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

Any exceptions to Birth to 3 Program policy or standard practice will only be allowed during the COVID‐19 pandemic.

Participant Contact Requirements

UPDATED Are face‐to‐face visits suspended for the Birth to 3 Program?

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

Wisconsin has experienced a drastic rise in COVID-19 cases throughout the state, which has led the Governor to declare a public health emergency (Executive Order #90). As the lead agency designated by the Governor to respond to this public health emergency, the Wisconsin Department of Health Services (DHS) is committed to reducing the risk of COVID‐19 exposure to program participants and staff. It is imperative to take measures to protect populations at an elevated risk of becoming seriously ill should they become infected.

County Birth to 3 Programs must work with families to affirm their acceptance of face-to-face service during the COVID-19 pandemic. The family leads this decision. Discussion with the family should address available options for service delivery and risks associated with each option.

County Birth to 3 programs must follow the requirements established in Emergency Order #1 regarding the use of face coverings in indoor and enclosed spaces when providing in-person (face-to-face) services to Birth to 3 Program participants. Programs should also 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.

What should the Birth to 3 Program consider prior to providing face-to-face services to a child during the COVID-19 pandemic?

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.

Medicaid Telehealth Policy

In response to the COVID-19 outbreak, is Wisconsin Medicaid changing policy requirements for services delivered through telehealth?

Yes, beginning on March 12, 2020, and 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 Temporary Changes to Telehealth Policy and Clarifications for Behavioral Health and Targeted Case Management Providers and Additional Services to be Provided Via Telehealth ForwardHealth Updates for further information.

Does DHS have further guidance regarding the types of covered ForwardHealth services that can be delivered with functional equivalency to face-to-face service?

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.

UPDATED Are texting and emailing reimbursable telehealth services under Wisconsin Medicaid?

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.

Does DHS have guidance available regarding billing and claims submission for telehealth 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.

Can therapists provide remote services, or is this a violation of their license?

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:

Can Birth to 3 Program providers use the TL modifier to receive the enhanced rate for providing services in natural environments if a child is served remotely via telehealth while in a natural environment?

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.

Can therapists bill Wisconsin Medicaid when using remote technology to complete an evaluation?

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 Telehealthfor additional guidance regarding when telehealth is an appropriate service delivery approach.

Can therapists bill for services without completing an evaluation?

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.

What if a family refuses services via telehealth?

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.

How are Birth to 3 programs to obtain consent for telehealth services from families?

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.

​What are the Health Insurance Portability and Accountability Act (HIPAA) regulatory requirements for remote communications technologies during the pandemic?

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.

Is there guidance on the types of remote communications that may be used during the COVID-19 outbreak?

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.

Private Insurance Telehealth Policies

How are private insurers responding to the COVID-19 pandemic? Are private insurers reimbursing for services delivered via telehealth?

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:

Family Educational Rights and Privacy Act

What guidance has been provided from the U.S. Department of Education regarding the Family Educational Rights and Privacy Act (FERPA) and virtual special education services, confidentiality and consent?

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

Private Insurance Telehealth Policies

How are private insurers responding to the COVID-19 pandemic? Are private insurers reimbursing for services delivered via telehealth?

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:

Guidance for Telehealth Visits

Is further guidance available regarding how to conduct telehealth visits?

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.

Is guidance available regarding the use of interpreters during telehealth visits?

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 for Intake, Evaluation, and the Individualized Family Service Plans (IFSPs)

Are there changes to the required timelines for intake, evaluation, and the individualized family service plan (IFSP)?

Timelines remain unchanged. DHS has received no direction from OSEP that timelines are changing. However, Wis. Admin. Code ch. 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.”

County Birth to 3 Programs may initiate services through interim IFSPs. The interim IFSP process can be used to expedite initiation of services for new referrals. Timelines do not apply under this section for exceptional family circumstances, which can include a public health crisis. Please see the “Interim IFSPs” section of this page for additional details.

How do we document delays in meeting the timelines due to COVID 19 in the Program Participation System (PPS)?

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. (See the Transition section regarding transition plans and transition planning conferences TPCs.)

Interim IFSPs

Where can counties find guidance about developing interim IFSPs?

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).

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 (OSERS) 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.

Does DHS have forms available for interim IFSPs?

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.

What fields in PPS should the Birth to 3 Program complete when developing an interim IFSP?

County Birth to 3 Programs are to complete the following four 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.

  1. 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.
  2. 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.
  3. 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.

Are county Birth to 3 programs required to develop interim IFSPs during the COVID-19 pandemic?

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.

Requirements for Consent and Signatures

How will parental consent and signatures on required forms be documented during the COVID-19 outbreak?

Due to the current need to adjust operational practices in response to the COVID‐19 pandemic, counties may accept telephonic (verbal) consent and electronic signatures. Telephonic consent and electronic signatures must be documented in a case note.

Written consent must be obtained as soon as possible after verbal consent is received.

How do county Birth to 3 programs obtain signatures on the Birth to 3 Program Exemption Request form?

County Birth to 3 programs can submit the Birth to 3 Program Exemption Request form, F-12023, 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.

Staff and Participant COVID‐19 Infections

What if a Birth to 3 Program service provider tests positive for COVID‐19?

Notify your technical assistance lead 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.

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.

What if a child or family member tests positive for COVID‐19?

Notify your technical assistance lead of the infection. 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.

Parental Cost Share

Are parents still responsible for paying a parental cost share during the COVID-19 outbreak?

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.

How should county Birth to 3 programs document waivers of the parental cost share?

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

Do county Birth to 3 programs need to issue a prior written notice for a change or reduction in a participant’s authorized services due to the COVID-19 outbreak?

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.

Transition

Are there any changes to the timelines and required activities for transition plans due to the COVID-19 pandemic?

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.”

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.

Effective March 16, 2020, until the COVID-19 emergency is over, county Birth to 3 programs are to use “family reason” for any transition plans on the IFSP that are late due to COVID-19.

How do county Birth to 3 programs conduct transition activities during the COVID-19 pandemic?

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 .

If the family does not want a transition planning conference or if the school district is closed and unable to participate in the TPC, use the exception reason, “Family was not available for the TPC.”

The timeline for the transition planning conference remains unchanged.

How are local education agencies (LEAs) responding to referrals from the Birth to 3 Program?

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.

Innovation in Social-Emotional Development Grants

When can counties expect to hear from DHS about the status of their Innovation in Social-Emotional Development grant proposal?

DMS Numbered Memo 2019-08 detailed an opportunity for local Birth to 3 programs to apply for one-time grants from the Wisconsin Department of Health Services (DHS) to fund projects that support the implementation of evidence-based practices and system changes to improve social-emotional outcomes for enrolled children. DHS reviewed all submitted grant proposals and selected 15. DHS has communicated to local Birth to 3 programs the status of their proposals.

DHS would like to thank all applicants for the time and effort they committed to completing their grant proposals.

Additional Requirements for Continued Operation of the Birth to 3 Program

What additional actions should counties undertake for continued operation of the Birth to 3 Program during the COVID-19 pandemic?

A message released on March 24, 2020, included important information for continued operation of the Birth to 3 Program. DHS is relying on county programs to protect and inform families, especially the most vulnerable, from serious harm during the COVID-19 pandemic.

County programs are instructed to undertake the following actions:

  • Reach out to key service providers and partners in your community. Learn what resources are open and available, stay updated about changes in local workforce and direct service provision, and share information with families. Valuable resources could include 211 Wisconsin and access to food assistance, medical, and other needed services.
  • Contact your technical assistance lead to share questions, ideas, and needs. We understand you are very busy during this crisis and expect you will need to triage prioritization. Please let us know what you need to do your jobs.
  • Stay connected. Confirm that you are subscribed to email messages, participate in DHS teleconferences, and follow the DHS website and social media.

How should county Birth to 3 programs report suspected child abuse and neglect during the COVID-19 pandemic?

As a result of the COVID-19 pandemic, children have fewer interactions with many of the professionals trained to observe and mandated to report suspected child abuse and/or neglect. This one-page flyer from the Department of Children and Families can help you and your partners understand the signs of abuse and neglect and know how to report suspected incidents.

COVID-19 Resources

Where can a county Birth to 3 program find guidance regarding requesting and using personal protective equipment (PPE)?

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 resources:

Last Revised: November 18, 2020