Medi-Cal’s Institutional Deeming Waiver 101
Several government benefit programs, including IHSS, require that your child be enrolled in Medi-Cal before you can access services. But for some families, parental income exceeds Medi-Cal’s qualifying threshold. If your child is a Regional Center client and this is the case for your family, you can enroll in full-scope Medi-Cal (which provides the full range of covered benefits, not just emergency services) using the Medi-Cal institutional deeming waiver for individuals with developmental disabilities regardless of parental income, as long as your child’s personal income and resource levels fall below program thresholds.
This might sound intimidating, but it’s less complicated than it sounds! Our Public Benefits Specialist Lisa Concoff Kronbeck breaks it down for us here.
What does institutional deeming mean?
Medi-Cal is a needs-based program that evaluates an applicant’s income and resources to determine eligibility. When a child with a disability lives at home with parents, or when an adult with a disability lives at home with a spouse, Medi-Cal will “deem” most of the parental or spousal income and resources to the applicant, which can render them ineligible for Medi-Cal (even if the deemed income isn’t enough to cover adequate care).
However, when a person resides in an institutional setting (such as a nursing home or a hospital), only the individual’s own income and resources may be counted for Medi-Cal eligibility.
The waiver program for people with developmental disabilities was designed to prevent unnecessary institutionalizations by funding home and community-based services for Regional Center clients who live at home, but who would otherwise qualify for placement in a state-funded residential care facility. If your child meets the admission criteria for such a facility (see the section below on eligibility), Medi-Cal will only look at your child’s income and resources, without regard to parental income.
Does this mean my child will be considered for facility placement?
No. The determination of institutional-deeming eligibility is theoretical for these purposes; the Regional Center is not assessing your child for actual placement in a facility.
How do I know if my child is eligible?
To be eligible for the institutional deeming waiver, a Regional Center client under the age of 18 must:
- live at home with their family;
- have a valid Social Security number;
- be ineligible for Medi-Cal due to family income;
- be diagnosed with a developmental disability;
- have two or more qualifying conditions in the areas of self-help, motor functioning, social/emotional functioning, special health care conditions, or extensive medical needs; and
- receive at least one funded Regional Center service and utilize that service at least once per year. Many families fulfill this requirement via respite hours.
How do I apply?
Once the Regional Center refers your child for the Medi-Cal waiver, you will receive a thick packet of paperwork in the mail. Ordinarily, families filling out this paperwork need to establish that their income falls below a certain threshold in order to qualify for the program. However, because only families with excess income can qualify for the waiver, the main purpose of this application for families above the income threshold is to establish that the child doesn’t qualify for Medi-Cal on an income basis. This means it’s usually not necessary to provide a detailed list of all your assets.
Examples of documents you may want to provide include copies of bank statements, paystubs, or a completed 1040 or a W2 form to establish income levels. If you have more than $2,000 (if unmarried) or $3,000 (if married) in savings, documentation of that balance should be sufficient to demonstrate that you don’t meet the resource threshold. Your child, however, must meet the income/resource thresholds to qualify. If your child has personal earnings or more than $2,000 in savings in their name, you might want to consult with a financial planner to determine the most appropriate course of action, e.g., creating an ABLE account and/or special needs trust.
Some Regional Centers have a designated Medi-Cal specialist who can set up an appointment with you to help you fill out this paperwork. Ask your child’s service coordinator whether this option is available to you.
What if my child is under age 3?
Prior to age 3, children receive early intervention services from Regional Center if they have or are at risk of developmental delays or disabilities. Because early intervention services use a different stream of funding and are based on different eligibility criteria, parents will often be told that children cannot be enrolled in the waiver program until age 3. This is incorrect. However, children under age 3 must have a diagnosed developmental disability that will continue to qualify them for Regional Center eligibility after age 3.
Because the criteria for eligibility are based on a child’s deficits relative to a typical child of the same age (and typically developing infants and toddlers are not generally capable of daily self-care), children under age three who qualify are most likely to have significant medical needs. A child must have at least two qualifying medical care needs to be eligible for the waiver.
There does not appear to be an explicit list of criteria, and parents have reported a variety of conditions being considered as qualifying, including heart defects, tube-feeding, oxygen, nebulizer treatments, monitoring placement of hearing aids and glasses, giving medications, and more, so we suggest emphasizing the extent to which your child’s gross and fine motor impairments require significant interventions on a regular basis.
Do I need to renew the waiver?
Yes. The waiver enrollment must be renewed each year. Along with any requested financial paperwork, you will need to obtain and submit a form letter from your Regional Center service coordinator establishing that your child remains a Regional Center client and continues to receive waiver-eligible services.
How do I use Medi-Cal services?
Most Medi-Cal recipients will enroll in a county-managed care plan. However, recipients who have private health insurance as their primary plan are usually (with some exceptions) required to opt out of managed care and enroll instead in fee-for-service Medi-Cal (sometimes referred to as “straight Medi-Cal”).
Fee-for-service Medi-Cal operates outside of the managed care system, and is always the secondary payer. Many families use this to fund medical, dental, and pharmacy copayments if the private insurance provider accepts fee-for-service Medi-Cal. Parents may also be able to get certain supplies funded that the private insurance will not cover, like diapers and other incontinence supplies, as well as services and equipment that may be excluded or limited by the private plan.
Many large hospitals accept fee-for-service Medi-Cal, including UCLA, many children’s hospitals, and Cedars Sinai. If you have primary insurance and hope to use Medi-Cal as a secondary coverage, make sure that your providers accept fee-for-service Medi-Cal.
Many families receiving Medi-Cal (whether managed care or fee-for-service) apply for In-Home Supportive Services (IHSS) for their child. IHSS is a Medi-Cal service that provides limited funding for caregiving to the extent a child’s care needs are above and beyond those of a typical child. Learn more about IHSS here.
What other questions do you have about Medi-Cal’s institutional deeming waiver? Let us know in the comments and we’ll address them in an upcoming interview with our Public Benefits Specialist Lisa Concoff Kronbeck; stay tuned for details!