AB 2299, as amended, Nazarian. Developmental services: health insurance copayments.
The Lanterman Developmental Disabilities Services Act authorizes the State Department of Developmental Services to contract with regional centers to provide services and supports to individuals with developmental disabilities. Under existing law, the regional centers purchase needed services for individuals with developmental disabilities through approved service providers or arrange for their provision through other publicly funded agencies. The services and supports to be provided to a regional center consumer are contained in an individual program plan or individualized family service plan, developed in accordance with prescribed requirements. Existing law authorizes a regional center to pay any applicable copayment or coinsurance for a service or support required by a consumer’s individual program plan if the service is paid for by the health care service plan or health insurance policy of the consumer or his or her parent, guardian, or caregiver and, among other conditions, the family or the consumer, as applicable, has an annual gross income that does not exceed 400% of the federal poverty level. Existing law prohibits a regional center from paying health care service plan or health insurance policy deductibles.
This bill wouldbegin delete delete the prohibition against payment of deductibles and would requireend deletebegin insert authorizeend insert a regional center, without regard to the family’s or consumer’s annual gross income, to pay any applicable copaymentbegin delete,end deletebegin insert orend insert coinsurancebegin delete, or deductibleend delete
for a service or support required by a consumer’s individual program plan if the support or service is paid for by the health care service plan or health insurance policy of the consumer or his or her parent, guardian, or caregiver.begin insert The bill would also authorize a regional center to pay a deductible associated with those plans or policies if the service or support is necessary to successfully maintain the child at home or the adult consumer in the least-restrictive setting and specified conditions relating to the financial need of the parent, caregiver, or consumer are satisfied.end insert
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
begin insertSection 4659.1 of the end insertbegin insertWelfare and Institutions
2Codeend insertbegin insert is amended to read:end insert
(a) If a service or support provided pursuant to a
4consumer’s individual program plan under this division or
5individualized family service plan pursuant to the California Early
6Intervention Services Act (Title 14 (commencing with Section
795000) of the Government Code) is paid for, in whole or in part,
8by the health care service plan or health insurance policy of the
9consumer’s parent, guardian, or caregiver, the regional center may,
10when necessary to ensure that the consumer receives the service
11or support, pay any applicable copayment or coinsurance associated
12with the service or support for which the parent, guardian, or
13caregiver is responsible ifbegin delete allend deletebegin insert bothend insert
of the following conditions are
14met:
15(1) The consumer is covered by his or her parent’s, guardian’s,
16or caregiver’s health care service plan or health insurance policy.
17(2) The family has an annual gross income that does not exceed
18400 percent of the federal poverty level.
19(3)
end delete
P3 1begin insert(2)end insert There is no other third party having liability for the cost of
2the service or support, as provided in subdivision (a) of Section
34659 and Article 2.6 (commencing with Section 4659.10).
4(b) If a service or support provided to a consumer 18 years of
5age or older, pursuant to his or her individual program plan, is paid
6for in whole or in part by the consumer’s health care service plan
7or health insurance policy, the regional center may, when necessary
8to ensure that the consumer receives the service or support, pay
9any applicable copayment or coinsurance associated with the
10service or support for which the consumer is responsible ifbegin delete both
11of the following conditions are met:end delete
12(1) The consumer has an annual gross income that does not
13exceed 400 percent of the federal poverty level.
14begin delete(2)end deletebegin delete end deletebegin deleteThereend deletebegin insert
thereend insert is no other third party having liability for the
15cost of the service or support, as provided in subdivision (a) of
16Section 4659 and Article 2.6 (commencing with Section 4659.10).
17(c) Notwithstandingbegin delete paragraph (2) of subdivision (a) or begin insert
subdivision (e)end insert, a regional center
18paragraph (1) of subdivision (b)end delete
19may pay abegin delete copayment or coinsuranceend deletebegin insert deductibleend insert associated with
20the health care service plan or health insurance policy for a service
21or support provided pursuant to a consumer’s individual program
22plan or individualized family service plan ifbegin delete the family’s or the service or support is necessary to successfully maintain
23consumer’s income exceeds 400 percent of the federal poverty
24level,end delete
25the child at home or the adult consumer in the least-restrictive
26settingbegin delete,end delete and the parents or consumer demonstrate one or more of
27the following:
28(1) The existence of an extraordinary event that impacts the
29ability of the parent, guardian, or caregiver to meet the care and
30supervision needs of the child or impacts the ability of the parent,
31guardian, or caregiver, or adult consumer with a health care service
32plan or health insurance policy, to pay thebegin delete copayment or begin insert deductibleend insert.
33coinsuranceend delete
34(2) The existence of catastrophic loss that temporarily limits
35the ability to pay of the parent, guardian, or caregiver, or adult
36consumer with a health care service plan or health insurance policy
37and creates a direct economic impact on the family or adult
38consumer. For purposes of this paragraph, catastrophic loss may
39include, but is not limited to, natural disasters and accidents
40involving major
injuries to an immediate family member.
P4 1(3) Significant unreimbursed medical costs associated with the
2care of the consumer or another child who is also a regional center
3consumer.
4(d) The parent, guardian, or caregiver of a consumer or an adult
5consumer with a health care service plan or health insurance policy
6shall self-certify the family’s gross annual income to the regional
7center by providing copies of W-2 Wage Earners Statements,
8payroll stubs, a copy of the prior year’s state income tax return,
9or other documents and proof of other income.
10(e) The parent, guardian, or caregiver of a consumer or an adult
11consumer with a health care service plan or health insurance policy
12is responsible for notifying the regional center when a change in
13income occurs that would result in a change in eligibility for
14coverage of the health care
service plan or health insurance policy
15copayments or coinsurance.
16(f)
end delete
17begin insert(d)end insert Documentation submitted pursuant to this section shall be
18considered records obtained in the course of providing intake,
19assessment, and services and shall be confidential pursuant to
20Section 4514.
21(g) Regional
end delete
22begin insert(e)end insert begin insertExcept as provided in subdivision
(c), regional end insertcenters shall
23not pay health care service plan or health insurance policy
24deductibles.
25(h)
end delete
26begin insert(f)end insert This section shall not be implemented in a manner that is
27inconsistent with the requirements of Part C of the federal
28Individuals with Disabilities Education Act (20 U.S.C. Sec. 1431
29et seq.).
Section 4659.1 of the Welfare and Institutions
31Code is amended to read:
(a) If a service or support provided pursuant to a
33consumer’s individual program plan under this division or
34individualized family service plan pursuant to the California Early
35Intervention Services Act (Title 14 (commencing with Section
3695000) of the Government Code) is paid for, in whole or in part,
37by the health care service plan or health insurance policy of the
38consumer or the consumer’s parent, guardian, or caregiver, the
39regional center shall pay any applicable
copayment, coinsurance,
40or deductible associated with the service or support for which the
P5 1consumer or the parent, guardian, or caregiver is responsible if
2both of the following conditions are met:
3(1) The consumer is covered by his or her own health care
4service plan or health insurance policy, or that of his or her parent,
5guardian, or caregiver.
6(2) There is no other third party having liability for the cost of
7the service or support, as provided in subdivision (a) of Section
84659 and Article 2.6 (commencing with Section 4659.10).
9(b) Notwithstanding subdivision (a), if the cost of a copayment,
10coinsurance, or deductible payment associated with a service or
11support is more than the cost of
directly purchasing the service or
12support, a regional center may directly purchase the service or
13support in lieu of paying the copayment, coinsurance, or deductible
14payment.
15(c) This section shall not be implemented in a manner that is
16inconsistent with the requirements of Part C of the federal
17Individuals with Disabilities Education Act (20 U.S.C. Sec. 1431
18et seq.).
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