Questions to OSEP regarding and

Transcription

1 Questins t OSEP regarding and The tpic f Family Cst Participatin (the use f public insurance, private insurance and family fees) has been the subject f discussin and debate ver the years and has been renewed with the publicatin f the 2011 Federal regulatins fr the Part C system. As state budgets have been stressed with the ecnmic dwnturn, and federal funds that are flat r shrinking, the ability f state part C system t utilize all available fiscal resurces is critical. As recgnized in Sec. 631 Findings and Plicies (b) POLICY. It is the plicy f the United States t prvide financial assistance t States (2) t facilitate the crdinatin f payment fr early interventin services frm Federal, State, lcal, and private surces (including public and private insurance cverage). As states implemented their statutry charge, the use f public and private insurance as well as family fees has been a critical cmpnent t their success in funding necessary supprts and services t eligible children and their families. In the recently cmpleted finance survey cnducted by ITCA, 40 states reprted using Medicaid, 29 states reprted using Private Insurance (fee fr service and managed care) and 18 states reprted using family fees t finance their early interventin system. The ttal amunt f revenue generated frm states able t prvide thse data was $934,317,079. If all states were able t reprt the revenue it wuld be ver $1Billin dllars. The breakdwn is as fllws: Of the frty states that reprted the use f Medicaid, 30 states (75%) were able t prvide revenue infrmatin in the amunt f $831,807,445; Of the twenty nine states that reprted the use f private insurance (fee fr service and managed care), furteen states (48%) were able t prvide revenue infrmatin in the amunt f $88,697,701; and Of the eighteen states that reprted the use f family fees, nine states (50%) were able t prvide revenue infrmatin in the amunt f $13,811,933. As demnstrated by these numbers, the interpretatin f the 2011 regulatins has the ptential fr significant negative financial impact n state Part C systems at a time when there are n new state r federal dllars available t replace public and private insurance revenue as well as family fee revenue. September 2012 Page 1

2 On the fllwing pages are questins that have been raised by ur members in relatin t the brad umbrella f family cst participatin cntained in and (a) (1) A State may nt use the public benefits r insurance f a child r parent t pay fr Part C services unless the State prvides written ntificatin, cnsistent with (a)(3), t the child s parents, and the State meets the n cst prtectins identified in paragraph (a)(2) f this sectin. And (a)(2)(ii) with regard t using the public benefits r insurance f a child r parent t pay fr Part C services, the State (ii) Must btain cnsent, cnsistent with and (a)(4), t use a child s r parent s public benefits r insurance t pay fr Part C services if that use.. Des the requirement fr written ntificatin t the child s parents and the requirement fr cnsent t use insurance, if there is a cst, need t be tw separate prcesses r can ne dcument be created that meets bth requirements? Culd the cnsent t bill public insurance when an increase f service is recmmended be cntained n the IFSP change page r must it be a separate dcument? What if the cnsent is btained ver the phne? Des the system still need t get written permissin befre billing? If there is n cst t the parents as a result f accessing public insurance, must cnsent fr release f identifiable infrmatin still be btained: When the lead agency is the same as the Medicaid Agency? When the lead agency is nt the same as the Medicaid Agency? (b)(ii) If a State requires a parent t pay any csts that the parent wuld incur as a result f the State s use f private insurance t pay fr early interventin services (such as c payments, premiums, r deductibles), thse csts must be identified in the State s system f payments plicies under ; therwise, the State may nt charge thse csts t the parent. Must the System f Payment plicy explicitly state that they will nt pay fr a family s premium? This als seems t state that a State may chse whether t pay fr c pays and deductibles that the family may incur. If they chse nt t pay fr them, must specific language related t wh will be respnsible fr c pays and deductibles be included in their system f payment plicy? September 2012 Page 2

3 (b) Use f private insurance t pay fr Part C services. (2) The parental cnsent requirements in paragraph (b)(1) f this sectin d nt apply if the State has enacted a State statute regarding private health insurance cverage fr early interventin services under Part C f the Act, that expressly prvides that (i) The use f private health insurance t pay fr Part C services cannt cunt twards r result in a lss f benefits due t the annual r lifetime health insurance cverage caps fr the infant r tddler with a disability, the parent, r the child s family members wh are cvered under that health insurance plicy; (ii) The use f private health insurance t pay fr Part C services cannt negatively affect the availability f health insurance t the infant r tddler with a disability, the parent, r the child s family members wh are cvered under that health insurance plicy, and health insurance cverage may nt be discntinued fr these individuals due t the use f the health insurance t pay fr services under Part C f the Act; and (iii) The use f private health insurance t pay fr Part C services cannt be the basis fr increasing the health insurance premiums f the infant r tddler with a disability, the parent, r the child s family members cvered under that health insurance plicy. Is it still permissible fr a state t bill cmmercial health insurance that is exempt frm any state insurance mandates and that will affect parents annual and lifetime caps, as lng as parents have signed cnsent? If a family s plicy des nt fall under the state statute, des permissin need t be btained? (b) (3) If a State has enacted a State statute that meets the requirements in paragraph (b)(2) f this sectin, regarding the use f private health insurance cverage t pay fr early interventin services under Part C f the Act, the State may reestablish a new baseline f State and lcal expenditures under (b) in the next Federal fiscal year fllwing the effective date f the statute. Can the baseline be recalculated n an annual basis if the state has the requisite statutry language? If there is statutry authrity t recalculate nce, why can t the baseline be recalculated n an nging basis as lng as the ttal State effrt is maintained? System f payments and fees. (a) General. If a State elects t adpt a system f payments in (b), the State's system f payments plicies must be in writing and specify which functins r services, if any, are subject t the system f payments (including September 2012 Page 3

4 any fees charged t the family as a result f using ne r mre f the family s public insurance r benefits r private insurance), and include. (3) The State s definitin f ability t pay (including its definitin f incme and family expenses, such as extrardinary medical expenses), its definitin f inability t pay, and when and hw the State makes its determinatin f the ability r inability t pay; If the state des nt charge any ut f pcket fr parents why have an ability t pay definitin? Can the state use bth family incme and availability f insurance in calculating ability t pay? (a)(4)(iii)Families will nt be charged any mre than the actual cst f the Part C service (factring in any amunt received frm ther surces fr payment fr that service) Hw des OSEP define actual cst? Des that include all agency/prvider csts t deliver the service? Des that include ttal system csts? If funding t the prvider is nt dne n a fee fr service basis, hw will the prvider break ut an hur f cst per child? (a)(4)(iv) Families with public insurance r benefits r private insurance will nt be charged disprprtinately mre than families wh d nt have public insurance r benefits r private insurance. Can states have a System f Payment plicy that charges a fee t families wh refuse access t their public r private insurance? Can the state bill cmmercial insurance AND parents as lng as the cmbinatin f the tw des nt exceed the state s cst fr ei services (excluding the state s cst fr thse services that must be ffered at n cst t families)? If the state can bill cmmercial insurance and charge a fee t parents as stated abve, can the state impse a higher fee schedule n thse parents wh have cmmercial health insurance but decline access t their insurance? (e) Prcedural Safeguards. (1) Each State system f payments must include written plicies t infrm parents that a parent wh wishes t cntest the impsitin f a fee, r the State s determinatin f the parent s ability t pay, may d ne f the fllwing: (i) Participate in mediatin in accrdance with (ii) Request a due prcess September 2012 Page 4

5 hearing under r , whichever is applicable. (iii) File a State cmplaint under (iv) Use any ther prcedure established by the State fr speedy reslutin f financial claims, prvided that such use des nt delay r deny the parent s prcedural rights under this part, including the right t pursue, in a timely manner, the redress ptins described in paragraphs (e)(3)(i) thrugh (e)(3)(iii) f this sectin. (2) A State must infrm parents f these prcedural safeguard ptins by either (i) Prviding parents with a cpy f the State s system f payments plicies when btaining cnsent fr prvisin f early interventin services under (a)(3); r (ii) Including this infrmatin with the ntice prvided t parents under If a state des nt charge any fees t the family, must they include a descriptin f plicies and prcedures t infrm parents that if they wish t cntest the impsitin f a fee r the State s determinatin f the parent s ability t pay? If a state is required t add that language t their SOP, it really cnfuses parents. The SOP shuld be an easy t understand dcument that explains the state s prcess. If the state des nt charge family fees, them why cnfuse the SOP with all that language? Additinal Fiscal Questins Payr f last resrt. (a) Nnsubstitutin f funds. Except as prvided in paragraph (b) f this sectin, funds under this part may nt be used t satisfy a financial cmmitment fr services that wuld therwise have been paid fr frm anther public r private surce, including any medical prgram administered by the Department f Defense, but fr the enactment f Part C f the Act. Therefre, funds under this part may be used nly fr early interventin services that an infant r tddler with a disability needs but is nt currently entitled t receive r have payment made frm any ther Federal, State, lcal, r private surce (subject t and ). Is it crrect that we have t seek Medicaid whenever pssible and have dcumented that the family either refused r cnsented? D we als have t seek private insurance as well if ur state statute prtects families frm all csts? September 2012 Page 5