Relates to insurance coverage of early intervention services

2 Co-sponsors

• George Latimer
• Terrence P. Murphy

BILL NUMBER:S1946

Title of bill

An act to amend the insurance law, in relation to coverage of early intervention services

Purpose

To amend the insurance law to ensure recoupment from commercial insurers for the cost of the early intervention program.

Summary of provisions

Section one amends subsection (a) of section 3235-a of the insurance law, as added by section 3 of part C of chapter 1 of the laws of 2002, to prohibit accident and health insurance policies from excluding from coverage services provided under title two-A of article twenty-five of the public health law. Section one also amends section 3235-a to add two new subsections (e) and (f). New subsection (e) provides that where a service provided to an insured under the early intervention program is a covered service under the insurer's policy, the individualized family services plan, upon certification by the early intervention official, shall be deemed to meet any Precertification, preauthorization and medical necessity requirements imposed on benefits under the policy. The early intervention official shall remove or redact any information contained in the individualized family services plan that is not required by the insurer for payment purposes. Payment of a service covered under the insurance policy shall be at rates established by the Commissioner of Health for such service pursuant to regulations. New subsection (f) provides that no insurer, including a health maintenance organization, shall deny payment of an early intervention claim based on the location where services are provided, the duration of the child's condition and/or that the child's condition is not likely to significantly improve within the time specified in the policy, or that the provider is not a network or participating provider.

Section two provides the effective date.

Justification

Although public and private commercial insurance is required by law to be maximized in financing early intervention (EI) services, reimbursement from third party payers, other than Medicaid, have been minimal leaving the cost of this entitlement to be paid by state and municipal tax dollars.

In recognition of the need to improve recoupment of insurance monies to help pay for EI, the Third Party Reimbursement Task Force of the New York State Early Invention Coordinating Council was convened in 1999. That Task Force examined data on billing and recoupment and found that private insurance collection was at a low rate of 9%. An updated survey conducted by the New York State Association of County Health Officials of billing and recoupment in 2000 found that, while, the amount billed to insurers had almost doubled, the recoupment rate remained a low 11%.

The Task Force also consulted with experts from Massachusetts, Indiana and Virginia, all states that have included in state law the specific requirements necessary to ensure insurance payments for EI. Experts from these three states indicated that requiring insurers to pay for EI services minimally impacted insurance premiums and that insurers may in fact have saved money in the long run due to the therapeutic interventions under EI. Experts from the three states confirmed the Task Force's finding that the single most important factor to improve collections as well as reducing administrative burdens was legislation requiring private commercial insurers to pay for EI.

Current insurance law does not include the necessary language to insure that payments are made nor does the language preclude the majority of reasons given for FT denials. As a result, it is necessary that specific language be adopted to fix this problem.

Legislative history

S. 4991/A. 2401 - Insurance Committee.

Fiscal implications

None to the state, savings for municipalities.

Effective date

Immediate.