3 Major Misconceptions About Accessing Public Benefits

Whether it’s therapies, medical supplies, or incontinence supplies, expenses for kids with disabilities can add up quickly. A crucial piece of our work involves educating families about public benefits and guiding them through the process of unlocking funding—an average of $33,000 per family in benefits and support! There are three major misconceptions about public benefits that we hear about frequently from our members. We asked Undivided Public Benefits Specialist Lisa Concoff Kronbeck and Undivided Director of Health Plan Advocacy Leslie Lobel to weigh in with the facts.

Misconception #1: “This isn’t for my family, we’re not going to qualify.”

Concoff Kronbeck notes that while yes, there are eligibility criteria for programs such as Medi-Cal, IHSS, and Regional Center, there are also many misconceptions around who is eligible and what services are available. “For example, not everybody knows that there are institutional deeming waivers through Regional Center or for children with high medical complexity who may be able to get Medi-Cal regardless of parental income,” says Concoff Kronbeck. It’s understandable that lack of awareness could lead families to assume that services are not available to them, but Concoff Kronbeck urges, “The reality is, if your child meets the eligibility criteria and has those needs, then it is meant for your child.”

It’s also important to double-check your family’s eligibility for benefits, even if a provider tells you that you won’t qualify. The Undivided team frequently hears from its members about misinformation communicated by well-meaning providers, usually in the realm of not qualifying for public benefits due to income level.

Misconception #2: “Medi-Cal can’t help if I already have private insurance.”

Medi-Cal—California’s Medicaid program—will always be secondary coverage for children with private primary insurance, but it can help fill some of the funding gaps by eliminating copays and many other out-of-pocket expenses when your child sees Medi-Cal contracted providers. Medi-Cal may also fund medical supplies (such as diapers and feeding-tube formula) and durable medical equipment. Be sure to check out our Medi-Cal 101 article for more details.

Lobel notes that Applied Behavior Analysis (ABA) therapy is a great example of how Medi-Cal and private insurance can cover costs in combination, and that it’s especially important to pursue combined coverage since a service like ABA has many session hours a week and costs add up quickly. “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,” notes Lobel.

Lobel also recommends that if you have a provider in mind, ask if they participate in the Medi-Cal plan your child has or consider changing enrollment to match the provider’s contract. The benefit of combining coverage through insurance and Medi-Cal? “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,” shared Lobel.

For additional details on combining sources to get costs covered, check out our article, 7 Ways To Get Your Child’s Needs Funded.

Misconception #3: “It’s not worth appealing a denial.”

When it comes to appealing denials, Lobel’s mantra is, “Never accept the first no as your last no.” Lobel notes, “Insurance companies and government benefits sources count on you being demure or going away or thinking you’re not entitled.” Concoff Kronbeck agrees: “There’s an appeal process for a reason and you have a right to use it.” A small fraction of people mount appeals, but Lobel estimates that a high rate of appeals—around 50 to 60%—are granted.

In order to best facilitate applications and appeals, it’s important to take care with the paperwork. Lobel encourages families to ensure that they have a solid basis for an appeal based on the benefits and coverage documented in the funding source’s own terms. “Read the reason you’re getting the denial and see exactly why it’s being denied and make sure your appeal is responsive to the actual reason why you’re being denied,” she advises. Concoff Kronbeck adds that when it comes to getting expenses covered, “it’s always going to be about medical necessity, not convenience.”

And be sure to build a paper trail as you request funding from different sources, which will be important both for applications and appeals. For example, Lobel notes that Regional Center will require written proof of denial of all other funding sources before considering a funding request.

For more information and to dig into additional funding options, check out our popular guide, How Do We Pay For It All? Undivided’s Guide to Funding Resources. And consider an Undivided membership so you can get your burning questions answered during our member office hours.