INSURANCE TOOL KIT
For Service Coordinators
1. Initial Service Coordinator Insurance Responsibilities
2. Ongoing Service Coordinator Insurance Responsibilities
3. Guidance Regarding Written Referral
4. Written Referral from Primary Care Practitioner Form
5. Authorization to Release Health Insurance Information Form
6. Request for Coverage Information Form
7. Collection of Insurance Information Form
8. Parent Letter Regarding Regulated Insurance
9. Parent Letter Regarding Non-regulated Insurance
10. Consent to Bill Non-regulated Insurance
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
Initial Service Coordinator Insurance Responsibilities
1) Discuss with the family the requirements in New York State Public Health and Insurance Law:
a. Under New York State Public Health Law (PHL), Early Intervention Program (EIP) services must be provided at no cost to parents [Section 2557 of PHL, 10 NYCRR Section 69-4.1(l)(iv)(d)].
b. Commercial Insurance and Medicaid are part of New York State’s system of payments for early intervention services. These third party payors are important resources for the EIP (Section 2559 of PHL).
c. Insurance will only be accessed for reimbursement of early intervention services if the family’s policy is subject to New York State law, or with parental consent, if the policy is not subject to New York State law.
i. EIP providers are required to first bill commercial insurance and Medicaid (including responsibility for subrogation notice).
ii. The service coordinator is responsible for informing the provider about the child’s insurance coverage. (For children in NYEIS, the provider will have access to the child’s insurance information.)
iii. Providers will receive payment from municipal funds for services that are partially reimbursed or denied by the insurer.
iv. The Medicaid Program covers all EIP services at payment rates established by the State.
v. Providers are prohibited from seeking payment for early intervention services from the parent.
d. EIP services, including service coordination and evaluations, and if the child is found eligible for the EIP, services included in the child’s IFSP, must be provided if the parent declines to provide insurance information or if the child is uninsured.
i. If a child is uninsured, the service coordinator is responsible for assisting the parent in identifying and applying for benefit programs for which the family may be eligible, including Medicaid, Child Health Plus, and Social Security Disability Income, however, the parent is not required to enroll in order for EIP services to be provided.
e. Protections for use of regulated insurance:
i. Parents do not pay any out-of-pocket costs, such as deductibles or co-payments for early intervention services
ii. Insurers are prohibited from charging any benefits paid for early intervention services against any maximum annual or lifetime policy limits ("caps")
iii. Early Intervention visits reimbursed by the insurer cannot reduce the number of visits otherwise available to the child and family for health care
iv. Insurers cannot discontinue or fail to renew a family’s insurance coverage solely because a child is receiving EIP services
v. Insurers cannot increase health insurance premiums solely because a child is receiving EIP services
vi. If a family’s insurance plan is not regulated by New York State, the plan will not be billed unless the parent gives informed written consent
f. Voluntary use of non-regulated insurance: If a family’s insurance is not regulated by New York State, their insurance benefits may not be protected as set forth above in (e) if billed for EIP services. In this case the insurance can only be used if the family is fully informed and chooses to give written consent (see 3c below).
2) Collect insurance policy information from family using the form, Collection of Insurance Information (10NYCRR 69-4.6(d))
a. For children whose records reside in the KIDS legacy data system, submit the form to the municipality for documentation of insurance information in KIDS
b. For children whose records reside in NYEIS, enter the child’s and family’s insurance information, including Medicaid and Child Health Plus policy information, directly into NYEIS
c. Explain to the parent that he or she should let their ongoing service coordinator know if there are any changes in the family’s insurance policy, including Medicaid and Child Health Plus
3) Provide written information to all parents on insurance protections
a. Assess if the family’s insurance plan is regulated by New York State Insurance Law
i. Plans administered by companies located outside of New York State or by third party administrators are often not regulated. Visit the Department of Financial Services website for assistance: http://www.dfs.ny.gov/insurance/tocol4.htm (select Insurance Company Search to find the company by name or search through a listing of companies)
ii. Self-insurance/self-funded plans are not regulated
iii. Contact the municipality for assistance in identifying which plans are regulated
b. If the parent’s insurance is regulated by New York State, give parent the Parent Letter Regarding Regulated Insurance
c. If the parent’s insurance is NOT regulated by New York State, complete the following (be aware the family’s insurance can only be accessed for payment of EIP services if the parent chooses to provide voluntary consent for this use):
i. Give the Parent Letter Regarding Non-regulated Insurance
ii. Ensure that the parent understands the information in this letter
iii. Complete with the parent the form Consent to Bill Non-regulated Insurance
iv. If the parent consents to use unregulated insurance for payment of EIP services, explain that this consent will need to be re-signed at every IFSP meeting
4) Initiate the process to obtain information from the insurer on the extent of benefits available to the child under the child’s/family’s insurance policy (Section 3235-a of insurance law)
a. Obtain parental consent on the form Authorization to Release Health Insurance Information
b. Complete the form Request for Coverage Information (provide the address of the municipality where indicated on the form)
c. Send both forms together to the insurer
i. The insurer is required to return information on the extent of benefits available to the child within fifteen days of the insurer’s receipt of the written request for coverage information and the notice authorizing the release of this information to the service coordinator and the municipality.
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF EARLY INTERVENTION
Ongoing Service Coordinator Insurance Responsibilities
1) Review with the family the requirements in New York State Public Health and Insurance Law as needed:
a. Under New York State Public Health Law (PHL), Early Intervention Program (EIP) services must be provided at no cost to parents [Section 2557 of PHL, 10 NYCRR Section 69-4.1(l)(iv)(d)].
b. Commercial Insurance and Medicaid are part of New York State’s system of payments for early intervention services. These third party payors are important resources for the EIP (Section 2559 of PHL).
c. Insurance will only be accessed for reimbursement of early intervention services if the family’s policy is subject to New York State law, or with parental consent, if the policy is not subject to New York State law.
i. EIP providers are required to first bill commercial insurance and Medicaid (including responsibility for subrogation notice).
ii. The service coordinator is responsible for informing the provider about the child’s insurance coverage. (For children in NYEIS, the provider will have access to the child’s insurance information.)
iii. Providers will receive payment from municipal funds for services that are partially reimbursed or denied by the insurer.
iv. The Medicaid Program covers all EIP services at payment rates established by the State.
v. Providers are prohibited from seeking payment for early intervention services from the parent.
d. Early Intervention Program services, including service coordination and evaluations, and if the child is found eligible for the EIP, services included in the child’s IFSP, must be provided if the parent declines to provide insurance information or if the child is uninsured.
i. If a child is uninsured, the service coordinator is responsible for assisting the parent in identifying and applying for benefit programs for which the family may be eligible, including Medicaid, Child Health Plus, and Social Security Disability Income, however, the parent is not required to enroll in order for EIP services to be provided.
e. Protections for use of regulated insurance:
i. Parents do not pay any out-of-pocket costs, such as deductibles or co-payments for early intervention services
ii. Insurers are prohibited from charging any benefits paid for early intervention services against any maximum annual or lifetime policy limits ("caps")
iii. Early Intervention visits reimbursed by the insurer cannot reduce the number of visits otherwise available to the child and family for health care
iv. Insurers cannot discontinue or fail to renew a family’s insurance coverage solely because a child is receiving EIP services
v. Insurers cannot increase health insurance premiums solely because a child is receiving EIP services
vi. If a family’s insurance plan is not regulated by New York State, the plan will not be billed unless the parent gives informed written consent
f. Voluntary use of nonregulated insurance: If a family’s insurance is not regulated by New York State, their insurance benefits may not be protected as above (e) if billed for EIP services. In this case the insurance can only be used if the family is fully informed and chooses to give written consent (see 3c below).
2) Update insurance information from family using the form, Collection of Insurance Information (10NYCRR 69-4.6(d))
a. Ask the family if there are any changes in their insurance status or coverage at every 6-month IFSP review/meeting or more frequently if needed
b. For children whose records reside in the KIDS legacy data system, submit the form to the municipality for documentation of insurance information in KIDS
c. For children whose records reside in NYEIS, enter the child’s and family’s insurance information, including Medicaid and Child Health Plus policy information, directly into NYEIS
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