Provides for the payment by the state of the costs of an evaluation and early intervention services to eligible children.
TITLE OF BILL: An act to amend the public health law, in relation to the financial responsibility for and reimbursement of payment for early intervention services by the state
PURPOSE OR GENERAL IDEA OF BILL:
To clarify the role of the state's early intervention (EI) fiscal agent and ensure that infants and toddlers in New York State have timely access to EI services.
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 of the bill amends subdivision 1 of Section 2557 of the Public Health Law to provide that EI providers must be paid in full at the State EI rate by the state or the State Fiscal Agent (SFA) designated by the New York State Department of Health (NYS DOH) within 30 days of the receipt by the state or its SFA of an initial claim from a provider.
Section 2 of the bill amends paragraph (a) of subdivision (3) of
Section 2559 of the Public Health Law to require the SFA to conduct fiscal management and payment of claims for the EI program to:
*seek payment on behalf of EI providers directly from all third payors including, the Medicaid program; and *track claims submitted to all third party payers and file and conduct all appeals of payment denials directly with all third party payors.
Section 3 of the bill adds a new subparagraph (iv) to paragraph (a) of subdivision (3) of Section 2559 of the Public Health to require the SFA to conduct reconciliation at least quarterly and to reimburse the State and municipalities for their share.
Section 4 of the bill amends paragraph (d) of subdivision (3) of Section 2559 of the Public Health Law to require the SFA instead of the EI provider to be subrogated to any rights that a person may have or be entitled to from third party reimbursement for EI services.
Section 5 of the bill provides that this act shall take effect 60 days after it is signed into law provided 1) it shall apply to EI provider claims that have not been paid in full prior to the effective date and 2) effective immediately the Department shall take all actions necessary to effectuate the act on its effective date
The 2012-13 State Budget (Section 11 of Part A of Chapter 56 of the Laws of 2012) transferred the responsibility for EI billing from county government to a State Fiscal Agent under contract with NYS DOH, effective April 1, 2013 in order to achieve a more efficient and effective process with the expectation that a larger proportion of EI claims would be paid by third party insurance. This bill makes clarifying amendments to ensure the original intent of making a more efficient and effective process are in fact realized.
Under the new system that has been implemented, providers are caught between patients, insurers and the fiscal agent awaiting decisions and information that is often out of their control. As a result they are experiencing devastating payment delays and administrative burdens which have made the EI program fiscally unsustainable for some providers. Access to services for infants and children who rely on this program for critical therapies may be seriously jeopardized as providers leave the program. This was not the intended consequence of the creation of a fiscal agent in the 2013-14 budget.
Providers are not able to make payroll or routine business decisions about the number of employees, salary and benefits, or caseload size if they cannot predict the level and timeliness of revenue from third party payors. Many providers are unable to pay their personal bills and are maxing out credit limits to support themselves and their agencies. Others are experiencing limits to their business' line of credit and increased interest rates because the problems have continued for months and the creditors do not see a solution in sight.
Tracking insurance claims has become a second full time job for providers. Many do not have the resources, infrastructure, and staff to navigate the complexities of commercial insurance and Medicaid payment systems. Providers receive no additional payment for this increased workload. In fact, EI has not experienced a rate increase in 16 years, but has had reimbursement rates cut in 2010 and again in 2011.
This bill clarifies the legislative intent and thereby preserves access to EI services for eligible infants and toddlers by requiring the SFA to pay providers within 30 days of the receipt of a commercial insurance claim from a provider, as the counties had done in the past. It also clarifies that the SFA shall pursue provider claims and payments and handle all appeals of payment denials by insurance companies in order to enhance third party reimbursement for certain EI services. Finally, the legislation provides an effective date that both gives the Department time to make the necessary changes in the payment system, while providing a remedy for providers to be paid for unpaid claims dating back to the April 1, 2013 implementation of a SFA.
PRIOR LEGISLATIVE HISTORY:
None. Continued delays and lack of access to preventative services will actually increase long, term costs for special education services for school age children. Additionally, a single SFA submitting and appealing commercial insurance claims statewide will be able to leverage greater reimbursements than the counties or providers which was the original intention.
This act shall take effect 60 days after it is signed into law provided 1) it shall apply to EI provider claims that have not been
paid in full prior to the effective date and 2) effective immediately the Department shall take all actions necessary to effectuate the act on its effective date.
STATE OF NEW YORK ________________________________________________________________________ 6002 2013-2014 Regular Sessions IN SENATE December 6, 2013 ___________Introduced by Sens. HANNON, SEWARD, BONACIC, BOYLE, CARLUCCI, DeFRANCIS- CO, FARLEY, GOLDEN, GRISANTI, LARKIN, LAVALLE, LITTLE, MAZIARZ, RITCHIE -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the public health law, in relation to the financial responsibility for and reimbursement of payment for early intervention services by the state THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subdivision 1 of section 2557 of the public health law, as amended by section 4 of part C of chapter 1 of the laws of 2002, is amended to read as follows: 1. The approved costs for an eligible child who receives an evaluation and early intervention services pursuant to this title shall be a charge upon the municipality wherein the eligible child resides AND THE STATE or, where the services are covered by the medical assistance program, upon the social services district of fiscal responsibility with respect to those eligible children who are also eligible for medical assistance. All approved costs shall be paid IN FULL AT THE STATE APPROVED EARLY INTERVENTION RATE in the first instance
[and at least quarterly by the appropriate governing body or officer of the municipality upon vouchers presented and audited in the same manner as the case of other claims against the municipality]BY THE STATE OR ITS DESIGNATED FISCAL AGENT TO A PROVIDER WITHIN THIRTY DAYS OF THE RECEIPT BY THE STATE OR ITS DESIG- NATED STATE FISCAL AGENT OF AN INITIAL CLAIM FROM A PROVIDER. WHERE A PROVIDER'S ASSIGNMENT IS CALLED FOR UNDER PARAGRAPH (D) OF SUBDIVISION THREE OF SECTION TWENTY-FIVE HUNDRED FIFTY-NINE OF THIS TITLE, THE ASSIGNMENT SHALL BE PART OF THE PROVIDER'S CLAIM. Notwithstanding the insurance law or regulations thereunder relating to the permissible exclusion of payments for services under governmental programs, no such exclusion shall apply with respect to payments made pursuant to thisEXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD13146-02-3 S. 6002 2
title. Notwithstanding the insurance law or any other law or agreement to the contrary, benefits under this title shall be considered secondary to any plan of insurance or state government benefit program under which an eligible child may have coverage. Nothing in this section shall increase or enhance coverages provided for within an insurance contract subject to the provisions of this title. S 2. The opening paragraph of paragraph (a) of subdivision 3 of section 2559 of the public health law, as amended by section 11 of part A of chapter 56 of the laws of 2012, is amended to read as follows:
[Providers of evaluations and early intervention services, hereinafter collectively referred to in this subdivision as "provider" or "provid- ers",]THE STATE OR ITS DESIGNATED FISCAL AGENT shall [in the first instance and], where applicable, seek payment from all third party payors including governmental agencies [prior to claiming payment from a given municipality]for evaluations conducted under the program and for services rendered to eligible children, provided that, the obligation to seek payment shall not apply to a payment from a third party payor who is not prohibited from applying such payment, and will apply such payment, to an annual or lifetime limit specified in the insured's poli- cy. THE STATE OR ITS DESIGNATED FISCAL AGENT SHALL BE RESPONSIBLE FOR FILING AND CONDUCTING ALL APPEALS OF PAYMENT DENIALS BY ALL THIRD PARTY PAYORS INCLUDING GOVERNMENTAL AGENCIES, AND TRACKING CLAIMS SUBMITTED TO ALL THIRD PARTY PAYORS INCLUDING GOVERNMENTAL AGENCIES. S 3. Paragraph (a) of subdivision 3 of section 2559 of the public health law is amended by adding a new subparagraph (iv) to read as follows: (IV) THE FISCAL AGENT SHALL, AT LEAST QUARTERLY, CONDUCT A RECONCIL- IATION OF THIRD PARTY REIMBURSEMENT PURSUANT TO THIS SUBDIVISION AND PROVIDE REIMBURSEMENT AT LEVELS IN ACCORDANCE WITH THIS TITLE TO THE STATE AND MUNICIPALITIES. S 4. Paragraph (d) of subdivision 3 of section 2559 of the public health law, as amended by section 11 of part A of chapter 56 of the laws of 2012, is amended to read as follows: (d) A municipality, or its designee, and [a provider]THE STATE OR ITS DESIGNATED FISCAL AGENT shall be subrogated, to the extent of the expenditures by such municipality or for early intervention services furnished to persons eligible for benefits under this title, to any rights such person may have or be entitled to from third party reimbursement. The [provider]STATE OR ITS DESIGNATED FISCAL AGENT shall submit notice to the insurer or plan administrator of [his or her]ITS exercise of such right of subrogation [upon the provider's assignment as the early intervention service provider for the child]. The right of subrogation does not attach to benefits paid or provided under any health insurance policy or health benefits plan prior to receipt of written notice of the exercise of subrogation rights by the insurer or plan administrator providing such benefits. S 5. This act shall take effect on the sixtieth day after it shall have become a law, and (a) shall apply to any claim for payment by a provider for services under title 2-A of article 25 of the public health law that has not been fully paid pursuant to such title on or after such effective date, whether filed before or after the effective date of this act and (b) effective immediately, the commissioner of health is author- ized and directed to promulgate regulations and take all actions neces- sary and appropriate to implement the provisions of this act on its effective date.