Andria Aparicio’s son, Johnathan, 18, needed braces and surgery to correct crooked, overlapping teeth and a misaligned jaw. But dentists insisted that Medi-Cal wouldn’t pay for the treatments, even though legal aid attorneys say he is entitled to the services. Embarrassed and in pain, Johnathan didn’t smile often, Aparicio said. (Courtesy of Andria Aparicio).

By Jocelyn Wiener
California Healthline

Tania Alvarado’s 13-year-old daughter doesn’t smile much anymore. She doesn’t want anyone to see her front teeth, which are so crowded they’re nearly growing atop one another. The crowding makes it painful to eat; it also embarrasses her.

“Am I going to get those braces this year?” the Los Angeles eighth-grader asks her mom, again and again.

Alvarado always answers her the same way: “It’s still not happening.”

For two years, dentists have told Alvarado that her daughter needs braces. They’ve also told her that because the girl has Medi-Cal — the government insurance program for low-income Californians — braces aren’t covered.

Legal aid attorneys say the dentists are wrong. They blame a confusing disconnect between state and federal law for preventing many California children from getting the health services to which they are federally entitled. Under federal law, children are eligible for a wide array of services, but confused providers and health plans often look only at the state’s narrow range of approved services for adults, and mistakenly apply those rules to kids.

Sometimes, as in Alvarado’s case, they simply refuse to submit a treatment authorization request to Medi-Cal, which is required to get the federal benefits.

Advocates say this has left countless low-income families scrambling to get help for their children. Some parents are savvy enough to appeal their children’s cases to the state. Others, in desperation, borrow money they can’t afford to pay back. Often, children simply go without the care they need, said Kim Lewis, a managing attorney with the National Health Law Program, which champions the health rights of low-income people.

“They’re being denied care that they’re entitled to,” she said. “That’s the bottom line.”

Lewis’ organization and the Western Center on Law & Poverty have sponsored legislation they believe can help ensure that kids get the care they need. SB 1287, which landed on Gov. Jerry Brown’s desk in late August, would align state law with federal law and help educate insurance plans and health providers about the broader range of services for which children on Medi-Cal are eligible. The bill would also update member handbooks and regulations.

Although the bill passed the legislature with overwhelming bipartisan support, two state agencies expressed early opposition to it. Brown has until the end of September to sign or veto the measure.

Federal law stipulates that children under 21 who have Medicaid — which is called Medi-Cal in California — are automatically entitled to Early and Periodic Screening, Diagnostic and Treatment services. That benefit includes an array of treatments considered necessary to correct or improve a physical or mental health condition or a substance abuse disorder.

But under California law, adults with Medi-Cal are entitled to a more limited range of services deemed necessary to “protect life, prevent significant illness or significant disability, or to alleviate severe pain.”

Advocates say the problem affecting the Alvarados and countless other families arises when doctors, dentists and health plans — and sometimes even the state itself — erroneously apply this stricter adult standard to children, telling them they are not eligible for braces, physical therapy or mental health treatment, even though federal law says they are.

In some cases, providers submit treatment authorization requests to Medi-Cal but fail to check the right box or use the “magic words” asking for coverage under the federal standard — and the patients get wrongly denied, Lewis said. Many families don’t know enough to appeal those decisions, advocates say.

The state Department of Health Care Services, which administers Medi-Cal, sent a letter to the Assembly Health Committee in June opposing an earlier version of the bill. Carol Gallegos, a deputy director of the department, wrote that the state already adheres to the federal standard allowing children to receive services that are not considered medically necessary for adults. Tony Cava, a department spokesman, said the department has not taken a position on the most recent version of the bill.

The state Department of Finance also wrote a letter of opposition to an earlier version of the bill, saying the issue would be more appropriately addressed by sending letters to managed-care plans and offering providers education and outreach.

Andria Aparicio’s son, Johnathan, 18, needed braces and surgery to correct crooked, overlapping teeth and a misaligned jaw. But dentists insisted that Medi-Cal wouldn’t pay for the treatments, even though legal aid attorneys say he is entitled to the services. Embarrassed and in pain, Johnathan didn’t smile often, Aparicio said. (Courtesy of Andria Aparicio)

Janet Kim, a staff attorney for the Legal Aid Society of San Diego, said she knows of a few cases this year in which children with disabilities were refused some of the weekly occupational or speech therapy that doctors said they needed. Medi-Cal generally limits those therapies to twice a month for adults, she said, but federal law doesn’t impose a similar limit on children.

Alexandria Forester, a staff attorney at Neighborhood Legal Services of Los Angeles County, said her organization sees dozens of cases each year in which children are denied services they’re entitled to.

“It is a major concern,” she said. “It is creating such a huge barrier for this population.”

One of those cases is Tania Alvarado’s. When she began trying to get braces for her daughter two years ago, the family was told that the longer they waited, the more teeth would eventually need to be extracted. The dentist, and later an orthodontist, refused to submit a treatment authorization request to Medi-Cal, Alvarado said. They insisted that Medi-Cal wouldn’t pay.

Alvarado is a single mom who works part time as a caregiver, and braces would cost her $5,000, more than she can afford. She explored a payment plan, but it was still too expensive.

In the meantime, her daughter complains that it hurts to chew. Other kids keep asking her why she hasn’t gotten braces yet. She doesn’t understand herself.

“Sometimes it’s holding her back,” Alvarado said. “I want her to really be at her full potential and really develop healthy. I don’t want this to traumatize her.”

Forester, of Neighborhood Legal Services, worries that for all the families her organization sees, there are many more people who aren’t aware of their rights or don’t know their children are entitled to services. Often, she said, those people end up entering into expensive credit agreements. The costs can range from a few thousand dollars to more than $10,000 for extensive dental work, she said.

“Sometimes they think this is their only option, to pay out-of-pocket,” she said.

That was the case for Andria Aparicio, a part-time funeral services assistant in Whittier. Dentists told her two years ago that her teenage son needed braces and surgery to correct crooked, overlapping teeth and a misaligned jaw. They also told her they wouldn’t submit an authorization request, because Medi-Cal wouldn’t pay for it. Her son, Johnathan, who is now 18, was embarrassed and in pain. Kids made fun of him.

His mother decided to forgo the surgery.

“I told them, ‘Does he really, really need it?’” said Aparicio, 48. “They said ‘He does need it, but it’s up to you.’ Of course, I didn’t have the money, so I didn’t do it.”

But she agreed to pay the dental office nearly $4,500 in increments of $100 each month to cover the braces. She was unemployed at the time, and took the money out of her son’s $910 monthly SSI (Supplemental Security Income) check, which she needed to cover many of the family’s other expenses as well.

“I had no choice but to do it,” she said. “I didn’t want him to suffer like that.”