Medi-Cal is the State of California’s public health insurance program for select individuals and families that satisfy its eligibility criteria.
Individuals with Down syndrome, or Trisomy 21, that are Regional Center clients potentially qualify for Medi-Cal under the Home and Community-Based Services Waiver for the Developmentally Disabled (HCBS-DD Waiver), also known as the Regional Center Waiver or the Medicaid Waiver.
The process that the Regional Center moves through to establish the eligibility of a candidate for Medi-Cal is called Institutional Deeming.
Individuals with Down syndrome may be eligible for the Medicaid Waiver regardless of their family’s income and assets. However, individuals that are accepted into the program cannot have income and assets greater than $2,000.00 in their own name.
A Common Misperception
Just because an individual has been diagnosed with Trisomy 21 does not merit waiver eligibility under the current system. Health, sensory, behavioral issues and/or substantial limitations in adaptive functioning (self help skills) are used to determine waiver eligibility, not the diagnosis itself. Furthermore, substantial limitations in adaptive functioning (self help skills) can only be considered for children who are over 4 years of age.
For individuals and families that are interested in applying for the waiver:
For children younger than 4 years old:
Eligibility is based upon medical, behavioral or sensory issues which are secondary to the condition of Trisomy 21. A child must have 2 of these conditions, in any combination, to meet the level-of-care eligibility criteria. For example, if your child with Trisomy 21 has a formal diagnosis of gastroesophageal reflux disease (health issue) plus hearing loss (sensory issue), they would be eligible. If your child has behavioral challenges that are being treated plus sleep apnea, they would be eligible. But if your child only needs glasses to correct severe nearsightedness, they would not be eligible.
For children between 4 and 18 years old:
Eligibility decisions are based upon medical, behavioral, sensory issues and/or severe limitations in adaptive functioning (self help skills). Again, the child must have 2 of these conditions, in any combination, to meet the level-of-care eligibility criteria. In this example, if you child had a formal diagnosis of gastroesophageal reflux disease (health) and needed assistance with toileting (self help), they would be eligible for the waiver. Self help skills can be considered in this age group.
- Verify that the applicant’s assets do not exceed nor will exceed $2000.00.
- Notify your Regional Center (RC) counselor that you are interested in the Medicaid Waiver. Regional Center will first determine if the applicant meets the Waiver level-of-care criteria for eligibility. If the applicant satisfies the eligibility criteria, your RC counselor will forward a pamphlet that describes the program very briefly. After reviewing the document and information available at the Department of Health Care Services web page, validate with your RC counselor that you still want to apply for the Medicaid Waiver. Your request will then be forwarded to the RC Nurse, who will then forward to you a packet with two important sets of documents.
- Choice Form. Complete this document as soon as you receive it and mail it back to the Regional Center in the attached envelope. The RC Medicaid Waiver QMRP will then forward a letter to the Long-Term Medi-Cal Waiver office to validate eligibility and request that a Medi-Cal application packet be sent to you directly.
- Pre-filled Example Application Forms. Pat Hevessy, the Harbor Regional Center’s Nurse, has gone to the effort of providing applicants with a completed document set that should be used as a guide when you are completing your own document set.
- Complete the application and then photocopy or scan the document set for your records before mailing it to the Medi-Cal offices. Direct any questions that you may have regarding the application process to the contact number in the cover letter from the Medi-Cal office.
- Medi-Cal Offices need 30 days to review applications for the Home and Community-Based Services Waiver for the Developmentally Disabled.
- During the review window, applicants will receive a computer generated document that assigns you a case worker and contact number. Use this contact number to inquire on the status of your application.
- Applicant will receive shortly thereafter a 1-page document, entitled a Notice of Action, which indicates that he/she has been accepted for services. The Benefits Identification Card (BIC) will come in a separate mailing about 1 week later.
- After you have received your BIC, notify your health insurance carrier of the Medi-Cal assignment and complete your carrier’s documentation to take advantage of what Medi-Cal has to offer.
Specific details about the Medicaid Waiver for individuals with Down syndrome may be found on the California Department of Health Services website.
Insured families that have an interest in the Waiver are encouraged to speak with their existing health plans to better understand how the Medi-Cal option can be used as an adjunct to their child’s existing health plan coverage.