Undivided Conversations: How Public and Private Health Plans Work Together

Parents often ask, “How do I afford it all?” From therapies to medical supplies, expenses for our kids' care can add up quickly. Lisa Concoff Kronbeck and Leslie Lobel, Undivided’s experts in public benefits and insurance, sat down with us to share their tips on maximizing private insurance and Medi-Cal to cover your child’s needs while saving money on out-of-pocket expenses.

Watch the full recording of our live event below, or check out a recap of the highlights here.

Hey, everybody, welcome to Undivided Live. I'm Lindsay Crain, and I head the Content and Community teams here at Undivided. Thank you for being here today, because we're talking about one of the most important topics for our families: funding. It can also be one of the most confusing. How does private insurance work with public benefits like Medi-Cal, Regional Center, and CCS? And are you utilizing all the resources your family is eligible for so your child gets what they need? We wish the answers were all black and white, but as everyone listening knows, that's not always the reality. So lucky for us, we have two incredible guests who can help us answer some of the most common questions and scenarios around funding options, Undivided’s Public Benefit Specialist Lisa Concoff Kronbeck and Undivided’s Director of Health Plan Advocacy Leslie Lobel. Hello ladies.

Hello.

Okay. Not only are they professionals in their field, they're also parents of individuals with disabilities. Let's talk money. Who pays for what and when? Let's find out. All right, Leslie, so before we jump into specifics, I would love for you to define the difference between public and private insurance. What do we mean when we refer to each.

Okay. Thanks, Lindsay. One type of public... private insurance is coverage that you buy on your own or with help of a broker, either to cover an individual or your entire family. Another type of health plan that's covered under the term of private insurance is employer sponsored health plan. All of this is different from public insurance benefits such as Medicaid, which is known in the good old state of California as Medi-Cal.

Perfect, and three common sources that help with public benefits for our families.... Leslie touched on one, right, Medicaid, Medi-Cal, Regional Center and CCS. So, Lisa, I would love for you to give a quick overview and confirm who is eligible for each so our families know what's out there and potentially available to them. So let's start with Medi-Cal. Lisa, who is eligible and what can it provide?

Yeah, totally, and I think that Brittany's going to put the links in the chat as I talk for our articles on each one of these programs. So Medi-Cal is California's version of Medicaid, so when you hear people talking about Medicaid, that's what they're talking about in California. That's called Medi-Cal. So most people qualify based on household income, but there are several avenues to Medi-Cal specifically for people with disabilities, like SSI or institutional deeming waivers that have additional services, and then there's also a few specific programs that use different financial criteria to allow people with disabilities to access the program if they have slightly higher income than what the usual rules allow.

What is Regional Center and who qualifies?

Yeah, so Regional Center.... Regional Centers are a statewide network of independently run nonprofit agencies. They're all governed by the same set of laws, the Lanterman Act, but each one of them runs slightly differently. They provide services and supports to people with developmental disabilities, and then they also provide early intervention services to children from zero to three who are at risk of or diagnosed with developmental delay.

And lastly, CCS. Who is eligible and what does it cover?

CCS is California Children's Services. It's a state program that provides and funds diagnostic and treatment services to kids under 21 with certain CCS eligible medical conditions, and this is regardless of developmental delay or cognitive disability, unlike the Regional Center, which has more developmental focus. Eligibility is based on medical diagnosis and financial aid... financial need, so it can be an avenue of assistance for kids who don't necessarily have a developmental disorder, but who do have significant medical needs. And medical... sorry, financial eligibility is based on household income or percent of out-of-pocket medical expenses relative to household income, and then there are some exclusions, for example, for diagnostics, for certain adopted children, for Medi-Cal and certain... if you have Medi-Cal, and then certain programs within CCS.

Yeah, it can get really specific, so like Lisa said, definitely check out those links that Brittany shared so you can really get in because it can get very specific into diagnoses. So okay, so let's take a family who has a private PPO health plan, for example, from a parent's employer in addition to Medi-Cal and Regional Center. So who pays first? Is there a general funding order or an order of operations that families should understand, Leslie?

So if you're using multiple funding sources, there's definitely an order of operations that you need to be aware of and you need to follow. Private insurance always pays first. That's essential to remember, so I'll repeat it. Private insurance always pays first. So the order of operations is private insurance, then Medi-Cal, CCS, and then finally when all other resources are exhausted, Regional Center will deem themselves necessary for them to pay. All those other options that you need to exhaust before Regional Center will fund, they refer to them as generic resources. That's Regional Center’s term for everyone who needs to fund before they'll consider funding.

So, Lisa, does that order depend on individual circumstances or is that order a hard rule?

I mean, it's... it's generally a hard rule. The Regional Center... there's... The Regional Center is always going to position itself as the payor of last resort, so 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. So, yeah, that's... I mean, the Regional Center is gnerally going to pay last.

Okay. And that order includes kids in Early Start, right? Age... Age doesn't matter or change?

Yeah, I mean, the one exception might be if you're actually applying for Regional Center eligibility in Early Start, and then they may... they may have assessments that they want to do at the Regional Center, regardless of whether you have private insurance or not. And I will also add that there may be a compelling reason why you can't utilize other resources that are available, and that's something to take into consideration, but you have to have exhausted those resources, whether it's because there's no coverage or because what they provide is not sufficient.

And what about CCS? How does that fit in with the others, Lisa?

Yeah. So, I mean, depending on the county, for most counties, if CCS is involved, they're kind of going to wedge in there between the private insurance and Medi-Cal, and sort of act as case management, so it'll go 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.

Okay. So let's take Regional Center out of it for a minute. So if a family's chosen provider takes their private insurance and Medi-Cal, can you give an example where they each would pay a portion of that visit and/or services, Leslie?

Sure. ABA is a common service, and it's a great example here. If your child's ABA provider is in-network for your private health plan and also contracted with the specific Medi-Cal managed care program in which your child is enrolled, the provider can balance bill Medi-Cal after your primary pays. If you have a provider in mind, you would most likely be well advised to ask them if they participate in the Medi-Cal plan which your child has or consider changing his or her enrollment to match the provider's contract. It's especially important to consider using both sources for a service like ABA, which has many session hours a week, and costs quickly add up, and also, it's significant to note that many ABA providers are in-network for a majority of HMO and PPO plans, and they're also often carrying a Medi-Cal contract.

Okay. And if you're using both sources of funding, then will you have to pay anything out of pocket?

Once in-network private insurance and Medi-Cal both pay the provider for a specific claim, there should be no family expense for that claim.

Okay. Which is a really... it's an important point because we hear from so many families that they don't use their Medi-Cal or they don't understand how it can help if they also have private insurance, and so that's what today is about, so you can realize what you can qualify for and how to use it, and for many of us, every dollar counts and every dollar saved adds up. So let's take co-pays as an example. Leslie, will Medi-Cal pay insurance co-pays and deductibles? This is a question we hear all the time, and we got a lot of these questions before the event.

Okay. So the answer is multi-part, right? Medi-Cal will pay towards deductible and co-pay, but only for the dollar amount that they allow for the specific service. So what does this mean? They should accept the two payments from the two sources as payment in full, regardless of whether there's any balance after both pay. They are obligated by being contracted with both those plans to write off any balance after they receive both payments. Sometimes the provider will attempt to bill a family after receiving payment from both funding sources. The families can often make that balance billing disappear by filing a grievance with Medi-Cal. However... and always there is a ‘however,’ right? However, if the provider that you've chosen, say, for ABA is out-of-network for your primary and contracted with Medi-Cal, it's sort of less clear about what's going to happen and who's going to be responsible for the deductible and the copay, and the answer sort of depends on who you ask. So you definitely want to be clear upfront with that ABA provider if they're out-of-network for your primary but contracted with Medi-Cal so you don't get any surprise billing from them.

Got it. And Lisa, we received a question ahead of time that's sort of a natural follow up to this. The parents said that they used to receive copay reimbursements when they had straight Medi-Cal, but after being moved over to managed care, they no longer receive that. So, Lisa, is this an expectation of managed care Medi-Cal that we should have?

So, I mean, I would want to know whether... whether it was copay reimbursements or whether Medi-Cal just covered the co-pays and they didn't... they didn't have to pay it, but most likely what happened is that the provider had a... was contracted with fee-for-service Medi-Cal and is not contracted with the managed care plan. So one thing that's useful for families to know, though, is that some families might qualify for co-pays essentially through the Regional Center if they're seeing a provider that accepts the private insurance but doesn't take Medi-Cal for the copayment, and that's usually going to be if families have income below 400% of the federal poverty level, although they're... the purchase of service standards often have exceptions for extenuating circumstances, but generally it's going to be 400%.

Got it. And if a family does not have private insurance and Medi-Cal is their child's only insurance, should they have any out-of-pocket expenses, Lisa?

Not for covered services. So I think we're going to... I think we'll talk a little bit later about sometimes there... there might be additional costs that are not covered by Medi-Cal if they've deemed them, for example, for convenience and not out of medical necessity, or they're like decorative accessories or something like that. They might not be covered by Medi-Cal, and so you want to kind of have an idea upfront, especially with DME, about what your... what the charges are going to be and what's covered and what's not, but as long as things are covered, they should be covered by Medi-Cal.

Okay. And so let's talk about things that are approved. So if a child's Medi-Cal doctor prescribes a therapy, a specialist, a medication, or supplies, does that mean that it's automatically approved?

I mean, is that the case with any insurance?

We can dream, Lisa. We can dream.

Sometimes some... It depends on the doctor. It just depends on what they're prescribing, but I would not say... I would never say that something is automatically approved. There are certain things that do not require authorization requests, prior authorization. There are... For example, there are certain medications that you know are in the formula and you know they'll be approved. There are certain medications that require prior authorization, a TAR, a treatment authorization request. With DME, you should be prepared to document medical necessity, especially if it's something where there are potentially cheaper commercial versions of it on the market. You might... they might... Right? They might push back and ask, well, have you tried... what else have you tried? Why do you need this more expensive piece of equipment? What else have you tried that is not as expensive? And just in general, you're going to want to have documentation from the provider about the medical necessity of that... of that item.

And we had a follow up question, I think it was from Tiffany, just now on this, Lisa. She said, “If we have private insurance and Medi-Cal and private insurance is not denying ABA, but they won't match with a provider the family has chosen, can Medi-Cal pay for the ABA with this provider?”

I... Generally... Generally they're going to expect you to go through your private insurance first, and if the private insurance offers the service, you would generally have to... have to be able to demonstrate why what the private insurance offers is not appropriate or adequate. It's not enough to say I just prefer this other provider.

Right. Okay. And, Leslie, I wanted to ask you the same question that we had asked Lisa with private insurance. Just because a doctor... I think we all know the answer to this, but because they're prescribing a therapy, a need, equipment, whatever it may be, does that mean it's automatically covered?

Well, and my answer basically echoes Lisa's, but I do have a little nuance to add. So my answer is, yeah, it depends on the plan and the service. A pre-authorization may be required right off the bat before the first treatment session, first date of service. It may be that the plan confers a certain set number of sessions for calendar year. 24, and then you need to get an authorization or some services require no authorization at all as long as they're medically necessary. So knowing your own plans, coverage, and limits is really the essential thing here. The best way you can find that out is to go online to the health plan website. Often you can find a summary of benefits and embedded in that summary of benefits may be the very answer about pre- authorization and limits for the service type that you want or you could try to ask the question in a live chat or the plan’s message center if your health plan has those options. All three of those are proposed as better methods of finding the information than making the ever dreaded live phone call to customer service representatives. But yeah, often you can find that out yourself by noodling around on the website.

Because we all know we all love calling insurance. Only Leslie. Let's see. And we had another... it looks like we had another question that is related to this. So it says, “My son has Kaiser Primary through my work and Medi-Cal is secondary. Kaiser referred my son to a PT who said they don't accept Medi-Cal as secondary, but if I assign my Medi-Cal to Kaiser, will Kaiser be able to cover the co-payment?”

So it depends on the clinic, but I mean, generally speaking, you... people don't really have the option to stay in fee-for-service anymore, so if you... if you assign your... your Medi-Cal to a different plan, then you're going to have this situation where nobody... who's going to be the primary insurance covering it and who's going to be paying... It’s tricky. The answer is going to vary on the provider. I have heard of some providers not wanting to take Medi-Cal patients, even if... even if their primary is Kaiser and their secondary is Kaiser Medi-Cal, because they don't want to accept the lower rate as opposed to what they have contracted with the private plan, but in other situations, yes. You just pay your copay to the provider as you would, because if you... if Kaiser’s contracting out to an outside clinic, when you go to that clinic, you're paying them the same co-pay that you would pay at Kaiser. It's going to vary. I've seen both scenarios happen. So you need to ask.... I think you'd want to ask both the provider and Kaiser if Kaiser... Like I said, it's a tough... I've seen it play out both ways, and I've seen people who have private Kaiser insurance not be able to go to certain providers because they don't want to deal with the secondary Medi-Cal. So, yeah.

All right. So what happens... This is another question we get a lot. What happens if a child qualifies for a therapy, let's say occupational therapy, but the family's choice of provider has a six month waiting list? Sadly happening all the time everywhere. The child is also a Regional Center client. Can the family get gap coverage?

Okay, so there's... there's two answers to this. The answer is yes. Theoretically they can... They can ask the Regional Center to cover... to cover that service in the interim. The other thing that they can do, and I'm not sure whether the Regional Center will ask them to do this first since the transition to managed care, is they can also ask the managed care provider to contract outside of the plan with an outside provider, because if they don't... if they don't have the service, that's functionally a denial. So they... they can ask the plan to contract... do a single case agreement temporarily with an outside provider while you're waiting for one of their providers to open up. So either avenue might potentially work. There are pitfalls to either one of them, but those are two potential outcomes in that situation.

And how long will Regional Center typically provide that coverage if they do?

It's going to be based on what the wait... Usually, often what they'll do is authorize it for a set period of time and then revisit it, after that set... or when that set period of time is set to expire and see where they are on the insurance and then potentially extend it, depending on what the insurance is reporting back.

And, Leslie, if that same family's insurance will only cover a certain number of therapy sessions, let's say PT sessions, in a year and the family finds themselves without PT, can they go to Regional Center and ask for PT sessions until the next year when insurance will pay again?

So that's a great question. Regional Center should pay if you've exhausted all the options within your plan for a medically necessary service, and have it in writing that no more benefits are available for the year, but it's really important for families to note that Regional Center will not likely cover if services are denied by the health plan from some other reason besides you've maxed out the benefit. If your... If your claim shows that you've made an error in submission, or if the claim was denied for lack of medical necessity, or if it was filed late, it has to really be... be successful with Regional Center that the plan's benefits have been entirely accessed and used up for the year.

Can I jump in for a second?

Yeah.

I want to clarify also that in terms of physical therapy specifically, you're mostly looking at early intervention, because once a child turns three, the Regional Center is going to say that the... that the school district has responsibility for providing physical therapy, but this same answer would apply, for example, with durable medical equipment or incontinence supplies is one that we see come up a lot, and we'll talk about that a little bit later, but it also has to be something that's within the scope of what the Regional Center is responsible for, for the child's given age.

Okay. And I want to dig into the age question and actually incontinence supplies in a minute, but another question that we receive a lot of confusion about, Lisa, is when does CCS provide OT and PT?

So that's going to happen generally with specific diagnoses, usually musculoskeletal diagnoses, cerebral palsy, muscular dystrophy. They have a network of medical therapy units that are housed at local educational sites, whether it's a school or a different district or other LEA site, and they're providing therapies that are medically necessary to kids who qualify based on very specific diagnoses.

Okay. And I think there might be some similar questions right now floating around to this one. Another common situation we hear about is when families change insurance and they want to retain the same provider. Leslie, can you explain what continuity of care means and how families can utilize it?

Yeah. This is another great subject. Actually, it may be that continuity of care is not what a family wants to request in this situation. Continuity of care is a short term exception that allows you to stay with your provider for a limited period of time while you transition to a new network provider. You are, in effect, agreeing at some point to transfer service providers with the new plan. What you may want to consider doing instead is to request to remain with your current provider by proving, if you can, that there's no one in the new plan at all at any point in time, in the present or the future, that's actually able to appropriately serve your child. Not that you have been with your current provider for a long time, and that you prefer them, but there are actually no medically appropriate or safe options for a network option. This is called an access- to-care exception, and actually access-to-care is a great term to use because access-to- care is what health plans are actually contractually obligated to provide. Proving access- to-care can be easy, or it can be a higher bar, and it may require... it may come through the first time and it may require appeal, but it can be a longer term solution with some plans than continuity of care. You're not agreeing that eventually you're going to transfer to a new network provider. You're making a bigger case that there just ain't nobody who can do it.

Right. And a lot of our kids see a lot of specialists. I mean, like special specialists, so it actually... it seems like a needle in a haystack, and it might be, but I know we all know circumstances where that was absolutely the case.

If I can just interject, a great example that I like to use when I'm talking to families is speech therapy. Very common service. If a child is working with a therapist and that therapist is a specialist in oral motor or in swallowing, and they have licensure training specific to that, that speech therapist or OT, because OTs can provide speech therapy, is trained to keep that child safe and not choking or aspirating while they're working on developing that swallow, so that would be a great common example of what the difference is between ‘I would like to have’ and ‘it's actually completely essential, and a safety and hazard situation for my... for me to be reimbursed for this particular child.’ And a doctor can write supporting documentation to get behind that.

Got it. Thank you. And, Lisa, I want to go back to when you were talking about the age question. So if a toddler is getting therapy through the Regional Center, will the Regional Center keep paying for their therapies after they turn three? You kind of touched on this, but I'd like you to expand.

So the short answer is no. The long answer is, like for every hard and fast rule, there's... there's going to be like one exception somewhere where something was granted as an exception in extraordinary circumstances. Generally speaking, once a child turns three, the school district is responsible for those therapies, generally speaking, but if a person has private insurance or Medi-Cal, they may be able to get medically necessary therapies funded that... because school only fund... they're only providing therapies to help a child access the curriculum. A lot of children still require medically based therapies outside of school, and that can come potentially through the private insurance or Medi-Cal. There has to be a pretty compelling reason why the child can't get those therapies from any of the other agencies that are on the hook for them, which is the school district and the private insurance and Medi-Cal. They're going to ask why... why can't...? Because it's always about generic resources and who else is responsible, so most of the time the answer is going to be no, but they can... if you do get copay assistance and the therapies are in the IPP that they're receiving therapies from the outside... from private insurance, you can potentially get copay assistance with those.

Okay. And just even zooming out a little, how should parents... how should the expectations change after three? I mean, what the school district pays for and what Regional Center pays for? Just so we...

I know it gets really confusing because all of the services come through the Regional Center, but before three and after three are actually governed and funded by two completely different sets of laws and allocations. So before age three, it's... Essentially, it's essentially special education. It's governed by the IDEA, which is the same law that governs education after three. It's just a different section. And so a lot of what they're providing in those early days is what the school district becomes responsible for once they turn three. So after three, you're looking at state law, which is the Lanterman act, whereas before age three it's federal law. So with the Lanterman Act, you're looking at things like respite, social skills classes, social rec camp and non-medical therapies were restored a couple of years ago. For adults, that may also include independent living skills, housing services, rep payee services for public benefits if they can't manage their own finances. It's a completely different set of governing laws and regulations for it. So once they turn three, a lot of the... the direct services are going to transition to the school district.

And this is something we touched on a minute ago, and Cami, I see that you're asking about this now as well. I'd love to walk through another common scenario around a non-therapy issue, which is incontinence supplies. So if a family has private insurance, Medi-Cal, and Regional Center, how would funding work to get incontinence supplies covered? Leslie, you want to start?

Sure. So, private insurance pays first, right? So if your private insurance plan covers incontinence supplies, then what you're going to need is a prescription from your doctor, and this is really important to get right the first time, detailing very specifics on that prescription. Diaper type? Is it a pull up? Is it not a pull up? Diaper size, and the quantity needed per month. How many packs, how many diapers, as well as other supplies that the plan may cover that you may require? Under pads, diaper ointment, which is often referred to as barrier cream, waterproof mattress covers, and some plans, sometimes even diaper wipes. If you're... if you have that prescription, you can contact your plan for a list of network providers. The category that you're going to be looking in is DME, durable medical equipment, and sometimes some plans will have a subheading which is expendables. You're asking for expendables under DME benefit. Conversely, if your plan doesn't have a benefit for incontinence supplies, you'll need to obtain proof of non-coverage in writing, proof that there is no benefit. You would then find out who's contracted with your Medi-Cal plan for medical supplies and provide them with a copy of the Medi-Cal doctor's prescription and the denial letter that you receive from private insurance.

And so, Lisa, where does Regional Center come into this or when?

Main two... two main situations where the Regional Center may step in, number one, for younger... Medi-Cal, they... after a child turns... They won't cover diapers until a child turns three if it's for a medical condition. I think it's a little higher if it's not for a medical condition, but if the diapers are medically necessary because of the incontinence related to a medical condition, Medi-Cal will generally cover it at age three. So before age three, a lot of... Generally speaking, the Regional Center is going to say that diapers are parent responsibility, but sometimes if there's a significant financial hardship in the family, you may be able to get diapers covered in that way. Another way that the Regional Center sometimes has to step in and fund incontinence supplies, especially diapers in particular, is that a lot of our kids have sensitivities to different types of materials and I've seen kids have allergic reactions to the diapers that Medi-Cal provides, and generally they're only going to cover a couple different brands, and the supply companies are not going to want to purchase some that might be commercially available on the market but not contracted with them, and so you're generally going to need... if you want to approach the Regional Center about something like that, first of all, the... Medi-Cal is still going to pay for other supplies, so, for example, you don't just change the whole order over. The under pads, the barrier cream, all that other stuff will still come from Medi-Cal, but the diapers in particular, you'll want... you'll want an order from the doctor showing that you've tried what Medi-Cal provides, that for some reason it's not medically appropriate. Either it doesn't fit, they don't fit right based on your child's unique structural makeup or they leak frequently, or the... the big... issue that comes up is that kids have allergic reactions to them, and so have the doctor write a letter of medical necessity showing not... specifically that they cannot use the brand that Medi-Cal offers and including which brand they need to use, which brand we already know that they're able to use, and in that way, the Regional Center can potentially fund... can fund those diapers.

Got it. And safety is a big winner there. Sitting in wetness leads to skin breakdown, leads to infection, child has sensitivities, liable to get an infection more than another child. Health and safety. Right,Lisa? That's...

Yeah, yeah. I'm just... I'm just remembering when my daughter was a baby and she was on Lasix and it causes them to... to have more wet diapers, and if you're in a situation where you're having diapers that are not very absorbent and have to be changed constantly and still don't contain everything, then yeah, you're dealing with health and safety and also with the Regional Center, the ability to engage in the community. Yeah. Because that's also a consideration with the Regional Center, is how can you participate with peers and be out in the community if your diapers are not functioning the way they're supposed to?

Right. A lot, a lot, a lot to think about, consider, and advocate for. It’s a great example of how much has to go into the way that we are thinking about these things, the way that we're presenting them, obviously with truth, but it matters, right? How we're asking and why we're asking, every little thing, which makes it all the harder. But here's... here's another question that... We got this several times with RSVPs, and I saw it in the chat today as well. Lisa, a lot of families want to know, is it just easier...? Is there a benefit if they would drop their private insurance and rely solely on Medi-Cal?

So, okay, I think in some cases there are rules against this. Like if... I would have to look up the specific regulations, but I think if you have employer provided health insurance at no cost, then you are supposed to take it and not drop it and rely on Medi-Cal, and like I said, I would have to do a little bit more specific research to find... to pinpoint the exact issues, but I think that there are sort of prohibitions against that, because they want you... they want people to use their private insurance first. This... So, there are people who have, but usually it's because they're paying a large amount out-of- pocket for that insurance, and they... they want to not be paying a large amount out-of-pocket for that private insurance. That's where a lot of parents wind up dropping private insurance. It depends on what your child's needs are. If you're in a situation where you're paying out-of-pocket for private insurance and you're considering dropping it, it's... it depends on what your child's needs are. It depends on what your private plan covers versus what Medi-Cal covers. It's not something where I don't think you could ever just make a blanket recommendation in either direction, except to say that generally my understanding is that if it's employer provided insurance at no cost, then you're... you need to accept it.

Okay. Okay. Also wanted to...

I'll look that up and I'll come back and put it in the chat because I don't want to misspeak, but... Because many, many... especially with prices for health care rising, many employer sponsored health plans do require the... the employee to contribute pretax dollars for... So it may still be that limitation is only for free coverage. It may still be available to a majority. I'll look... I'll look into that and put it in the chat so that... to answer that question.

Great. Thank you.

But there may... there may be situations where there's stuff that the private insurance covers that Medi-Cal doesn’t, so it... it just depends on the child's needs.

Right. Yeah.

And if there's... if you have preferred providers, people that you don't want to lose... I mean, looking at any health... health plan, making sure that they have what you need, what your child needs.

So, appeals. Obviously we always get a lot of questions about appeals, which could be an entire event in itself. So, Lisa, if you can tell us what parents should do if they want to appeal a Medi-Cal, Regional Center, or CCS decision.

Yeah, sure. I think Brittany can put in the chat our articles about appealing with these agencies. Generally... generally, you're going to appeal to the agency that governs that particular... that particular service. So Medi-Cal’s Department of Health Care Services, Regional Center, also CCS, and then Regional Center’s Department of Developmental Services. Now with Medi-Cal, it's going to depend also on whether you have fee-for-service or managed care, and most of our kids have managed care. There are a few exceptions to that. If you have fee- for-service, then you file a hearing request, you file a state hearing request. If you have a managed care plan, you file... you have to file a grievance with the managed care plan first and then depending on the outcome of the managed care grievance, you can decide whether you want to go request a state hearing or whether you wanted to go to the Department of Managed Health Care and request an independent medical review. Now... But if the question is about enrollment and eligibility for Medi-Cal outright, then you're going to a state hearing, but if you're already in a plan and it's about a denial of a specific service, then you file a grievance with the plan first. With CCS, there's another... another layer of appeal within CCS before you request the state hearing, and then with Regional Center, there's... you request the state hearing, but on the hearing form there's an option to... to also ask for an informal dispute, like an informal meeting and mediation. So you file the request for hearing at the same time, but you have the option to request sort of alternative dispute resolution in the process of requesting the state hearing, and often they'll try to resolve the issues before you actually get to hearing.

Okay. Yeah, definitely check out the links that Brittany just shared, because obviously those are three very different processes, so it’s very specific as Lisa just covered, so check out the articles. Those will lead you through. We got this follow up question. Lisa, how do you recommend going about getting documented denials of certain services from Medi-Cal or private insurance without first submitting a claim?

So in the case of a managed care plan, if you call member services, what they will often ask you to do is just file a grievance. It's because that way, you'll file a grievance, it'll get directed to the people who can look at your policy and see what it... And this is... this is true for managed care plan, regardless of whether it's Medi-Cal or private insurance, is that if you need a denial without submitting an order, what you... what you're going to want to do is call member services and file a grievance. Now, it may be that you need to submit an order, because you need to find out if your plan accepts it or not, and what their reasoning is for not accepting it, but if you know off the bat... If you know that your... your private plan has an exclusion on incontinence supplies or hygiene items like a shower chair or bath chair, if you know already and you don't want to bother having the doctor submit it, you still need the prescription from the doctor. You need the order regardless of who's going to pay for it, but you can get the order from the doctor and then file a grievance with Member Services to get the denial.

Okay, great. Thank you.

Also you can file... you can file... you can ask a provider for a health plan to file a test claim. There's a process where they can actually... it's not like an actual order that generates an actual claim. They can file what's known as... It's like an experiment. You can ask for a contracted provider to file a test claim.

Okay. And what happens after the test claim?

It tests out whether that billing code from that provider type with that licensure is covered. They'll answer the question. Used to be able to call the plan and say, “Oh, a man told me this code number is never... Here's the call reference number.” Now you can ask providers. Sometimes they're willing to file a test claim for you. It's sort of a pretend claim.

Got it, right. Got it. Okay, that's a great tip. So Leslie, obviously every insurance plan is different, but what do you want to say about insurance, private insurance denials or appeals? I kind of want to talk about the general overall steps in the process.

There's two levels of appeal at the plan. There's your original request. You get a yes? Good. You get a no? You file a grievance. When you... If you get a negative determination back, they'll ask you, “Do you want to file a second level of appeal of the claim, or do you want to go to outside arbitration?” Often you want to go right to outside arbitration and you can appeal at this higher level external to the plan. That could be the Department of Managed Health Care, the DMHC, or it could be the Department of Insurance, the DOI, or for some plans it can be a private company entity, Maxim is one, or it can be at a self-funded, plan, it could be the board of directors at the health and pension fund. Your plan will be able to tell you which is the appeal entity that's appropriate to your plan. You don't get to decide that you like the DMHC better than the Department of Insurance. You can either ask your plan or if you go and look at the back, either online or electronically, or if you get paper claims, if you look at all those pages that nobody ever looks at in their claim, there's translation information and before the translation information, often it will say, “If you disagree with this determination, you may appeal at...” and it'll either say the Department of Insurance or what the entity is or the DMHC, so you can find that information out. And the only other thing I'll say is many times people file an appeal and they get a no and they think they're done. I always tell families the first no is not the final no. They count on a certain percentage of people getting a no and going away. If you have the stomach or the time or support, you can continue to fight if it’s... if it's a good fight and you think that you have a legitimate reason to consider next levels of appeal. Yeah. Take it through the whole process if you can... if you can hang in there.

If you want, if you're fighting the right fight, it's a good fight. You can prevail.

Right. Hopefully. Fingers crossed. We’ve had both. We've been in both.

Some of those entities are really on your side, like DMHC, if they believe in your case and the plan says no to them, they have attorneys that work at the DMHC and often one of their attorneys will take up your case with the health plan, but if it gets under the DMHC’s skin or they've seen a lot of them and they can also fine the plan if they see a bunch of cases with Blue Shield where Blue Shield is doing the same thing over and over again, they keep demographics on appeals, they can... the award doesn't go to you, but the plan knows it's more than a slap on the wrist from the DMHC, so if you keep the process going, they'll... there's people there who’ll be behind you.

Thank you. And Lisa, if your... if your private insurance denies something and your provider also takes Medi-Cal, can you request that Medi-Cal pick up that expense?

Yeah. Yeah. If it's something that is bigger like a wheelchair or hearing aids or an AAC device, you're going to want to get pre-authorizations and it'll help if you kind of go into it with an understanding of what the insurance is going to cover, and sort of coordinate that ahead of time so that there are no surprises, and then make sure that the provider does accept Medi-Cal and that you have all the documentation, like I... as I said before, Medi-Cal may ask for more documentation of medical necessity than the private insurance does, and it’s also going to matter why the private insurance denied it. If they're saying it's not medically necessary versus if they're saying this is not a covered benefit, or we only pay up to this amount, and if they only pay up to this amount, and it's a Medi-Cal... it's a covered Medi-Cal service, Medi-Cal can pay the balance up to the amount that Medi-Cal has contracted for it. And then you would... you shouldn't have out-of-pocket expenses because by contracting with Medi-Cal, the provider is agreeing to accept up to the Medi-Cal rate for Medi-Cal recipients. Just like the ABA.

Right, right. Yeah. And we had a question... Actually, this was superbills, from Francesca. She said, “If you're seeing a doctor who's out-of-network for PPO and Medi-Cal...” Wait, “who's out-of-network for PPO and Medi-Cal, can you submit a superbill to Medi-Cal after your PPO has covered everything they're going to cover?”

There's no out-of-network benefits for Medi-Cal, is the short answer.

Okay.

Yeah. There's... yeah. Yeah, there... In order for Medi-Cal to pay for it, the provider has to be contracted with Medi-Cal. And that's the only person who can submit a claim. There's no member submitted claims with Medi-Cal like there is for your PPO.

With one exception, because there's always an exception, is if you... if you just got med... I mean, it's always good if you just got your Medi-Cal and you were covered at the time and the Medi-Cal contracted provider refused to resubmit the claims after you've got Medi-Cal, it goes back 90 days, and refused to reimburse you and resubmit the claims to Medi-Cal, there is a department at Medi-Cal that you can submit those claims to, but it's a very niche specific circumstance. Generally speaking, it's not going to be like... The provider still has to accept Medi-Cal. It's just... It's resolving a situation with an existing Medi-Cal provider.

Okay. I mean, Lisa, what... What do you think the biggest misconception about public benefits is, and what do parents need to know about it?

I feel like the biggest misconception... Okay, what do parents need to know is never accept the first no as your last no just like Leslie said, but the biggest misconception is, oh, this isn't for my family, or we're not going to qualify. Certainly there are eligibility criteria for each program, Medi-Cal, IHSS, Regional Center, but there's a lot of misconceptions around who's eligible, what services are available. Not everybody knows that there are institutional deeming waivers through, for example, the Regional Center or for children with high medical complexity who may be able to get Medi-Cal regardless of parental income. Not everybody's aware of those, and so they might look at those services and be like, “Oh, that's not meant for us,” and the reality is, if your child meets the eligibility criteria and has those needs, then it is meant for your child.

Yeah. And always, always double check your eligibility for benefits because many providers think that they understand who qualifies for what, but we hear misinformation on a daily basis, so we have step- by-step guides for eligibility and ways to apply for all public benefits in our member app. You can sign up for the Undivided platform and create a roadmap for your child that leads you through every step. I just... we can't reiterate enough that we'll hear people, from well-meaning providers that say, “Oh, you can't get that. That's income based,” right, where there's just the misinformation, so just double check. And there may be situations where people don't qualify, but yeah.

Yes. We've also received a lot of worried emails. Elections can bring change and change for our families can bring up lots of emotions. We don't know anything today, but many people are terrified of losing the Affordable Care Act and the reinstatement of preexisting conditions and lifetime caps and insurance, so Leslie, as we wait to see what changes the new administration will bring, what do you want to say to families?

Well, what we want to say is that, and this applies to my family specifically as well, for families who are renewing private health plans, non-employer based private health plans right now, like right now, these weeks coming up for plans that are effective January 2025, plans remain available, with the usual annual small incremental changes to premiums and deductibles, right? 6% increasing. Not that it's nothing, but it's the same... It's the same old, same old for 2025. 2026? Plans may have and will likely have more severe limits and changes. The kind of environment that was available for private plans before the ACA. The examples that come to my mind are the ones you just gave. Perhaps we’ll see a return of preexisting conditions, which is the one that's frightening for my family, for my daughter. Lifetime caps or perhaps an offering of plans that don't have the set of coverages that the ACA defined as essential coverages. They may be plans that people are buying that just don't do that one thing or cover dentistry or whatever it is. Right now, what we have is a very, very uncomfortable state of uncertainty for 2026, but right now, for 2025, sign up. Plans should look the same, just like the same, the same as before.

Thanks, Leslie. And Lisa, I mean, every day again, we're hearing from parents asking what will happen to IHSS, Regional Center, Self-Determination Program and Medi-Cal if there are Medicaid cuts. What do you want to say to those families?

I mean, first of all, Regional Center is largely... I mean, certainly Medicaid has an impact but Regional Center is state law and state funding, so I'm not saying there would be no impact, but that's... that's largely a state program. But Medicaid is a big part of that, and I have a lot of questions too. I have a lot of questions and a lot of concerns, but ultimately, right now, all we can do is sort of speculate and stay aware and stay on top of sort of what is happening and what's being talked about. I don't know what advocacy is happening at the state level right now to put in any safeguards for people with disabilities who rely on Medicaid to stay safely in their homes and communities. In the past, we have seen when there have been... at the state level, when there have been budget shortfalls, we have seen attempts to cut IHSS significantly. State advocacy orgs have managed... 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've had... 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, but for a while there was... there was a cut. We don't know. All I can say is that we will continue to inquire and look into what's happening at the state level and update you as we get more information.

Absolutely. Like Leslie said, Lisa, Leslie, and I, we're all moms too. We also want to know what's ahead so we can organize, plan, advocate and activate just like we do with everything else. Our kids and so many of yours, their lives depend on these systems to survive and to thrive, so we will aggressively follow any developments. You don't have to figure this out on your own. We will have action plans. We will have step- by-step guides on how to navigate these changes, and we will continue offering our weekly office hours so experts like Lisa and Leslie can answer your questions directly, and our Navigators will be here to help lead you through it, and as parents, we show up no matter how hard it might get. We keep going because we have to, and because no one could stop us if they tried. So thanks again to Lisa and Leslie and to all of you. Our mission is to support you so your children can thrive, and we want you to thrive too. We'll see you soon.