Provides for the payment by the state of the costs of an evaluation and early intervention services to eligible children

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

Justification

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.

Fiscal implications

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.

Effective date

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.