Troubleshooting Common Issues with Public and Private Health Plans

If your child has a developmental disability, chances are that you have to coordinate multiple different doctors, specialists, and therapists, along with medical supplies and equipment, which can be a hassle even before figuring out how to pay for it all! Funding is one of the most important topics for families, but it can also be one of the most confusing.

How does private insurance work with public benefits like Medi-Cal, Regional Center, and California Children’s Services? Are you utilizing all of the resources your family is eligible for so that your child gets the care they need?

We sat down with two experts to help us answer some of the most common questions and scenarios around funding options. Keep reading for wisdom and insights from Undivided’s Public Benefits Specialist, Lisa Concoff-Kronbeck, and Undivided’s Director of Health Plan Advocacy, Leslie Lobel!

When we say private insurance, we mean coverage that you purchase on your own or with the help of a broker on an individual or family basis. Another type of private insurance is an employer-sponsored plan.

Public insurance for many families in California comes in the form of Medi-Cal, which is funded by Medicaid. Other key public benefits programs for families raising kids with disabilities include Regional Center and California Children’s Services (CCS). These programs can all be used together to pay for your child’s medical and therapeutic care, but there’s a specific “order of operations,” as Leslie says, or an order in which they’ll take responsibility for paying.

When you see a doctor or therapist or you pay for medical supplies:

1. Private insurance is billed first.
2. Medi-Cal will be billed next if your provider accepts Medi-Cal.
3. CCS typically works in tandem with Medi-Cal.
   • Leslie says, “Depending on the county you're from, for most counties, if CCS is involved, they're going to wedge in there between the private insurance and Medi-Cal and sort of act as case management. So it'll go to private insurance and then CCS. CCS will route it to Medi-Cal if it's something that Medi-Cal covers, and if not, then it'll come back to CCS for funding.”
4. Regional Center always pays last after you’ve exhausted other resources.
   • Lisa clarifies, “The Regional Center is always going to position itself as the payer of last resort. They're only going to consider stepping in — and that's not to say they will step in — but they will not consider funding something until you can demonstrate in writing that you've already tapped all of the other generic resources.”

Given all the complexities of these different systems, it’s reasonable for some families to wonder whether they should bother using both private insurance and Medi-Cal, or if it’s easier to use just one or the other. Lisa says, “There may be situations where there's stuff that the private insurance covers that Medi-Cal doesn't. It just depends on the child's needs, and if you have preferred providers, people that you don't want to lose. Looking at any health plan, make sure that they have what you need for your child.”

Here are some frequently asked questions and answers about navigating your health plan.

What if all the in-network providers have a long wait list?

Both private insurance and Medi-Cal will typically only cover services from providers they have contracted with, but what if the provider your child needs to see has a lengthy wait list? It’s possible to see an out-of-network provider and get it paid for by the health plan or Regional Center. Hear Lisa’s explanation:

What if I want to keep my provider after switching health plans?

Our kids often see therapists and doctors for months or years at a time, so switching providers isn’t just a hassle but also hard for our children and the relationships they’ve built with their therapists. If you switch insurance plans and your new plan doesn’t cover your current provider, what can you do? Some families may have heard of a continuity of care agreement, but Leslie says that an access to care exception is a better solution. Here’s how and why:

Can I get a documented denial without submitting a claim?

Because of that funding order of operations, you may be required to show proof of denial from your private insurance if you want Medi-Cal or Regional Center to step in and fund something. Often, you’ll need to show a written denial. Hear Lisa and Leslie’s tips for getting this:

Can I submit a superbill to Medi-Cal?

If you’re seeing an out-of-network provider, you may be able to submit what’s called a superbill to your health plan to try to get it reimbursed. However, it’s important to note that this is only applicable to private insurance. “There’s no out-of-network benefits for Medi-Cal,” says Leslie. Lisa adds, “In order for Medi-Cal to pay for it, the provider has to be contracted with Medi-Cal.”

We’ve heard from many families who are worried about their child losing access to public benefits with the new political administration in 2025, so we asked Leslie and Lisa their advice on what will or won’t change. Leslie says that private or employer-sponsored health plans for 2025 are unlikely to change, other than the typical 5-6% increase in premiums seen every year. 2026 plans may have more severe limits and changes, but we won’t know anything for certain.

Lisa says, “I have a lot of questions and a lot of concerns, but ultimately, right now, all we can do is speculate and stay aware and stay on top of what is happening and what's being talked about. In the past, we have seen attempts to cut IHSS significantly, and state advocacy orgs have fought against those cuts and managed to sort of cushion the blow and minimize the impact and reduce the total cuts. But there have been cuts in the past. If you have an older child, you probably remember that there was a 7% across-the-board cut to IHSS years ago that was eventually restored.”

We know this is a broad concern for families in the disability community, so we will continue to look into what's happening at the state level and update the Undivided platform if processes, laws, or options change, so you’ll know exactly what you need to do. Join here if you don’t already have an account.

Thank you to Lisa and Leslie for sharing their expertise earned through many years of advocacy for kids with disabilities, including navigating insurance systems and public benefits for their own kids!

You can watch the full replay of our event here, where we go into more detail and also answer some questions that parents asked in the chat during our livestream.

Are you applying for Medi-Cal for the first time, or looking to get more out of your benefits? The Undivided platform has goals with step-by-step walkthroughs to help you! Explore your Undivided account today if you already have one, or join Undivided to get started.