Docstoc

Connecticut Private Health Insurance

Document Sample
Connecticut Private Health Insurance Powered By Docstoc
					                                             INSURANCE INFORMATION FORM
 Child’s Name                                                                                Birth to Three Case #

 Date of Birth                     Service Coordinator                      Program Name & Phone

The Connecticut Birth to Three System provides services to eligible children, paid for by a combination of state and federal funds as well as
reimbursement from private health insurance, Medicaid, and parent fees. The following information is necessary to access such reimbursement.

                                   INSURANCE COVERAGE INFORMATION & PERMISSION
                                    (Please sign in the box that applies to your child’s insurance coverage)
 My child is covered by private health insurance or Medicaid. The State of Connecticut and its authorized agents including the Birth to
 Three System Lead Agency, Birth to Three System contractors, and the CT Fiscal Service Center has my permission to bill the insurance
 carrier(s) identified below for payment in full or in part, for services received by my child who is named on the top of this form, and his or her
 family in the Connecticut Birth to Three System. I authorize the release of any medical or other information necessary in order to process
 claims. The State of Connecticut and its authorized agents including the Birth to Three System Lead Agency, Birth to Three System
 contractors, and the Connecticut Fiscal Service Center, has my permission to receive reimbursement for claims submitted to my insurance
 carrier or federal Health Care Financing Administration on behalf of my child, who is being evaluated and as a result may be enrolled in the
 Connecticut Birth to Three System. If payment for Birth to Three services is sent to me directly, I will send that payment to my Birth to Three
 program. I understand that if I do not, all direct early intervention services will be suspended until payment is made. I understand that even
 though my insurance will be billed, I am still responsible for paying monthly fees if my family’s adjusted gross income is $45,000 or more.
       (If your health insurance plan is exempt from state law (self-funded or out-of-state), please complete form 1-3a also.)
 PRIMARY INSURANCE CARRIER*                                                     SECONDARY INSURANCE CARRIER*
 Insured:                                                                       Insured:

 DOB:                                 Relationship to Child                 DOB:                                 Relationship to Child:


 : Address:                                                                 Address:



 Insurance Carrier:                                                         Insurance Carrier:


 Phone #: (             )                                                   Phone #: (              )

 Claim Address:                                                             Claim Address:


 Member Number:                       Plan Name:                            Member Number:                       Plan Name:

 Group Number:                        Effective Date:                       Group Number:                        Effective Date:

 Employer:                                                                  Employer:

 Address:                                                                   Address:



 _________________________________________             __________     ________________________________________   ___________
 Insured Signature                                     Date           Insured Signature                          Date
   MEDICAID (HUSKY A)*
 Child’s Medicaid Number(issued by Dept. of Social Services):_______________________________________________________________

 Plan Name:__________________________________________ Check one:  Medicaid Fee for Service OR                          Medicaid Managed Care
 -
 Plan Address:

                                                                             ______________________________________________________
 Plan Phone:                                                                               Parent Signature                               Date

                             *If your insurance changes, please notify your service coordinator immediately
 My child is NOT covered by private health insurance or Medicaid at this time. I understand that monthly fees may be charged.
 Parent Signature                                                     Date


  My child is covered by private health insurance and I DO NOT authorize billing. I understand that higher monthly fees may be
 charged.
 Parent Signature                                                  Date



 Connecticut Birth to Three Form 1-3 (Revised 11/1/10)
                   INFORMED CONSENT TO BILL HEALTH INSURANCE PLANS
                        EXEMPT FROM STATE INSURANCE MANDATES

Child’s Name                                                         Birth to Three Case #


Connecticut laws 38a-516a and 38a-490a require health insurance plans to provide coverage for Birth
to Three services. The laws also specify that no payment made for Birth to Three services shall be
applied against the maximum annual or lifetime limits of the policy. Some types of plans, however,
(those self-funded by employers and those issued by companies that do not sell health care coverage
in Connecticut) are exempt from following state insurance laws. Therefore, these plans are not
required to pay for Birth to Three services, and if they do, these claims may be applied against the
maximum limits of the policy.

The law also requires the Birth to Three System to charge fees to all parents whose adjusted gross family
income is $45,000 or more, using a sliding scale adjusted for family income and family size. Higher fees
are applied in cases where permission to bill insurance is not granted.

It has been determined that your health insurance plan is one of those that is exempt from state
insurance laws. You may choose to either request that the Birth to Three System file claims with your
plan or to make a higher monthly contribution according to a sliding fee scale (see Form 1-9a.)

In order for you to make a decision that is best for your family, you should know that:

   The decision to allow or not allow billing is completely up to you as the named insured
   Your decision may be changed at any time and for any reason
   Your child and family will continue to receive the services and supports specified on your
     Individualized Family Service Plan (IFSP) regardless of your decision about insurance billing.
   Your decision will not change the types or amounts of service specified in your IFSP.

If you decide to allow the Birth to Three System to bill your health insurance plan, you should also
consider the following:

   Your health insurance plan may or may not agree to cover Birth to Three services. Their decision
    will not affect you or your family in any way.

   If your health plan decides to provide coverage, the plan may apply such payments against the
    maximum annual or lifetime limits of the policy. If your health plan does not agree to exempt such
    payments from the maximum lifetime or annual limits of your policy, your family’s access to
    such coverage for non-Birth to Three services will be affected.

Please discuss this decision with your service coordinator, employer, and family as needed to achieve
full understanding before making your decision.


I hereby grant permission to the Birth to Three System Lead Agency and its agents as described in Form
1-3 to receive reimbursement for claims submitted to my insurance carrier on behalf of my child. I
understand that this may affect the maximum lifetime or annual limits specified in my policy. This
permission remains in effect during the time in which my child is enrolled in the Connecticut Birth to
Three System until I revise Form 1-3 to indicate otherwise.

________________________                                     _______________________
         Parent Signature                                                     Date
Connecticut Birth to Three Form 1-3a (Revised 1/1/10)

				
DOCUMENT INFO
Description: Connecticut Private Health Insurance document sample