Chapter 10: Public and Private Insurance Use Determination

10.1 Policy for Public Benefits

• 10.1.1 All families shall be provided the Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet at Intake and at each annual IFSP explaining EI's system of payment provisions and no cost protections.
• 10.1.2 CFCs will not require any family to have an application for Public Benefits (AllKids) submitted on their behalf by the AllKids Application agent (CFC). But, families with no public benefits who may qualify for AllKids should be encouraged to apply for AllKids. If the family chooses to apply, the CFC must assist the family in applying for AllKids.

10.2 Procedures for Public Benefits

• 10.2.1 During Intake and at each annual IFSP, the CFC will provide Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet to all families. Ensure the families have all concerns answered.
• 10.2.2 Based on the results at Intake and each Annual IFSP of the Screening Device for Determining Family Fees and Eligibility for All Kids & DSCC, determine if the family is currently enrolled in AllKids or is potentially eligible for AllKids. Explain to family that DSCC eligibility will require a family to cooperate with DSCC financial factors if DSCC is to fund any service/device for their child. Failure to cooperate with DSCC will result in a status of non-cooperation with EI which may cease EI service/device subject to Family Participation Fees.
• 10.2.3 Provide the family the Notice to Use Public Benefits-AllKids Enrolled or Potentially Eligible for AllKids. Document the receipt of this notice. If the family is already enrolled in AllKids (excluding Premium Level 2 and AllKids rebate):
  • Obtain a copy of the current AllKids card or a screen print of the PA42 showing current eligibility. AllKids Premium Level 2 and AllKids Rebate are not billable to AllKids for reimbursement and do not qualify as public benefits.
• 10.2.4 If the family is not currently enrolled in AllKids but the screening tool shows potential eligibility, advise the family that they are not required, but are encouraged, to submit an application for AllKids and offer any assistance for that process. Provide the family with the Notice to Use Public-AllKids Enrolled or Potentially Eligible for AllKids and document the receipt.
  • Ask the family for future outcome information on any application submitted to HFS. Check with the family periodically if they have indicated they did apply. PA42 should also be used to review eligibility status once an application is processed by HFS.
• 10.2.5 If the family is not currently enrolled and does not show potentially eligible for AllKids, remind the family to also report any changes to income or household circumstances that may cause potential eligibility and offer to assist in the future if needed.

10.3 Benefits Verification Process for Public Benefits

• 10.3.1 For families currently enrolled in or potentially eligible for AllKids (except Premium Level 2 and AllKids Rebate), and no private insurance plan:

  • Ensure the family signed the Consent to Collect, Store & Utilize Personally Identifiable Information PII,
  • Indicate in the Cornerstone system using the Insurance Flag set to "No Private Insurance".
  • There is no need to complete a benefits' verification.
• 10.3.2 For families enrolled in or potentially eligible for AllKids (except Premium level 2 and AllKids Rebate) and also do have private health insurance:
  • Ensure the family signed the Notice to Consent to Use Private Insurance and the Consent to Collect, Store & Utilize Personally Identifiable Information PII:
  • If the family consented to use of their private insurance for any services subject to insurance billing, submit the normal benefits verification outlined in Chapter 10.6 below.

10.4 Policy for Private Health Insurance Benefits

• 10.4.1: During Intake and at each IFSP, the CFC will provide Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet to all families. Ensure the families have all concerns answered. Families whose children are enrolled under private insurance plans are asked to consent to use their benefits to assist in meeting the costs of covered EI services and AT devices.
• 10.4.2: No family with private insurance can be mandated to use their private insurance plans. A family who declines use of private insurance benefits must sign the informed consent indicating they decline the use of their private health insurance benefits to be used for EI. Families who consent to using their private insurance may also receive waivers and exemptions for certain or all covered services based on criteria outlined in the following procedures.
• 10.4.3: A parent may revoke their consent at any time. The revocation is not retrospective and any services provided prior to the revocation can be processed through the private insurance plan.
• 10.4.4: EI service providers are required to follow authorizations for services, including insurance usage, waivers, exemptions, etc and bill appropriately following policies and procedures. NOTE: The following services are the exception to insurance billing: Developmental Therapists, Translators/Interpreters, Deaf Mentors, and Physicians providing only medical diagnostics, Transportation providers and Parent Liaisons.

10.5 Procedures for Private Health Insurance Benefits

• 10.5.1 During Intake and at each annual IFSP, the CFC will provide Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet to all families. Ensure the families have all concerns answered. Document receipt of the notices.
• 10.5.2 The CFC will provide the family the Notice to Consent and Use Private Insurance form for their review and signature. For families who decline a specific service(s) but consent to others, use the Notice to Consent and Use Private Insurance for Specific Service(s).
• 10.5.3 The family must also be fully informed of the ramifications of waivers, exemptions and Family Fees based on the results of the benefits verification process and provider choice options. A family that agrees to private benefits usage must follow the policies and procedures of their private health insurance plan with regards to provider choice and the philosophy and principals of EI.

10.6 Benefits Verification Process for Private Health Insurance - Family Consented

• 10.6.1 Submitting a Benefits Verification Request
  • Obtain a copy of the front and back of the private insurance card.
  • Indicate the proper insurance flag of "Bill Insurance First" in Cornerstone for each authorization billable to private insurance.
  • Submit a copy of the front and back of the insurance card, the signed Notice to Consent and Use Private Insurance along with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates form to the CBO for the benefits verification process.
  • If a family needs to consent separately to bill private insurance based on specific services, complete the Notice to Consent to Use Private Insurance for Specific Service(s).

• • Indicate each IFSP insurance-billable service and have the family mark the appropriate consent indicator and sign the form.
  • Include a copy of the form to the CBO with the benefits verification process.
  • The CBO will verify the private health insurance benefits and provide a result to the CFC within 5 working days to assist the family and CFC in determining Provider Choice limits, if applicable.
  • The CBO will inform the CFC if the results indicate a need for a pre- billing waiver due to finding no enrolled EI providers or due to the private benefits plan indicating the EI services are not covered under the plan. The CBO will work with the CFC to automatically issue a pre-billing waiver to the service provider.
  • If the provider is not known yet, the CBO will issue a pre-billing waiver for the specific discipline.
  • The CFC must inform their CBO Insurance Processor when a payee/provider is located. The CBO will re-issue the pre-billing waiver in the individual payee/provider's name for the records.
  • The CFC must pass a copy of the pre-billing waiver to the rendering provider for their records. No provider should be asked to perform services without the waiver process being completed and a wavier in hand for their records.
  • The CBO will provide a pre-billing waiver automatically if the PCP referral is unobtainable due to the PCP not referring to an EI enrolled provider.
  • The CFC must inform their CBO Insurance Processor when a payee/provider is located. The CBO will re-issue the pre-billing waiver in the individual payee/provider's name for the records.
  • The CFC must provide a copy of the pre-billing waiver to the rendering provider for their records. No provider should be asked to perform services without the waiver process being completed and a wavier document provided for their records.
• NOTE: The physician's prescription must still be obtained prior to direct service provision. A copy must be forwarded to the appropriate service provider and a copy maintained in the record for services provided by Audiologists, Speech Language Pathologists, Occupational Therapists and Physical Therapists.
  • The CBO benefits verification process is a high-level request and does not replace the more comprehensive and detailed benefits verification the rendering provider must perform with the insurance plan to ensure accuracy of billing/payment. Remind the providers that providers who fail to perform their own comprehensive benefits verification risk non-payment for services rendered.

• 10.6.2 Waiver or Exemption of Private Insurance Use
  • Determine if the CBO benefits verification process results renders the need for a pre-billing waiver or exemption of using the private insurance and submit the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update indicating the applicable waiver/exemption request.
  • If the benefits verification limits the choice of EI providers and the CFC has contacted all the providers on the list with no success of locating a provider who can accept the referral within 15 days, the CFC must submit a pre-billing waiver request.
  • Provider Not Available: Complete the Waiver request section of the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update, the Pre-Billing Wavier Request form and submit, along with the appropriate case documentation (notes indicating the results of the contacts with the list of insurance mandated providers including the date of contact, phone number or e-mail address and, date services could begin by the insurance mandated provider), to the CBO.
  • Provider Not Enrolled: Complete the Waiver request section of the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update, the Pre-Billing Wavier Request form and submit, along with the appropriate case documentation (notes indicating the results of the any contacts providers including the date of contact, phone number or e-mail address), to the CBO. NOTE: If the CBO is aware that there are no insurance-enrolled, EI credentialed providers at the time of the benefits verification, a pre-billing waiver will be automatically issued.
  • Excessive Travel Time or Distance: If the insurance mandated provider must be a clinic-based provider based on the IFSP team's decision due to the needs of the child and the family would have to travel more than 15 miles or 30 minutes from their home, a pre-billing waver must be submitted. Complete the Waiver request section of the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update, the Pre-Billing Wavier Request form and submit, along with the appropriate case documentation (notes, address of clinic family will travel to), to the CBO.
  • If any information is incomplete or missing on the request, the CBO will have no choice but to deny the request and the CFC must resubmit a new request including all the above indicated required forms, documents or items.
  • The CBO will process and inform the CFC the results within 10 working days of receipt of the Waiver request.
  • Maintain all documentation and requests in the child's permanent record.
  • Based upon the type of private insurance plan, plan restrictions, waivers or exemptions, the CFC must assist the family in choosing the provider based on the allowances of the private benefits plan, the availability of EI providers and the plans coverage. If the insurance plan will not approve benefits to an out-of-network provider, the family will be required to accept services from an EI enrolled in-network provider following all other policies and procedures of accepting private insurance usage.
• 10.6.3 Exemption of Insurance Use
  • If the family has chosen, or if the CFC becomes aware of a need for an exemption to using private insurance, the CFC should submit that request by indicating on the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates as early in the process as possible. The current Exemption request may be necessary based on an Individually Purchased/Non-Group Plan, A plan that has a Lifetime cap (limits) that EI services may exceed or exhaust the amount if the plan is used for EI and the family has a Tax Savings Plan (such as a Health Savings Account or Health Reimbursement Account) that is automatically withdrawing funds when claims are submitted to the health plan.
  • Complete the appropriate section and include all noted documentation necessary to complete the request.
  • For Tax Savings Plan exemptions, the CFC must also submit the completed CFC Tax Savings Account Information Sheet to let CBO know the contact information for the tax savings plan account. NOTE: Families may decline the exemption for tax savings plan as long as the family is well informed of the consequences of their decision. If the family does request EI to utilize the tax savings account to pay for EI services, have the family sign the Acknowledgement to Decline Exemption for Tax Savings Account form and submit to the CBO with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates indicating "other" as the required attachments in Section 4.
  • CBO will process and inform the CFC the results within 10 working days of receipt of the Exemption request.

• 10.6.4 Updating Insurance Information
  • When status of private insurance changes the CFC must act immediately to ensure continuance of services and reimbursement to providers.
  • Check monthly with the family to ensure all coverage is the same. Being especially mindful of major plan year changes such as end of calendar year or fiscal years (each plan is different). Ask specific questions to families to ensure the most current accurate information is known. It might be the provider who discovered the update first. If so, take appropriate actions immediately when informed by provider or family.
  • Use the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates and complete the Change/Update section on an active child with an IFSP.
  • Inform parents of needed consent to use of private benefits as outlined in procedures above. If parent consents, follow procedures listed above, if parent declines, follow procedures below.
  • Families obtaining insurance for the first time will receive a 45-day exception to insurance billing for providers, beginning the day the CBO receives the request from the CFC. This 45-day exception allows the services to continue and the provider to bill the CBO directly for a period of time while the CBO, the CFC and the provider all process the benefits verification information to determine benefits coverage. As soon as the results of the benefits verification are received by the CFC, or once the 45-days are over, the services must be delivered in the manner matching the benefits verification results, including any need for a waiver or exemption. NOTE: The CFC must ensure the insurance flag is correctly set on each authorization.
  • Families changing private benefits plans (including new plan within same insurance company/carrier) will also receive a 45-day exception to insurance billing, beginning the day the CBO receives the request, while the CBO, the CFC and the provider all process the benefits verification information to determine benefits coverage and start date of services. NOTE: The CFC must ensure the insurance flag is correctly set on each authorization.
  • Families changing from having private benefits to having no private benefits will have all services billed directly to EI which will impact the Family Fee if the family participates in Family Fees. Again, submit the update request to the CBO and adjust Cornerstone only when the CFC receives the results from the CBO confirming the date of the lapse in private benefits coverage. After the CFC receives the confirmation of Lapse Date of private benefits, the CFC must adjust the insurance flag in Cornerstone accordingly and must re-write all direct service authorizations to correctly reflect the insurance status to providers. Immediately inform providers of changes to insurance status.
  • If the family does not have the new insurance plan card or identification yet, the CFC must complete the CFC Change of Insurance Notification form along with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates to assist the CBO in processing the benefits verification request.
  • The CFC should recommend families who lack private benefits to research options such as AllKids. Answer any questions as needed for families.

10.7 Families Declining Usage of Private Health Insurance Benefits

• 10.7.1 During Intake and at each annual IFSP, the CFC will provide Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet to all families. Ensure the families have all concerns answered. Document receipt of the notices.
• 10.7.2 The CFC will provide the family the Notice to Consent and Use Private Insurance form for their review and signature.
• 10.7.3 EI cannot mandate a family use their private health insurance for EI services.
• 10.7.4 The family must be fully informed of the cost assurances of EI services using public and private benefits and program costs including Family Fees along with the philosophy and principals of EI.

10.8 Benefits Verification Process for Private Insurance - Parents did not Consent

• 10.8.1 No benefits verification is necessary for families who do not consent to using their private health insurance benefits but EI must keep a record of these families for statistical purposes.
• 10.8.2 Indicate the proper insurance flag in Cornerstone.
  • If the family does not consent to using their private insurance benefits, does or does not have public benefits (AllKids - except AllKids Premium Level 2 or AllKids Rebate), the Service Coordinator must choose "Private Insurance-Declined" for each direct service authorization billable to insurance.
• NOTE: If a family does not consent to some services but does consent to others, indicate on each authorization the correct insurance flag. Use the Notice to Consent to Use Private Insurance for Specific Service(s) form for the parents to indicate specific services they do or do not consent to billing their private insurance. Follow the policies and procedures of the benefits verification process.