost Medi Cal will have a Share of Cost (SOC) based on their income and family size. Kaiser Permanente Child Health Plan provides low cost health care coverage for uninsured children who are not eligible for no cost Medi Cal or Healthy Families. This program covers children under age 19 who live within Kaiser Permanente s California service area. Cost varies by county and depends on family size and income. For more information, call toll free The Healthy Families Program provides low cost health, dental and vision coverage for children who are not eligible for no cost Medi Cal. Premiums are $4 to $24 each month with a maximum of $72 per family. Eligibility is determined by family size, children s ages and family income. This program is available to U.S. citizens, U.S. nationals and qualified immigrant children under age 19. For more information and to request a mail in application, call toll free CaliforniaKids provides low cost health care coverage for uninsured children who are not eligible for no cost Medi Cal or Healthy Families in select California counties. There are no income limits. For more information, call toll free Healthy Kids provides low cost health care coverage for uninsured children who are not eligible for no cost Medi Cal or Healthy Families in select California Counties. Eligibility varies by county. For more information, visit 5 Please see other side for income levels. If family size (number of persons in family) exceeds the family size shown, please call the program(s) for more information. National Health Foundation Rev. April 2011

11 CALIFORNIA HEALTH CARE PROGRAMS COMPARISON CHART Children s Health Access and Medical Program (CHAMP) The Healthy Families Program Child Health and Disability Prevention (CHDP) Program Questions Medi Cal Percentage Program Uninsured children from birth to their 19 th birthday. Children 18 or under whose income meets the requirements may be able to apply on their own. Minors that are emancipated may be eligible to apply for themselves and their children. Children birth to their 19 th birthday or Children birth to their 21 st birthday if children have Share of Cost Medi Cal Who is eligible? Children birth to their 19 th birthday Pregnant women Note: Other Medi Cal programs are available for certain adults. Children birth to 1: 200% to 250% FIG Children 1 through 5: 133% to 250% FIG Children 6 through 18: 100% to 250% FIG Children birth to their 19 th birthday: up to 200% FIG Children birth to 21 st birthday: on Medi Cal with a Share of Cost For no cost Medi Cal: Children birth to 1 and Pregnant Women: up to 200% FPL Children 1 through 5: up to 133% FPL Children 6 through 18: up to 100% FPL What are the income limits? There are two costs for Healthy Families: Premiums paid every month are $4 to $24 per child. Co payments of $5 are paid for some services. There is a monthly maximum of $72 for premiums per family. There is an annual cap of $250 that the family must pay for health co payments. No cost If children have Medi Cal and are found to need treatment during the CHDP screening exam, Medi Cal will be billed for those treatment services. What does it cost? If income falls within the limits, services may be no cost. Share of Cost (SOC) Medi Cal costs vary based on family income. Families have to meet their SOC before Medi Cal pays for services. Resources do not count in this program. Resources do not count in this program. Resources do not count for pregnant women and children who are eligible for no cost Medi Cal. What are the resource limits? U.S. citizens and certain immigrants may qualify. The immigration status of the parents or applicants is not requested. No, all children within the income limits for this program are eligible to receive CHDP services. Citizens, Legal Permanent Residents and certain other immigrants may receive full scope Medi Cal. Undocumented immigrants can still receive Restricted Medi Cal for emergency conditions and pregnancy related services only. Undocumented immigrants may qualify for full scope Medi Cal if they have PRUCOL Status (contact CHAMP for more information) Does immigration status matter? California residency is required. California residency is required. California residency is required. Proof of income Proof of immigration status or citizenship for the children Proof of deductions Self stated monthly income families state their incomes when they apply at their doctors offices or clinic Is California residency required? What documents are required? Proof of income, identification, and California residency Immigration status and Social Security Number (SSN) or proof of application, if applying for full scope Medi Cal No SSN/proof needed if applying for Restricted Medi Cal Checking and savings account statements Proof of pregnancy if pregnant 6 *Federal Income Guidelines (FIG) lists amount of income the federal government says a family requires to meet its basic needs. Also known as Federal Poverty Level (FPL). For more information on any of the programs listed please askthetrainers@champ-net.org or call (213) You can also visit our website: National Health Foundation- Rev. April 2011

12 CALIFORNIA HEALTH CARE PROGRAMS COMPARISON CHART Children s Health Access and Medical Program (CHAMP) The Healthy Families Program Child Health and Disability Prevention (CHDP) Medi Cal Percentage Program Questions Call toll free to request an application & handbook in the mail. Applications and assistance are available at community centers and places such as clinics, hospitals and schools. At participating doctors or clinics that are CHDP approved At local CHDP offices and other community sites (clinics and schools) Call toll free CHDP to learn more Applications for children and pregnant women who qualify for nocost Medi Cal may be mailed when complete. For an application call toll free At Medi Cal offices and other community sites such as clinics, hospitals and schools Where can families apply? Completed applications must be processed within 10 days of when they are received. Families should get an answer back in the mail within 20 days. Children can immediately receive services if they qualify for CHDP. Up to 45 days Note: Another Medi Cal program, Presumptive Eligibility, provides pregnant women and certain disabled people with temporary Medi Cal coverage while their Medi Cal applications are being processed. How long does it take to get benefits? Medical office visits, dental and vision care, hospitalizations, needed medical tests, prescription medicines, and mental health services. All medically necessary services including preventive care. CHDP covers preventive care services based on an age schedule. Medical office visits, vision and hearing tests, dental screening, doctor and dentist referral Hospitalizations are not covered. Medicines are given by prescription. Full scope Medi Cal covers: medical office visits, hospitalizations, dental and vision care, prescription medicines, mental health services, substance abuse services and needed medical tests. Restricted Medi Cal covers: emergency and pregnancy related services. Note: Minor Consent provides treatment for sexually transmitted diseases, drug and alcohol abuse, family planning, sexual assault, mental health, pregnancy and pregnancy related services to children under the age of 21. What benefits are covered? Services are provided through health plans. Applicants choose health, dental and vision plans for their children when they apply. The health plans send applicants information about their doctors, clinics, and hospitals. Applicants must then choose a doctor for each of their children in Healthy Families. Dental and vision services are separate plans. To find or verify that doctors are CHDPapproved, call the local CHDP office: Los Angeles Co CHDP Orange Co Riverside Co San Bernardino Co Santa Barbara Co Ventura Co CHDP exams are provided by: CHDPapproved doctors, county health centers, some school districts, and Medi Cal managed care doctors (if child is enrolled in Medi Cal managed care). Most children will be in enrolled in managed care health plans (HMOs) except children in foster care, adoption assistance, those with Share of Cost Medi Cal, those with Restricted Medi Cal, and disabled children. Health plan information is mailed to families after they are enrolled in Medi Cal. Individuals enrolled in an HMO must choose a primary care doctor and get referrals from their primary care doctors to see specialists. Managed care plans must provide the same benefits as regular Medi Cal. Individuals not enrolled in managed care health plans may use fee for service (regular) Medi Cal and may go to any provider who accepts Medi Cal (fee for service). How and where do participants receive services? Children who have not been insured for at least 90 days under employer sponsored insurance are eligible for this program. Parents may have other insurance. Children may still be able to get CHDP even if they have health insurance ask their CHDP doctors. Medi Cal might pay for services that the other health insurance does not cover. Ask an Eligibility Worker or call the Health Insurance Premium Payment program (HIPP) toll free if families need assistance paying for the insurance they have. What if participants have other health insurance? Call the Healthy Families Program at or visit their website at: Contact information: Visit Medi Cal s website at cal.ca.gov Visit CHDP s website at: aspx 7 *Federal Income Guidelines (FIG) lists amount of income the federal government says a family requires to meet its basic needs. Also known as Federal Poverty Level (FPL). For more information on any of the programs listed please askthetrainers@champ-net.org or call (213) You can also visit our website: National Health Foundation- Rev. April 2011

13 CALIFORNIA HEALTH CARE PROGRAMS COMPARISON CHART Children s Health Access and Medical Program (CHAMP) CaliforniaKids (CalKids) Questions Healthy Kids Kaiser Permanente Child Health Plan Any child age 2 thru age 18 who are not eligible for fullscope, no cost Medi Cal or other state assistance programs for health care, such as Healthy Families. Children may be enrolled in California Children s Services for specialty care and be eligible for CaliforniaKids for basic outpatient services. Uninsured children up to age 19 who are not eligible for other public/private programs, such as Medi Cal or Healthy Families. Note: Enrollment for this program is based on the available funding. Please check with the program to verify if they are accepting new applications. Who is eligible? Children from birth to their 19 th birthday Children who are not eligible for either no cost Medi Cal or Healthy Families. Note: Currently, applications are no longer being accepted for children greater than 5 ½ years old. Please call to find out if enrollment has been extended to other ages. There are no income limits. Children under age 19, between 0% FPL and 300% FPL Children under age 19, between 0% FIG and 300% FIG. What are the income limits? The monthly premium is $75.00 per child plus one time processing fee of $10.00 All children have co payments of $10.00 $ depending on the services provided by California Kids. All services have a co payment, including preventive care. The monthly premium is $8 or $15 per child depending on families incomes. Families only have to pay premiums for the first three children enrolled. There are co payments for some services. What does it cost? Monthly premiums range from $0 to $6 per child for 0 5 program Monthly premiums are $15 for 6 18 program There is a $5 co payment for some services. $15 co payment for ER visit for 6 18 program. (Maximum co pay of $250 per family per year) Resources do not count in this program. Resources do not count in this program. Resources, things the family owns (cars, jewelry, savings accounts) do not count in this program. No. Undocumented children within the age limits for this program are eligible to receive CaliforniaKids services No. Undocumented children within the income limits for this program are eligible to receive services. No. Undocumented children within the income limits for this program are eligible to receive services. What are the resource limits? Does immigration status matter? Only a completed application Proof of income (last filed income tax return, W 2 forms or pay stubs, disability check stubs for the last complete calendar month) Proof of income and documentation for deductions What documents are required? Call to request an application Applications must be mailed in when complete Applications and assistance are available in places around the community such as child care centers, clinics, schools, Boys/Girls clubs, group homes, and other organizations that see children. Call (free) to request applications. Applications must be mailed when complete. Applications are available at some schools. Families can call to request an application or for more information. Where can families apply? 2 6 weeks after CaliforniaKids receives the applications About 45 days to process the application. Coverage begins on the 1 st day of the month following approval. If application is submitted by the 19 th the children will get enrolled the following month. How long does it take to get? 8 *Federal Income Guidelines (FIG) lists amount of income the federal government says a family requires to meet its basic needs. Also known as Federal Poverty Level (FPL). For more information on any of the programs listed please askthetrainers@champ-net.org or call (213) You can also visit our website: National Health Foundation- Rev. April 2011

14 CALIFORNIA HEALTH CARE PROGRAMS COMPARISON CHART Children s Health Access and Medical Program (CHAMP) CaliforniaKids (CalKids) Questions Healthy Kids Kaiser Permanente Child Health Plan Comprehensive preventive and primary care coverage: medical office visits, dental and vision care, prescription drugs, mental health services, substance abuse services, and needed lab tests. Hospitalizations, major surgery and pregnancy related services are not covered. Comprehensive preventive, primary, and specialty health care coverage: medical office visits, vision care, prescription drugs, mental health services, substance abuse services, health education, hospital services, and needed lab tests. This program offers health, dental, vision, prescription, and mental health services. What benefits are covered? Through the provider network of CaliforniaKids, including community clinics, independent offices, and medical groups. Call for a list of providers in a specific area. Children receive services through Kaiser Permanente medical offices and hospitals. Children receive dental coverage through DeltaCare USA, a subsidiary of Delta Dental California. Children receive medical services from LA Care Providers. Children receive dental coverage through Safeguard Dental and vision coverage through VSP Vision Care. Families that want to change their doctors can call How and where do participants receive services? Children who are eligible or enrolled in full scope, nocost Medi Cal or Healthy Families, are NOT eligible for CaliforniaKids. Children may be enrolled in California Children s Services and still be eligible for CaliforniaKids. Children cannot have other health insurance, such as employer coverage or health coverage through Medi Cal or Healthy Families to be eligible for this program. Children may be eligible for Healthy Kids even if they receive Restricted (Emergency) Medi Cal or Share of Cost Medi Cal. Children currently enrolled in employersponsored insurance, Medi Cal or Healthy Families are not eligible. What if participants have health other insurance? Please contact California Kids at or visit their website: Please contact Kaiser Permanente Member Services at or visit their website at: Contact information: In Los Angeles, County, please contact L.A. Care for more information at or visit their website: For other counties, visit: 9 *Federal Income Guidelines (FIG) lists amount of income the federal government says a family requires to meet its basic needs. Also known as Federal Poverty Level (FPL). For more information on any of the programs listed please askthetrainers@champ-net.org or call (213) You can also visit our website: National Health Foundation- Rev. April 2011

15 Federal Income Guidelines The Federal Income Guidelines (FIG) are dollar amounts set annually by the federal government that state what a family needs to make in order to meet their basic needs. Federal Income Guidelines (April 1, 2011 through March 31, 2012) Family Size 100% FIG 133% FIG 200% FIG 250% FIG 300% FIG 1 up to $ 908 up to $ 1,207 up to $ 1,815 up to $ 2,269 up to $ 2,723 2 $ 1,226 $ 1,631 $ 2,452 $ 3,065 $ 3,678 3 $ 1,545 $ 2,054 $ 3,089 $ 3,861 $ 4,633 4 $ 1,863 $ 2,478 $ 3,725 $ 4,657 $ 5,588 5 $ 2,181 $ 2,901 $ 4,362 $ 5,453 $ 6,543 6 $ 2,500 $ 3,324 $ 4,999 $ 6,248 $ 7,498 7 $ 2,818 $ 3,748 $ 5,635 $ 7,044 $ 8,453 8 $ 3,136 $ 4,171 $ 6,272 $ 7,840 $ 9,408 9 $ 3,455 $ 4,594 $ 6,910 $ 8,636 $ 10, $ 3,774 $ 5,019 $ 7,548 $ 9,432 $ 11,318 Each additional person, add $ 319 $ 424 $ 638 $ 796 $ 955 Medi Cal Family Size Pregnant Women and Children Birth through Age 1 Children Age 1 through 5 Children Age 6 through 18 1 $ 0 to $ 1,815 $ 0 to $ 1,207 $ 0 to $ 908 2* $ 0 to $ 2,452 $ 0 to $ 1,631 $ 0 to $ 1,226 3 $ 0 to $ 3,089 $ 0 to $ 2,054 $ 0 to $ 1,545 4 $ 0 to $ 3,725 $ 0 to $ 2,478 $ 0 to $ 1,863 5 $ 0 to $ 4,362 $ 0 to $ 2,901 $ 0 to $ 2,181 6 $ 0 to $ 4,999 $ 0 to $ 3,324 $ 0 to $ 2,500 *A pregnant woman counts as two people. 10

16 Healthy Families Program Family Size Children Birth through Age 1 Children Age 1 through 5 Children Age 6 through 8 1 $ 1,816 to $ 2,269 $ 1,208 to $ 2,269 $ 909 to $ 2,269 2* $ 2,453 to $ 3,065 $ 1,632 to $ 3,065 $ 1,227 to $ 3,065 3 $ 3,090 to $ 3,861 $ 2,055 to $ 3,861 $ 1,546 to $ 3,861 4 $ 3,726 to $ 4,657 $ 2,479 to $ 4,657 $ 1,864 to $ 4,657 5 $ 4,363 to $ 5,453 $ 2,902 to $ 5,453 $ 2,182 to $ 5,453 6 $ 5,000 to $ 6,248 $ 3,325 to $ 6,248 $ 2,501 to $ 6,248 *A pregnant woman counts as two people. Kaiser Permanente Child Health Plan Family Size Annual Income 1 $0 to $ 32,670 2 $0 to $ 44,130 3 $0 to $ 55,590 4 $0 to $ 67,050 5 $0 to $ 78,510 6 $0 to $ 89,970 Access for Infants and Mothers (AIM) Family Size Monthly Household Income Total Cost for Pregnancy 2* $ 2,453 to $ 3,679 $ 442 to $ $ 3,090 to $ 4,634 $ 556 to $ $ 3,726 to $ 5,589 $ 671 to $ 1,006 5 $ 4,363 to $ 6,544 $ 786 to $ 1,178 6 $ 5,000 to $ 7,499 $ 900 to $ 1,350 7 $ 5,636 to $ 8,454 $ 1,015 to $ 1,522 *A pregnant woman counts as two people National Health Foundation and CHAMP Net. All rights reserved. 515 South Figueroa Street, Suite 1300 Los Angeles, CA Net.org 11

17 PUBLIC HEALTH CARE PROGRAM COMPARISON CHART QUESTIONS WIC REGIONAL CENTER COMMUNITY MENTAL HEALTH Who is eligible? Low-income pregnant, breastfeeding or postpartum mothers Children under 5 What are the income limits? What does it cost? What are the resource limits? (Are other assets like a car or a house included?) Do I have to be a legal resident? Under 18 with certain disabilities including retardation and related diseases, cerebral palsy, epilepsy, autism, developmental disabilities Regular medical check-ups are required Gross income below 200% FPL None None Children and adolescents with full service Medi-Cal Special ed. referrals from schools Nothing Nothing Nothing except for psych. Emergency services if not covered by Medi-Cal or other health insurance. None None None No No No What papers do I need? Medical form to be filled out by doctor Proof of address Proof of income Child s food records Where can I/we apply? Contact WIC Office (888-WIC-WORKS) to find where to pick up an application. How long does it take to get? What benefits can I/my child get? How and where do I/my child get services? What if I/we have health insurance? Immediate benefits after completing application and providing papers Food vouchers Nutritional counseling Breastfeeding support Referrals for health care and other services At WIC clinics Health services can be obtained from the doctor of your choice Medical records None Call your local Regional Center or the Dept. of Developmental Services, days for an assessment Immediate Assessment, rehabilitation and training, treatment, therapy, prevention, special living arrangements, community integration, family support, crisis intervention, special equipment, transportation, interpreter/translator, advocacy, vouchers Call your local Community Mental Health Service or ask your school for a referral Outpatient assessment or psych. Evaluation and referral to community practitioners. All services required of an IEP including day and residential treatment as necessary. Psych. Emergency service (for a fee if not covered by insurance). Local Regional Center will refer After assessment has been done, referrals will be given to community practitioners or treatment centers Does not affect WIC benefits Does not affect benefits Does not affect benefits, but will bill Medi-Cal or private insurance with permission. 12

18 PUBLIC HEALTH CARE PROGRAM COMPARISON CHART QUESTIONS EARLY START UNDER I.D.E.A. Who is eligible? Children birth through 2 years 9 months of age who: Experience developmental delays Have a diagnosed physical or mental condition that has a high probability of resulting in a developmental delay or Are at high risk for developmental disabilities What are the income limits? None Same as SSI income limits What does it cost? Nothing Nothing What are the resource limits? None Same as SSI resource limits (Are other assets like a car or a house included?) Do I have to be a legal resident? IN-HOME SUPPORTIVE SERVICES (IHSS) Individuals who are eligible for SSI/SSP, or similar types of assistance, and If IHSS is needed for the individual to live safely in his/her home without assistance. No California resident yes. Immigrants permanently living legally in the U.S. may be eligible for IHSS. What papers do I need? Medical records Results of specific diagnostic tests indicating disability Where can I/we apply? At the Regional Center or the local Special Education Plan Area (SELPA) How long does it take to get? Within 45 days of the child s referral to the agency: An assessment must be completed An Individual Family Service Plan must be developed to decide upon the services for the family and child. The county worker will fill out forms known as SOC 293 and SOC 293a, which will set out how much time per week you have been allowed for service. Your county worker must give you copies of these forms if you ask for them. Apply at the Department of Social Services, also known as the welfare office. You may be able to initiate the process by phone. To find your local IHSS office call or look in the Resources section of this manual. Once the application is filed, a home visit will be scheduled. The application must be processed within 30 days. This includes eligibility determination, the needs assessment and the notice of action. An exception to the 30-day requirement may be made when a disability determination has not been received within that time period. Benefits may be approved back to the date of the initial application regardless of when the assessment is done. 13

19 PUBLIC HEALTH CARE PROGRAM COMPARISON CHART QUESTIONS EARLY START UNDER I.D.E.A. What benefits can I/my child get? How and where do I/my child get services? What if I/we have health insurance? Assistive technology devices/services Audiology services Family training, counseling, and home visits Some health services Medical services for diagnostic or evaluation purposes only Nursing Nutrition counseling Occupational therapy Physical therapy Psychological services Respite Service coordination (case management) Social work services Special instruction Speech and language services Transportation services Vision services Others as needed This varies from county to county. Children with lowincidence disabilities may receive services from the Special Education Local Plan Area or the County Office of Education. Children with other disabilities receive services from programs funded by the Regional Center. Other insurance does not affect the services you are eligible for. Regional Center may ask that your primary insurance be billed first for some services that are also provided by Regional Center. If those services are denied, Regional Center will then pay for them. IN-HOME SUPPORTIVE SERVICES (IHSS) Domestic and related services (cooking, cleaning, laundry, shopping) Personal care services (toileting, dressing, helping the person eat) Essential transportation (e.g., to doctor s appointments) Protective supervision (e.g., watching and intervening if someone would walk into the street, etc.) Paramedical services, including giving injections. Under the condition that the person will become more self-sufficient, some teaching and demonstration can be included. The IHSS recipient hires his/her own care provider. Services are provided in the recipient s home. The care provider must complete timesheets in order to be paid. Other insurance does not affect IHSS. 14

20 PUBLIC HEALTH CARE PROGRAM COMPARISON CHART QUESTIONS CALIFORNIA CHILDREN SERVICES (CCS) Who is eligible? Children and young adults 21 and under with certain medical conditions whose parents pay for some or all services What are the income limits? Less than $40,000 If family income is greater than $40,000, medical expenses must be greater than 20% of family income Diagnostic services and PT and OT have no requirement You may have to also apply for Medi-Cal What does it cost? There is an income adjusted enrollment fee for treatment services except for people below 200% FPL What are the resource limits? (Are other assets like a car or a house included?) Do I have to be a legal resident? GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP) Adults over 21 with certain inherited diseases such as Cystic Fibrosis, PKU, Hemophilia, Sick Cell Anemia None None None No, but proof of county residence necessary Yes What papers to I need? Federal Income Tax form or other proof of income Medical records Where can I/we apply? Referrals from doctors or social workers are preferred Call How long does it take to get? Up to 120 days after application and medical records received What benefits can I/my child get? How and where do I/my child get services? What if I/we have health insurance? Free diagnostic services All services which apply to condition: doctors, hospital, surgery, PT, OT, lab tests, x-rays, orthopedic and medical equipment, case management including transportation An income adjusted enrollment fee Federal Income Tax form or other proof of income Medical records Call About 2 weeks after medical report received All services must be pre-approved by case manager: medical care in and out of hospital, dental care, home health care, prescriptions and nutritional supplements, respite care, medical and orthopedic equipment, transportation CCS approved doctors and hospitals GHPP approved centers, private physicians working with these centers, local hospitals CCS will cover only those services which have been denied Other insurance is allowed. GHPP will cover unpaid expenses by other insurers and provide services if outside insurance is lost. 15

21 QUICK REFERENCE GUIDE FOR ASSISTORS To estimate qualified family income What income counts and does NOT count? Who is considered a family member? If the family member gets paid Then Weekly Multiply amount by 4.33 Counts Doesn t count Who counts as children? Who counts as an adult family member? Multiply amount by Every 2 Weeks (i.e. every other Friday) Supplemental Security Income/State Supplementary Program (SSI/SSP) payments Unborn child of a family member Multiply amount by 2 Earnings from your job, including cash, wages, salary, commissions, and tips Twice Monthly (i.e. 1 st and 15 th ) Foster care payments Natural or adoptive parents of the child who would get benefits Self-employment net profits All children, full and halfsiblings, under age 21 living in the home Monthly Use the amount of that paycheck CalWORKS (replaces the former AFDC program) payments Husband of the pregnant woman Yearly Divide annual amount by 12 Government benefits, such as Social Security, Workers Compensation, Unemployment All children, full and halfsiblings, under age 21 away at school and claimed as tax dependents Pregnant woman General Relief payments Step-parents Alimony Received Use the amount of the alimony received Grants or scholarships, college work study used for college expenses All stepchildren under age 21, who live in the home Use the adjusted gross income and divide by 12 If using Federal Tax Return Earnings from a job of a child under age 14 Child support Alimony/spousal support Use only the positive amounts (lines 7-21) and divide by 12 If using Federal Tax Return & Schedule C for Self Employed Earnings from a job of a child attending school Income of a step-parent Pensions or retirement NOTE: The above rules apply to Medi-Cal and Healthy Families. Caretakers, foster parents, and legal guardians are NOT listed as family members, and their income is not counted. To estimate income deductions If the family member Then deduct from monthly income Maximum of $90 Some government benefit payments please check with your local county welfare office Receives wages, self employment, or Temporary Workers Compensation Disability Insurance Other income including, but not limited to, grants for living expenses, settlement benefits, rental net profit, gifts, lottery/bingo winnings and interest income Steps to estimate income 1. List qualified family members 2. List qualified family income 3. Determine deductions -Maximum of $175 for children age 2 and over -Maximum of $200 for children under age 2 Is in day/childcare while parents work/train for job Maximum of $175 Pays expenses for the care of a disabled dependent Maximum of $50 deduction per family Receives alimony or child support The amount paid, up to court-ordered amount Pays court-ordered alimony or child support 16 National Health Foundation Rev. April 2011

22 INCOME ELIGIBILITY GUIDELINES EFFECTIVE APRIL 1, 2011 MARCH 31, 2012 Child Age 0 18 Safety Net Programs Child Age 0 1 Child Age 0 1 Child Age 1 5 Child Age 1 5 Child 6 18 Child Age 6 18 Kaiser (based on annual income) Healthy Families Healthy Kids Healthy Families Medi Cal Healthy Families Medi Cal or Pregnant Woman Medi Cal Family Size 1 $0 $1,815 $1,816 $2,269 $0 $1,207 $1,208 $2,269 $0 $908 $909 $2,257 $0 $2,723 $0 $32,670 2 $0 $2,452 $2,453 $3,065 $0 $1,631 $1,632 $3,065 $0 $1,226 $1,227 $3,036 $0 $3,678 $0 $44,130 3 $0 $3,089 $3,090 $3,861 $0 $2,054 $2,055 $3,861 $0 $1,545 $1,546 $3,815 $0 $4,633 $0 $55,590 4 $0 $3,725 $3,726 $4,657 $0 $2,478 $2,479 $4,657 $0 $1,863 $1,864 $4,594 $0 $5,588 $0 $67,050 5 $0 $4,362 $4,363 $5,453 $0 $2,901 $2,902 $5,453 $0 $2,181 $2,182 $5,373 $0 $6,543 $0 $78,510 6 $0 $4,999 $5,000 $6,248 $0 $3,324 $3,325 $6,248 $0 $2,500 $2,501 $6,153 $0 $7,498 $0 $89,970 7 $0 $5,635 $5,636 $7,044 $0 $3,748 $3,749 $7,044 $0 $2,818 $2,819 $6,932 $0 $8,453 $0 $101,430 8 $0 $6,272 $6,273 $7,840 $0 $4,171 $4,172 $7,840 $0 $3,136 $3,137 $7,711 $0 $9,408 $0 $112,890 9 $0 $6,910 $6,911 $8,636 $0 $4,594 $4,595 $8,636 $0 $3,455 $3,456 $8,490 $0 $10,363 $0 $124, $0 $7,548 $7,549 $9,432 $0 $5,019 $5,020 $9,432 $0 $3,774 $3,775 $9,269 $0 $11,318 $0 $135,810 Important Telephone Numbers EE/CAA Help Desk Medi Cal Ombudsman (Los Angeles County) Healthy Families Membership Line Healthy Families & Medi Cal Information Line Healthy Families & Medi Cal Outreach Line Report problems with your health plan Information on CAA training Update registration information Ask basic eligibility questions Ask questions about HF coverage Report change of address Report change in family size Add a child to HF Ask general question regarding Medi Cal or Healthy Families Programs Request and application Find a CAA in your area Application assistance Apply by phone Request and Application Check status of an application VISIT THE WEBSITE AT 17 National Health Foundation Rev. April 2011

23 Items You May Need with Your Application The Healthy Families Program Proof of income Deduction documentation (if applicable) Identification with name & address Proof of children s immigration status* Proof of children s US citizenship* First Premium Payment* (Money order, cashiers check, or personal check) Medi Cal Proof of income (copies of income stubs, tax returns or W 2) *Due within 60 days of application. Proof of deductions Identification with name & address Social security card (if applicable) Copy of birth certificate or proof of immigration status Proof of California residency If pregnant, verification of pregnancy with estimated due date Healthy Kids Kaiser Permanente Child Health Plan Proof of Income (copies of income stubs, tax returns, profit/loss statement, self stated affidavit, etc. ) Deduction Documentation (if applicable) Proof of Income (one full month s worth; copies of income stubs, tax returns, profit/loss statement, enclosed self stated affidavit, etc. ) Valid California residency information County Residency Documentation Please see other side for examples of Proof of Income, Verification of Citizenship, Proof of California Residency, etc. 18 National Health Foundation Rev. April 2011

24 Examples of Documents Identification*: California driver s license DMV ID card Picture ID Birth certificate Hospital or clinic card Bill with your name and address Proof of Income*: Most recent paycheck stub (within 45 days of application) Unemployment benefits statement Letter from employer indicating how much you make and how often you get paid (on company letterhead) Letter from person supporting you Immigration Status*: Green Card Employment authorization card Military identification card Verification of Citizenship*: Birth certificate Passport Naturalization certificate Proof of California Residency*: Rent, mortgage or utility receipts in your name Car registration in your name Voter registration California ID or driver s license Proof of employment Proof of registration with an employment agency Proof of child s enrollment in a California school Proof you receive other public assistance, such as WIC/AFDC *This list is not complete. If you do not have any of these documents, call the program(s) for which you want to apply. They may be able to help. 19 National Health Foundation Rev. April 2011