Navigating Ohio’s System of Payments Welcome to Ohio’s System of Payments for Early Intervention. We have revised the System of Payments rule, or SOP rule, in an effort to simplify and streamline processes related to the funding of EI services. The SOP rule is also designed to help resolve issues of inequity statewide. Today’s training will highlight the changes to the rule and provide guidance on what Service Coordinators need to know to assist families with the funding aspect of EI. POLR@dodd.ohio.gov

O b j e c t i v s Understand how Early Intervention services are funded in Ohio Become familiar with terms used in Ohio’s System of Payments Know what services are provided at no cost to families Understand the System of Payments rule This training is designed to explain the System of Payments rule so you feel confident helping families understand and access funding for EI services. Our objectives for this training are listed above. We’ll start by providing some background, including an introduction to new terms and an overview of the SOP process. We will look at new forms developed to help Service Coordinators as they assist families with funding. We will then walk through the process step-by-step, focusing on the activities the SC will coordinate at each step. Let’s start with some background. Understand the System of Payments process and the Service Coordinator’s role

Mandated Responsibilities of Service Coordination under IDEA, Part C § 303.34 (b)(9) Coordinating funding is one of the ten federally-mandated responsibilities of the Service Coordinator. The Service Coordinator explains the System of Payments process to the family, helps them access services and helps guide them through the process of accessing funding for the services. (9) Coordinating the funding sources for services required under this part

IFSP process not changing Helpful new forms and brochure for families SOP conversation flows from other conversations While the new Rule represents some significant changes, there are some positive elements that we wanted to point out right from the start. For one, the IFSP process is not changing. Teams will still follow the same process to determine eligibility and need for services and to identify outcomes. Teams will determine the services needed to meet the outcomes prior to determining how services will be funded. Another positive change is the introduction of new forms. They are simple and easy to use and will provide the Service Coordinator with helpful information to guide the process. We will look at the forms later in this training. Finally it is expected that the funding conversation will flow naturally from conversations the SC is already having with families, such as creating an Ecomap to talk about resources and supports.

System of Payments Process IFSP Process System of Payments Process Answers the question Answers the question While the IFSP process and the SOP process intersect at certain points, they are two separate processes. The IFSP process answers the question of which services are needed. The SOP process answers the question, how will those services be funded? As we are going through this training, think about what you are doing now in your IFSP process and how and where the SOP process with intersect. Which service(s) are needed to meet the outcome(s)? How will needed services be funded?

What is the “IFSP Year?” A. One of the Chinese zodiac signs 5123: 2-10-01 (B) (11) A. One of the Chinese zodiac signs B. A system for organizing your calendar C. The first year the IFSP was used in Early Intervention D. None of the above START Now let’s move on to definitions of some new terms related to the SOP. Many of the definitions in the rule have not changed and will be familiar to you. However, there are some new terms, and we want to highlight the ones that may be the most unfamiliar . The IFSP year refers to the period, not to extend beyond the child’s third birthday, beginning on the day signatures are secured on an initial or annual IFSP and ending on the day immediately prior to the day signatures are secured on a subsequent annual IFSP. END The period, not to extend beyond the child’s 3rd birthday, beginning on the day signatures are secured on an initial or annual IFSP and ending the day immediately prior to the day signatures are secured on a subsequent annual IFSP. 5123:2-10-01 (B) (11)

What is a “unit?” 5123:2-10-01 (B) (17) Another new term is “unit” of service. A unit refers to either: Sixty (60) minutes of early intervention services OR One hundred dollars ($100) expended for an assistive technology device. A unit of service may consist of multiple sessions (e.g., two 30-minute sessions constitute one 60-minute unit). Sixty minutes of early intervention services One hundred dollars expended for an assistive technology device OR

for any member of the family residing in the home with the child What are Extraordinary Medical Expenses? 5123:2-10-01 (B) (8) Hospital Stays Physician Visits Dental Care for any member of the family residing in the home with the child Vision Care Prescribed medications, supplies, therapies The last new term is Extraordinary Medical Expenses (or EMEs). EMEs are non-reimbursable costs paid during the IFSP year by the FAMILY of the eligible child for medical and related care. This can include, but is not limited to hospital stays, physician visits, dental care, vision care, prescribed medications/supplies/therapies, health insurance premiums/copayments/deductibles, and modifications to the child’s home to make the home accessible (for the child and/or any member of the family residing in the home with the eligible child). These expenses are calculated from the date of the IFSP signature to the end of the IFSP year. They reset at the beginning of each annual IFSP. There are other definitions, many of which you probably already know, located in Section B of the SOP rule. Now that we’ve explained these new terms, let’s talk about some key components of the rule. Health insurance premiums, co-pays, deductibles Modifications to make home accessible

5123:2-10-01 (C) (1) Which services are provided at no cost to eligible children and their families? Child Find Evaluation and Assessment Service Coordination Activities related to IFSP Development Implementation of Procedural Safeguards Fifty-five (55) Units of Services Again, keep in mind that the IFSP process has not changed. Funding decisions would not occur until after the child is found eligible and in need of services, and the team has identified outcomes, services, and strategies. However, in anticipation of participation, some tasks related to funding are now completed “up front” to make the process easier later on. The rule identifies early intervention functions the federal government mandates must be provided at no cost to eligible children and their families. They are Child Find Evaluation and Assessment Service Coordination . Activities related to IFSP development Implementation of procedural safeguards Ohio has added an additional element: An eligible child and the child’s family may receive up to as many as 55 units of early intervention services at public expense per IFSP year, identified as needed on the IFSP, regardless of their income. Fifty-five units, however, is not a limit on the frequency and intensity of services on a family’s IFSP. The number of units a family receives is determined by the team’s decisions about what the family needs to meet IFSP outcomes. The 55 units are what is available to all families, regardless of income, at public expense. [See also slide #5] We will talk more about this when we walk through the System of Payments process. NEW!

Parent Cost Participation (after first 55 units) Which funding sources need to be examined? Parent Cost Participation (after first 55 units) County Boards The Department (DODD) Private Insurance Public Insurance A number of funding sources may be involved depending on a family’s income and ability to pay. These can include the following: County Boards Private Insurance Public Insurance Parent Cost Participation, and The Department (DODD/POLR) 5123:2-10-01 C (2)

When is inability to pay determined? Initially (within the first 45 calendar days), and Within 45 calendar days of each annual IFSP review The Service Coordinator will: Explain the SOP rule, Provide a copy of the SOP brochure, Determine inability to pay for EI services. Because in some cases the team may identify the need for more than 55 units in an IFSP year, SCs will determine parent ability to pay prior to the development of the IFSP. However, as mentioned earlier, the IFSP process has not changed. Funding does NOT determine the frequency and intensity of services on an IFSP. The team will still develop outcomes based on child and family assessment and other information and then identify services and strategies. Only at that point will funding be fully addressed. We start with the assumption that ALL families have the ability to pay for their early intervention services. Therefore, the SC will determine if the family has an inability to pay. In addition to other responsibilities during the 45-day timeline, the SC will: Explain the SOP rule to the family, Provide a copy of the SOP Parent Brochure, and Determine if the parent has an inability to pay for EI services. We developed a new form (EI 1701) that will make it easy for SCs to make this determination; we will look at the form later in the training. All of the forms are located in the Forms Tile of the Provider Section of the EI website. Counties will determine when this conversation will happen with families, recognizing that this can be a sensitive topic for many families. The SC will also re-determine the family’s inability to pay within 45 days of each scheduled annual IFSP review. This is at minimum; inability to pay may be redetermined anytime a parent requests. 5123:2-10-01 (D)

How are parents determined to be unable to pay for their EI services? Determined by SC WIC Determined by SC Medicaid Income less than or equal to threshold for Ohio Children’s insurance Program (CHIP) (206% Federal Poverty Level) Determined by SC There are three easy ways to determine that a parent is unable to pay for EI services: The parent is receiving services from WIC The parent or child is receiving Medicaid benefits The family income is less than or equal to that required for children without insurance for Ohio’s Children’s Health Insurance Program eligibility (CHIP) – 206% of the Federal Poverty Level (FPL) When the family has EMEs, this requires a different level of review. In this situation, DODD makes the determination of whether the EMEs result in a determination that the parent is unable to pay. This would be decided after the first IFSP. Determined by DODD EMEs (after first IFSP)

What happens if a parent chooses not to share financial information? 5123: 2-10-01 (D) (3) What happens if a parent chooses not to share financial information? If a parent does not wish to disclose financial information requested by the Service Coordinator, they will be determined able to pay and will be responsible for payment for EI services over 55 units. If a parent chooses not to disclose financial information requested by the Service Coordinator, that is ok. However, that parent will be determined able to pay and the parent will be responsible for payment for their early intervention services that exceed 55 units because they have not provided information to show that they have met one of the ways to be determined unable to pay.

Who pays for the first 55 units of services? County Board? OR Private insurance (when DODD pays co-pays and deductibles)? Public Insurance? The Department (POLR) If none available or denied Part of a SC’s job is to be knowledgeable about which funding sources are available locally. When the first 55 units of services are not available or are denied by the funding sources previously discussed (county board, private insurance, public insurance), the Department will pay qualified personnel to provide the services identified on the IFSP regardless of the family’s ability to pay. When a parent consents to using the parent’s private insurance to pay for EI services AND DODD pays the parent’s co-pays and deductibles, those services are considered to be provided at public expenses and count toward the first 55 units. Providers of EI services other than the county board must enter into a contractual relationship with the Department before using DODD funds to pay for EI services on the IFSP. 5123: 2-10-01 (C)

What if more than 55 units are needed? Parent able to pay Parent unable to pay Parent pays for services POLR (or other public source) pays for services When more than 55 units of EI services in the IFSP year are identified as needed: A parent identified as able to pay will be responsible for paying the cost of early intervention services (other than service coordination). A parent identified as unable to pay will continue to receive early intervention services at public expense. Any public source could pay – Medicaid; County Boards of Developmental Disabilities; or, when DODD pays the co-pays and deductibles, private insurance. 5123:2-10-01 (C)(4)

Using Private Insurance Service Coordinator must: Explain rule Provide System of Payments brochure Obtain consent (form 1701) initially and with any increase in services Prior to using the parent or child’s private insurance, the Service Coordinator must explain the System of Payments rule and provide a copy of the brochure, “Ohio’s Early Intervention System of Payments.” The SC must obtain parental consent prior to the use of the private insurance of a child or parent to pay for early intervention services initially and with any increase in the amount, duration, or scope of early intervention services With every IFSP, the SC must obtain consent. Consent is documented on form 1701. 5123: 2-10-01 (F)

Using Private Insurance The EI System will: Pay co-payments and deductibles for the first 55 units of EI services per IFSP year (DODD) NOT pay insurance premiums( DODD) Inform the parent of potential costs (SC) If the parent provides consent, the EI System will: Pay the cost of copayments and deductibles for the first 55 units of EI services per IFSP year for parents who are able to pay. For parents unable to pay, DODD will pay the co-pays and deductibles beyond 55 units. Not pay the cost of insurance premiums, (DODD) Inform the parent of potential costs (e.g., co-payments, deductibles, premiums, or long-term costs such as the loss of benefits because of annual or lifetime health insurance coverage caps of the insurance policy) that the parent may incur when the private insurance of a child is used to pay for early intervention services. (SC) We do not expect the service coordinator to know every potential cost for every insurance plan. But we do expect service coordinators to coach and help parents identify the questions to ask of their health insurance company, the people to ask in order to get the information to make an informed decision.

Using Public Insurance The Service Coordinator will: Obtain initial, one-time consent for disclosure of PII Make available the EI services for which the parent has given consent Provide written notification to the parent prior to using public insurance via the System of Payments brochure When using public insurance (Medicaid), the Service Coordinator will: Obtain a one-time, parental consent for disclosure of the child’s personally identifiable information to the public insurance program (Medicaid) for billing purposes , Make available the EI services on the IFSP to which the parent has provided consent, and Provide written notification to the parent prior to using the public insurance of the child or parent to pay for EI services. Written notification is providing the parent the SOP parent Brochure and documenting in your case notes. 5123:2-10-01 (G)

Using Public Insurance The EI System will: Share information about public insurance programs Not require a child/parent to enroll in public insurance program in order to receive services Not enroll the child/parent in public insurance programs The EI system will: Not enroll a child/parent in public insurance programs or require a child or parent to enroll in public insurance programs as a condition of receiving EI services, but MAY share information about the enrollment process for such programs.

Procedural Safeguards Mediation State Complaint Procedures Due Process Hearing A parent contesting the determination of ability to pay or imposition of parent cost participation is afforded the procedural safeguards set forth in Part C. This includes: State Complaint Procedures, Mediation, Due Process Hearing Procedures EI services may not be delayed or denied to an eligible child of a parent determined unable to pay. EI services may not be delayed or denied to an eligible child due to lack of: Parent consent to use the private insurance of the child/parent to pay for EI services The child’s or parent’s enrollment in public insurance programs, OR Parental consent to share the child’s personally identifiable information with public insurance programs Parents may be notified of the procedural safeguards of the SOP rule at the time of determination of ability to pay and prior to finalization and securing of signatures on the IFSP. The SC must explain and provide the Ohio Early Intervention System of Payments brochure. 5123:2-10-01 (H)

Services identified to meet outcomes System of Payments Process SC Collects financial information and determines if parent is unable to pay Screening, Evaluation, Assessment IFSP Completed Services identified to meet outcomes If services not provided by CBDD, SC helps parent make POLR application SC monitors units; when 55 units almost exhausted, facilitates IFSP review and re-determines if parent is unable to pay Here is a recap of the System of Payment process and how it fits into the IFSP process. The process begins early in a family’s EI journey. The SC explains the SOP rule, provides a copy of the SOP Parent brochure, gathers financial information and determines if the parent is unable to pay. At the same time, the SC is facilitating other activities required in the 45 day timeline: evaluation, assessment, and the initial IFSP meeting, where the team develops outcomes and identifies services needed to meet the outcomes. Once services are identified, SCs must coordinate funding for the services. In general, the provider will provide the “funding source” information. As the IFSP is implemented over the IFSP year, the SC monitors the number of units. While 55 or fewer units will be needed to meet the needs of most families, some may need more than 55. The IFSP meetings are the venues for identifying payment source, including parent payment for those parents determined able to pay when more than 55 units are needed d in an IFSP year. As the family approaches the depletion of their 55 units, the SC conducts an IFSP review and re-determines ability to pay., with consideration of EMEs At this point, the process may revert back to the need for a POLR application. For families with an anticipated need of more than the 55 units in the IFSP year, the SC should be sure to help the family with their Extra Ordinary Medical Expenses (EME). We will address this in more detail later in the training. POLR application as needed 45 Days

IFSP and SOP processes intersect IFSP and SOP processes intersect System of Payments Process IFSP and SOP processes intersect If services not provided by CBDD, SC helps parent make POLR application SC monitors units; when 55 units almost exhausted, facilitates IFSP review and re-determines if parent is unable to pay SC Collects financial information and determines if parent is unable to pay Screening, Evaluation, Assessment IFSP Completed Services identified to meet outcomes The IFSP process and the SOP process intersect at certain points. One example is during the identification of needed services to meet outcomes, decisions must be made about funding to provide the identified services. Later in the process, as services are being delivered, the SC is monitoring the services to determine if the 55 units are close to being used. If the family is getting close to using all 55 units, the SC then must follow the SOP process to determine the next steps. Remember: The 55 units are not a limit on the frequency and intensity a family can receive on their IFSP. Instead, the 55 units are a limit on how many units of service must be provided at no cost to the parents that have an ability to pay. In addition, remember that parents with an inability to pay will receive all of their early intervention services at no cost. IFSP and SOP processes intersect POLR application as needed

What happens if a family is re-referred OR transfers from another county? These situations do not “re-set” the 55 units available at no cost to the family. If the family leaves EI and then re-enters or moves to a different county within the IFSP year, the units they have already used will count towards the 55 units in the course of the IFSP year.

Ability to Pay Determination Form (EI 1701) This is the first page of EI 1701: Documentation to Determine Parents Are Unable to Pay for Early Intervention Services. The Healthy Start Eligibility for Uninsured children is located at the bottom of the second page. There are three ways to determine whether a parent is unable to pay using EI 1701. You only need to document one of the three ways to document the parent’s inability to pay. The service coordinator does not need to make a copy of the documentation. The SC will sign EI 1701 verifying that the SC has seen the documentation. If the parent does not have a Medicaid card or WIC card, then the service coordinator will move on to the income verification using the parent’s pay information. The family will decide what constitutes their family. The Service Coordinator will get income verification from every working adult who has been identified as part of the family unit. The gross amount will be multiplied by how the adult is paid to get the yearly gross income. All incomes will be added together to get the total gross annual income for the family. The service coordinator will take the family size and the total annual income and look at the Healthy Start Eligibility for Uninsured children that is located at the bottom of page 2. If the income is equal to or less than the amount for the family size, the parent has an inability to pay. If the income is greater than the amount for the family size, the parent is able to pay for their early intervention services after the initial 55 units. The service coordinator will mark what was used to determine the parent’s inability to pay. The parent and the service coordinator will both sign the form.

Ability to Pay Determination Form (EI 1701) This is the back of EI 1701:: Documentation to Determine Parents Are Unable to Pay for Early Intervention Services. This is where a parent can consent to using his/her private insurance or consent to sharing the parent’s PII with Medicaid. Private Insurance: Remember: Prior to using the parent or child’s private insurance, the Service Coordinator must explain the System of Payments rule and provide a copy of the brochure, “Ohio’s Early Intervention System of Payments.” The SC will obtain parental consent prior to the use of the private insurance of a child or parent to pay for early intervention services initially and with any increase in the amount, duration, or scope of early intervention services. With every IFSP, the SC must obtain consent. If the parent wishes to have private insurance billed for early intervention services, the service coordinator will mark yes and complete the insurance information. The parent will sign and date the form. If the parent wishes not to use their private insurance, the service coordinator will check no and the parent will sign. If the parent does not consent to using private insurance, the SC will not document the insurance information.

Ability to Pay Determination Form (EI 1701) Public Insurance: Remember: When using public insurance (Medicaid), the Service Coordinator will: Obtain a one-time, parental consent for disclosure of the child’s personally identifiable information to the public insurance program (Medicaid) for billing purposes, Make available the EI services on the IFSP to which the parent has provided consent, and Provide written notification to the parent prior to using the public insurance of the child or parent to pay for EI services. Written notification is providing the parent the SOP parent Brochure and documenting in your case notes. If the parent consents to share his/her personally identifiable information (PII) with Ohio Medicaid and have the public insurance billed for early intervention services, the service coordinator will mark yes and complete the insurance information. The parent will sign and date the form. If the parent does not consent to sharing his/her personally identifiable information (PII) with Ohio Medicaid, the service coordinator will check no and the parent will sign. There is no need to document the insurance information. The insurance information does not need to be completed at the same time that the parent is determined unable to pay. It just needs to be completed in the first 45 days after the initial EI program referral and prior to the initial IFSP or 45 days prior to the annual IFSP.

Payment for Early Intervention Services (EI 1702) This is form EI 1702: Payment for Early Intervention Services. This will be submitted along with the IFSP and EI 1701 to the Department to review for approval when the service is not provided by a county board. If the county board is providing the family with all of their services, this form will not be completed. It must include the service type, name of the provider, and frequency and intensity of visits. Form EI 1702 will be used for any family that is making a POLR application due to their identified service not being funded by the local county board. All other funding sources for the first 55 units will require this form to be submitted to DODD. After the first 55 units, this form will be submitted for parents that have been determined unable to pay and whose early intervention service is not funded by the county board. EI 1702 will always be submitted to the department with EI 1701 and the most recent IFSP.

EME Worksheet (EI 1703) This form is the EI 1703 Extraordinary Medical Expenses Worksheet. This is the form that the service coordinator will use if the parent has an ability to pay and has services that exceed the first 55 units of publicly funded early intervention services. This form determines the amount of out of pocket non-reimbursable medical expenses that needs to be met before the Department will pay for early intervention services. The top part of this form is similar to EI 1701. For this form, the service coordinator will take the family’s total annual income and find it on the chart on page 2. This chart will give the service coordinator a range of percentages. The service coordinator will find the family income range on page 1 and multiply it by the percent of income to determine the family’s EME amount. For example- A family’s totally annual income is $72,000 for a family of 5. $72,000 is between 241% and 270% Federal Poverty Level which is 5% or .05 of the family income. $72,000 is multiplied by .05 which equals $3,200. This is the amount of out of pocket medical expenses the family needs to meet before being determined unable to pay by the Department.

EME Worksheet (EI 1704) This form is EI 1704 Extraordinary Medical Expense Tracking. This is the form that the family will use to document their non reimbursable medical expenses. Please refer to slide number 8 or 5123:2-10-01 (B) (8) for more information on the EME definition. Parents will need to provide receipts for any medical expense over $100. Please call the POLR line if you have any questions about the EME documentation. This will affect a very small percentage of the families you will be working with. When a family has documented their EME, the service coordinator will submit EI 1701, EI 1702, EI 1703, EI 1704 with receipts and the most recent IFSP to DODD for the determination of the parent’s inability to pay for early intervention services.

Early Intervention Services System of Payments Rule 5123:2-10-01 Section Topic A Purpose B Definitions C Provisions D Determination of a parent’s ability to pay for early intervention services E Parent cost participation F Using the private insurance of a child or parent to pay for early intervention services G Using the public insurance of a child or parent to pay for early intervention services H Procedural safeguards This is a quick reference to the information that can be found in each section of the SOP Rule.

Questions? POLR@dodd.ohio.gov http://ohioearlyintervention.org/ Please refer to the system of payments section on the early intervention website for all of the forms, tools and guidance. If you have any questions, please talk with your supervisor, or contact the Early Intervention Resource Coordinator at 614-728-2155. POLR@dodd.ohio.gov http://ohioearlyintervention.org/

Thank you very much for your time, attention and participation today!