Indiana is committed to a family-centered, community based system of early intervention services for eligible infants and toddlers and their families. All relevant funding sources must be utilized to ensure that needed services are provided to all eligible children and their families. The Family and Social Services Administration/Division of Disability and Rehabilitative Services/Bureau of Child Development Services (FSSSA/DDRS/BCDS) has established a Central Reimbursement Office (CRO) to ensure this combination of federal, state and local, public and private funding is maintained and that the correct funding sources are used for each eligible child and family.
A series of detailed rules and regulations at the federal and state level prescribes which funding source is to be used first and/or last. Providers no longer have to determine which eligible children are enrolled in various funding sources. The IFSP document, signed by the Primary Medical Home, is the prior approval document that allows the CRO to obtain the appropriate funding from Children’s Special Health Care Services (CSHCS) and Hoosier Healthwise. By participating in the CRO, early intervention provider agencies ensure that appropriate fiscal controls and procedures in accounting for and dispensing funds are in place. The operation of the CRO ensures that all financial and demographic reporting needs for all relevant federal, state and local funding sources are met. Since all resources used to fund early intervention services are to be tracked by the CRO electronically, the system meets the specific reporting needs that ensure fiscal accountability and the appropriate use of funds.
Families report their income information on the First Steps Enrollment Form, including family size and family income, which is utilized when determining the family’s federal poverty level. The assessment of the co-payment applies to those families exceeding 251% of the federal poverty guidelines. Families at or below 250% of the federal poverty level are exempt from co-payment. Families that meet this “inability to pay” are not charged for any IFSP services provided to the child and family.
The Division of Disability and Rehabilitative Services has established procedures to implement the First Steps early intervention system cost participation plan (see Cost Participation Manual). The Service Coordinator is responsible for the implementation of the Individualized Family Service Plan (IFSP) and verification of family income and insurance. The family must submit documentation of income and insurance (this does not apply to children who are wards of the state and in foster care). Documentation must include:
Failure to provide income documentation and/or insurance will result in the family’s cost participation co-pay at full fee status.
A family may request that medical and personal care needs expenses be considered in the calculation of the family income and co-payment. The total amount of these expenses is deducted from the family’s gross income, potentially lowering the family’s co-payment. Deductions for medical and personal care needs of a family member, as defined in the Cost Participation Procedures, must be documented on the Financial Deduction Worksheet and be supported by records. Appropriate deductions must be documented on the Financial Deduction Worksheet and must include out-of-pocket health or medical expenses for a family member for whom the family was not reimbursed and must be supported by written receipts. Confirmation of level of income and percent of federal poverty level is calculated at the SPOE by data entry of the family’s income and family size.
In order to maximize the opportunity to share the costs of services, the First Steps System accesses private health insurance, as allowed by law. Families provide access to private health insurance by submitting a copy of their insurance card, completing the Private Medical Insurance Supplement Form and Private Medical Insurance consent-to-bill-insurance form. Families who decline to give private health insurance information or access to bill their private health insurance provider may choose either the maximum co-payment per treatment, up to the actual cost of treatment, or access entitlement services only (e.g., Service Coordination).
Families have the right to dispute any collection procedure or oppose their placement in the cost participation co-payment plan. If families disagree with any action or decision regarding the cost participation program, they may request reconsideration by the Division under Cost Participation Administrative Review. Email requests to FirstStepsWeb@fssa.in.gov.
The CRO is responsible for notifying families if any co-payments are due and for collecting all revenue generated by this process. Each month, the Family Cost Participation Statement includes the co-payment and any past payments due. A family has thirty (30) days to pay their co-payments upon receipt of the Family Cost Participation Statement. Payment must be made regardless of anticipation of potential insurance recovery. Any insurance recoveries are reflected on the next statement or reimbursed to the family if the child/family has left the First Steps System. If payment has not been received after 60 days, the family will go on the suspension list and may lose services.
While First Steps submits claims for eligible First Steps services to the health insurance provider, the state cannot guarantee claims will be accepted or paid by the insurance provider. Claims payment is dependent on the insurance plan and the service type, diagnosis, provider, and location of services. When a claim is denied by the health insurance provider, an Explanation of Benefits (EOB) is generated indicating the reason for denial. When a claim is rejected, no EOB is generated and there may not be a record indicating why the claim was rejected.