Medical and Dental Equipment; and Supply Services and Therapies Funding Guidelines

General health care needs for Regional Center clients are similar to the needs of all members of the community. Ordinarily, parents of minors are expected to provide for all medical and dental care, equipment and medical supplies and therapies for their children through private insurance, California Children’s Services or other sources of health care and funding available to the general public. In most instances adult clients have their medical, dental and equipment needs met through Medi-Cal and in some cases California Childrens Services or other government or private funding resources.

For children under the age of three years, regional centers may use private insurance as a generic service only if there is no cost to the family as a result of its use. Cost includes deductibles, co-pays, or a reduction in the lifetime benefit cap. Regional centers may pay the cost of accessing private insurance (e.g. deductible or co-pay amounts).

Medical and dental care, durable and non-durable equipment, and supplies may be purchased to improve or maintain the client’s health status and allow him or her to function in their place of residence, educational, vocational or social recreational setting.

The Regional Center may purchase medical or dental services, equipment, and supplies for clients if the following criteria are met:

1. The needed treatment or equipment is associated with or has resulted from, a developmental disability
   
   AND
   
   For clients over three years of age, the client has been denied or is not eligible for Medi-Cal or California Children’s Services and has no access to private insurance or another third party payer coverage.
   
   OR
   
2. The generic resource does not provide for or has denied the needed service.

Regional center clients in residential care facilities generally are eligible for, and are expected to utilize, the benefits of the Medi-Cal and/or Medicare programs.

A client who is not eligible for Medi-Cal or California Children’s Services coverage and who has no access to private insurance, who requires surgery, hospitalization or other complex treatment, will be referred to a medical facility with other funding mechanisms such as county facilities. Individuals using county facilities will be expected to participate in the ability to pay process.

Medical and dental care services that may be purchased by the Regional Center include those services prescribed by and provided by a qualified professional. These services may include medications, assessments for particular therapies, and nursing care.

Equipment, both durable and non durable, and supplies may include wheelchairs, lifts, suction machines, adaptive utensils for eating, communication devices and diapers or incontinent supplies for clients five years of age and older. Medical equipment must be prescribed by a licensed physician, occupational and or physical therapist or speech pathologist.

Therapy services may be necessary to maximize potential or prevent significant deterioration which is related to a developmental disability. Therapy services may be provided either individually or in small groups and include but are not limited to occupational therapy, physical therapy, sensory integration therapy, speech and language therapy, and nutritional therapy.

When the need for therapy services is identified, funding from generic resources such as Medi-Cal, California Children’s Services, the school district, or private insurance will be sought to meet the need for children over three years of age.

For children of school age, services related to education are the responsibility of the school district and we will assist families to secure them through the IEP process. These may include psychological or psychiatric services, and physical, occupational, and speech therapy.

If no other funding source exists, the Regional Center may fund the therapy service if an appropriate Regional Center consultant (for example, an occupational therapist reviews occupational therapy requests) reviews the written documentation supporting the need for the therapy request and documents that the therapy is necessary. Therapy services are to be time limited, with specific outcomes identified.

Reauthorizations or continuation of funding will depend upon client and/or family satisfaction with the service, and the provider’s ability to achieve the specific, agreed-upon outcomes.

ADOPTED BY BOARD OF DIRECTORS: MAY 26, 1999