Chapter 10: Public and Private Insurance Use Determination - REVISED 02/2014

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 FirstPrivate Insurance-Bill" 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 planthe required PCP referral is unobtainable. 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.
  • If a waiver has been issued, but later an in-nework provider is located that is also EI credentialed and enrolled, the CFC must work with the family to follow insurance use compliance and, if necessary, make the necessary changes in authorizations to use the in-network EI provider.

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 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.

10.7 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 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.