1. KYLA PATTERSON, M.S. CREATING CONNECTIONS TO SHINING STARS CONFERENCE JULY 24, 2013 How to Implement Family Cost Share Practices in Real Family Situations

2. 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

3. 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 available Dispute resolution available

4. For Families

5. No Insurance Scenario: No Insurance Income $60,000 Family size: 4

6. Checklist Intake  Notice and explanation Prior to IFSP Meeting  Further explanation  Complete Agreement form At Annual  Notice and explanation  Complete new Agreement form

7. 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.

8. 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.

9. Monthly Cap

10. Sliding Fee Scale

11. 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.

12. Medicaid/FAMIS Scenario: Child covered by Medicaid Income $30,000 Family Size: 3

13. Reminders for Use of Medicaid Consent requirements  Does not have Medicaid yet  Release of information for billing No cost protections Must provide written notice to parents

14. 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

15. 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.

16. 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.

17. FCS Agreement Information Release

18. Private Insurance Scenario: Agree to use private insurance Income: $90,000 Family Size: 6 Flexible spending account that auto-pays provider: $500

19. Reminders for Use of Private Insurance Written consent required Must provide copy of family cost share policies when seeking consent Must identify potential costs for use of private insurance

20. 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

21. 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.

22. 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.

23. Monthly Cap

24. Sliding Fee Scale

25. FCS Agreement Flexible Spending Account Explain carefully. Family will need to pay full amount of co-pays and deductibles until the $500 is gone.

26. IFSP Review

27. Preparing for IFSP Review Review current Agreement ahead of meeting Discuss options ahead of meeting, if appropriate Bring copy of current Agreement Bring a blank Agreement form

28. Private Insurance and Medicaid Private Insurance Medicaid Income $50,000 Family Size: 5 No flexible spending account

29. 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

30. 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.

31. 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.

32. Temporary Agreement At initial or annual If 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

33. Temporary Agreement Form- Section A

34. Temporary Agreement Form – Section B

35. Flow Chart

36. 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