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HomeMy WebLinkAboutEI-104 Payer of Last Resort1 FRANKLIN/FULTON COUNTY MENTAL HEALTH/INTELLECTUAL & DEVELOPMENTAL DISABILITIES/EARLY INTERVENTION 425 Franklin Farm Lane Chambersburg, PA 17202 (717) 264-5387 MH/IDD/EI PROCEDURE STATEMENT PROCEDURE SUBJECT: Payer of Last Resort PROCEDURE NUMBER: EI-104 Effective Date: April 26, 2010 Date Revised: October 23, 2018 References: - Chapter 4426, Early Intervention Services – sections 4226.13 and 4226.14 - Announcement: EI-13 #02 Pennsylvania System of Payment INTRODUCTION: In accordance with ACT 212 and IDEA, Early Intervention services are provided at no cost to families. The Department of Human Services receives money from the State and Federal governments for Early Intervention services (tax dollars, Medical Assistance, Infant, Toddlers, & Families Waiver). This money is in turn allocated to the MH/IDD/EI office which provides local match dollars. The Franklin/Fulton Early Intervention Program utilizes a variety of sources to fund programs for eligible children. The Office of Child Development and Early Learning (OCDEL), the Office of Medical Assistance Programs (OMAP) and Franklin/Fulton Early Intervention Program agree that Early Intervention Services are not usually covered by a Third Party Insurance (TPI). This policy outlines the funding streams and clarifies when one funding stream will be accessed versus another, utilizing MH/IDD/EI funding as the payer of last resort. Services on the Individual Family Support Plan (IFSP) may not be denied or delayed because another public or private funding source, including Medicaid, is unavailable. PROCESS: Service Coordinator (SC) will explain at the initial visit how Early Intervention is funded. SCs will also inquire into insurance coverage for the child in order to identify the appropriate funding stream that may be used should the child be determined eligible for services. SCs will inform families about Medical Assistance and encourage them to apply so as to make available to families potential benefits (e.g. community services). SCs will remind families that services are to be provided at no cost to the family. SCs will review funding sources at IFSP meetings. 2 Service Coordinators assist the family in identifying all potential funding. It is MH/IDD/EI policy to identify and exhaust all other public and private sources of funding. Early Intervention is the payer of last resort. SC discusses all possible sources of funding with the child’s parent and documents those sources in the child’s file. The child’s Individualized Family Service Plan (IFSP) provides written documentation about how each specific EI service is funded. The provider will receive an authorization indicating the type of funding. Parents are not required to enroll in Pennsylvania’s Medical Assistance Program, but the supportive benefits received when doing so will be clearly explained to the family. If a family enrolls in Medical Assistance (MA), the Early Intervention system can bill Medical Assistance for Early Intervention services. Service Coordinators will assist families in this process if requested. Although private insurance is considered a potential funding source for EI services under Chapter 4226.13, Pennsylvania insurance companies do not consider EI services as a covered service under their health insurance policies. For children who are covered by both third party insurance and Medical Assistance, Service Coordinators shall inform families that if the IFSP team determines that a therapy service would best suit their needs, the therapy service will be billed to Medical Assistance with third party denial. The Service Coordinator would have the family sign a form stating they do not wish for their private insurance to be billed and consent for services to be billed to Medical Assistance. Service Coordinators will include in their documentation and all discussions relative to funding, including conversations regarding insurance, Medical Assistance, and Infant, Toddlers, & Families Waiver.