Photo: Courtesy Lucile Packard Foundation for Children’s Health
SAN FRANCISCO – For over a year, Pamela DiBattista had watched her autistic daughter, Catalena, make remarkable progress in her communication and interpersonal skills.
The nearly 4-year-old girl had also become more controllable, thanks to the two hours of occupational therapy and 19 hours of behavioral analysis sessions she had received each week through her Healthy Families insurance plan. If you added to those hours the time she spent receiving speech therapy, her care totaled 23 hours each week.
But last week, DiBattista found out that Catalena’s therapy has been cut to four hours starting April 4.
“That’s a big chunk of therapy to take away from a child with special needs,” said the San Jose, Calif., mom. “She made so much progress; now she could regress.”
Catalena is one of about 1,000 autistic children in California facing this change because the state is transitioning all low-income kids (about 875,000) from Healthy Families into Medi-Cal (California’s name for Medicaid) in a process continuing through the next few months.
Asked why autistic children who have transitioned to Medi-Cal are being denied adequate therapy, state Department of Health Care Services spokesman Anthony Cava blamed it on a law.
"The Healthy Families Program is required to provide behavioral health treatment, which includes applied behavioral analysis (ABA) therapy treatment for autism, under the California mental health parity law," he said. "The law exempts Medi-Cal from providing this coverage."
But he added: "The department is still assessing the specific availability of ABA services for its Medi-Cal members."
Medi-Cal Managed Care
The experience of Catalena and the other autistic children runs counter to what the state said it hoped would happen when it decided last year to shift California’s low-income children from Healthy Families to Medi-Cal managed care.
In approving the transition, the California Legislature asserted that Medi-Cal would simplify eligibility and coverage for children and families, while providing additional benefits and lowering costs for children at certain income levels. The state also claimed it would gain administrative efficiencies, achieve General Fund savings and provide a more consistent health plan contracting process.
Both programs serve low-income families, but the popular Healthy Families (the state’s name for the State Children’s Health Insurance Program, or S-CHIP) was aimed at children up to age 19 in families that don’t qualify for Medi-Cal and have incomes up to 250 percent of the federal poverty level, or $46,000 for a family of three.
Some of the children in Medi-Cal have received their care through managed-care plans, and others see doctors or go to hospitals reimbursed from a fee schedule set by the state. These families have not been required to pay any premiums for their coverage.
The care delivered to children with special needs has received sharp criticism even before the transition began. According to the Lucile Packard Foundation for Children’s Health, in Palo Alto, Calif., which runs the website, Kidsdata.org, California children with special health care needs have been receiving care that is less coordinated and less family-centered.
Children’s health care advocates had warned the administration of California Gov. Jerry Brown when it was considering eliminating Healthy Families last June that as troubling as Medi-Cal's operation was, it has too few doctors to serve thousands of the new patients the transition would bring in. The program's low reimbursement rates has resulted in poor participation by doctors.
The transition, which began in January, was scheduled to be carried out in four phases over this year. The first phase included about 197,000 children in a largely healthy group.
During the implementation of that phase, Jane Ogle, deputy director for the state Department of Health Care Services (DHCS), observed that she did not anticipate any problems in the implementing of phase 2 either, which began this month with 273,000 children, among them Catalena.
The next two phases, beginning in August, could be more challenging, she had said. That’s because later phases would require children to choose new plans and/or providers.
'Potential Problems" and Smaller Savings
An issue brief released earlier this year by the Packard Foundation warned that the state should have in place alternate plans in the event that the transition presents “potential problems.”
“During the transition, particular attention should be paid to children with special health care needs,” to avoid disruption in their care, the brief said.
At a Sacramento hearing last week, the Legislative Analyst's Office revealed that the originally estimated savings of $13.1 million for the Healthy Families transition in 2012-13 shrank to $137,000. Savings for next fiscal year (2013-14) were estimated at $52 million and that estimate has been revised to $43 million.
At the hearing, Scott Ogus, of the state’s Department of Finance, cited several factors contributing to the revised figures. Delays in implementation by the DHCS led to caseload changes. Department officials justified the delay, saying they slowed down some of the early phases of the transition so children would have less disruption in continuity of care.
"The main reason for the erosions is because of caseload changes," Ogus said. "Those eye-popping numbers from $13 million to $137,000 are due to some of these delays."
But Sen. Bill Emmerson, R-Hemet, commented, "Last year I opposed eliminating Healthy Families and all information I've seen since then confirms that [was the proper stance]. The latest network assessment shows much more limited [provider] networks than the Healthy Families network did."
“The state,” Emmerson said in an interview, “was ill-advised to eliminate Healthy Families. We believe the children of the working poor should have access to health care.”
Children Now’s Health Policy Director Kelly Hardy, who was among 15 or so other children’s advocates at last week’s legislative hearing, said the state should suspend transitioning additional children to Medi-Cal until “all the kinks are worked out.”
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