SERVICE POLICY GUIDELINES
HEALTH CARE SERVICES
Tri-Counties Regional Center enhances the quality of life for persons with developmental disabilities by working with individuals and their families to secure assessment and treatment supports and services that maximize their opportunities and choices for living, learning, working, and pursuing recreational activities in their community.
Tri-Counties Regional Center will coordinate, support and advocate for individuals to obtain appropriate health care services in their community. Tri-Counties Regional Center works and advocates within the communities it serves to develop and identify appropriate health care services provided by professionals experienced with and sensitive to the needs of individuals with developmental disabilities. Such services maximize the potential for persons served to develop and/or prevent deterioration in their development.
Tri-Counties Regional Center recognizes that some of the general health care needs of individuals with developmental disabilities may be similar to the general health care needs of the general population. Like the general population, persons served must have access to and use private or public health care services to meet their general medical needs.
For children under the age of three (3), in accordance with Government Code section 95004, Tri- Counties Regional Center shall require families to first pursue using private insurance as a generic service for medical services identified in the IFSP, other than for evaluation and assessment. If a service or support is included in the IFSP and paid for by a health care plan or health insurance, Tri-Counties Regional Center will pay any applicable copayment, coinsurance or deductible associated with the service or support; as long as there is no other third party having liability for the cost of the service and the cost of the copayment, coinsurance or deductible does not exceed the cost of funding the services entirely. Tri-Counties Regional Center will continue to ensure the timely provision of required early intervention services.
For individuals three years of age or older, access to specialized health care services directly related to the developmental disability of the individual may be necessary for the health and functional ability of some individuals. Tri-Counties Regional Center may authorize funding only for a health care service that is directly related to, or is the direct result of, the individual’s disability when it is determined by the Planning Team that the service is required and that there are no generic or private resources available and/or responsible to meet the need. The individual or family shall document that coverage by their health insurance plan is being pursued, an administrative appeal is pending, or commencement of services is pending by their health plan. Tri-Counties Regional Center may authorize funding for the purchase of specialized medical, dental, nursing, nutritional, or pharmacy services while coverage is being pursued or it is determined that an appeal of the insurance plan’s denial by the family does not have merit.
Tri-Counties Regional Center will advocate for and work with individuals and their family members to ensure that generic and private health care service providers discharge their obligations to meet the needs of persons with developmental disabilities. In accordance with Lanterman Act section 4659.1, it is the financial responsibility of individuals or their families to pay premiums and, for any non-IPP services, meet any required deductible amount of their health care service plan or health insurance policy. If a service or support which is included in the individual program plan, is paid for through a health care service plan or health insurance policy, Tri-Counties Regional Center may pay any applicable copayment, coinsurance, or deductible when the individual’s or family’s annual gross income does not exceed 400 percent of the federal poverty level. When the annual gross income exceeds 400 percent of the federal poverty level, Tri-Counties Regional Center may, by exception, pay a copayment, coinsurance, or deductible for an IPP service if the person or family can demonstrate either the existence of an extraordinary event, a temporary catastrophic loss, or significant unreimbursed medical costs associated with the person served by Tri-Counties Regional Center that impacts the ability to pay copayments, coinsurance, or deductibles.
Except as legally prohibited by the terms of a Special Needs Trust instrument, trust funds established for the care or benefit of a person served are considered a private resource and it is expected that this source of funds be used prior to regional center authorized use of public funds. When at all possible, TCRC shall be provided the opportunity to review a proposed Special Needs Trust and present timely input to the court. Once established by the court, the Special Needs Trust documents shall be provided to TCRC for the case record.
If a generic or private resource initially denies request for a required health care service that Tri- Counties Regional Center has determined to be their responsibility, that denial will be appealed, unless it is determined that the appeal does not have merit. Tri-Counties Regional Center may authorize funding for a health care service while a person served or family member appeals a denial of service by the generic or private resource under the following circumstances:
For individuals who reside in health care facilities, health care services are expected to be provided as part of the individual’s program, rather than as a separately funded service. Tri-Counties Regional Center service coordinators will actively advocate with health care facilities providers, California Children’s Services, and health care agencies to ensure the delivery of required and mandated health care services. Tri-Counties Regional Center will not authorize funding of any health care service that is considered experimental, optional or elective in nature. The expected result from the provision of a health care service must meet measurable outcomes as stated on the person’s Individual Program Plan or Individualized Family Service Plan. The provision of any health care service must be both clinically and fiscally an effective use of public funds.
Exception Policy:
Tri-Counties Regional Center recognizes that some individual needs are so unique that they may not be addressed in this Service Policy and may require an exception. Such requests for an exception to a Service Policy will be made through the Planning Team process.
Approvals:
