COVID-19: Birth to 3 Program Operational Questions and Answers

No, effective May 13, 2020, the following contacts may be completed either face-to-face or remotely, by phone or alternate electronic or virtual method:

• Intake (initial home visits)
• Evaluation and Individualized Family Service Plans
• Ongoing service delivery (home visits)
• Service coordination 

County Birth to 3 Programs must discuss options for service delivery with families. Discussion with the family should address available options for service delivery and risks associated with each option. Programs are not required to provide face-to-face (in-person) services. 

County Birth to 3 Programs should review available information from their local public health department authorities and align their practices for face-to-face service delivery with the guidance from those local authorities. The county Birth to 3 Program’s practice must be consistent and applied to all participants served by the county Birth to 3 Program. Remote provision of services continues to be available. Dispute resolution options must be shared with families if there is a conflict between the family’s preference for face-to-face service delivery and the county Birth to 3 Program’s practice.  

The county Birth to 3 program and the family should consider the options available for providing services and the risk of exposure to any individual or family member.

Considerations should include:

• Discussion with the family.
• Assessment of any health condition or vulnerabilities of the child.
• Evaluation and consideration of risk of exposure to the participant, family members or caregivers or providers; this includes risk to any vulnerable family member.
• Ongoing or increased need for the service.
• Alternatives to face-to-face contact.
• Current guidance provided by local public health agencies.

For the duration of the COVID-19 pandemic, Wisconsin Medicaid will allow telehealth services utilizing interactive synchronous (real-time) technology, including audio-only phone communication, for currently covered services that can be delivered with functional equivalency to the face-to-face service. This applies to all service areas and all enrolled professional and paraprofessional providers allowable within current ForwardHealth coverage policy, including targeted case management, speech therapy, physical therapy, and occupational therapy.

This change is intended to support the health and safety of all providers and members. Please see the ForwardHealth temporary telehealth policy.

When the public health emergency ends, ForwardHealth permanent telehealth policy will be in place. See Topic # 510: Online Handbook Display.  

Per ForwardHealth Update 2020-15: Additional Services to be Provided Via Telehealth, telehealth may be appropriate for goals that can be accomplished through verbal and visual cueing. Telehealth is not appropriate for activities that require physical interaction or for goals that require hands-on support or physical prompting. Providers should exercise professional judgment in determining whether services can be delivered appropriately and effectively via telehealth.

Text messages and email may be used to communicate with families. For targeted case management reimbursement, emailing and texting is billable to ongoing monitoring and service coordination recordkeeping and includes time to prepare and respond to correspondence with members and collaterals as necessary for case planning, service implementation, coordination and monitoring. ForwardHealth does not reimburse for recordkeeping activities unless there is also a member or collateral face-to-face or telephone contact during the calendar month. Please see the Telehealth FAQs for additional information. Email and texting are not reimbursable telehealth services under Wisconsin Medicaid for PT, OT, and SLP services.

Guidance on claims submission for telehealth services can be found in ForwardHealth Update 2020-15: Additional Services to be Provided Via Telehealth. Please see the section titled “Claims Submission for Services Allowable Under Temporary Telehealth Guidance.”

ForwardHealth recently posted additional Billing Clarifications for Telehealth Services to their website. This webpage provides a billing for telehealth services flowchart and answers many questions regarding telehealth billing. It also discusses use of the TL 95 modifier when billing for telehealth services. Providers are encouraged to include the TL 95 modifier for all telehealth services delivered during the COVID-19 pandemic.

Per ForwardHealth Update 2020-15: Additional Services to be Provided Via Telehealth, all enrolled professional and paraprofessional providers allowable within current ForwardHealth coverage policy may provide telehealth services for currently covered services that can be delivered with functional equivalency to the face-to-face service. This includes therapists who bill Medicaid.

Information regarding telehealth services has also been posted on the websites for the following Wisconsin associations:

• Wisconsin Physical Therapy Association
• Wisconsin Speech Language Pathology and Audiology Association

Yes, Wisconsin Medicaid will allow use of the TL modifier when the child is served in a natural environment, regardless of whether the visit occurred via telehealth. Please see Alert 013: “Enhanced Reimbursement for Therapy Provided as Part of the Birth to 3 Program Using Telehealth” on the COVID-19: ForwardHealth News and Resources page for additional guidance.

During the COVID-19 pandemic, Wisconsin Medicaid is temporarily allowing currently covered services to be provided via telehealth using real-time technology as long as the service can be delivered with functional equivalence to the face-to-face service. This applies to all service areas and all enrolled professional and paraprofessional providers allowable within current ForwardHealth coverage policy.

Therapists must exercise their professional judgment in determining whether an evaluation for a child in the Birth to 3 Program can be delivered appropriately and effectively via telehealth. Please refer to ForwardHealth Update 2020-15: Additional Services to be Provided Via Telehealth for additional guidance regarding when telehealth is an appropriate service delivery approach.

Prior to the provision and billing of PT, OT, and SLP services, ForwardHealth requires an evaluation to be completed. The purpose of this evaluation is to determine a plan of care for the child in the Birth to 3 Program. This evaluation may be completed by the therapist remotely.

If a family declines or refuses services delivered via telehealth or the provider is unable to deliver services face-to-face, counties must inform families by providing the required components of prior written notice (PWN):

• The action that is being proposed
• The reasons for taking the action
• Other options considered
• Information upon which the proposed action is based
• All procedural safeguards available to the parent

This information can be provided electronically and does not require the use of a PWN form. The county should also include a plan to resume services as soon as possible after the COVID-19 restrictions have been removed.

Contact with all families is essential during this pandemic. Programs should continue service coordination and periodically check in with families who do not want telehealth services. Continued support and service coordination is needed to maintain quality services.

County Birth to 3 programs must develop and implement methods of informed consent to confirm that a family agrees to receive services via telehealth. Verbal consent to receiving services via telehealth is an acceptable method of informed consent when it is documented in case notes.

The Office of Civil Rights within the U.S. Department of Health and Human Services announced on March 17, 2020, that they will not impose penalties for noncompliance with Health Insurance Portability and Accountability Act of 1996 regulatory requirements for remote communication technologies in connection with the good faith provision of telehealth during the nationwide COVID-19 public health emergency. However, providers should enable all available encryption and privacy modes when using remote communications. Providers are also encouraged to let patients know that these communications can introduce privacy risks.

Providers are also reminded that during the COVID-19 pandemic, participants may be in close proximity to other household members, and that participants may have limited options for private telehealth communications in their homes. Providers are reminded that they must continue to implement reasonable safeguards to protect patient information against intentional or unintentional impermissible uses and disclosures.

Read more about COVID-19 and health privacy.

Providers may use any nonpublic-facing remote communication product that is available to communicate with patients. Public-facing video communication applications, such as Facebook Live, should not be used in the provision of telehealth. Providers are encouraged to let patients know that these third-party applications can introduce privacy risks. Providers should also enable all available encryption and privacy modes when using such applications.

County Birth to 3 Programs should consult with IT and privacy and confidentiality staff within their agency to identify appropriate applications to be used with families. County programs should make families aware of applications that can be used and inform families of all options available.

The U.S. Department of Education has released a FERPA FAQ.

The Bureau of Children’s Services does not monitor private insurance. It is the county Birth to 3 program’s responsibility to work with private insurers to identify allowable telehealth services and reimbursement for those services. The program should contact individual insurance companies and individual plans for more information.

The America’s Health Insurance Plans (AHIP) website is tracking how private insurers are responding to the COVID-19 pandemic and may assist counties with questions related to private insurance.

The Wisconsin therapy associations are also tracking private insurance telehealth policies and may also assist counties with questions related to private insurance:

• Wisconsin Physical Therapy Association
• Wisconsin Occupational Therapy Association
• Wisconsin Speech Language Pathology and Audiology Association

The Early Childhood Technical Assistance Center (ECTA) has published guidance regarding service delivery through telehealth. This guidance includes videos and tutorials regarding early childhood intervention telepractice.

The Family, Infant and Preschool Program has resources available for programs and practitioners moving to tele-intervention. Resources include how to get started with tele-intervention, tele-coaching, and how to use natural learning environment practices via tele-intervention.

The American Physical Therapy Association, American Occupational Therapy Association, and American Speech Language Hearing Association have all published guidance, including webinars and FAQs regarding how to provide services via telehealth.

Counties may continue to use their established providers for interpretation services. Resources regarding how to incorporate language interpretation services into telehealth technologies are available online. Programs should review resources specific to the telehealth technologies they are utilizing to deliver services.

The Hands and Voices Organization has published guidance regarding making online and phone meetings accessible for deaf and hard of hearing individuals.

Timelines remain unchanged. Further information on requirements for timelines is available from the Birth to 3 Program Operations Guide, sections 6.6, 7.4, and 9.3. 

Effective March 16, 2020, until the COVID-19 emergency is over, county Birth to 3 programs are to use “family reason” for any IFSPs or start of services that are late due to COVID-19 impact on the family. (See the Transition section in the Birth to 3 Program Operations Guide regarding transition plans and transition planning conferences, or TPCs.)

Guidance regarding interim IFSPs can be found in in the federal Part C regulations in 34 C.F.R. 303.345 and Wis. Admin. Code § DHS 90.10(2). The Birth to 3 Program Operations Guide provides guidance on the use of interim IFSPs, section 9.3.2.

According to Wis. Admin. Code § DHS 90.10(2), if exceptional family circumstances exist that make it difficult to complete the evaluation and assessment within 45 days, the county is to:

1. Document the exceptional circumstances in the child’s early intervention record.
2. Develop and implement an interim IFSP that includes the service coordinator’s name, the early intervention services that are needed immediately, and the circumstances and reasons for development of the interim IFSP.
3. Obtain the parent’s consent to the services, and to a revised deadline for completion of the evaluation and assessment.
4. Complete the evaluation within the extended period agreed upon by the family and early intervention team.

34 C.F.R. 303.345 (Interim IFSPs—provision of services before evaluations and assessments are complete), states the following:

Early intervention services for an eligible child and the child's family may commence before the completion of the evaluation and assessments in 34 CFR 303.321, if the following conditions are met:

(a) Parental consent is obtained.
(b) An interim IFSP is developed that includes—

(1) The name of the service coordinator who will be responsible, consistent with 34 CFR 303.344(g), for implementing the interim IFSP and coordinating with other agencies and persons; and
(2) The early intervention services that have been determined to be needed immediately by the child and the child's family.

(c) Evaluations and assessments are completed within the 45-day timeline in 34 CFR 303.310.

The federal Office of Special Education and Rehabilitative Services has previously provided guidance to states indicating that weather or natural disasters, including the COVID-19 pandemic, may constitute “exceptional family circumstances.” Programs are to complete evaluations, initial assessments, and the initial IFSP meeting as soon as possible after the exceptional family reason no longer exists.

There are no separate forms available for interim IFSPs. Counties should continue to use the IFSP forms available on the Birth to 3 Program forms and publications page. Only certain sections of the IFSP packet need to be completed for an interim IFSP.

The interim IFSP needs to include the following:

Name of service coordinator, services to be provided that are needed immediately and parental consent. These requirements typically equate to the following pages of the IFSP:

• Cover page
• Demographics page
• Services page
• Consent page

Consider including information as it is gathered from any evaluation or assessment information on the Summary of Development pages.

County Birth to 3 Programs are to complete the following fields in PPS:

1. Demographics and referral information as usual.
2. Evaluations section
   • Include any evaluations or assessments that were completed for the child using the professional disciplines of the individuals completing the evaluation and assessment. Service coordination cannot be one of the disciplines.
   • If two evaluations or assessments were not completed, choose the discipline(s) of the person who reviewed the information known about the child and determined they believe the child will likely be eligible for the program.
3. Eligibility: The county Birth to 3 Program should choose the appropriate eligibility option for the child based upon why the team believes the child is likely eligible for the Birth to 3 Program.
4. Initial IFSP date: The county Birth to 3 Program should enter the date the interim IFSP was developed. Later, when the county completes the evaluations and develops an IFSP for a child found eligible, that IFSP meeting will be considered a IFSP update.
5. Child outcome ratings: The IFSP team should determine the entry child outcome ratings based on the information they have available on the child at the time of the rating.

No, counties are not required to develop interim IFSPs during the COVID-19 pandemic. During the COVID-19 pandemic, counties may use remote technology to conduct intake and evaluations and develop IFSPs within the required timeframes if able to do so and if the family consents.

Interim IFSPs are a resource available to counties during the COVID-19 pandemic if/when completing evaluations, assessments and IFSPs within required timeframes is not possible.

In response to the COVID-19 public health emergency, local Birth to 3 Programs have the flexibility to initiate services through an interim IFSP, without conducting an evaluation to determine eligibility, if exceptional family circumstances related to the pandemic make it difficult to complete the evaluation. If a local Birth to 3 Program is unable to confirm a child’s eligibility based upon evaluation tools administered after the development of an interim IFSP, the local Birth to 3 Program is directed to complete the following steps: 

• Consider additional evaluation tools, specifically incorporate evaluation tools that are sensitive to social and emotional delays—Studies have indicated that the COVID-19 pandemic poses potential risks to social-emotional development due to social restrictions, increased stress levels of parents and caregivers, financial challenges, and other stressors related to the pandemic. Assure appropriate tools have been used to assess the impact of COVI-19 on the child’s development and future needs.
• Use informed clinical opinion to determine eligibility—The early intervention team can use their informed clinical opinion to determine if a child is considered developmentally delayed and should be eligible for the Birth to 3 Program, even if the child does not have an evaluated delay of at least 25 percent as measured by the tool. 
• Prior to initiating any discharge from the program, contact your children and family program specialist for technical assistance and review of the not eligible decision if evaluation information continues to indicate the child as not eligible.

Continuing Public Health Emergency—The ongoing COVID-19 pandemic continues to impact families and may increase exposure to pre-existing vulnerabilities within families that impair development. Explore the needs of the family due to COVID-19 and how those needs can be addressed (for example. referrals to other resources or provision of Birth to 3 Program services). 

County Birth to 3 programs can submit the Birth to 3 Program Exemption Request form, F-12023 (PDF), to Maximus without a signature if the following occurs:

• The county Birth to 3 Program has a conversation with the family regarding the request to exempt the child enrolled in the Birth to 3 Program out of their Medicaid HMO.
• Verbal consent from the family is obtained.
• Documentation of the previous two conditions is submitted with the Birth to 3 Program Exemption Request form.

Notify your children and family program specialist of the infection and how it may affect participants. Do not report identifying information about the provider, only that the infection occurred and the county’s plan for other staff and participants. If the provider who has tested positive for COVID‐19 has had contact with a child enrolled in the Birth to 3 Program  or one of the child’s family members, please report this to your children and family program specialist.

Discuss with local leadership how this may affect other program staff and children and families in the program in which in the person has had contact and determine next steps for informing impacted staff and families.

Notify your children and family program specialist of the infection. Let your children and family program specialist know when the child participating in the Birth to 3 Program tested positive for COVID-19, as well as the number of other family members that have tested positive. This will help coordinate supports and services to assist the child and family.  Do not report identifying information, only that the infection occurred.

Discuss with local leadership how this may affect other program staff with whom the person has had contact and determine next steps for informing impacted staff and families.

The parental cost share system allows for a modification per Wis. Admin. Code § DHS 90.06(2)(i)(4), which states that counties are responsible for informing parents of their right to request a waiver of the parental cost share in part or in whole if the request is based on unique circumstances of the child or family.

The COVID-19 pandemic is a unique circumstance. If this has not already occurred, county Birth to 3 programs must reassess parental cost share for all participants.

• If the family is experiencing hardship due to COVID-19, the parental cost share must be waived. Hardship is defined as a change in eligible household income and/or a COVID-19 positive test result in a member of the household.
• If services have been reduced due to COIVD-19, the cost of the IFSP must be reassessed and parental cost share is to be recalculated to determine if parental cost share would be reduced based upon the reduction in services.

The modifications detailed above and specific to COVID-19 are in addition to the established modifications allowed by the Parental Cost Share System based upon changes to the IFSP or other unique circumstances of the child or family.

If a county Birth to 3 Program previously developed a countywide policy for waiving all parental cost shares during the COVID-19 pandemic and intends to keep this policy in place throughout the duration of the pandemic, parental cost shares for participants in the program do not need to be reassessed.

County Birth to 3 programs should develop their own parental cost share waiver forms and maintain the parental cost share waiver form in the child’s file.

If the Birth to 3 program has adopted a county-wide policy regarding parental cost share (such as waiving all parental cost shares during the COVID-19 pandemic), the program can reference the county policy in case notes.

Prior written notice (PWN) does not need to be provided to a family when the method of providing services on an IFSP will be changed due to COVID-19. In this case, only the method of service delivery has changed. Families need to be fully informed of how services will be provided during this public health crisis. PWN should be provided if the services will be reduced or not provided due to COVID-19. The county Birth to 3 Program must maintain documentation via a case note in the child’s file. If the program is recommending a permanent change to the services offered, an IFSP update is required.

Timelines remain unchanged. DHS has received no direction from OSEP that timelines are changing for transition activities. However, DHS 90 and the IDEA Part C regulations do provide for flexibilities regarding timelines for intake, evaluation, and IFSP development due to “exceptional family circumstances.”

Further information on requirements for timelines is available from the Birth to 3 Program Operations Guide, section 11.1.

DHS expects that the development of transition steps will still be completed with families remotely and within the required timeframe. This includes a conversation (and PWN documentation) with the family about potential eligibility for LEA services.

LEA notification and referral to the LEA is to be completed electronically and should adhere to required timeframes. The transition planning conference can only be completed if the LEA is operating and is able to offer remote services. Transition planning conferences may occur via technology with districts that are open or providing distance learning during the COVID-19 public health crisis .

Further information on requirements for timelines is available from the Birth to 3 Program Operations Guide, section 11.4.

The Department of Public Instruction (DPI) has provided guidance to LEAs on responding to referrals during the COVID-19 pandemic through an Extended School Closure Due to COVID-19: Special Education Question and Answer Document.

PPE requests should go through county or tribal emergency management. Each county or tribe has developed its own process for accepting these requests.

Emergency managers submit a weekly request to the State Emergency Operations Center (SEOC). The SEOC will review and allocate resources to counties and tribes based on the county population and other additional factors. Resources will be distributed weekly to each county or tribe.

Local emergency management agencies have been asked to exhaust all other potential sources, including the regular supply chain and neighboring providers prior to submitting requests.

Programs can connect also with their county or tribal emergency manager to learn more about the request process.

Additional PPE resource: Masks and Children During COVID-19 (American Academy of Pediatrics)

County Birth to 3 Programs can find information at the DHS COVID-19: Vaccine webpage. This webpage includes COVID-19 vaccination data and frequently asked questions. Everyone in Wisconsin ages 6 months and older is eligible to get the COVID-19 vaccine at no cost.

County Birth to 3 Programs should also review available information about the COVID-19 vaccine from their local and tribal health departments.