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Healthcare Systemsfor Children

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Medicaid (Medi-Cal)

California’s Medicaid program

Health insurance for low-income families and individuals

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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

HMOMost common kind of

Medi-CalOnly choice for most

childrenPrimary 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 qualifyShare of costWaiver

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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 Medi-Cal 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 Medi-Cal

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 Children age 0 – 19 Working families Under 250% FPL

($3,928 for a family of 4).

United States Citizen or documented resident

California resident

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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 19who 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 Maximum of $24

a month Co-pay for some

services

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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 PlanLow-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 19not eligible for Medi-Cal

• below 200% FPL Children in Head Start and State

Preschool programs (generally ages 3-5).

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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 Medi-Cal, Healthy Families, EPSDT or private pay

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Other related programs for children

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In Home Supportive Services (IHSS)

An alternative to out-of-home 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 Must meet SSI/SSP disability criteria

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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

Must receive SSI to qualify

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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 If service is covered by both

programs, it will be funded by PSCP

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Supplemental Security Income (SSI)

not a healthcare system provider

federal program that gives a monthly payment

automatically eligible for fee for service Medi-Cal

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Eligibility for SSI

SSI for ChildrenUnder age 18 or

• Under age 22 and still receiving special education services

Low incomeLimited

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