TM: That is not the case in all states and there are other instances in which the term spend down is applied eg asset limitations. But not all states allow you to "spend down" because your income is too high. Wish mine did.
Kathy: I can't comment on the rules in Texas or the other plans available. There are very extensive differences from state to state. While Medicaid may be Federally funded, in part anyway, each state has different plans. They allow and don't allow different things, include and don't include different people.
It is generally true that any hospital that takes any kind of state funding, including Medicaid that also has an ER, has to have some kind of "indigent" or low income/ uninsured patient plan. That is, the hospital cannot turn anyone away for insurance reasons. They are required to provide treatment and work out payment arrangements later. The terms (income limits, co-pays, etc) are typically determined by the state and often follow Medicaid numbers. FYI they also typically get money from the state to subsidize their "shortfalls" for treating such patients. So if you are receiving services in a hospital under this umbrella then they have to take Medicaid. I will qualify for those who have other situations, that it is possible in some states that if the doctor is not an employee of the hospital or affiliated with the hospital the rules might be different. But I'm not personally aware of any such state. Note that with regard to life threatening services, eg ER services, no such hospital or doctor can refuse any patient period.
The other rule, and again I'm not sure but I believe this is Federal for Medicaid... if you are on Medicaid no doctor can take you as a private paying patient. You need to check this before you start looking at docs. It's also true that there are few private providers in the psychiatry and psychology fields who take Medicaid. They just don't pay enough. Most of us end up at those hospital clinics which will take Medicaid....same hospitals as above.
Since your state has one of the highest numbers of illegal aliens/ indigent and uninsured populations I'm sure your state has tight reins on Medicaid spending and indigent treatment co-pays. Also, since the kind of services I think you're looking for such as social skills classes is considered elective or not medically necessary there are probably even tighter restraints. Again, you need to ask Medicaid if they even cover the kind of services you want.
Suggestions:
1. I keep my income under their limits so I don't have to deal with all this hassle. Also,check into how they look at your income. eg if it's the W-2 and you have a 401(k) or medical cost plan that is pre-tax, increase your contribution to that plan by the $89.
2. Talk to the providers of services like social skills classes and ask if they can change the treatment numbers on the insurance forms to something that will be covered. In particular, Pervasive Developmental Disorder (PDD) is a developmental disability, not a psychiatric disease. Can they find a way to ethically use a code under daughter rather than psychiatry to get more of this covered? So when my Pervasive Developmental Disorder (PDD) kid gets speech therapy or Occupational Therapist (OT) it's got a daughter code, not a psychology code. This involves some creativity and you may need to offer some suggestions to get them thinking creatively. eg if once a week psychology is allowed and once a week social skills is allowed and they call their twice a week class social skills can they call one session social skills and one session psychology?
3. Again, talk to the hospital providing services and ask if you can work out a payment plan for the deductibles.
4. Many charities will help with deductibles. Many clinics have grants to serve people who can't afford treatment. If you are near a teaching or research place, see if there are any research programs you can get into that will provide services.
5. Have you applied to the State for daughter services? While there's a waiting list in every state, if you put him on it when he was younger and his name has come up.... you might get them to pay for this sort of thing.
6. Many programs have scholarships. You only need a partial one. Try to find a program that will give you a partial scholarship.
7. Apply for grants for daughter kids yourself. Eg some time ago I posted that CAN was offering $500 grants to parents. Check your local and state charities focused on kid's medical expenses or on daughter kids to see if you can find one you can apply to. eg local Lions group, catholic charities, etc. They may want to pay the provider directly, but that's OK.
8. I'd worry less about the SD. Remember that if you don't agree with their person's diagnosis you have the right to make them pay for a second opinion.
Yes, all of this is very complex and time consuming. Ask for something on paper explaining the program in detail.
This is totally off topic, but you mention your younger son is a climber. You are aware that climbing is not uncommon to Pervasive Developmental Disorder (PDD) kids, right? It's proprioperceptive stimulation that many of them crave. While that it a sort of Sensory Integration Disorder (SID) kind of symptom, with another Pervasive Developmental Disorder (PDD) son, given that Pervasive Developmental Disorder (PDD) runs in families... you have had him tested, right?
http://www.sensory-processing-disorder.com/sensory-processing-disorder-checklist.html