What is Medi-Cal Out-of-Pocket Expense Reimbursement (Conlan)?

https://www.dhcs.ca.gov/conlan

California has a program (stemming from the Conlan v. Shewry litigation) that allows Medi-Cal beneficiaries to seek reimbursement for out-of-pocket medical or dental costs they paid, under certain conditions.

Key eligibility conditions include:

• The service must have been a Medi-Cal–covered service, on a date when the person was Medi-Cal eligible.

• You must have paid out of pocket (or someone paid on your behalf).

• The provider must have been a Medi-Cal provider on the date the service was provided.

• The claim must be submitted within certain time limits (e.g. within one year of service or 90 days after issuance of Medi-Cal card, whichever is longer) for services on or after November 16, 2006.

If all criteria are satisfied, Medi-Cal may reimburse you through one of these:

1. Voluntary Provider Reimbursement (provider refunds you)

2. Involuntary Provider Recoupment (Medi-Cal recovers the cost from the provider)

3. Medi-Cal reimbursement up to Medi-Cal rate (if provider can’t or won’t pay)

So if your child’s co-pay was for a service that would be covered by Medi-Cal, and the provider qualifies, then yes — in theory you could get reimbursed under this scheme.

How the DDS / Regional Center / DD Waiver factors in?

Because your child is a Regional Center consumer and has a DDS waiver (a DD or HCBS waiver), things get more intricate.

• Having the DD waiver means Medi-Cal can cover certain services the regional center provides (or helps coordinate) as part of the developmental disability services framework.

• But that doesn’t automatically make every private-insurance co-pay eligible for reimbursement, especially if the private plan’s co-pay was for services not strictly “Medi-Cal covered” under the rules, or by a provider not enrolled in Medi-Cal.

• Regional centers may sometimes assist with co-pay assistance (depending on your household income, the regional center policies, etc.). The Process can be found here.

• Even when regional center funding or assistance is possible, it’s often a “payer of last resort” — meaning everything else must be exhausted first (insurance, Medi-Cal reimbursement, etc.).

In short: being a consumer with a regional center + waiver helps your case in terms of access and coordination, but it doesn’t guarantee reimbursement of private co-pays.

The Process

1. Verify that the service and provider qualify.

• Was the service one that should be covered by Medi-Cal?

• Was the provider a Medi-Cal–approved provider on the date of service?

• Did you or someone pay the co-pay out of pocket?

2. Gather documentation.

• Receipts, bills showing the co-pay, explanation of benefits (EOB) from private insurance, proof of Medi-Cal eligibility at that date.

• Provider statements about refusing to reimburse you for a service Medi-Cal should have covered.

3. Check your Medi-Cal eligibility window.

• The service must have been rendered during a period when you were covered by Medi-Cal (or within the retroactive eligibility window).

• If the service was before your Medi-Cal became active, see if retroactive eligibility applies (and was approved) for those dates.

4. Submit a Conlan claim.

• Fill out the Medi-Cal out-of-pocket reimbursement (Conlan) claim forms.

https://www.dhcs.ca.gov/services/medi-cal/Pages/Online-Conlan-Claim-Forms.aspx

• Submit via mail (or other method if allowed) to the DHCS Beneficiary Services Center.

Mail the completed Conlan claim packet to the Department of Health Care Services (DHCS) at:

Beneficiary Service Center

• Make sure it’s within the allowed deadline (1 year from service or within 90 days after card issuance, whichever is longer).

• If a provider refuses to reimburse, Medi-Cal can attempt recoupment from the provider.

5. Talk to your regional center.

• Ask your service coordinator whether the regional center can cover that co-pay (or a portion) in “payer of last resort” fashion.

• Ask whether your regional center’s policy allows co-pay assistance for the particular service and provider you used.

• If regional center does provide it, get the procedure and forms.

6. Prepare to appeal.

• If Medi-Cal denies your request, you have the right to request a hearing (state hearing) within 90 days of the notice. This information can be found on the back of the notice of action letter.

• Also, if the regional center denies co-pay assistance, you may need to appeal via regional center or under your Lanterman Act rights.

For children with special needs in California, Medi-Cal provides a broad set of benefits, especially if the child is also receiving services through Department of Developmental Services (DDS) and has a waiver (e.g., DD/HCBS waiver). These services go well beyond standard pediatric care. Below is a rundown of the most common Medi-Cal covered services relevant to children with developmental disabilities or complex medical needs.

Core Medical Care

• Primary Care: routine checkups, sick visits, immunizations.

• Specialist Care: pediatric neurology, genetics, developmental-behavioral pediatrics, gastroenterology, pulmonology, endocrinology, orthopedics, etc.

• Hospital Services: inpatient and outpatient care, surgeries, ER visits.

• Durable Medical Equipment (DME): wheelchairs, gait trainers, walkers, standers, communication devices, etc.

Therapies

• Speech Therapy (ST)

• Occupational Therapy (OT)

• Physical Therapy (PT)

• Feeding and swallowing therapy

• Behavioral therapies (see ABA below)

Behavioral and Mental Health

• Applied Behavior Analysis (ABA)

o For children with autism or related conditions.

o Must be medically necessary and prescribed by a physician or psychologist.

• Mental/behavioral health therapy (individual, family, group)

• Psychiatric evaluations and medication management

• Crisis stabilization and inpatient psychiatric care if required.

In-Home and Long-Term Care Supports

• In-Home Supportive Services (IHSS): personal care assistance, protective supervision, paramedical services.

• Home health nursing (e.g., LVN/RN support for medically fragile children).

• Private duty nursing when medically necessary.

Medications and Supplies

• Prescription medications (brand or generic, if medically necessary).

• Over-the-counter medications if prescribed.

• Incontinence supplies, feeding supplies, tracheostomy care, respiratory supplies, etc.

Dental and Vision Care

• Preventive and restorative dental services through Denti-Cal.

• Vision exams and glasses through the Vision Care benefit.

• Orthodontia if medically necessary (e.g., for cleft palate, craniofacial anomalies).

Transportation

• Non-emergency medical transportation (NEMT): gurney, wheelchair van, or ambulance when required for medical reasons.

• Non-medical transportation (NMT): mileage, gas, bus passes to get to appointments.

Case Management & Care Coordination

• Targeted Case Management (TCM) for medically fragile children.

• Regional Center coordination for children with DDS waiver.

• Managed Care Plan care coordinators for children with multiple needs.

Special Programs

• California Children’s Services (CCS) for children with qualifying medical conditions (e.g., cerebral palsy, congenital heart disease).

• EPSDT Supplemental Services: anything medically necessary to “correct or ameliorate” a condition, even if it’s not normally covered for adults.

• Respite services through IHSS or Regional Center (not directly Medi-Cal, but waiver-linked).

Waiver-Based Enhancements

For children on the Home and Community-Based Services Waiver for the Developmentally Disabled (DDS Waiver):

• Expanded access to Medi-Cal regardless of parental income.

• Streamlined authorization for home-based nursing and personal care.

• Supplemental habilitation or day services.

• Increased respite and transportation support