Mental Health & Autism Health Project MEDICAID/Medi-Cal
Autism Providers Who Accept Medi-cal
- Anthem California
- Beacon Autism Providers
- Contra Costa County
- San Francisco County
- San Mateo County
- Santa Clara County
- Santa Cruz/Monterey/San Benito Counties
Medi-Cal, the CA version of Medicaid, is free or low-cost health insurance for California residents who qualify. It is administered by the CA Department of Health Care Services (DHCS). Most Medi-Cal plans now run through a managed care plan administered by the county and regulated by the Department of Managed Health Care (DMHC). Those counties not regulated by DMHC are considered a County Organized Health System (COHS).
Is your plan a COHS plan?
The following are County Organized Health System (COHS) plans:
- • CalOPTIMA (Orange County – HCP 506)
- • Central California Alliance for Health (Merced County –HCP 514, Monterey County – HCP 508 and Santa Cruz County – HCP 505)
- • Health Plan of San Mateo (San Mateo County – HCP 503)
- • Partnership HealthPlan of California (PHC) (Del Norte County – HCP 523, Humboldt County – HCP 517, Lake County – HCP 511, Lassen County – HCP 518, Marin County – HCP 510, Mendocino County – HCP 512, Modoc County – 519, Napa County – HCP 507, Shasta County – HCP 520, Siskiyou County – 521, Solano County – HCP 504, Sonoma County – HCP 513, Trinity County – HCP 522 and Yolo County – HCP 509)
- • CenCal Health (San Luis Obispo County – HCP 501 and Santa Barbara County – HCP 502)
- • Gold Coast Health Plan (Ventura County – HCP 515)
Medi-Cal recipients in these plans are not regulated by the Department of Managed Health Care and have their medical disputes resolved in a fair hearing before an administrative judge rather than going through the independent medical review process. If you are in one of these plans/counties, and are having difficulty securing autism treatments for your child, please contact the Department of Health Care Services at firstname.lastname@example.org, or reach out of the Medi-Cal Ombudsman office. You may also reach out to the local affiliate of the Health Consumer Alliance if you need individual assistance.
In July 2014, the Centers for Medicaid & Medicare Services issued federal guidance to the states indicating that ABA is a covered benefit for children under 21-years-old. This benefit was hard fought for by families, advocates and supportive public officials.
How to get Behavioral Intervention Therapy (ABA)
In order to be eligible, children will need to have a diagnostic assessment of autism spectrum disorder, and a prescription for ABA therapy from either a psychologist or treating physician. The prescribing professional will need to explain why ABA therapy is medically necessary for a child.
Speech and Occupational Therapies
Speech and Occupational therapy ARE covered benefits under Medi-Cal. The Department of Health Care Services (DHCS), which oversees all Medi-Cal Managed Care Plans, issued an all plan letter on December 12, 2014 stating unequivocally that speech therapy is a required benefit. The letter states on p.5, "MCPs are required to provide speech therapy, occupational therapy, and physical therapy services when medically necessary to correct or ameliorate defects discovered by screening services, whether or not such services or items are covered under the state plan unless otherwise specified in the applicable MCP contract with DHCS."
Members of MHAIP meeting with several Medi-Cal Health Plan managers.
How to Request Speech or OT
If you are in a Medi-Cal managed care plan the first step to requesting speech or OT is to visit your child's primary care doctor and request a speech or OT evaluation. Your doctor can make the request to the health plan on your behalf. Unfortunately, physician requests are sometimes denied by the health plan, so it is in your interest to request a letter of medical necessity from your doctor, in the event that you have to appeal. Here is a sample letter that you can give to your doctor or psychologist for him or her to edit.
What if my doctor says no?
If your doctor tells you that this is not a covered benefit, or that you need to obtain speech or OT through your school district, they are wrong! Show them the All Plan Letter mentioned above. If they still refuse, ask them to put this denial in writing for you so that you can appeal it to the health plan and the Department of Managed Health Care. You should also send a formal written request for services to your health plan. We have created a sample letter to request service.
What if my doctor says yes, but I never hear from the health plan?
If your doctor orders a speech or OT assessment from you, mark the date of their request on your calendar. It would also be helpful for them to put in writing for you that they made the request on a particular date. If you do not hear back from your health plan within 30 days, visit the www.dmhc.ca.gov and file a complaint with your health plan. Follow up by phone, getting a tracking number for the call. If the answer is not satisfactory, file an expedited complaint with the DMHC. They will contact you and your health plan, and force them to respond and comply with the law.
What if my health plan responds within 30 days and says no?
If your health plan responds with a no, you can appeal. If they deny based on medical necessity, use the letter of medical necessity that you requested from your child's MD when you requested the service.
You are going to want to carefully review the plan’s reason for denial and address that in your appeal letter. The health plan cannot simply refer you to your school district for treatment, as this violates federal EPSDT statutes. EPSDT is a federal law which stands for Early Periodic Screening Diagnosis and Treatment and requires Medi-Cal to screen for, diagnose, and treat disabilities in low-income children. The program must “correct or ameliorate defects, physical and mental illnesses, and conditions discovered by screening services, whether or not such services are covered under the Medicaid State Plan." For a thorough discussion of what can be provided under EPSDT statutes, read this article.
Speech Therapy Denials
FALSE: Only Two Visits Allowed Per Month In 2013 and 2014 many Medi-Cal patients received notice that their child's speech therapy visits were cut to twice monthly. Denial letters stated that two visits per month is the maximum amount allowed by the law. This is not true! The law in questions AB X3 5 (Evans, Chapter 20, Statutes of 2009) specifies that additional speech therapy is available to individuals under 21 through Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Services where medically necessary. We have created a sample appeal letter that you may use to appeal the denial to your health plan. Be sure to attach this document about the law AB X3 5.
FALSE: Please Contact Your School District for Families often report being denied speech therapy with the explanation that this is a service they should seek from their local, public school district. This is an inadequate explanation, and if you have received this type of letter, you should appeal. We have created a sample letter that you may use to appeal the denial to your health plan.
If you are having difficulty with your health plan and are not sure what your rights are, the Medi-Cal Ombudsman’s office may be able to help.
No Available Providers/Timely Access to Care & Evaluation
The DMHC will get involved if families are having difficulty accessing autism specialists, including speech therapists, occupational therapists, and others such as psychologists and developmental pediatricians, after you have filed an appeal or grievance with your plan. While in some counties there are qualified autism professionals that are in the plan network, in many counties, Medi-Cal plans have inadequate autism networks. The only way to get these treatments is to follow through and insist on single case agreements. A single case agreement is a special contract that the health plan sets up with a specialist, just for your child, because they don’t have an adequate network. The plan must make up the difference in cost between their usual rate and the rate that the provider requests if they do not have an adequate network. If your Medi-Cal managed care plan does not have providers, please contact the DMHC for assistance: 1-888-466-2219.
In some counties, families wishing to have their child evaluated for autism must wait 6-12 months. This is too long! Under the law, patients should be able to schedule with a specialist within three weeks. We have created a sample appeal letter that you may customize to request a single-case agreement with another qualified autism evaluator.
Other Mental Health Services
Sometimes children with autistic spectrum disorders need other mental health treatments, besides or in addition to ABA, such as weekly or more frequent psychotherapy. Sometimes it may be for the treatment of anxiety, depression, or something else, or it may be for symptoms related to autism. Recently, all mental health services within Medi-Cal have been carved out to the county mental health departments.
Typically, those with mild to moderate mental health symptoms and those with autism are being treated within the main mental health plan. Those with more involved mental health conditions are being “carved out” to the county mental health system. Some county mental health programs have been turning away people with autism, saying that they are not equipped to handle their issues or they are not allowed to treat the symptoms of autism. We are very concerned about this type of discrimination, and are very interested in hearing from you if you have been told this. Please contact us and let us know if this has happened to you. This information can help us correct a system that is not working right. You also may want to reach out to your local legal aid for assistance.
Appeals, grievance, and your rights
In the Managed Care Medi-Cal system, if you do not agree with the decision of the health plan, there are usually instructions on how to file an appeal in the denial letter. If they try to tell you on the phone that services are not covered, ask for the letter in writing (they legally have to provide this). If you are currently getting services, and the plan notifies that you that they will be terminating or cutting back on services, you have the right to aid paid pending (that means they continue the services until you go to fair hearing), but you have to fill out and return the form within ten days. You would then file an appeal letter with your health plan (you can do this by phone or in writing, if you do it in writing, you will have a copy for your records). If the plan continues to deny your request, you can choose to go to fair hearing or to an independent medical review with the DMHC. A fair hearing is a small trial in front of an administrative law judge. If you have health professionals that support your child getting the care, it is a good idea to get one of them to come or at least submit a written statement. The independent medical review process is often a better option, especially if your child has a good medical reason to get care, because all the information goes out to a medical expert to decide. Overall, rates of success are higher in IMR than in fair hearing. If you need help in preparing your case, you may want to reach out to your local legal aid for assistance.
The county mental health system does not allow the option of independent medical review. Your only dispute resolution option is fair hearing. If you can get your mental health care within the HMO, however, you can use the IMR process for disputes.
Medi-Cal waivers are special programs that are available to those with certain types of disabilities. They allow the person with the disability to “waive” or bypass the income requirements that people without disabilities are subjected to. The most common Medi-cal waiver that children with developmental disabilities get is the Home and Community Based waiver, which they typically get through the regional center system. Some regional centers try to put all of their clients on the waiver, as they get a greater contribution from the federal government, while others do not. The idea behind this waiver is that it is much less expensive for someone to live in their home and community than in an institution, and so the government waives the income requirements for people that are at risk for being institutionalized. It is also possible to get on Medi-Cal through SSI, this may involve considering family income, but the family can have a higher income than Medi-Cal beneficiaries who are not disabled.
CoPays, CoInsurance & Deductibles
When you have Medi-Cal through the waiver and another health plan, Medi-Cal is nearly always secondary. See our section on cost sharing.
If your child has an IEP through the school district, your Medi-Cal plan may ask to see a copy of it. The IEP is a federally-protected, confidential document and you do not have to supply it to your health plan if you don't want to. Sometimes health plans will try to deny your child speech, OT or other treatment by arguing that they are already receiving that treatment through the school district.
More Sample Letters
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