NYSED / P-12: EMSC / Special Education / Publications / Parental Consent for the Use of Public Benefits or Insurance / Attachment 2

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Written Notification Regarding Use of Public Benefits or Insurance to Pay for Certain Special Education and Related Services

SAMPLE FORM
Written Notification Regarding Use of Public Benefits or Insurance to Pay for Certain Special Education and Related Services

This form has been adapted from the U.S. Department of Education’s model Notification Form1. 

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INTRODUCTION

You are receiving this written notification to give you information about your rights and protections under the federal Individuals with Disabilities Education Act (IDEA), so that you can make an informed decision about whether you should give your written consent to allow your school district to use your or your child’s public benefits or insurance to pay for special education and related services that your school district is required to provide at no cost to you and your child under IDEA.

Funds from a public benefits or insurance program (for example, Medicaid funds) may be used by your school district to help pay for special education and related services, but only if you choose to provide your consent, as explained below. 

Before your school district can ask you to provide your consent to access your or your child’s public benefits or insurance for the first time, it must provide you with this notification of the rights and protections available to you under IDEA.  This notification is intended to help you understand these rights and protections, including the type of consent your school district will ask you to provide.  If you choose not to provide your consent, or later decide to withdraw your consent, your school district has a continuing responsibility to ensure that your child is provided all required special education and related services under IDEA at no charge to you or your child.

PARENTAL CONSENT
34 CFR §300.154(d)(2)(iv)(A)-(B) and 8 NYCRR §200.5(b)(8)(i)

Beginning on July 3, 2013, before your school district can use your or your child’s public benefits or insurance for the first time to pay for special education and related services under IDEA, it must obtain your signed and dated written consent.  Your school district is only required to obtain your consent one time.

This consent requirement has two parts.

1. Consent to share records about your child: Your school district is required to obtain your written consent before disclosing [sharing] personally identifiable information about your child (such as your child’s name, address, social security number, individualized education program (IEP), and evaluation results) from your child’s education records.  In asking for your consent, the district will (1) identify the records [or information] about your child that will need to be shared (for example, about the services that may be provided to your child); (2) tell you the purpose of sharing the records (for example, billing for special education and related services); and (3) identify the agency to which your school district may disclose the information (for example, the Medicaid agency).
2. Consent to bill your public insurance program (for example, Medicaid):  Your consent must include a statement specifying that you understand and agree that your school district may use your or your child’s public benefits or insurance (e.g., Medicaid) to pay for some of your child’s special education services. 

If your school district has on file your consent that you provided before July 3, 2013 to release your child’s records and to use your or your child’s public benefits or insurance to pay for special education and related services, your school district is required to request a new consent from you only when there is a change in any of the following: the type of services to be provided to your child (for example, physical therapy or speech therapy), the amount of services to be provided to your child (for example, hours per week lasting for the school year), or the cost of services (that is, the amount charged to the public benefits or insurance program).

If any of these changes occur, your school district must obtain from you a new one-time consent.  Before you provide your school district the new, one-time consent, your school district must provide you with this notification.  Once you provide this one-time consent, you will not be required to provide your school district with any additional consent in order for it to access your or your child’s public benefits or insurance even if your child’s services change in the future.  However, your school district must continue to provide you with this notification annually.

You have the right to withdraw your consent at any time.  If you withdraw your consent, the school district must still provide all of your child’s IEP special education and related services at no cost to you.  To withdraw your consent, you will need to submit your request in writing to your child’s school district. 

NO COST PROVISIONS
34 CFR §300.154(d)(2)(i)-(iii) and 8 NYCRR §200.5(b)(8)(ii)(b)-(d)

The IDEA “no cost” protections regarding the use of public benefits or insurance are as follows:

1. Your school district may not require you to sign up for, or enroll in, a public benefits or insurance program in order for your child to receive a free appropriate public education. 
2. Your school district may not require you to pay any out-of-pocket expenses, such as the payment of a deductible or co-pay amount for filing a claim for services that your school district is otherwise required to provide your child without charge. 
3. Your school district may not use your or your child’s public benefits or insurance if using those benefits or insurance would:
   1. decrease your available lifetime coverage or any other insured benefit, such as a decrease in your plan’s allowable number of physical therapy sessions available to your child or a decrease in your plan’s allowable number of sessions for mental health services;
   2. cause you to pay for services that would otherwise be covered by your public benefits or insurance program because your child also requires those services outside of the time your child is in school;
   3. increase your premium or lead to the cancellation of your public benefits or insurance; or
   4. cause you to risk the loss of your child’s eligibility for home and community-based waivers that are based on your total health-related expenditures.

We hope this information is helpful to you in making an informed decision regarding whether to allow your school district to use your or your child’s public benefits or insurance to pay for special education and related services under IDEA.

Contact information:  For additional information and guidance on the requirements governing the use of public benefits or insurance to pay for special education and related services see: http://www2.ed.gov/policy/speced/reg/idea/part-b/part-b-parental-consent.html.  

Last Updated: November 12, 2013