Public and Private Insurance Use Determination

10.1 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.
  • 10.1.3 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.
  • 10.1.4 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.
  • 10.1.5 Ensure the family has been provided the Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits. Ensure documentation the receipt of this notice. If the family is already enrolled in AllKids:
    • Obtain a copy of the current AllKids card or a screen print of the PA42 showing current eligibility.
  • 10.1.6 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. Ensure the family is provided the Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits 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.
  • 10.1.7 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.

10.2 Benefits Verification Process for Public Benefits

  • 10.2.1 For families currently enrolled in or potentially eligible for AllKids, and no private insurance plan:
    • Ensure the family signed the Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits,
    • Indicate in the Cornerstone system on each authorization "No Private Insurance".
    • There is no need to complete the benefits verification.
  • 10.2.2 For families enrolled in or potentially eligible for AllKids and also do have private health insurance:
    • Ensure the family signed the Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights and the Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits.Submit the normal benefits verification outlined in Chapter 10.6 below.

10.3 Private Health Insurance Benefits

  • 10.3.1 During Intake, at each IFSP and at any time consent for services is required due to an increase (in frequency, length, duration or intensity) in the provision of services in a child's 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 that are not Employer-Self Funded must allow use of their benefits to assist in meeting the costs of covered EI services and AT devices.
  • Families whose children are enrolled in Employer Self-Funded plans must provide informed consent prior to use of the plan to assist in meeting the costs of covered EI services and AT devices.
  • 10.3.2 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.
  • 10.3.3 The CFC must perform a Benefits Verification as outlined in 10.4. The Benefits Verification process will inform the Service Coordinator whether the private insurance plan is an Employer Self-Funded plan or not.
    • Upon completion of the Benefits Verification, the CFC will provide the family the Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights form for their review and signature. All families with private insurance must complete the form.
      • Families with Employer Self-Funded plans must complete both the consent section and the Assignment of Rights section.
      • Families with plans that are not Employer Self-Funded only complete the Assignment of Rights section.
  • 10.3.4 The family must also be fully informed of the ramifications of waivers (See Chapter 10.5.1 and 10.5.2), exemptions (See Chapter 10.6) and Family Fees (See Chapter 11) based on the results of the benefits verification process and provider choice options. A family must follow the policies and procedures of their private health insurance plan with regards to provider choice and the philosophy and principals of EI.
  • 10.3.5 The family must understand the prerequisite to use Non Employer Self-Funded or Employer Self-Funded for AllKids outlined in the Notice of System of Payments and Fees.

10.4 Benefits Verification Process for Private Health Insurance

  • 10.4.1 Submitting a Benefits Verification Request
  • Obtain a copy of the front and back of the private insurance card.
  • Submit a copy of the front and back of the insurance card along with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates form to the CBO for 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 if the plan is Employer Self-Funded or not.
  • 10.4.2 Employer Self-Funded:
  • If the CBO Benefits Verification results indicate the family has an Employer Self-Funded plan, the CFC must immediately contact the family to obtain informed consent for use of the plan for EI services.
  • The family must complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights indicating they consent to the use of the plan or decline the use of the plan.
  • For families who consent, the CFC must ensure any authorizations indicate "Bill Insurance First" as appropriate. The CFC must follow the processes of 10.5 and 10.6 to determine any need for waivers or exemptions.
  • For families who decline, the CFC must ensure any authorizations indicate "Private Insurance-Declined" as appropriate.
  • 10.4.3 Non Employer Self-Funded:
  • If the family does not have an Employer Self-Funded plan, the CFC must work with the family to determine Provider Choice based on the results of the Benefits Verification. The CFC must have the family complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights indicating they assign billing rights to EI.

10.5 Waiver procedures for Non Employer-Self Funded and consenting Employer Self-Funded plans

  • 10.5.1 Automatic Waiver of Private Insurance Use:
    • 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.
  • 10.5.2 Request for Wavier of Private Insurance Use:
  • 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 Exemption of Insurance Use for Non Employer Self-Funded AND consenting Employer Self-Funded plans

  • 10.6.1 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 1) an Individually Purchased/Non-Group Plan; 2) 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 3) 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.
  • NOTE: Effective 06/28/13, State law provides the following assurances regarding the use of Non Employer Self-Funded plans to pay for Part C services: (1) cannot count toward or result in a loss of benefits due to annual or lifetime caps; (2) cannot negatively affect the availability of health insurance; (3) cannot be used to discontinue health insurance; and (4) cannot be used as a basis for increasing health insurance premiums.
  • 10.6.2 If a family communicates that their private insurance plan is not consistent with these assurances, the CFC should contact their EI Specialist who will begin an investigation. DHS may exempt the family's private insurance from use based on the investigation.
  • Complete the appropriate section and include all required 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 Acknowledgment 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.

10.7 Updating Insurance Information

Ensure compliance with Benefits Verification to determine proper consent if plan is Employer Self-Funded.

  • 10.7.1 When the status of private insurance changes the CFC must act immediately to ensure continuance of services and reimbursement to providers by ensuring the following occur:
    • 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.
  • 10.7.2 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 authorization correctly indicates Bill Insurance First.
  • 10.7.3 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 authorization correctly indicates Bill Insurance First.
    • 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.
  • 10.7.4 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 Fee Notice of System of Payments and 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 authorizations to No Private Insurance and must send new authorizations to all direct service authorizations to correctly reflect the insurance status to providers.
  • The CFC should recommend families who lack private benefits to research options such as AllKids. Answer any questions as needed for families.

NOTE:  Below are forms that relate to the above revisions.  To better explain the form while not in a PDF versions, areas where guidance is provided is italized.

CHILD AND FAMILY CONNECTIONS - NOTICE OF SYSTEM OF PAYMENTS AND FEES (pdf) form

(To view this form as a PDF, please click on title above.)

The Illinois Early Intervention (EI) Program is funded through various sources and every attempt is made to maximize these sources. Some of the sources involve the family. Family sources for funding EI may include any combination of private insurance, AllKids and Family Participation Fees.

Private Insurance

Private insurance plans can be Employer Self-Funded Plans or Non Employer Self-Funded Plans. The distinction is important in Illinois Early Intervention. Employer Self-Funded Plans are plans for employees where the employer uses their own funds to administer the benefits. Non Employer Self-Funded Plans means an employer contracts with an insurance company to the costs to administer the benefits.

Non Employer Self-Funded Plans

To receive Early Intervention services, families whose children are enrolled under Non-Employer Self-Funded Plans must allow Early Intervention the use of their benefits to assist in meeting the costs of covered EI services and AT devices. State law provides the following assurances to protect families with Non-Employer Self-Funded Plans: (1) cannot count towards or result in loss of benefits due to annual or lifetime caps; (2) cannot negatively affect the availability of health insurance; (3) cannot be used to discontinue health insurance; and (4) can't be used as a basis for increasing health insurance premiums. If your insurance company is not following State law assurances, contact your Service Coordinator immediately. You also have the right to request the Illinois Department of Insurance (DOI) to investigate your complaint by filing a consumer complaint with the DOI, either electronically or in hard copy.

Employer Self-Funded Plans

If it is verified that you possess an Employer Self-Funded Plan, Early Intervention must obtain your consent before submitting any claims to the plan for covered Early Intervention services. You may decline the use of your Employer Self-Funded Plan and, if you decline, your child will still receive Early Intervention services consented to on your families Individual Family Services (IFSP). If you do consent, you may revoke your consent at any time except to the extent that it has already been acted upon.

If you possess an Employer Self-Funded Plan, Early Intervention must obtain your consent in the following circumstances: (1) when Early Intervention seeks to use the private insurance benefits to pay for the initial provision of Early Intervention services in the IFSP; and (2) each time consent for services is required due to an increase (in frequency, length, duration or intensity) in the provision of services in your child's IFSP;

General Insurance Usage

Early Intervention will not be responsible for paying a family's private insurance premiums, or loss of benefits because of annual health insurance coverage caps under your policy.

If you believe you may encounter a loss of benefits because of lifetime health insurance coverage caps, talk to your Service Coordinator about obtaining an Exemption. If an Exemption is not obtained, Early Intervention will not be responsible for the loss of benefits because of lifetime health insurance coverage caps under your policy.

EI will process insurance claims for EI Providers to cover the cost of covered EI services. If a private insurance Explanation of Benefits (EOBs) indicates no insurance payment or a reduced payment due to deductibles, the Bureau will make the necessary payments to the provider. If the family is subject to Family Participation Fees (see below), the cost of the deductible paid by Early Intervention may impact the amount of Family Participation Fees the family owes. (See Family Participation Fees below).

If private health insurance is used AND the family is subject to Family Participation Fees, the use of private insurance can reduce the amount EI pays which can reduce the amount of Family Fees paid. Families with private health insurance will not be charged disproportionately more than families who do not have private health insurance.

Families agree to check with their private health insurance to determine coverage and share any concerns with their EI Service Coordinator.

AllKids

AllKids is the state public benefits program. For certain AllKids eligible families, Early Intervention receives funds from AllKids to pay for Early Intervention services. The use of AllKids to reimburse Early Intervention for a portion of the cost for an eligible child's services will not: (1) decrease available lifetime coverage or any other insured benefit for your child under AllKids; (2) result in fees for services that would otherwise be covered by AllKids; (3) result in any increase in premiums or discontinuation of AllKids for you or your child; or (4) risk loss of eligibility for you or your child for home and community based waivers based on aggregate health related expenditures.

If your child is already enrolled in AllKids when entering Early Intervention, Early Intervention does not need to obtain consent to utilize AllKids. If your child is not AllKids enrolled when entering Early Intervention, Early Intervention may not require a parent to sign up for or enroll in AllKids as a condition of receiving Early Intervention Services and must obtain a family's consent to utilize AllKids. If you do not consent, the State lead agency must still make available Early Interventions services on the IFSP for which you have consented.

Early Intervention must obtain your consent to disclose personally identifiable information (PII) for billing purposes to the Illinois Department of Healthcare and Family Services (HFS), the state public agency responsible for administration of AllKids. Early Intervention services, as specified in your child's Individualized Family Service Plan (IFSP), and to which you have consented, cannot be denied due to your refusal to disclose your child's personally identifiable information (PII) to HFS. You have the right to withdraw your consent to disclose your child's PII at any time without affecting the EI services your child is receiving as specified in the IFSP. If you would like to withdraw your consent, notify your EI Service Coordinator.

If you have private insurance in addition to AllKids, AllKids will require the use of private insurance as the primary insurance. You will be provided a copy of the Consent to Use Private Insurance/Healthcare Plan Benefits and Assignment of Rights to explain those no-cost protections.

Families with public insurance or benefits not be charged disproportionately more than families who do not have public insurance or benefits.

You may contact your EI Service Coordinator if you are interested in more information about AllKids eligibility.

Family Participation Fees

EI requires that families help pay for EI services when financially able. The fee assessment calculates how much your family is able to pay (see Family Participation Fees Program Fact Sheet) and is recalculated annually or at any time reported changes could impact your family fee calculation. You are not required to pay more than the maximum out of pocket calculated based on their ability to pay.

To determine ability to pay, EI compares household size and taxable reported income to the Federal Poverty Level on a sliding scale and considers out of pocket medical/disaster expenses. A family meets the definition of ability to pay if the family falls within the scale and does not have proven out-of-pocket medical (allowable as IRS deductions) or disaster (fire, flood or act of nature) expenses in excess of 15% of the reported income.

Inability to pay is defined as a family whose household size and taxable reported income does not fall within the sliding scale and/or has proven out-of-pocket medical (allowable as IRS deductions) or disaster (fire, flood or act of nature) expenses in excess of 15% of reported income. A family will not experience a delay or denial of services for an inability to pay if the family meets the State's definition of inability to pay. These families must be provided all EI IFSP approved and consented services at no cost.

Families will not be charged any more than the actual cost of the EI services subject to fees (factoring in any amount received from other sources for payment such as private health insurance). If a private insurance Explanation of Benefits (EOBs) indicates no insurance payment, a reduced payment due to deductibles or established insurance reimbursement rates lower than Early Intervention rates, the Bureau will make the necessary payments to the provider. These costs paid by Early Intervention will be counted towards the actual cost of EI services subject to fees. However, the family will not be charged more than the actual cost of EI services subject to fees OR the maximum out-of-pocket calculated for their Family Participation Fees - WHICHEVER IS LESS. This means if the Family Participation Fee is calculated to be more than the actual cost EI pays for services, then EI will only charge the amount EI paid out for services and not the full Family Participation Fee. If the Family Participation Fee is calculated to be less than the actual cost EI pays for services, then EI will only charge the Family Participation Fee.

Fees will not be charged for the services that a child is otherwise entitled to receive at no cost. (See below, EI Services Provided At No Cost)

A family may decline to provide the requisite income information and documentation. Any family who declines to provide the required income information and documentation will be charged the highest amount on the fee scale.

EI Services Provided at No Cost

  • Child Find
  • Evaluations and Assessments
  • Service Coordination Services (including but not limited to Transition, IFSP Meetings, etc.)
  • Development, review and evaluation of IFSPs and interim IFSPs
  • Developmental Screenings
  • Medical Diagnostic Services
  • Interpretation
  • Translation Services
  • Administrative and Coordinative activities related to Procedural Safeguards
  • All Early Intervention services when the parent or family meets the State's definition of inability to pay

EI Services Subject to One or More of the Following: Family Participation Fees, Insurance Billing and/or AllKids Reimbursement

  • Assistive Technology (Durable Medical Equipment and Supplies)
  • Audiology
  • Aural Rehabilitation and Other Related Services
  • Developmental Therapy
  • Health Consultation
  • Nursing Services
  • Nutrition Services
  • Occupational Therapy
  • Physical Therapy
  • Psychological and/or Other Counseling Services
  • Social Work and Counseling Services
  • Speech Language Therapy
  • Transportation
  • Vision Services

Payor of Last Resort

Illinois Department of Human Services is the Payor of Last Resort. In other words, the Department will pay for services to prevent a delay in the timely provision of Early Intervention Services, pending reimbursement from the agency or entity that has ultimate responsibility for the Payment. Part C Funds may be used for this purpose.

Illinois Early Intervention Services System - Family Participation Fees Program Fact Sheet (pdf) form

(To view this form as a PDF, please click on title above.)

Family Participation Fees:

Family Participation Fees are payments made by families for Early Intervention (EI) services that are subject to fees. Not all EI services are subject to fees. Direct services, like Physical Therapy, Developmental Therapy, or Speech Therapy are subject to fees. Other services such as Service Coordination, Evaluations, Assessments and Individualized Family Service Plan (IFSP) Development are not subject to fees. You can find a detailed list of services subject to fees in the Notice of System of Payments and Fees and the Early Intervention Cornerstone Family Fee Report you receive from your service coordinator.

Requirement for Households Paying Family Participation Fees:

The Early Intervention Program requires a family meeting our definition of ability to pay help pay for their child and family's EI services.

Comparison of Free Services Provided by the School District:

The Free Appropriate Public Education (FAPE) requirement does not apply to Early Intervention. The Individuals with Disabilities Education Act (IDEA) says that EI services must be "provided at no cost except where Federal or State law provides for a system of payments by families, including a schedule of sliding fees," (Section 632 (B)). 325 ILCS 20/ Early Intervention Services System Act is the state statue that allows a sliding scale payment system.

Calculation of Amount of Family Participation Fees:

The fee assessment first calculates how much your family is able to pay over the course of one year and then breaks that down into a more convenient monthly amount called the Level Payment Amount. Fees are redetermined annually. Fees are calculated using your family size (for tax reporting purposes), your annual gross income (for tax reporting purposes) and considers any excessive out-of-pocket medical/disaster expenses. You can estimate your fee amount using the following table. When families choose not to disclose their income to EI, the family agrees to accept the highest family monthly installment while active in EI. This table is updated annually based on the Federal Poverty Levels.

FY 2014 FEE CALCULATION (Effective July 1, 2013)

Find column where family size and gross income meet to determine child's monthly fee installment:

Family Size $0 / Month Installment $10/Month
Installment
$20/Month
Installment
$30/Month
Installment
$50/Month
Installment
$70/Month
Installment
$100/Month
Installment
$150/Month
Installment
$200/Month
Installment
Percent of FPL 0-185%  185-200% FPL 200-250% FPL 250-300% FPL 300-350% FPL 350-400% FPL 400-500% FPL 500-600% FPL 600%
Family Size of 2 $0 - 28,694 $28,695 - 31,020 $31,021 - 38,775 $38,776 - 46,530 $46,531 - 54,285 $54,286 - 62,040 $62,041 - 77,550 $77,551 - 93,060 Above $93,060
Family Size of 3 $0 - 36,131 $36,132 - 39,060 $39,061 - 48,825 $48,826 - 58,590 $58,591 - 68,355 $68,356 - 78,120 $78,121 - 97,650 $97,651 - 117,180 Above $117,180
Family Size of 4 $0 - 43,568 $43,569 - 47,100 $47,101 - 58,875 $58,876 - 70,650 $70,651 - 82,425 $82,426 - 94,200 $94,201 - 117,750 $117,751 - 141,300 Above $141,300
Family Size of 5 $0 - 51,005 $51,006 - 55,140 $55,141 - 68,925 $68,926 - 82,710 $82,711 - 96,495 $96,496 - 110,280 $110,281 - 137,850 $137,851 - 165,420 Above $165,420
Family Size of 6 $0 - 58,442 $58,443 - 63,180 $63,181 - 78,975 $78,976 - 94,770 $94,771 - 110,565 $110,566 - 126,360 $126,361 - 157,950 $157,951 - 189,540 Above $189,540
Family Size of 7 $0 - 65,879 $65,880 - 71,220 $71,221 - 89,025 $89,026 - 106,830 $106,831 - 124,635 $124,636 - 142,440 $142,441 - 178,050 $178,051 - 213,660 Above $213,660
Family Size of 8 $0 - 73,316 $73,317 - 79,260 $79,261 - 99,075 $99,076 - 118,890 $118,891 - 138,705 $138,706 - 158,520 $158,521 - 198,150 $198,151 - 237,780 Above $237,780

** Based on FFY 2013 Federal Poverty Level Guidelines. This table is updated annually.**

The Level Monthly Payment Amount begins when your family's services subject to fees are authorized to begin and ending when your family's IFSP ends. This period, called the Family Fee Effective Period, is listed on your Early Intervention Cornerstone Family Fee Report.

Your maximum out-of-pocket Family Fee (listed on your Early Intervention Cornerstone Family Fee Report) is calculated based on your Family Fee Effective Period. The monthly level payment amount is sent each month to any family who qualifies for a Family Fee. The monthly level payment amount accrues the first month that one or more of your Authorizations for services subject to fees begins on or before the 15th of the month. You will receive a bill (invoice) for each month your family is active in Early Intervention through the month your IFSP ends on or after the 16th of the month.

Required Financial Documentation used to Determine the Family Participation Fee Amount:

You will be asked to provide your family's most recent Federal Income Tax form(s) in order to document gross annual income. If a recent Federal Income Tax form does not accurately reflect your annual gross income or is not available, two recent consecutive check stubs may be used.

If your child is covered by Medicaid/AllKids or WIC, you will be asked to provide a copy of his/her current Medicaid/AllKids Recipient Card or WIC Identification Card. In addition, you will be asked to provide a verbal indication of your annual gross income.

Family Participation Fee Household Calculation:

One Family Fee is assessed per family, even if more than one child is enrolled in the Early Intervention Program. Neither your maximum-out-of-pocket nor your monthly level payments will increase due to multiple children entering/receiving Early Intervention at the same time because the Family Participation Fee is based strictly on household size and income when you entered, not how many children participate in the program.

Affording Family Participation Fees during Changes or Extenuating Circumstances:

The Illinois EI definition of ability to pay is comparing household size and taxable reported income to the Federal Poverty Level on a sliding scale and considers out-of-pocket medical/disaster expenses. A family meets the definition of ability to pay if the family falls within the scale and does not have proven out-of-pocket medical (allowable as IRS deductions) or disaster (fire, flood or act of nature) expenses in excess of 15% of the reported income. The inability to pay is defined as a family whose household size and taxable reported income does not fall within the sliding scale and/or has proven out-of-pocket medical (allowable as IRS deductions) or disaster (fire, flood or act of nature) expenses in excess of 15% of reported income. If a family does not meet the state's definition of "ability to pay", the family must be provided all EI IFSP approved and consented services at no cost without delay.

You may request that your family fee be re-assessed at any time if your income or family size changes or if current medical expenses or other expenses due to natural disaster such as fire, flood or tornado as defined above exceed 15% of your gross annual income.

Changes to your family's fee may only be applied prospectively. This means that the portion of your fee that has accrued up to the time you request a re-assessment or exemption cannot be changed in the system. Therefore, it is important that you notify your Service Coordinator as quickly as possible when a re-assessment or exemption is needed.

You must request a re-assessment or exemption through your Service Coordinator. You must follow the policies and procedures of requesting a Family Fee Exemption. This includes steps such as signing an Exemption Request form and providing documentation of the expenses. If approved, the Exemption begins when the Department of Human Services Bureau of Early Intervention receives the signed form from the Service Coordinator.

A family will not experience a delay or denial of services for an inability to pay if the family meets the State's definition of inability to pay. These families must be provided all EI IFSP approved and consented services at no cost.

Family Fee Statements

If your family has been assessed a fee, you will receive a monthly invoice, like the one below, from the Early Intervention Central Billing Office (CBO).

Family Fee Invoices are mailed during the first week of every month. Payments are due to the State on the date shown on the Invoice. Families with more than one child in EI should receive one Family Fee Invoice. If your family has more than one child in EI and is receiving more than one invoice, contact your Service Coordinator and notify him/her of the problem.

IMAGE OF FAMILY FEE EXPLANTION OF BENEFITS SAMPLE

Understanding Your Family Fee Invoice

These definitions may help you understand your Family Fee Invoice. You may refer to the Sample Family Fee Invoice (see page 3) to see how these items are arranged on the Invoice.

  • Monthly Level Payment: The Maximum Out Of Pocket (from your Cornerstone Family Fee Report) broken down into monthly installment amounts. This level payment assists families in budgeting their Early Intervention expenses.
  • CBO Payments to Date for Services Subject to Fees: This is the total amount accumulated from the beginning of the affected IFSP. It is strictly an amount to determine if any Minimum Due is owed by your family. You will accrue a monthly level payment each month but only owe a Minimum Due if CBO pays any direct services for your child(ren)/family.
  • Family Payments to Date towards Maximum Out Of Pocket: This is the total amount accumulated from the beginning of the affected IFSP that your family has sent to Early Intervention.
  • Total Adjustments/Credits for current IFSP: This is any amount Early Intervention determines your family was incorrectly charged. This may be credits issued because your family fee maximum out of pocket was decreased due to changes of household size/income or credits issued because your services ended prior to the end of the IFSP but the case was not correctly closed in the system.
  • Amount and Date of most recent payment: The amount and date of when Early Intervention received your most recent payment.
  • Minimum Payment: This amount is calculated by taking the amount paid by Early Intervention during the IFSP period for the family's services subject to fees, minus the family payments to date based on the monthly level payment amount, whichever is less. NOTE: You will not be required to pay more in fees than the State pays for your family's services subject to fees.

Payment Options

Determining monthly payment amounts:

You will be required to pay at least the Minimum Payment amount listed on your family's fee invoice. However, if the amount Early Intervention paid for services is less than your Current IFSP Maximum Out Of Pocket, you have two payment options. You may choose to either:

  1. Pay the Monthly Level Payment amount as indicated (this is the recommended payment option because it is the only way to make sure that your minimum due is never higher than the level payment amount); or
  2. Pay the Minimum Payment amount as indicated on your fee invoice.

The Minimum Payment amount is based on how much the State has paid your EI service provider(s) for services subject to fees. This amount may vary by month because providers have up to 9 months from the date of service or last written correspondence with the insurance company to bill for EI services. This means that the State may not pay anything for your family's services subject to fees for several months.

Later, when your provider starts submitting claims to Early Intervention, Early Intervention will begin making payments which does affect your Family Fee.

If you do not pay the Monthly Level Payment amount, and instead wait to pay until Early Intervention incurs some expense on behalf of your family, you may be required to pay an amount much higher than

the level payment plan would have required. For this reason, families are usually encouraged to select the level payment plan by paying their Monthly Level Payment every month.

Utilizing private health insurance to reduce costs to the Early Intervention program:

Only EI services subject to fees that are paid for by the State are used to calculate the Minimum Payment amount. This means that you will not be charged for EI services subject to fees that are paid for by your private insurance. Providers must accept the insurance payment as "payment in full" for the service unless the amount reimbursed by insurance is less than the EI rate. EI may make partial payments for insurance covered services up to the EI rate if there is still a remaining deductible or if the negotiated rate of reimbursement is less than the EI rate. Any amount EI pays the provider will accumulate towards the maximum out of pocket calculated for a family.

Delinquency and Reconciliation

Skipping Family Participation Fee Payments:

If a Minimum Payment amount becomes equal to three or more Monthly Level Payment amounts overdue, EI services subject to fees, including Assistive Technology devices, will be discontinued with written prior notice to you. Services not subject to fees may continue. Your family has the right to appeal this decision. If your family does appeal, certain services may continue during the appeal process.

Overpaying Family Participation Fees:

Nine months after the IFSP has ended (or earlier if possible), the State will verify that you have not paid more in fees than the State has paid for your services subject to fees. This is called reconciliation, or reconciling your account. If you have overpaid and one or more children remain in the EI Program, your current account will be credited any amount overpaid in previous accounts. If you do not have any other children in the EI Program, your overpayment will be refunded.

Early Intervention will not automatically refund an overpayment before your account has completed the reconciliation period. There is a potential to receive the refund earlier if all criteria is met. You must request an early refund by contacting your Service Coordinator. In order to allow an early refund, Early Intervention must obtain written documentation from your EI service provider(s) verifying that they have been paid in full and will not be billing the State for any other authorized EI services. There is not a requirement of the service provider to comply with such a request so the policy of the reconciliation process is the primary way of refunding any overpayment.

Understanding Your Rights

Disagreement with Family Participation Fee Calculations:

If you do not agree with the fee your family has been assessed, you have the right to dispute the assessment. You should notify your Service Coordinator of any errors on the calculation no more than 30 days after you receive your family's Early Intervention Family Fee Report that tells you your fee amount to have it corrected prospectively in the system and a new report printed and sent to you.

If you wish to contest the imposition of a fee or the State's determination of the ability to pay, you may do one of the following:

  1. Request Mediation;
  2. Request a Due Process Hearing; and
  3. File a State Complaint

You may request a form from your Service Coordinator.

More Information

If you have questions about your fee statement, you may contact the Early Intervention Central Billing Office at 800/634-8540.

If your income and/or family size has changed and you wish to request a re-assessment of your family fee or you are experiencing excessive medical or disaster expenses and wish to request a fee exemption, you must contact your Service Coordinator immediately. As explained on the Early Intervention Cornerstone Family Fee Report, changes are only made on future monthly installments. The system has no way of making changes for past months.

If you would like more information about the Early Intervention Program, you may visit the DHS Early Intervention website at www.dhs.state.il.us/ei/.

Screening Device for Determining Family Fees and Eligibility for AllKids & DSCC (pdf) form

(To view this form as a PDF, please click on title above.)

STEP ONE  - FAMILY FEES

A. Family's total annual gross income: field for entering total

B. Family Size: field for entering number

STEP TWO

Is the child both an Illinois Resident and either a U.S. Citizen or Legal Immigrant? 

If Yes, (Proceed to STEP THREE) or

If No, (No referral - Proceed to SIGNATURES)

STEP THREE - ALL KIDS

A. Is the child currently enrolled in All Kids?

If Yes (Proceed to STEP FOUR)

If No, Proceed 

B. Has the family already submitted an All Kids application? 

If Yes (Proceed to STEP FOUR)

If No, Proceed Monthly Family Gross Income Guidelines

  • $3,153 for a family of 2
  • $3,978 for a family of 3
  • $4,803 for a family of 4
  • $5,628 for a family of 5

For family sizes above 5, add $825 for each additional family member.

  • If a family's gross income falls within these guidelines, ask if the family would like to file an All Kids application.
  • If a family's gross income exceeds these guidelines, ALWAYS ask if the family has high medical bills. If the family's medical bills exceed $2,000 per month, do not take an All Kids application. Refer the family to their local Department of Human Services Office / Family Community Resource Center to apply for medical assistance.
  • If a family's gross income exceeds these guidelines and the family does not have medical bills over $2,000 per month, ask if the family would like to file an All Kids application. Never refuse to take or discourage a family from filing an All Kids application.

C. Does the family's gross income fall within these guidelines? 

Answer Yes or No

D. Choose one of the following:

Yes means applicant needs to Enter Date All Kids application was filed

If No, All Kids application was not filed

STEP FOUR - DSCC

Is the child currently enrolled in University of Illinois Division of Specialized Care for Children (DSCC) or has the child already been referred to DSCC?

If Yes (Proceed to SIGNATURES)

If No (No referral - Proceed to SIGNATURES)

Choose one of the following options:

  • Option 1 means Referral to DSCC is not indicated at this time.
  • Option 2 means Referral to DSCC for a diagnostic evaluation. Child MUST have a suspected potentially DSCC medically eligible condition. Check all suspected medical conditions below that apply.
  • Option 3 means Referral to DSCC is indicated due to physician diagnosis or medical condition that is or could be potentially DSCC eligible. (Refer to Child and Family Connections Procedure Manual, Chapter 9, Eligibility Determination.) Check all diagnosed medical conditions below that apply.
  • For Options 2 or 3, check all that apply:
    • Orthopedic conditions (bone, muscle, joint disease)
    • Heart defects
    • Hearing loss
    • Neurological conditions (nerve, brain, spinal cord, does not include autism or developmental delay)
    • Certain birth defects
    • Disfiguring defects such as cleft lip, cleft palate, and severe burn scars
    • Speech conditions which need medical treatment
    • Certain chronic disorders such as hemophilia and cystic fibrosis
    • Certain inborn errors of metabolism, including PKU, and Galactosemia
    • Eye impairments, including cataracts, glaucoma, strabismus and certain retinal conditions - excluding isolated refractive errors
    • Urinary system impairments (kidney, ureter, bladder)

Applicant is asked to provide Comments: 

Contact DSCC for additional technical assistance for referral. If referral to DSCC is indicated and a Consent for Release of Information form has been completed and signed by the parent/guardian, send the following Cornerstone screens/reports to your local DSCC office with a copy of this form: Participant Enrollment Information (HSPR0770), Assessment History (HSPR0207), and Insurance (HSPR0794).

Note to Parents: If your family's income appears to exceed DSCC financial eligibility criteria, DSCC cannot offer financial assistance for medical treatment services. All available insurance and/or All Kids benefits must be used. Families having no insurance with incomes above DSCC financial eligibility criteria are encouraged but not required to apply for the All Kids program.

SIGNATURES

I certify that the information given above is correct to the best of my knowledge. I understand that I will still be able to receive Early Intervention services and assistive technology devices subject to fees even if I have chosen not to file an All Kids application.

Parent/Guardian Printed Name, Parent/Guardian Signature & Date, and Service Coordinator Signature & Date requested here.

CHILD AND FAMILY CONNECTIONS CONSENT TO USE PERSONALLY IDENTIFIABLE INFORMATION (PII) & BILL PUBLIC BENEFITS (pdf) form

(To view this form as a PDF, please click on title above.)

This form requests the Child's full name, date of birth and 6-digit Early Intervention Number.

PII Collection/Usage

I hereby grant permission for my Child and Family Connections (CFC) to collect Personally Identifying Information (PII) related to my child and family. I understand this information will be stored electronically and in a hard copy case record. Early Intervention (EI) utilizes a data system called Cornerstone that collects records on a wide range of health care services to individuals. Those services include Women, Infants and Children (WIC); Immunizations; Case Management; Prenatal and Postpartum Care; Pediatric Primary Care; Early Intervention; Breast and Cervical Cancer; Diabetes Control; and Healthy Families Illinois. Cornerstone is maintained by the Department of Human Services (DHS) and the Illinois Department of Public Health (DPH). Using Cornerstone, DHS and DPH may learn your child is participating in EI but cannot access detailed information regarding these services. Necessary aggregate information, without any client's name, may be sent to federal agencies that fund these programs. The Cornerstone user with access to the system has a legal and ethical duty to keep the information confidential and private and not release it to anyone without your consent or unless required by law.

The detailed information collected will be used only for purposes permitted by the Individuals with Disabilities Education Act (IDEA) Part C EI Services Act which includes referrals, eligibility determinations, EI services provision and claiming. My Service Coordinator, service providers and DHS and its designees, may see and discuss the information with each other for the purposes listed above. I understand if I transfer to a new CFC office within Illinois, my information will be transferred to the new CFC office without further consent.

Public Benefits Assurances and Billing/Usage

If I am currently enrolled in AllKids and/or later become enrolled in AllKids while in EI, I hereby grant permission for my CFC to collect and share the above collected PII for the purposes of billing, care coordination and analysis with the Department of Healthcare & Family Services (HFS), the State agency responsible for the administration for AllKids. If I am not currently enrolled but later become enrolled in AllKids, I grant permission for my CFC to do the aforementioned actions with PII as well as submit claims for reimbursement to HFS.

I understand the following assurances:

  • EI services, as specified in my child's IFSP, and to which I have consented, cannot be denied due to my refusal to disclose my child's PII to HFS, the state agency responsible for the administration of AllKids. If I would like to withdraw my consent, I will notify my Service Coordinator.
  • If I am not currently enrolled in AllKids but later become enrolled and do not consent to allow EI to bill AllKids for reimbursement for services rendered, EI must still make available those services on the IFSP to which I have provided consent.
  • The use of AllKids for EI services will not (1) decrease available lifetime coverage or any other insured benefit for myself or my child under AllKids; (2) result in me paying for services that would otherwise be covered by AllKids; (3) result in any increase in premiums or discontinuation of AllKids for myself or my child; and (4) risk loss of eligibility for myself or my child for home and community based waivers based on aggregate health related expenditures.
  • If I have private insurance, AllKids requires the use of my private insurance as the primary insurance. I will be given the document entitled Notice to Consent to Use Private Insurance/Healthcare Benefits & Assignment of Rights to sign.

In addition, this disclosure allows the release of information from DHS to HFS about a child, including name, AllKids recipient identification number, date of birth, and information about a child's referral to and eligibility for EI, including services received and other referrals made by EI. HFS may also share information with my child's assigned primary care provider/doctor (PCP), whom I identified on my IFSP as a team member, and treating doctors within the group, for care coordination. Care coordination allows my child's PCP to be notified of my child's EI assessment, eligibility for services and services received. HFS may also use the information for analysis purposes and to measure the quality of the care coordination process between the PCP and EI. Information and reports resulting from data analysis will not be released with any personally identifying information about my child.

Consent

I am making this consent within the legal limits of my authority. I understand that I may withdraw my consent, in writing at any time, except to the extent that it has already been acted upon. I understand my refusal to grant permission or withdrawing my permission will not affect the services outlined in the IFSP that I consented to receive. To revoke my consent, I will contact my EI Service Coordinator.

I understand that my child's records are required to be maintained for a period of six years and will be destroyed at my request or at the end of that period unless legal action is pending.

(Applicant is asked to check one of these statements.)

  • I give my consent to collect, store and utilize personally identifying information only with the parties identified above and for the purposes outlined above.
  • I do not give my consent to collect, store and utilize personally identifying information only with the parties identified above and for the purposes outlined above.

ONLY COMPLETE THIS SECTION IF NOT CURRENTLY ENROLLED IN ALLKIDS:

(Applicant is asked to check one of these statements, if not enrolled in AllKids program.)

  • If I am not currently enrolled in AllKids but later become enrolled in AllKids while in EI, I consent to the use of my AllKids benefits as outlined above.
  • If I am not currently enrolled in AllKids but later become enrolled in AllKids while in EI, I do not consent to the use of my AllKids benefits as outlined above.

Parent/Guardian Printed Name, Parent/Guardian Signature & Date, and Witness Signature & Date requested here.


CHILD AND FAMILY CONNECTIONS CONSENT TO USE PRIVATE INSURANCE/HEALTHCARE PLAN BENEFITS & ASSIGNMENT OF RIGHTS (pdf) form

(To view this form as a PDF, please click on title above.)

This form requests the Child's full name, date of birth and 6-digit Early Intervention Number

Private Insurance/Healthcare Plan Benefits:

As an EI family, I understand my private health insurance/healthcare plan benefits (hereinafter referred to as "Plan") could be used to pay for certain EI direct services. I understand there are certain EI services which are provided at no cost through the Individuals with Disabilities Education Act (IDEA) Part C (See Notice of System of Payments and Fees). I understand there is no charge to me or my Plan for Service Coordination, Evaluations, Assessments and the creation and implementation of the Individualized Family Service Plan (IFSP).

I understand I have been provided a copy of the Notice of System of Payments of Fees explaining all potential uses and risks involved in my Plan's use or non-use and I understand I must allow EI to verify my Plan to determine potential use and coverage.

I understand that unless I possess an Employer Self-funded plan, I must allow EI, if appropriate, to submit claims for any covered services. If it is verified I possess an Employer Self-Funded plan, I understand EI must obtain my consent before submitting any claims to the plan for covered EI services subject to private insurance billing.

If my plan is not Employer Self-Funded and I do not sign the Assignment of Rights of Insurance on this consent, my child will not receive any services other than those offered at no cost through IDEA as listed above.

I understand that I am responsible for checking and confirming the coverage of my Plan and sharing any concerns with my Service Coordinator. I agree to cooperate with providing current and up-to-date Plan information and assist in whatever way necessary to ensure prompt processing of any claims submitted to my Plan including notification to providers of any rejections.

I understand that if my Plan sends payment(s) directly to me that I must forward any payment(s) to the EI provider involved. Failure to forward the payment(s) could result in legal action by the EI provider.

Employer Self-Funded Plans:

If I possess an employer self-funded plan, by signing below I agree to allow EI (or its' designee) to bill my plan for covered services and I consent to the assignment of rights of payment to EI (or its' designee). I understand I can decline the use of my employer self-funded plan benefits and, if I decline, my child will still receive EI direct services consented to on the IFSP Implementation and Distribution Authorization page. I also understand if I do consent, that I can revoke my consent at any time except to the extent it has already been acted upon.

Tax Savings Plan benefits attached to my private insurance/healthcare plan

If I possess/utilize a Tax Savings Plan such as a Health Savings Account, Medical Savings Account, Health Reimbursement Account or any account utilizing pre-tax dollars for payment of allowable out-of-pocket medical services not otherwise paid by insurance, I understand I am required to provide my Service Coordinator with current information regarding any such account. Failure to disclose this information at any time in EI could result in lost funds from the accounts, which are not reimbursable by Early Intervention.

Waiver or Exemption of use of private insurance/healthcare plan

I understand that even if EI (or it's designee) submits claims to my Plan that those services may not be covered. If the service is not covered by my Plan, OR if there are no insurance enrolled providers who can provide EI services, EI may waive or exempt the procedure for an EI provider to submit claims to my Plan. This will allow the EI provider to submit claims directly to EI for payment. I understand my Service Coordinator will inform me if any of my child's services will receive a waiver or exemption from private insurance/healthcare plan use. I understand I am responsible for understanding the deductible aspect of my private insurance/healthcare plan benefits.

I also understand that if I participate in Family Participation Fees AND EI pays for any services due to deductibles, waivers or exemptions, this may impact the amount of Family Participation Fees I owe. I understand I am not required to pay more than the maximum out of pocket calculated based on my ability to pay.

ONLY use this section for EMPLOYER SELF-FUNDED PARTICIPANTS as indicated on the benefits verification results page from the EI Central Billing Office

Consent To Use Employer Self-Funded Insurance/Healthcare Plan Benefits:

Applicant is asked to check one of these statements.

  • I give my consent to the Illinois Department of Human Services, EI program or its' designee, to submit claims to my Plan for the specified services consented to in my child's IFSP.
  • I do not give my consent to the Illinois Department of Human Services, EI program or its' designee, to submit claims to my Plan for the specified services consented to in my child's IFSP.

NOTE: If a family declines use of Plan, no signature on Assignment of Rights of Insurance section below is necessary.

Parent/Guardian Printed Name, Parent/Guardian Signature & Date, and Witness Signature & Date requested here.

ONLY use this section for plans that are NON EMPLOYER SELF-FUNDED AND for plans that are EMPLOYER SELF-FUNDED when the family has consented.

Assignment Of Rights Of Insurance:

By signature below, I hereby assign the benefits from my Plan to be paid to my child's authorized EI provider(s) or its designee, and consent to the release of information regarding benefit determinations, payee information and claims to the Department of Human Services or it's designee, CFC staff and my child's authorized EI provider(s).

Parent/Guardian Printed Name, Parent/Guardian Signature & Date, and Witness Signature & Date requested here.

Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law.

CHILD AND FAMILY CONNECTIONS FAX COVER SHEET FOR INSURANCE BENEFITS VERIFICATION REQUESTS/UPDATES (pdf) form

(To view this form as a PDF, please click on title above.)

All of these items are completed by the Child and Family Connections office who serves the family.

Section 1: Complete this section completely 

To: Central Billing Office / COB Unit From: Name of Service Coordinator

Fax Number Sent to: 1-217-492-5602 CFC #:  entry requested

Total Pages including cover: entry requested

Date: entry requested

Senders Phone: entry requested

Child's Name: entry requested Child's EI#: entry requested

Insurance Plan Owner's Name: entry requested

Primary Care Physician Name: entry requested

Primary Care Physician Phone # : entry requested   

Section 2: Benefits Verification Request

Insurance benefits check for (check only applicable services):

  • PT physical therapy
  • PT Group 
  • STspeech therapy
  • ST Group 
  • OToccupational therapy 
  • OT Group
  • SW social work
  • SW Group 
  • NU nutrition
  • NU Group 
  • Psychpsychology
  • Psych Group
  • AU/AR audiology or aural rehabilitation

Required Attachments

  • Enlarged insurance card copy (front and back) entry requested to acknowledge completion
  • Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights entry requested to acknowledge completion

Location Required for all services identified above. Choose appropriate location for each or all services as indicated under Required Attachments. 

Required Attachments

  • All Offsite 
  • All Onsite Other (specify)
  • Partial Offsite (check services)  PT ST OT Other (specify)
  • Partial Onsite (check services) PT ST OT Other (specify)

Assistive technology benefits check entry requested to acknowledge completion

Required Attachments

  • Enlarged insurance card copy entry requested to acknowledge completion
  • Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights  entry requested to acknowledge completion
  • Copy of AT request cover page entry requested to acknowledge completion

Annual Meeting Date: entry requested Only needed if submitting request for annual more than 30 days prior to IFSP end date showing in Cornerstone

 Section 3: Change/Update to current IFSP insurance information (not for Initial/Annual)

Existing Insurance Ended 0 New/Different Insurance Obtained entry requested

Required Attachments

  • Date insurance reportedly ended:entry requested
  • AND
  • Any letters from insurance company, if available.

New/Different Insurance Obtained entry requested

Required Attachments
Complete Sections 1 and 2 and include copy of card (front and back) and Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights. If no card is available, complete the CFC Change of Insurance Notification form and submit along with this request.

CFC TRANSFER INFORMATION:

Receiving CFC must submit new BV request if changing providers.

Required Attachments

Receiving CFC #:entry requested

AND

Sending CFC #:entry requested 

Section 4: Waiver / Exemption Request Required Attachments

Pre-billing Waiver request

  • Provider not available entry requested to acknowledge completion

Required Attachments

  • Case note of conversation with Payee/Provider(contact person, date of contact, phone/email) entry requested to acknowledge completion
  • Pre-Billing Insurance Wavier Request form completed entry requested to acknowledge completion

Pre-billing Waiver request (if not discovered and approved during initial BV):

  • Provider not enrolled entry requested
  • Case note of conversation with Payee/Provider (contact person, date of contact, phone/email)
  • Pre-Billing Insurance Wavier Request form completed

Pre-billing Waiver request

NOTE: This waiver type is not applicable for offsite services

  • Travel time/distance 0

Required Attachments

  • Family's primary mode of transportation AND
  • Address the family is traveling from
  • Pre-Billing Insurance Wavier Request form completed


Exemption request (If not automatically discovered and exempted during initial BV):

  • Individual purchased/ non-group plan 0

Required Attachments

  • Written documentation from insurance company stating plan is privately purchased and not part of a group

Exemption request

Annual or Lifetime cap entry requested to acknowledge completion

Required Attachment

  • Written documentation from insurance stating amount of annual/ lifetime cap entry requested to acknowledge completion OR
  • Written documentation from insurance showing remaining amount of annual/lifetime cap entry requested to acknowledge completion AND
  • Cornerstone authorizations entry requested to acknowledge completion

Exemption request 

  • Automatically withdrawing Tax Savings Plan entry requested to acknowledge completion

Required Attachments

  • Completed CFC Tax Savings Account Information Sheet entry requested to acknowledge completion

New Payee Waiver request (not due to change of insurance):

  • Change of Provider entry requested to acknowledge completion (new Payee only)

Required Attachments

  • Case note indicating reason for change
  • Complete Section 2 and follow procedures to maximize insurance.

Responding to CBO request Name of Person

  • Other area for comments

IMPORTANT: This facsimile transmission contains confidential information, some or all of which may be protected health information as defined by the federal Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return or destruction of the information and all copies.

CHILD AND FAMILY CONNECTIONS PRE-BILLING INSURANCE WAIVER REQUEST (pdf) form

(To view this form as a PDF, please click on title above.)

This form requests the Child's full name, date of birth, Current IFSP Begin & End Date, and 6-digit Early Intervention Number

This form serves as certification of the existence of criteria defined in Illinois State Law and/or Administrative Rule to waive the requirement of private insurance use for Early Intervention services. A decision will be made within ten (10) business days of your request. The Waiver will only apply to the service and/or plan or policy for which the outlined criterion exists.

Check type of pre-billing waiver requested applicant must check one of the following choices

  • 1. Insurance provider NOT available to receive the referral and begin services immediately (i.e. within 15 business days).
  • 2. Insurance provider NOT enrolled and credentialed as a provider in the Early Intervention System.
  • 3. Family would have to travel more than an additional 15 miles or an additional 30 minutes to the insurance provider is compared to travel to a different enrolled and credentialed provider.

Name, Discipline Type & Tax ID of Authorized Provider, for option 1 and 2.

Provider Name, Provider Discipline Type, and Tax ID of rendering provider entry requested. 

CFC Program Manager Certification & Date entry requested

Service Coordinator Certification & Date entry requested

Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law.

**CFC must submit form and documentation to Central Billing Office for review**

PRE-BILLING INSURANCE WAIVER REQUEST APPROVAL/DENIAL

For CBO Use Only: entry requested

Waiver Approved:entry requested CBO Staff Initials:  entry requested

Date:entry requested Effective Dates: entry requested

Waiver Denied: entry requestedReason:  entry requested 

Date: entry requested

CHILD AND FAMILY CONNECTIONS TAX SAVINGS ACCOUNT INFORMATION SHEET (pdf) form

(To view this form as a PDF, please click on title above.)

Child Information

This section requests the Child's full name, date of birth, Current IFSP Begin & End Date, and 6-digit Early Intervention Number

Plan Holder Information (family member who owns the tax savings plan):

This section requests the Plan Holder Information name, date of birth, phone number and the last 4 digs of the social security number.

Tax Savings Plan Information (name of company administering the funds):

This section requests the Company/Plan Name, Company/Plan Phone Number, Representative's Name, Group #, Other ID #, Effective Begin Date, Effective End Date, a choice of yes or no for automatic withdraw, and a section for comments.

CHILD AND FAMILY CONNECTIONS CHANGE OF INSURANCE NOTIFICATION (pdf) form

(To view this form as a PDF, please click on title above.)

This section requests the Child's Last Name, First Name & Middle Initial, Child's Date of Birth (Month/Day/Year),  CBO/EI #, Insurance Company Name, Insurance Company Phone #, Policy Holder's Name,  Policy Holder's Date of Birth (Month/Day/Year) and Policy Number.

CFCs are to use this form in addition to the Child and Family Fax Cover Sheet for Insurance Benefits Verification Requests/Updates form when requesting the exemption. The CFC must also ensure the family is aware of potential Family Fees when using exemptions or waivers. Failure of a family to provide the necessary information may result in inaccurate information from the tax savings plan verification process. This may result in funds withdrawn unnecessarily.

IMPORTANT: This facsimile transmission contains confidential information, some or all of which may be protected health information as defined by the federal Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return or destruction of the information and all copies.

NOTE: Use this form only when no insurance card is obtainable by the family. Submit this form along with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates. A 45-day exception period will begin the date that the CBO receives them. During the 45-day exception period, all providers may bill the CBO for services. No insurance company EOB will be required during this period unless all conditions and requirements of the new insurance plan have been identified and met by the provider OR until the expiration of the 45-day exception period. The CFC will receive a Child & Family Connections 45 Day Insurance Exception Form completed by the CBO verifying the dates of the 45-day exception period. The CFC is responsible for informing the Payee/Provider and ensuring proper service authorizations are utilized. Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law.