KYLA PATTERSON, M.S.CREATING CONNECTIONS TO SHINING

STARS CONFERENCEJULY 24 , 2013

How to Implement Family Cost Share Practices in Real Family

Situations

Principles

No child denied services due to inability to pay

Families understand their options and implications of choices … informed consent

Agreement regarding family’s financial obligation is in writing

Family cost share practices are standard and equitable

Reminders

Services at no cost – Service coordination, eligibility determination, assessment, IFSP development

All other services subject to family cost share practices

Sliding Fee Scale available to establish monthly cap based on family size and taxable income

Fee appeal process availableDispute resolution available

For Families

No Insurance

Scenario:

No Insurance

Income $60,000

Family size: 4

Checklist

Intake Notice and explanation

Prior to IFSP Meeting Further explanation Complete Agreement form

At Annual Notice and explanation Complete new Agreement form

FCS Agreement

Use of Medical Insurance

USE OF MEDICAL INSURANCE (check all that apply) Uninsured: My child is not covered by any medical

insurance. I want my service coordinator to help me apply for

Medicaid. I want my service coordinator to help me apply for

Family Access to Medical Insurance Security Plan (FAMIS).

I am already in the process of applying for Medicaid or FAMIS

Health (medical) Insurance: My child is covered by medical insurance. (If selected, check one) My insurance should be billed for covered services. I

agree to pay for any applicable co-payments, co-insurance, deductibles and/or non-covered services in the manner indicated in the CHARGES option below.

My insurance should NOT be billed for covered charges. I agree to pay for services in the manner indicated in the CHARGES option below.

Medicaid/FAMIS: My child is covered by Medicaid or FAMIS and I understand Medicaid/FAMIS will be billed for covered services.

FCS Agreement

Checking Medicaid

Charges

CHECKING FOR MEDICAID COVERAGE (If your child is not currently covered by Medicaid/FAMIS, check one) I give permission for my local early intervention system to routinely

check to see if my child is covered by Medicaid or FAMIS. I do not give permission for my local early intervention system to

routinely check to see if my child is covered by Medicaid or FAMIS

CHARGES (check one) Full Charge: I do not wish to provide financial information. I will pay all

applicable co-payments, co-insurance, deductibles, and/or the full early intervention reimbursement rate for services not covered by insurance.

Discounted Fees (If selected, check one) Monthly Cap: Documentation of my actual or estimated federal taxable

income has been viewed. This determines the amount I will pay. I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Fee Appeal (If selected, check one):__The amount of the monthly cap as calculated on the family cost share fee

scale is a financial hardship. My monthly cap is based on the additional financial information that is attached, OR

__I am unable to document either my actual or estimated taxable income. Attached is a copy of my pay stub or my written statement certifying my income amount, as well as any additional financial information required.

I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Medicaid/FAMIS/No Income: My child is eligible for Medicaid/FAMIS and/or I have no income at this time. Therefore I have an inability to pay, and will receive all of my child’s early intervention services at no cost to my family. (If selected, check one) Copy of my Medicaid/FAMIS card is attached OR __ eligibility verified on

____________ by _______________________ . My written statement certifying that I have no income is attached.

Monthly Cap

Sliding Fee Scale

FCS Agreement

Flexible Spending Account

Statements of Agreement

These sections are completed the same way for all families

Flexible spending account section explains requirements. Must check the box for all families.

Medicaid/FAMIS

Scenario:

Child covered by Medicaid

Income $30,000

Family Size: 3

Reminders for Use of Medicaid

Consent requirements Does not have Medicaid yet Release of information for billing

No cost protectionsMust provide written notice to parents

Checklist

Intake: Complete Family Cost Share Agreement Consent to release personally identifiable information

for billing Medicaid number in ITOTS

Service Delivery Confirm Medicaid coverage at least monthly

FCS Agreement

Use of Medical Insurance

USE OF MEDICAL INSURANCE (check all that apply) Uninsured: My child is not covered by any medical

insurance. I want my service coordinator to help me apply for

Medicaid. I want my service coordinator to help me apply for

Family Access to Medical Insurance Security Plan (FAMIS).

I am already in the process of applying for Medicaid or FAMIS

Health (medical) Insurance: My child is covered by medical insurance. (If selected, check one) My insurance should be billed for covered services. I

agree to pay for any applicable co-payments, co-insurance, deductibles and/or non-covered services in the manner indicated in the CHARGES option below.

My insurance should NOT be billed for covered charges. I agree to pay for services in the manner indicated in the CHARGES option below.

Medicaid/FAMIS: My child is covered by Medicaid or FAMIS and I understand Medicaid/FAMIS will be billed for covered services.

FCS Agreement

Checking Medicaid

Charges

CHECKING FOR MEDICAID COVERAGE (If your child is not currently covered by Medicaid/FAMIS, check one) I give permission for my local early intervention system to routinely

check to see if my child is covered by Medicaid or FAMIS. I do not give permission for my local early intervention system to

routinely check to see if my child is covered by Medicaid or FAMIS

CHARGES (check one) Full Charge: I do not wish to provide financial information. I will pay all

applicable co-payments, co-insurance, deductibles, and/or the full early intervention reimbursement rate for services not covered by insurance.

Discounted Fees (If selected, check one) Monthly Cap: Documentation of my actual or estimated federal taxable

income has been viewed. This determines the amount I will pay. I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Fee Appeal (If selected, check one):__The amount of the monthly cap as calculated on the family cost share fee

scale is a financial hardship. My monthly cap is based on the additional financial information that is attached, OR

__I am unable to document either my actual or estimated taxable income. Attached is a copy of my pay stub or my written statement certifying my income amount, as well as any additional financial information required.

I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Medicaid/FAMIS/No Income: My child is eligible for Medicaid/FAMIS and/or I have no income at this time. Therefore I have an inability to pay, and will receive all of my child’s early intervention services at no cost to my family. (If selected, check one) Copy of my Medicaid/FAMIS card is attached OR __ eligibility verified on

____________ by _______________________ . My written statement certifying that I have no income is attached.

FCS Agreement

Information Release

Private Insurance

Scenario:

Agree to use private insurance

Income: $90,000

Family Size: 6

Flexible spending account that auto-pays provider: $500

Reminders for Use of Private Insurance

Written consent requiredMust provide copy of family cost share

policies when seeking consentMust identify potential costs for use of

private insurance

Checklist

Intake/Prior to IFSP Explain potential costs of using insurance

IFSP Review New consent if services are increasing

Service Delivery Confirm at least monthly whether insurance has

changed

FCS Agreement

Use of Medical Insurance

USE OF MEDICAL INSURANCE (check all that apply) Uninsured: My child is not covered by any medical

insurance. I want my service coordinator to help me apply for

Medicaid. I want my service coordinator to help me apply for

Family Access to Medical Insurance Security Plan (FAMIS).

I am already in the process of applying for Medicaid or FAMIS

Health (medical) Insurance: My child is covered by medical insurance. (If selected, check one) My insurance should be billed for covered services. I

agree to pay for any applicable co-payments, co-insurance, deductibles and/or non-covered services in the manner indicated in the CHARGES option below.

My insurance should NOT be billed for covered charges. I agree to pay for services in the manner indicated in the CHARGES option below.

Medicaid/FAMIS: My child is covered by Medicaid or FAMIS and I understand Medicaid/FAMIS will be billed for covered services.

FCS Agreement

Checking Medicaid

Charges

CHECKING FOR MEDICAID COVERAGE (If your child is not currently covered by Medicaid/FAMIS, check one) I give permission for my local early intervention system to routinely

check to see if my child is covered by Medicaid or FAMIS. I do not give permission for my local early intervention system to

routinely check to see if my child is covered by Medicaid or FAMIS

CHARGES (check one) Full Charge: I do not wish to provide financial information. I will pay all

applicable co-payments, co-insurance, deductibles, and/or the full early intervention reimbursement rate for services not covered by insurance.

Discounted Fees (If selected, check one) Monthly Cap: Documentation of my actual or estimated federal taxable

income has been viewed. This determines the amount I will pay. I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Fee Appeal (If selected, check one):__The amount of the monthly cap as calculated on the family cost share fee

scale is a financial hardship. My monthly cap is based on the additional financial information that is attached, OR

__I am unable to document either my actual or estimated taxable income. Attached is a copy of my pay stub or my written statement certifying my income amount, as well as any additional financial information required.

I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Medicaid/FAMIS/No Income: My child is eligible for Medicaid/FAMIS and/or I have no income at this time. Therefore I have an inability to pay, and will receive all of my child’s early intervention services at no cost to my family. (If selected, check one) Copy of my Medicaid/FAMIS card is attached OR __ eligibility verified on

____________ by _______________________ . My written statement certifying that I have no income is attached.

Monthly Cap

Sliding Fee Scale

FCS Agreement

Flexible Spending Account

Explain carefully.Family will need to pay full

amount of co-pays and deductibles until the $500 is gone.

IFSP Review

Preparing for IFSP Review

Review current Agreement ahead of meetingDiscuss options ahead of meeting, if

appropriateBring copy of current AgreementBring a blank Agreement form

Private Insurance and Medicaid

Private Insurance

Medicaid

Income $50,000

Family Size: 5

No flexible spending account

Checklist

Intake Explain both Medicaid and private insurance

information Complete Family Cost Share Agreement

IFSP Review New consent if services increasing

Service Delivery Confirm Medicaid and private insurance coverage at

least monthly

FCS Agreement

Use of Medical Insurance

USE OF MEDICAL INSURANCE (check all that apply) Uninsured: My child is not covered by any medical

insurance. I want my service coordinator to help me apply for

Medicaid. I want my service coordinator to help me apply for

Family Access to Medical Insurance Security Plan (FAMIS).

I am already in the process of applying for Medicaid or FAMIS

Health (medical) Insurance: My child is covered by medical insurance. (If selected, check one) My insurance should be billed for covered services. I

agree to pay for any applicable co-payments, co-insurance, deductibles and/or non-covered services in the manner indicated in the CHARGES option below.

My insurance should NOT be billed for covered charges. I agree to pay for services in the manner indicated in the CHARGES option below.

Medicaid/FAMIS: My child is covered by Medicaid or FAMIS and I understand Medicaid/FAMIS will be billed for covered services.

FCS Agreement

Checking Medicaid

Charges

CHECKING FOR MEDICAID COVERAGE (If your child is not currently covered by Medicaid/FAMIS, check one) I give permission for my local early intervention system to routinely

check to see if my child is covered by Medicaid or FAMIS. I do not give permission for my local early intervention system to

routinely check to see if my child is covered by Medicaid or FAMIS

CHARGES (check one) Full Charge: I do not wish to provide financial information. I will pay all

applicable co-payments, co-insurance, deductibles, and/or the full early intervention reimbursement rate for services not covered by insurance.

Discounted Fees (If selected, check one) Monthly Cap: Documentation of my actual or estimated federal taxable

income has been viewed. This determines the amount I will pay. I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Fee Appeal (If selected, check one):__The amount of the monthly cap as calculated on the family cost share fee

scale is a financial hardship. My monthly cap is based on the additional financial information that is attached, OR

__I am unable to document either my actual or estimated taxable income. Attached is a copy of my pay stub or my written statement certifying my income amount, as well as any additional financial information required.

I agree to pay charges up to, but not exceeding, my family’s monthly cap of $_________ .

Medicaid/FAMIS/No Income: My child is eligible for Medicaid/FAMIS and/or I have no income at this time. Therefore I have an inability to pay, and will receive all of my child’s early intervention services at no cost to my family. (If selected, check one) Copy of my Medicaid/FAMIS card is attached OR __ eligibility verified on

____________ by _______________________ . My written statement certifying that I have no income is attached.

Temporary Agreement

At initial or annualIf family unable to provide financial

information and complete Family Cost Share Agreement prior to IFSP meeting

Part C funds may be used to ensure timely start of services

Temporary Agreement Form- Section A

Temporary Agreement Form – Section B

Flow Chart

Resources

www.eipd.vcu.edu Local Systems Oversight and Management Tools of the Trade

www.infantva.org Coming soon – Fiscal Section Strengthening Partnerships Notice/Facts About Family Cost Share Practice Manual Forms