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Medi-Cal And Assistive Technology

Taymour Ravandi, Staff Attorney
PROTECTION & ADVOCACY, INC.
100 Howe Avenue, Suite 235N
Sacramento, California 95825
Phone: (800)776-5746

1. What services and equipment does Medi-Cal provide?
   
   Federal law requires that Medi-Cal provide certain mandatory services.
   
   These Include:
   • physicians' services
   • inpatient hospital care
   • outpatient hospital care
   • laboratory & x-ray services +
   • skilled nursing facility services for persons 21 and older +
   • home health services for persons 21 and older +
   • rural health clinic services, among others
   • EPDST services for children under age 21
   
   In addition, California has chosen to provide certain nonmandatory services. Those which are most important to the provision of assistive technology include:
   • rehabilitation services +
   • physical therapy +
   • occupational therapy +
   • speech therapy +
   • audiology +
   • services provided by intermediate care facilities for the developmentally disabled
   • hemodialysis +
   • emergency and essential diagnostic and restorative dental services +
   • home health care services +
   • prosthetic and orthotic devices and eyeglasses +
   • hearing aids +
   • durable medical equipment +
   • medical supplies
   • transportation to doctor visits and to other medically necessary covered services +
   
   The provider must get Medi-Cal approval before providing the "+" services. Approval is obtained by the provider completing a Treatment Authorization Request (TAR) and submitting it to Medi-Cal. Medi-Cal then has 30 calendar days to approve or deny the TAR. If it fails to do so, the TAR is deemed to be approved. Welf. & Inst. Code Section 14103.6.
   
   Assistive technology under the Medi-Cal program will generally be classified as medical supplies or durable medical equipment and will require prior approval. Many Medi-Cal services are provided subject to "utilization controls." For example, physical and occupational therapy visits are limited to two per month.
   
2. What is the EPSDT program and how does it work?
   
   The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a federal Medicaid obligation imposed on the states as a condition of receiving federal Medicaid money. Under EPSDT, recipients up to the age of 21 (referred to as children by the program) are not limited to the Medi-Cal services available to adults but may, based on medical necessity, be entitled to an expanded scope of benefits.
   
   There are two parts to the program -- the screening part and the diagnosis and reatment part. Screening services include both periodic medical examinations (like "well baby" examinations provided pursuant to a schedule) and interperiodic screens which are defined as any encounter with a health professional who identifies a need for follow-up diagnostic services or treatment services. 42 U.S.C. Section 1396d(r)(1)(A). In California, periodic screens are often provided Medi-Cal children under the CHDP program -- Child Health and Disability Prevention Program.
   
   The screening services trigger a very broad treatment mandate under EPSDT. Ordinarily, states have the option of not covering certain services in their state plan. However, under EPSDT, California and other states are required to cover any optional service -- that is anything California could have opted to include in its Medi-Cal program -- if the EPSDT medical necessity definition is met. 42 U.S.C. Section 1396d(r)(5).
   
3. What does Medi-Cal consider to be Medically Necessary?
   
   State law defines "medically necessary" as those services, medicines, supplies and devices necessary to protect life, to prevent a significant illness or disability, or to alleviate severe pain. Welf. & Inst. Codes Sections 14059.4, 14133.3. medically necessary services include rehabilitation and other services needed to attain or retain the capability for normal activity, independence or self care. Medi-Cal will not pay for treatment, medicines or devices that are considered experimental. 22 C.C.R. Section 51303(g). Medi-Cal will cover, with prior authorization, services which are investigational, provided they meet the criteria in 22 C.C.R. Section 51303(h). For certain low incidence disabilities, what may appear to be "investigational" in fact is not if the treatment is one which is generally accepted by those health care professionals who treat the low incidence disability.

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In some cases a different medical necessity standard is applied:

• Children:
  The restrictive Medi-Cal definition of medical necessity does not apply to treatment of children's health needs identified by an EPSDT program screening or evaluation, or by a treating physician during an inter-periodic screen. The applicable definition is the federal EPSDT standard: diagnostic or treatment services which are medically necessary "to correct or ameliorate defects and physical and mental illness and conditions discovered" during a regular (periodic) or interperiodic screen. 22 C.C.R. Section 51184(b).
• Medi-Medi's:
  Individuals who are eligible for Medicare in addition to Medi-Cal, known as Medi-Medi's, may use the Medicare standards of medical necessity, which defines medically necessary more broadly than Medi-Cal's definition. For example, Medi-Cal will pay for cataract surgery for loss of vision in one eye only if both eyes are affected; Medicare will pay for cataract surgery to restore sight even if only one eye is affected. Under Medicare you get two good eyes; under Medi-Cal you get only one good eye.
• Persons in nursing facilities:
  Federal law provides that individuals who are in long-term care facilities are entitled to receive "the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accord with the comprehensive assessment and plan of care." 42 CFR Section 483.25 This, too, is broader than California's medically necessary standard for Medi-Cal.
• Dual eligible (CCS & Medi-Cal) children:
  Children who are covered by both Medi-Cal and CCS are entitled to have TARs for services related to their physically handicapping condition evaluated under the CCS medical necessity standard. CCS is also expected to case manage such children for services needed because of the CCS eligible condition and should request the provision of Medi-Cal services when necessary. CCS uses a common sense medical necessity standard consistent with its purpose of minimizing the long-term disabling effects of an eligible condition.

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  Reprinted with author(s) permission. Author(s) retain copyright.