Disabled California Children May Lose Medical Services

Until recently, the California state Medi-Cal insurance program covered home health care services to disabled children. The program paid for home nurses to administer medications, handle feedings and provide other treatment for children whose disabilities require skilled care, allowing them to remain at home. In July 2011, the Gold Coast Health Plan took over the administration of the Medi-Cal plan in Ventura County, and was charged with containing costs. Families feared there could be changes in coverage.

Gold Coast has begun the process of determining which patients and families do not meet the criteria for the medical treatment they were previously receiving. Some families, despite receiving letters stating coverage would not change during the transition from Medi-Cal to Gold Coast, discovered that their children's home care coverage had been denied. Gold Coast takes the position that care by a provider with a nursing license is not medically necessary for some of these disabled children, so it need not provide coverage for the care. Some patients can be transitioned to other government medical services, so Gold Coast can avoid paying for their care. In other circumstances, families are told that an aide with minimal training can administer some of the basic care that was previously provided by nursing professionals and paid for by Medi-Cal.

Families facing denial of services they had with Medi-Cal worry that the transition of services will not match the level of care their children previously received and will compromise the health of their loved ones. Furthermore, families are concerned that without skilled home health care nurses, they will not be able to care for their disabled children at home. Administrators from Gold Coast argue that the issue is solely the medical necessity of treatment and they should not pay for services that are not ruled to be necessary.

Currently a number of California families are hoping the state will conduct hearings on Gold Coast's decision to deny services for disabled children. The issue of what constitutes medical necessity is at the core of these disputes. The health and welfare of many people who heavily rely on California's health plan may well depend on how medical necessity is defined through this process. Besides the disabled children who could lose home health care support, disabled adults and low-income Californians also stand to lose some health care coverage under Gold Coast's administration.