Leslie Lobel, Undivided's Director of Health Plan Advocacy, and Lisa Concoff Kronbeck, Undivided's Public Benefits Specialist, explain the funding resources available to parents and how to navigate them during this Undivided Live event. Watch the full replay above or catch the recap here.
To learn about how to pay for medical and therapeutic needs that are sometimes harder to get approved through traditional means, read our article, How Do We Pay For It All? Undivided’s Guide to Funding Resources.
Lindsay Crain
Welcome to Undivided live. I'm Lindsay Crain and I head the content and community teams at Undivided. With me today we welcome back a power duo: Undivided's Public Benefits Specialist Lisa Concoff Kronbeck and our Director of Health Plan Advocacy, Leslie Lobel. Not only are they beacons of knowledge, they're also parents of children with disabilities. So they intimately understand the emotions and the necessities around what they do. So welcome, Leslie and Lisa.
Lisa CK
Thank you.
Lindsay Crain
So some of the major government programs that can help pay for medical visits, therapies, durable medical equipment, services, and more are Medi-Cal, Regional Center, and CCS. So that's where we're going to focus today. So before we jump into specifics, Lisa, I'd love for you to give an overview and confirm who is eligible for each so our families know what's actually available to them. And let's start with Medi-Cal. So who's eligible and what can they provide?
Lisa CK
So for Medi-Cal there's, for our purposes, in this discussion, there's two primary ways that people are going to qualify, maybe three. One is, is by family income by modified adjusted gross income. One is if the child is receiving SSI. And the third is if you don't get an SSI, just in case somebody doesn't know what that means. Supplemental Security Income, it's it's a benefit from from the Social Security Administration for people with disabilities. And the third one is if you don't qualify by any of the financial thresholds, you can, if your child is a Regional Center client, you can also qualify for the Medi-Cal institutional deeming waiver for people with developmental disabilities. And your child can enroll in Medi-Cal without regard to family income.
Lindsay Crain
Is it all ages?
Lisa CK
A lot of times once once our kids turn 18, they qualify for Medi-Cal based on income, because they no longer consider parental income. So for Regional Center, most of the time, you're going to see kids on the waiver, that's not always the case. But most of the time for SSI, that's going to be all ages and for modified adjusted gross income, that's also going to be all ages.
Lindsay Crain
I was gonna ask about the two different plans and Medi-Cal.
Lisa CK
Okay, we're really getting in, okay, so Medi-Cal is there's two kind of different ways of delivery. The first is fee for service, which is where you can go to any provider who accepts Medi-Cal fee for service and they swipe your benefits card, and Medi-Cal will cover depending on what your primary insurance, your private insurance situation is. The other the other, and more dominant method of delivery is managed care at this point. Managed cares, HMO, basically, on each county has choices of different plans, and you go to providers within that network. If you have to get out of network, you need referrals. And there has to be exceptions, and but generally speaking, you're going to be within the network. And we can talk later about who is in fee for service and who is in managed care. Um, but those are the two basic types.
Lindsay Crain
And just a clarification, depending on which plan that you choose for Medi-Cal, does one work with other funding sources differently? So if you pick a managed care plan, does that work differently with insurance than straight Medi-cal?
Lisa CK
So they're generally going to operate similarly, but not identically with private insurance. Things go a little bit differently with CCS. But with private insurance, I mean, again, the or I guess, for the first time this week, the major issue is that your provider, your provider has to contract with the form of Medi-Cal that you have. So if you have a doctor who is a fee for service provider, but is not contracted with the plan, and you have a managed care plan, that's that's going to be a disconnect. So it's going to work similarly, in the sense that your private insurance is always going to pay first. But it's it's going to always depend on who your provider is contracted with.
Lindsay Crain
So that's where the focus is, obviously find out where your provider is, and that, yes, you know, a leading factor. And does Medi-Cal cover out of network providers?
Lisa CK
No, your provider needs to be contracted with Medi-Cal, there are some times when you can get a single case agreement, depending on the provider and the situation whether there is an in network provider, a contracted provider who can offer the service, but they need to be a Medi-Cal contracted provider in order to fill that account.
Lindsay Crain
And we did have one just quick follow up about SSI. Lisa wanting to know how does a child qualify for SSI?
Lisa CK
That's going to be income based. I mean, it's going to be disability based, but also they're going to look at family income.
Lindsay Crain
Do you and just off the top of your head. Do you remember the threshold?
Lisa CK
Not offhand because number it's based it's it's is kind of tied to the federal poverty level. But it varies by family size, and it changes every year.
Lindsay Crain
And then Regional Center. So we can talk about who qualifies, and what is that?
Lisa CK
So that's going to be, we're going to talk mostly about kids who are over age three. So that's going to be kids who have a diagnosed or or adults who have a diagnosed developmental disability and have significant impairments, in in at least three of the designated areas, which include things like independence, and the ability to manage their own finances, ability to like social, emotional, that just general developmental areas, ability to work, there's a whole bunch. And you have to you have to have deficits in at least three areas within that. Self Care. A lot of it, a lot of them are adaptive skills. So the ability to care for themselves and live independently.
Lindsay Crain
And there are more details. I know, Donna's got, I think she just shared the our Regional Center 101 article that we worked on that we'll go into. Yeah, and they're all listed out there. Yeah. But just to clarify, Lisa, and Regional Center covers birth to death for for qualifying conditions with a difference though for early start for the zero to three has a bigger coverage area than after three.
Lisa CK
Yes, it does. There are some situations where you may need to get qualified under Lanterman, before age three, but generally speaking, zero to three is for children who are at risk of developmental delay. There are certain automatic qualifiers, but it's going to be children who are at risk, but they don't always have a diagnosis. And then there's also a new provisional status for kids who still continue to have developmental delays, but don't have a formal diagnosis for kids who are three and four, and then there'll be reassessed at age five, that's new.
Lindsay Crain
Great. And I, you might have already said this, but if I missed it, and I think the golden phrase to always remember about Regional Center is they're the payer of last resort.
Lisa CK
Payer of last resort always going to come last. Always, always always.
Lindsay Crain
And so lastly, for the overview, CCS who is eligible, because a lot of times CCS comes up and parents are like, what's that? So so what is that a new one?
Lisa CK
So CCS is California Children's Services. It is strictly medical. So there's a lot of overlap between Regional Center eligibility and CCS. But eligibility for one does not convey eligibility for the other, because there are a lot of conditions that are CCS eligible but not Regional Center eligible, and vice versa. So it's going to be strictly strictly medically based. There's a whole long list of diagnoses and disorders of various bodily systems at that, and then explain which conditions are eligible.
Lindsay Crain
For like three of the major ones, right, isn't it like CP, cerebral palsy?
Lisa CK
CP, severe gastrointestinal issues, lung issues, heart issues, cancer, hearing impairments.
Lindsay Crain
Just to give people an idea.
Lisa CK
Musculoskeletal conditions like, like, you know, like muscular dystrophy, kind of like there's
Lindsay Crain
Autism is not covered under CCS, correct?
Lisa CK
I mean, it's not, it's not covered. If a child has autism and a significant medical condition, they're not going to rule them out, because they also have autism. But the need for CCS has to derive from the CCS eligible condition.
Lindsay Crain
All right, so this is, you know, very brief, right? Because we, you know, we'll we'll definitely, you know, we have events on these, but we wanted to give you know that that really brief overview of of who these, you know, programs affect. So let's take so let's look into some scenarios now. So let's take a family who has private insurance, Medi-Cal, and Regional Center. So who pays first? I mean, is there a general funding order that that family
Lisa CK
Yes, there is
Lindsay Crain
Leslie you want to you want to start off?
Leslie
Thank you. When a family's using multiple funding sources, there is definitely a specific order of operations that parents should be aware of and should definitely follow. Lisa hit on it a little bit earlier, but the general mantra is private insurance always pays first. So the order of operations is private insurance, then Medi-Cal, and finally, Regional Center, which you alluded to self identifies as the payer of last resort. So that what that what that means is they're going to require written proof of denial of all other pertinent funding sources before they'll consider a funding request. So don't even go to Regional Center until you have all your other nice packet of written denials all lined up like ducks in a row.
Lindsay Crain
So I'm going to ask an annoying question. Now, you said this is the general order. But does that order depend on any kind of circumstances? Or is that pretty? That's reliable, right? Insurance, Medi-Cal, Regional Center. That's, that's pretty much what parents can rely on, right? And and then what about CCS? So if we add that in Lisa, how does that how's that? Keep that order? Does that throw that?
Lisa CK
Yeah, yes and no and all over the place. So there's a lot of coordination between CCS and Medi-Cal happens behind the scenes, like sometimes you don't even know about it. But if you have CCS, CCS kind of operates as case manager. And so it'll go to your private insurance, and then it'll go to CCS and CCS will review it. And if it's something that Medi-Cal will pay for, then Medi-Cal will pay for it. And if it's not something Medi-Cal will pay for, then it goes back to CCS. An example is hearing aids, Medi-Cal has a hearing aid cost cap. And so and that that price cap generally is not going to cover the kind of complex devices that young kids require. And so CCS will review it if they need if what they need is covered within Medi-Cal then Medi-Cal will pay for it. If not, then it's going to go back to CCS. Um, sometimes CCS will deny something because it wasn't reviewed by a CCS doctor or because they know that Medi-Cal will pay for it. So they'll say no, this is Medi-Cal. But yeah, so it's like it's it's private insurance, CCS, Medi-Cal, CCS, Regional Center.
Lindsay Crain
Right, always, you know, you can have like a traffic cop.
Lisa CK
There are some exceptions in different counties, because some some counties have tried to kind of streamline the delivery of CCS and Medi-Cal. And there's also some exceptions if you have managed care versus fee for service. But generally speaking, that's that's the order.
Lindsay Crain
Okay. What's an example of CCS yes and Medi-Cal no?
Lisa CK
Like specific hearing aids would be an example. Like, like I said, Medi-Cal has, they cover hearing aids, but only up to a cap. And a lot of hearing aids are more expensive than that, especially pediatric hearing aids. And so that would be a CCS. Yes. Medi-Cal No.
Lindsay Crain
Got it. Okay. And then many families are confused about when and how they can use Medi-Cal and their insurance together very common, right. So if, if a family's chosen provider takes their private insurance and Medi-Cal, can you give an example of where they would each pay a portion of that visit and or services? Leslie, you want to start with this one?
Lindsay
Sure.
Leslie
Sure. Thanks. ABA is a great example we use here. If you're seeking services for ABA, with a provider that accepts your primary insurance and is also contracted with the specific type of Medi-Cal that you have, either fee for service or managed care. And if managed care, they're associated with the program in your county, that you have elected for your child, then the combination of those two funding sources will absolve you of all payment. In fact, the provider for ABA or any, any service that is contracted with both your private insurance and your particular source of Medi-Cal is obligated to and must accept those those two combine those two combined funding sources as payment in full if both of the funding sources approve the treatment.
Lindsay Crain
So just to clarify, so if you're using both sources of funding, and they're both approved, right, it's an approved procedure or service, then you have to pay nothing out of pocket, you should not have to pay anything. If you're using insurance and Medi-Cal, they both approved something, the family should pay nothing out of pocket.
Leslie
Yeah, the provider's obligated by virtue of their contracts, they're obligated to accept that payment from both sources as payment in full, except I'll give you, because there's always an exception, right. An exception that I'll highlight here is if you're going to a durable medical equipment provider for major piece of equipment, Medi-Cal or CCS and insurance together will meet your funding except for certain items that are not determined to be medically necessary. A good example is some accessories saved for a wheelchair like a cup holder or some specialty wheels. You and I may consider a cup holder as an essential item on a wheelchair, but your insurance plan is not going to and it's the durable medical equipment's provider's responsibility as they are compiling your order to let you know any items that are not going to be covered. So if you want want your kid to have those great looking wheels to sport or you want a dedicated space for your iced latte. Even if you have approval from both Medi-Cal and from your health plan, those items are just not going to be covered if they're not medically necessary. And you'll be out of pocket there.
Lisa CK
So I'm going to jump in and say that this this is actually for both examples that Leslie gave, this is actually a really good example of where the Regional Center will jump in. Because we're so for the example of ABA, if you have a managed care plan, ABA is covered through managed care regardless of diagnosis if it's if it's necessary. But a lot of private insurance companies will not cover ABA, if the child does not have a diagnosis of autism. And again, managed care, Medi-Cal will do that. But but the ABA companies don't contract with fee for service Medi-Cal. And so if you have private insurance that's denied ABA because your child doesn't have autism, but you have a referral because your child needs ABA. The next funding source is going to be the Regional Center because Medi-Cal fee for service Medi-Cal doesn't cover it. And this is this has been all going to change next year. So we'll talk about that later. But for right now, the Regional Center is going to provide ABA for for kids who can't get it through private insurance or Medi-Cal. The other example that Leslie gave is kind of accessories on a wheelchair. If those accessories are medically necessary, and the insurance and Medi-Cal won't fund them, sometimes the Regional Center will be able to fund those additional additional items. For example, a sunshade for the wheelchair, if your child is sensitive to heat, or they have disautonomia and can't regulate their body temperature. And you can document that with with a letter of medical necessity from the doctor, the Regional Center may be able to help you fund those additional costs. And I'll just throw this in. I don't know how applicable it is across the board. But some DME companies if you have to pay for something out of pocket may give you a discount if they contract with your private insurance. So that's also something to ask for. If you can't get it funded through Regional Center, if you can I mean, if you have to pay through anything besides the insurance, they might be willing to give a discount. So just be aware of that as well.
Lindsay Crain
How about getting a car seat for a large kid approved as medically necessary? Have people done this, it's a safety issue, but not sure if it's medical.
Leslie
If it's an issue of being able to be safe in transport and transport into your community and transport to medical appointments or anywhere that a child needs to go. If they have an issue with maintaining correct posture to be safe, then definitely it can be covered, it could be appealed or be covered or pre authorized with the health plan first.
Lisa CK
I would agree that that is at least at least one of those main sources should jump in because if it is medically necessary, I mean, if your child can't get to doctor's appointments, or even an adult like Not, not everybody's able to maintain an upright position. And a shoulder strap doesn't cut it for a lot of our kids, they need a five point harness.
Leslie
In fact, I had a personal situation where I got a new wheelchair for my daughter, and the health plan did not want to pay for tie downs. They did not want to pay for that wheelchair to be safe and be anchored in an adaptable van. And that was that was an appeal that I won because it was it was I couldn't I couldn't push her in her chair to every medical appointment. So it's an it's an arguable and winnable thing with the correct documentation from a medical physician to establish that and a cover letter full of outrage is always helpful.
Lindsay Crain
Sure, that would not be hard to muster in that situation. Right.
Lisa CK
Yeah. And I would add that that's it's always going to be about medical necessity and not convenience. So like if you need like something to to, like carry things for your child. And it's medically related. Like if there's an oxygen tank or machinery. That's a different argument from like, I need somewhere to put my purse or I need somewhere to put my coffee cup
Leslie
To our earlier example.
Lindsay Crain
Yeah, and so will will Medi-Cal pay insurance co pays?
Lisa CK
So I'm not really sure how they do it behind the scenes but generally speaking Medi-Cal's gonna pay whatever whatever the private insurance doesn't cover up to the Medi-Cal reimbursable rate and then you're not supposed to be billed for anything on top of that. There are certain situations through Medi-Cal however there may be a copay, but generally speaking when you're dealing with the private insurance and Medi-Cal together there Medi-Cal is going to pay the remainder of what insurance will pay up to the Medi-Cal rate. You shouldn't see additional out of pocket expenses.
Leslie
What about including deductible?
Lindsay Crain
That's what I was going to ask what about, will Medi-Cal pay private insurance deductibles?
Lisa CK
It's if it's if it's an out of pocket expense that you would be expected to pay, then Medi-Cal should be paying, if it's medically necessary, and if the provider contract is Medi-Cal and all of that.
Lindsay Crain
Okay, can I ask a layperson question? So if you know, your deductible beginning of the year here, you know, here's your deductible. So then, you you have to be going to a provider who takes your insurance and Medi-Cal to get that deductible, obviously, so maybe we should try to target specialists if they take both of you know, so that and then that means that your deductible is paid off, right? Like I mean, you know, if they're paying, it isn't like, well, Medi-Cal paid this, we're just gonna like tack it on to the end was like if it's paid by Medi-Cal with a visit or two then.
Leslie
Right, it's really an advanced user of their insurance. So a savvy user could definitely plan what time of year they want to do certain things, bulk load things to the beginning of the year. Or if you're a family that doesn't have Medi-Cal, for whatever reason, you'll want to bulk load something expensive towards the end of the year when you've met your deductible somewhere else, right. So it really becomes once you have the basics down, you can sort of do some of that chess playing. I would also add, if anybody's feeling uncertain about having Medi-Cal cover their deductible, as desirable as seems, if they're feeling there's some awkwardness or they're not sure they want to tap into that, I would encourage them to because my understanding of the reasoning behind it is that the the government is doing that in order to encourage families to keep their private insurance in order to make it easier to carry private insurance so that Medi-Cal doesn't become the sole funding source for all of the services and equipment and necessities for the child. So please, if you're feeling any hesitation, get over it and take advantage of what's offered to you. And or at least be fully aware, even if you have discomfort, that that's an option that's available to you. And that's the reasoning behind it.
Lindsay Crain
I also feel like there needs to be an article out of this, Leslie, right, how to plan your visits throughout the year, not that anything's guaranteed. But that's those are some amazing tips. And we have a lot of parent questions coming in. The first was if I if I have a copay, if I have copay assistance through Regional Center, does it go away once I get Medi-Cal, Lisa?
Lisa CK
So it depends on the provider. It's not going to go away because you've got Medi-Cal. What's going to happen is the Regional Centers gonna want to know if the provider is a Medi-Cal provider. And if they're not, then they may continue to pay the copay as long as the service is in the IPP. But they're not going to pay the copay if you have Medi-Cal and it's a Medi-Cal provider.
Lindsay Crain
Sherry has a really good question. And I hear this really frequently from parents. She said my private insurance keep sending letters asking if my son has other insurance, he has straight Medi-Cal. So how do I answer that? Some said if we share that, they might try to get his care covered by Medi-Cal first.
Lisa CK
They they can't. I mean, you you can let them know that you have Medi-Cal. Medi-Cal is never, if you have private primary insurance, Medi-Cal is never going to come before that. Your your private insurance is always going to be primary over Medi-Cal. If you have five insurance plans, you somehow wind up with five insurance plans. Medi-Cal will always be the last one. And so it should not impact your private coverage or to let them know that you have Medi-Cal.
Leslie
Some plans are so interested in getting that what they call coordination of benefits question answered that they will actually pause processing your claims until until you answer their prompt to answer that question.
Lindsay Crain
Crystal she asked my son has autism and qualified for OT at school but school said he probably needs medical OT too. Medi-Cal said he didn't qualify. So Kaiser Kaiser said he didn't qualify can I take Kaiser's denial and ask Regional Center to cover OT? We don't have Medi-Cal we're working on it.
Lisa CK
Generally speaking Regional Center is going to defer to the school district for those services from age three to 17. The Regional Center for medical therapies they're gonna they're still going to defer to the to the school district and it gets complicated. If, first of all, the Regional Center should be assisting you in trying to get Medi-Cal, if your Regional Center clients who qualifies for the waiver, they should assist you in getting that. And Medi-Cal should cover those therapies. But yeah, the Regional Center, there may be very, very limited circumstances in which the Regional Center may cover those if you can, if you can prove that it's not available from any other source, but you have to show that you have attempted to get it from other sources. What I would suggest in that case, and maybe Leslie, you can chime in, is I would file a grievance with Kaiser, I would start there. Because that's who has the primary responsibility for providing that service.
Leslie
So calling Kaiser and finding out what the process is to appeal. And then following that process and having a great appeal package with a with support of your Kaiser physician to say yes, it is medically necessary. And these are the reasons why it's medically necessary. And writing that nice cover letter that makes your your your child and your case come alive for the reviewer. And having an either a Kaiser therapy assessment or investing in an independent assessment to have an independent practitioner say, Here, here's here's the treatment plan. And here are goals. And here, here's what needs to be done. I would say maybe there'd be a better crack at an appeal with Kaiser than an appeal with Regional Center, or or both could be attempted.
Lindsay Crain
What about additional funding for out of network providers for OT, PT, and speech, other than any reimbursement available from our private insurance? Will anyone step in and help with funding for out of network providers? Lisa, any of those government sources?
Lisa CK
Medi-Cal is only going to pay if it's a Medi-Cal provider. If the plan doesn't have the Medi-Cal provider who provides that specific service, you can request that they contract with one, but they're not there, you can't submit a super bill and get reimbursement, that's just not going to happen. I think for Regional Center, they would also argue that you have the resources available to you to get those services through Medi-Cal. And so I don't, I don't think that they're going to step in, unless, again, you have a compelling reason why your insurance or Medi-Cal can't provide those services because there are no providers for those specialized services.
Leslie
And if you can make that argument that there's nobody in network who can meet your child's needs. Another thing to do would be to make an appeal directly to the insurance company, for them to fund more for them to give in network reimbursement for out of network services. It's kind of a heavy lift. And then even if you get it, it often takes a lot of time to get those claims processed correctly. But before looking for an alternate an alternate source to increase reimbursement beyond the insurance plan, you should really take a careful look at what might be possible directly at the plan. They are required to provide by law, they're required to provide access to care. So you would want to make an access to care appeal that they need to reimburse you at a higher rate because it's their obligation to provide access to care. And again, it has to be something that is medically necessary and essential rather than a preference of of one provider over another.
Lisa CK
I do want to jump in though and say one thing about the Regional Center is that if we're right now we're talking about medical services. But if you're talking about non medical therapies like music therapy, art therapy, equestrian therapy, those are things where the funding for that has actually been restored at the Regional Center and you can I don't believe that they do parent reimbursement for that. But if if if those therapies would help your child meet one of their goals in their IPP, you can request funding from that Regional Center because your insurance isn't going to pay for music therapy, right? Because they operate on a medical model, but a lot of no less is making make less than they will but if you're dealing with something that's not medically necessary, but and is considered non medical, but may help your child meet their their goals for their IPP, you may be able to get that covered by the Regional Center.
Leslie
Or to reference my face that I made earlier if it's musical therapy or it is a hippotherapy. If the services the music therapy or horseback services are provided by a provider who is licensed as a service provider under a medical model, if that music therapist is a marriage and family counselor, or they're a psychiatrist, psychologist, if they have a licensure, that's covered with medical, by medical insurance, you could get you could use out of network benefits there. And, and to the other example, if the person who's doing the equestrian therapy is has a licensure that is covered as hippotherapy, then you could again, it would be out of network. Likewise, swimming, if it's provided by a licensed OT or PT, it can be can fall under those benefits. So there's lots of examples there of ways to consider funding it.
Lisa CK
Thanks for that correction, I appreciate that.
Leslie
It's very rare that I can add anything to comment on yours. I jumped.
Lisa CK
Oh, it's awesome. Awesome.
Lindsay Crain
Great. Those were perfect examples, Leslie. We and then we had a follow up question, can it be considered continuity of care speech, since my son has been getting it since he was two and he's now 11?
Lisa CK
In certain situations, if you have a relationship with a provider, where it would be really detrimental to your child to change providers,
Lindsay Crain
Sorry, that information just came in. Same provider.
Lisa CK
Same provider. So So if, if the issue is that Medi-Cal wants you to switch to someone in the managed care plan, and, you know, I'm not sure how this works with therapy, but for complex medical conditions, if you're working with a doctor, and your child has an active treatment for a medical condition, and it would be really detrimental to your child's health to switch providers in the middle of that treatment, you can get some continuity of care coverage, where if the doctor and the managed care plan can agree to a rate that they can do a single case agreement so that you can have that continuity of coverage. I'm not sure how that works with therapy. But that would be a good question to research.
Lindsay Crain
Well, yeah. And Lisa, or I'm sorry, Leslie, there was a follow up to that it's for an out of network provider, and they're looking to get more coverage from private insurance. So I guess, can a parent who has been seeing an out of network provider for that long, can it be considered continuity of care for them to get that speech coverage from private insurance? Can you try to get the person in network by using continuity of care if you've seen that out of network provider for a long time?
Leslie
For insurance, continuity of care is sort of like a gap exception. It's it's about a change of provider. So I kind of want to, and it's a short term fix. It's saying the insurance is going to pay the old provider for 90 days until you find a new provider. So I want to remove the continuity of care appellation and I want to maybe get some more clarification to answer the question. If the question is that for the last nine years, they've had an authorization and they've had sessions, and now for some reason, it's ending, the insurance company is no longer wanting to fund it, an argument can be made that this has been essential, and nothing has changed, and the child still has level of need. And if you can show progress towards the set goal or do a reeval, then you can move forward based on the fact that there's a history of authorization, but but forgive me if that's not an answer to the question that's being asked.
Lindsay Crain
So then we got another question. This is from a mom about early intervention. She said my insurance has agreed to pay for physical therapy, but all the providers have a six month waiting list. My daughter's also Regional Center client. So what can I do, Lisa?
Lisa CK
So the Regional Center is, generally speaking, if you have private insurance, the Regional Center is going to make you exhaust your private insurance resources first. They can provide gap coverage, if all of your providers at your insurance have a waiting list, the Regional Center can step in and should step in, to provide that that service while you're waiting for your private insurance, and you'll have to provide documentation of the waiting list about how long they expect it to take if there are other providers. But the Regional Center should be able to step in and provide that service temporarily on the basis that your insurance your private insurance is not able to cover it during that period of time.
Leslie
But the caveat there is that the Regional Center provider of the services will also not have to have a waiting list. Right?
Lisa CK
That's true. That's true. I went through that with my daughter with speech therapy because there's I mean, there's just a national shortage of speech therapists, and we had a long waiting list for her for when she was in early intervention. And we went to the Regional Center. And they said, Sure, here's the list of providers that you can go to. And they all had waiting lists too.
Leslie
Right. So one alternative there is, is, again, the access to care appeal. I've called every provider that's listed in my network, and none of them can do it. I've called 167 people within a 10 mile radius of my home, this is a medically essential service, here's a prescription, here's a letter of medical necessity, you need to reimburse me. I have an out of network provider who's able to meet my child's need, you must provide access to care, my child cannot be absent of adequate reimbursement for medically necessary services, just it's not my financial responsibility that your network is deficit. I can find the services elsewhere, you must reimburse me at a higher rate. You can try that while you're waiting for a Regional Center provider to become available, you can maybe work those two avenues at once. But you can tell that I always like situation where an appeal is possible when it's warranted and when it's substantiated, be it at any of the various funding sources that we're discussing, right? Appeals can be made at Medi-Cal.
Lindsay
We can touch on appeals in a minute, but I wanted to ask sort of a twist to that to that question, Leslie. So if, if that same family's insurance will only cover a certain number of PT sessions in a year, right, they say, Oh, great, we cover like 25. And the family finds themselves without PT because they've exhausted those 25, you know, sessions, can they go to Regional Center and ask for PT sessions until the next year, when insurance will pay again?
Lisa CK
If it's medically necessary, if they have if they have the documentation to demonstrate that it's medically necessary. I mean, Leslie might have some comments on how to appeal with the private insurance, see if they can allow more sessions if it's medically necessary. Once you've exhausted once you've exhausted your your your private insurance, then you can go to either Medi-Cal or the Regional Center.
Lindsay
You would have to exhaust all private insurance options, which you know, can take months, sometimes depending right, so you have to exhaust all of those before Regional Center would say okay.
Lisa CK
I mean, yeah, if if it were me, and I knew that they only cover 25 sessions, and I had documentation from the physical therapist, and I had already gone to the private insurance. And they said, No, this is a hard cap, I would probably take it to the Regional Center a couple months ahead and say, Look, this is medically necessary service. My private insurance has already said and I've already filed a grievance. They've they've already said they're only going to cover until June because it's this many visits. Is there any way that we can set up an authorized so that there won't be a gap in coverage? Can you authorize starting in June when those appointments end to provide until the new calendar year? I would I would approach that in advance if you know kind of when it's going to run out so that you're not scrambling.
Leslie
And also you can get on a waitlist for a provider who might be able to accept the Regional Center at the same time, you can be proactive in getting on a waitlist to get that because an authorization from Regional Center or any source is great to have in hand. But it has to be usable and has to be applicable. And I'll also add this comment that may be helpful to families. There's all sorts of limits at the plan. And it may well be that your plan has a hard cap that 24 or 30 per calendar year are just a hard cap. And there's no two ways about it. But you should be sure. Before you start looking for alternate sources, just check or double check that there aren't that there aren't any exceptions or by diagnosis maybe with autism or complex care that there's no way to exceed or authorize more or appeal for more. Just double check before you go down an alternate road that you've done all your due diligence and completely understand what's going on at the health plan. And one more tip that I'll offer is if you have an employer based plan rather than an individually purchased plan, if you have a employer based plan, you can try to go to the HR department and ask them if they'll make an exception for your child to that 24 or 30 or 50 or whatever it is per calendar year limit, if they can do an extra contractual arrangement for your child, so they go directly to their client where they were the employer group has bought the insurance and and arrange for your child to have a one time exception for the year to exceed that limit. And, and you know, you never know, you never know what the HR department is going to do for you. If they say no, nothing ventured, nothing gained. But I always say you don't know who you're going to speak to at that HR department. Maybe they're a parent like we are, maybe they have a niece and nephew who has a disability, maybe they're willing to reach out and try to arrange something special. Is it a high probability outcome? No. But it's, it's another way to explore something that may be possible. If your family feels comfortable with making that outreach at the provider at the HR department, at the employer.
Lindsay
I got a call from our private insurance one time denying us and it was usually you can tell they're uncomfortable. And she almost sounded like she was in tears, though. And she said, I said you're denying like this, this and this. And she said, I'm the parent of a child with disabilities. And she said, I'm so sorry to make this phone call, like you could I mean, she was really she couldn't do anything about it in that moment. But you're right, Leslie, you never you never know who's gonna be on the other end.
Lisa CK
And I just want to clarify from my comments about about therapies and stuff that that again, that's assuming that the Regional Center has the next responsibility in line for so I'm talking about early intervention, primarily that that if you've exhausted your your primary insurance, because if they're over, you're going to they're going to want to refer you to Medi-Cal and the school district.
Lindsay
So I know we're running late on time. And we have you know, we're running short on time, I should say. And we're getting lots of questions. So quickly, though, we would we did want to touch on some common needs. And then and we've had some questions about these exact needs. So you can let us know how the funding would work in these situations. incontinence supplies, Leslie, you want to start there?
Leslie
Sure. So once again, the old martra comes to bear: private insurance first. So your first step is to be is to contact your health insurance plan and find out if they cover diapers or pull ups or other supplies, under your Durable Medical Equipment your DME benefit, if they do cover, then you're going to want to grab a prescription from a physician and get on the phone with some of those suppliers and find a supplier who, confirm that they still are in network with your plan, and also confirm that they're a Medi-Cal provider and then you know whiz bang, boom, you should be all set up with insurance primary and Medi-Cal as secondary. Something that I learned from Lisa is that Medi-Cal will fund incontinence supplies for children ages three and up if the incontinence is due to their disability. So kudos to you, Lisa, that's something I learned from you. Conversely, if there is no benefit for incontinence supplies on your plan, then you want the person you speak to to produce or connect you to someone who can produce a letter that says incontinence supplies are a non covered benefit on this program, then you can take that letter to one of two places: to a provider who is a Medi-Cal provider and you can prove that your primary is not going to pay for diapers and you'll be all set. The caveat is because there's always a caveat that the the incontinence supplies that your insurance company or Medi-Cal will pay for may not be the brand that you're used to using. And in that case, you can mount an appeal to Regional Center for the specific brand your child uses. If you have a compelling medical necessity, right? Again, it can't be brand preference, it has to be something that can be promoted as a health and safety issue. So so it's it's insurance first, they either will or won't cover. Medi-Cal second, we know we know the order of operations here, probably you'll be able to find a provider who will give you incontinence supplies with the combination of insurance and Medi-Cal. But if you want to take that extra step and you feel you have the rationale to get a specific brand covered, then that's an appeal to Regional Center.
Lisa CK
I just want to add one thing, a couple of things. The first thing is you're going to need a prescription from the doctor either way, so you've got to get the prescription from the doctor. You might want to do that at the same time that you're checking with your private with your private insurance. Because you're gonna need if your private insurance does not cover consumable medical supplies like incontinent supplies, you're gonna need the prescription from the doctor and the denial. Another thing I wanted to add is that incontinent supplies, not just diapers and pull-ups, they also will often include and this anything that you're going to have covered has to be in the prescription. And it also has to be in the denial. So if you if you want to have your your doctor or your your doctor write a prescription for diapers or pull ups, waterproof underpads, barrier cream, they generally will not provide wipes, they may provide cleanser, but they generally will not fund wipes. And I think maybe once or twice a year, they'll cover waterproof mattress covers. All of that has to be in the order from the doctor. And all of it has to be in the denial. So the denials can't just be we don't cover incontinent supplies. We don't cover diapers, we don't cover pull-ups, we don't cover barrier cream, we don't cover waterproof mattress covers, and you take that. And so it has to be in the prescription, and then the denial, and then you take that to a provider. And again, it has to be somebody who contracts with your specific Medi-Cal plan.
Leslie
And also in that detailed prescription should also be the quantity and the size.
Lisa CK
Quantity and size and why. You may be able to find a provider who offers your your the brands that you need. The Regional Center is going to want to see if you go to the Regional Center, if my child is allergic to the diapers that they send from Medi-Cal, and a lot of our kids have sensitive skin, they have dermatology, dermatology issues, they come up with a rash with some of the diapers, you're gonna need to show not just that they can't use those, but that you've already tried to find a brand that will work and that you can't find one that Medi-Cal will cover. And so you want to ask around to a few different agencies and see if anybody provides. And that's, it's a little bit easier to find that when they're babies because you like baby diapers are a little bit easier to find. But once those diapers get bigger, it can get really challenging to find a brand that works. And then once you find one that works, you want to stick with it. And if it's not provided by an agency that that is contract with Medi-Cal, then then you want to gather your documentation and go to the Regional Center.
Leslie
And another compelling piece to put into that overall packet is it if you happen to have tried the Medi-Cal or insurance provided diapers, and you failed with them, if you have some log of failure, you know, a rash occurred, we had to go to the doctor with this rash. And you can also use arguments of especially compelling with Regional Center that use of those inferior products led to your child not being able to successfully access their community as they would if they had a product that provided more coverage or or or were enabled them to go, you know, out of the house for a longer period of time. So those Medi-Cal diapers can be awful skinny.
Lisa CK
Awful, awful skinny and made out of materials that that kids are often quite sensitive to.
Lindsay
Good point, and Lisa there was a clarification from Margaret. She said do children have to be Regional Center consumers to qualify for incontinence supplies through Medi-Cal, and she was specifically saying it's a child over three, not a Regional Center consumer, they did receive early intervention services.
Lisa CK
No, no, they have to have Medi-Cal to receive it from Medi-Cal. They do have Medi-Cal coverage, they should be able to get it from Medi-Cal. They might have a more difficult time getting a different brand if their child is not able to use that. But they can always appeal. If they don't have any other any other way to get those funded. They could appeal and just be like this look like my child can't use these diapers. But no, you Medi-Cal and Regional Center are separate agencies. And there are plenty of children who have complex medical needs who are not Regional Center eligible because they don't have significant cognitive impairments, or they don't have one of the diagnoses that that is listed or something similar. There are plenty of kids who are who are very medically complex.
Leslie
You could use insurance alone. You could get incontinence if your plan covers incontinence supplies, you can get it from insurance alone, but you'll be subject to a copay or an in-network deductible. So you can take that process and use as many different sources as you as you care to.
Lindsay
And I'm gonna ask one thing, and then I'm gonna ask you guys to like, I'm gonna ask you a question that could be an event in itself that you have to answer in 30 seconds. But really quickly, we did have a question about Lisa this one would be for you for Medi-Cal, how difficult is it to get dental added to Medi-Cal?
Lisa CK
Medi-Cal for children includes dental coverage, the challenge is finding a provider that accepts it. Now the area where it can be really, really important that Medi-Cal includes dental coverage is that sometimes our kids cannot just go to the dentist, sometimes they need to be sedated for dental procedures. And sometimes that has to happen in a hospital setting. And our insurance may, our private insurance may or may not cover that, but Medi-Cal should. It's not covered by your private insurance. And so a lot of the big hospitals, children's hospitals, for example, are able to do dental procedures in a hospital setting where it's supervised by an anesthesiologist. And you should be able to use your Medi-Cal there if your private insurance will not cover that service. So yes, Medi-Cal automatically for children includes includes dental coverage.
Leslie
And it never hurts and Dental Cal is an interesting example. It never hurts to ask. Sometimes your provider you've been going to you can discover a way that they are accepting Medi-Cal, no guarantee, but to the to the Dental Cal point, check with your with your current dentist. They may not accept Medi-Cal as secondary in their private office setting. But they may have privileges at a hospital setting and it can be used there. It doesn't have to be a different doctor necessarily at the teaching hospital or the children's hospital. It could be your current dentist does a small portion of their work at one of those settings.
Lindsay
So here's the last question. In 30 seconds or less, but appeals right? We kind of touched on it. But like, and I know yours will be a little harder, Lisa, because we're kind of we're talking about three big things. But in 30 seconds, I don't know what do you want to say to people about appeals? Because as we know, a lot of parents get there. They're counting on a lot of whether it's insurance or public benefits. A lot of times they're counting on you not not to keep pushing through. You know, what do you want to say, you know, we can say a lot about appeals. But you know, in 30 seconds, Lisa, but what do you want to say to parents about appeals?
Lisa CK
Don't be afraid to appeal. Don't be afraid to appeal. If you if you if you have documentation that the service is medically necessary. Don't be afraid to appeal like there, there's a system set up for due process for a reason. And you have a right to use it. If you feel your child needs that service and you're getting gatekeepers, who you feel are being unreasonable, you feel that your child really does qualify for it. Just that's my advice is don't be afraid to use that that appeal process.
Lindsay
And that goes for Medi-Cal?
Lisa CK
Yeah, that goes for any of any of the services.
Lindsay
Yep. Leslie?
Leslie
Well, I would add in a small fraction of people mount appeals, and a surprising number, you know, something like 50 or 60% of appeals are granted. Insurance companies and government benefits sources count on you being demure or going away or thinking you're not entitled. But I would encourage families to make sure they have a solid basis for their appeal, that it's not just something they want or feel their child is entitled to. But something in their benefits and coverage that actually they can key that appeal to to make sure they're they're arguing on the funding source's own terms. Don't appeal on medical necessity if it's not a medical necessity issue. Read the reason you're getting the denial, look at all those boring pages in the back of your claim and see exactly why it's being denied and make sure your appeal is responsive to the actual reason why you're being denied. Target your response that makes them more when regardless of what the the funding source is, that's a more winnable argument when you're talking apples to apples or oranges or oranges.
Lisa CK
That's really important advice.
Lindsay
Thank you both so much. You know, you're you're it's always amazing. There's no way that I can have a conversation with either of you and not learn something, many things in it. So, you know, we know that this is a subject that can be incredibly confusing and like we said, it's emotional because it's an essential support in our lives and the lives of our children. So, to both of you, thank you so much for breaking it down in ways that are easier to understand than say my explanation of benefits or Medi-Cal website. So thanks again to Leslie and Lisa for talking with us today and to Donna and Iris in the chat, and especially to all of you for stopping by Undivided live. Have a beautiful weekend.
