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GOVERNOR CUOMO’S EXECUTIVE BUDGET SFY 2012-13

Early Intervention Reform Proposal. GOVERNOR CUOMO’S EXECUTIVE BUDGET SFY 2012-13. Goals. 2. Stabilize program funding Reduce administrative burden and provide fiscal relief to local governments

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GOVERNOR CUOMO’S EXECUTIVE BUDGET SFY 2012-13

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  1. Early Intervention Reform Proposal GOVERNOR CUOMO’S EXECUTIVE BUDGET SFY 2012-13

  2. Goals 2 • Stabilize program funding • Reduce administrative burden and provide fiscal relief to local governments • Improve access and quality of care by integrating early intervention services with other service systems, including Medicaid Managed Care, Child Health Plus, and OPWDD waiver programs for individuals with developmental disabilities 01/01/02

  3. Goals 3 • Increase insurance revenues by aligning insurance claiming for early intervention services with claiming for health care services • Achieve efficiencies and improve accountability in fiscal operations by establishing a centralized State Fiscal Agent under the authority of the Department • Control administrative costs and direct State funding to direct care or services 01/01/02

  4. How will this proposal impact EIP providers? 4 • All EIP providers must be approved by the Department • Providers may be required to enter into agreements with the Department to deliver evaluations, service coordination services, or early intervention services • Providers will no longer enter into contracts with municipalities to deliver EIP services 01/01/02

  5. Impact on EIP providers 5 • An “arms length” relationship will be required between the service coordinator, evaluator, and service provider authorized to provide services to the child • The service coordinator, evaluator, or provider delivering services to the child cannot be from the same agency • Applies to employees and contractors • The Department, in consultation with the EIO, may determine that an approved provider is the only appropriate provider for a child and waive the arms length requirement 01/01/02

  6. Impact EIP providers 6 • Providers will be required to establish and maintain contracts or agreements with a sufficient number of insurers, including Medicaid and CHP • The Department will determine the number of insurers considered sufficient for the approved provider • The Department may choose to approve a provider without contracts/agreements with insurers if the provider offers a service that meets a unique need • Providers will be required to submit information and documentation to the Department about their contracts/agreements with insurers • Department approval will be terminated if documentation is not acceptable to the Department or not submitted 01/01/02

  7. Impact on EIP providers 7 • Providers will be required to use the Department’s Fiscal Agent and data system for all EI claiming • The State FA will bill third party payors, including Medicaid, on behalf of the provider • When insurance benefits are available, payment will be at rates negotiated with insurers • Providers must accept payments made by insurers as payment in full 01/01/02

  8. Impact on EIP Providers 8 • When third party coverage is not available or has been exhausted, payment will be at rates set by the Department • If a provider’s claim to an insurer is denied on any other basis, and the service is a covered service in the child’s policy, the provider must exhaust all appeals prior to claiming to the municipality via the SFA • The provider cannot delay or discontinue services to eligible children during the appeals process 01/01/02

  9. Impact on EIP Providers 9 • Service coordination providers will be responsible for • Notifying OPwDD if a child is potentially eligible for OPwDD services • Ensuring IFSPs are implemented in a timely manner in accordance with State standards • Selecting EIP providers to deliver services in the IFSP who are • Approved by the Department • Under contract or agreement with the child’s insurer, unless • No provider in the insurer’s network is available or appropriate to serve the child and family, as determined by the insurer • Benefits have been exhausted 01/01/02

  10. Impact on EIP Providers 10 • Service coordinators will be required to report to the municipality on delivery of services to eligible children • Municipalities will specify the format • If the municipality finds that service coordinators have not been performing their duties to implement the IFSP, the municipality may request • The municipality may request a parent to select a new service coordinator if the service coordinator is not performing his or her responsibilities, or if IFSP services have not been provided • Service coordinators will be responsible for notifying school districts of the potential transition of a child receiving EI services to preschool special education services and convening transition conferences 01/01/02

  11. What are the proposed requirements for insurers? 11 • Effective date: January 1st, 2013 • As policies are amended, renewed, established • Public (Medicaid and Child Health Plus) and private insures will be required to: • Include State-approved EI providers in networks • Negotiate rates of payment for EI services with State-approved EI providers • Demonstrate to the Department that, by 1/1/2013 and every subsequent three year review, an adequate network of approved EI providers is maintained to deliver evaluations and EI services to covered children and families 01/01/02

  12. Proposed Requirements for Insurers 12 • Supply municipalities and service coordinators with information on the extent of benefits available to a covered child within 15 days of receiving a request for this information and parent consent to release the information • Participate in IFSP meetings for covered children when available to attend • Arrangements may be made for participation by phone or other means (e.g., written input) if not available on the date of the meetings • Decisions about services included in the IFSP will continue to be made by consensus and based on child and family needs 01/01/02

  13. Proposed Requirements for Insurers 13 • If in-network providers are not available to begin evaluations or provide timely services needed by children and families, payment is at the State-established rate for services delivered by approved EIP providers • If the child needs a specialized provider outside of the network, as determined by the insurer, payment is at the State-established rate for services delivered by approved EIP Providers • Deliver appropriate and timely care to EI children, in compliance with Public Health Law and IDEA 01/01/02

  14. Proposed Requirements for Insurers 14 • For children in Medicaid Managed Care • Health services will be included in MMC reimbursement and delivered by network providers at negotiated rates • Claims for EI services not in plan benefits (e.g. special instruction) will continue to be reimbursed at State fee-for- service rates, funded by local and State funds • Premiums will be adjusted to account for added costs due to delivery of EI health-related services by Medicaid Managed Care plans 01/01/02

  15. Proposed Requirements for Insurers 15 • Child Health Plus Plans • Must pay for EI services up to the scope and level of coverage for the same services included in benefit packages for all children • For children in CHP, when benefits are exhausted and for non-covered services (e.g., special instruction), claims for EI services will continue to be reimbursed at State fee-for-service rates and paid for by local and State funds 01/01/02

  16. Proposed Requirements for Insurers 16 • Insurers will be required to use of Department Fiscal Agent and data system to: • Accept claims for payment approved EIP providers • Provide the Department with information on claims submitted for evaluations and early intervention services provided to children under the EIP, including disposition of claims • Use of the Department fiscal agent and data system will streamline and improve the efficiency of payment and claiming process, comply with HIPAA standards, and assure accountability in use of public funds 01/01/02

  17. How will this proposal impact municipalities? 17 • Municipalities will continue to be responsible for: • Child Find (accepting/managing referrals to the EIP) • Designating Initial Service Coordinators • May continue to directly provide service coordination services as an agency provider approved to deliver these services • Reviewing evaluations and eligibility determinations • Convening IFSP meetings and authorizing services in IFSPs • Payment of local share of EIP services 01/01/02

  18. Impact on Municipalities 18 • Municipalities will continue to be responsible for ensuring IFSP services are delivered, via oversight of service coordinators, including • Implementing and reviewing reports submitted by service coordinators • Requesting parents select a different service coordinator if • Service coordinator fails to meet responsibilities • IFSP services are not provided 01/01/02

  19. Impact on Municipalities 19 • Local Administrative burden will be reduced by eliminating municipalities responsibilities for • Contracting with EIP providers and arranging for EIP services • Paying providers • Claiming third party payers for EIP services • Notice to school districts and convening transition conferences for toddlers potentially eligible for preschool special education services • All payment and claiming functions will be managed by the State Fiscal Agent • Municipalities must grant sufficient authority to the fiscal agent to act on their behalf 01/01/02

  20. How will this impact municipalities? 20 • Local fiscal burden will be reduced by using ALL increased insurance revenues to: • Eliminate the current payment lag in reimbursement of the State share of EI services • Department will have the discretion to pay counties prior to April 1st of the program year (July 1-June 30) in which payments are made for EI services • Once the lag is eliminated, the Department may, with DOB approval, increase the State share of EI services • The 2% across the board reduction in Medicaid payments for early intervention services is being eliminated 01/01/02

  21. How will this impact children and families? 21 • Children will still be referred to municipalities • EIO/Ds will still assign initial service coordinators to families • Families will still choose their child’s evaluator and ongoing service coordinator • IFSPs will still be a team decision and municipalities will authorize services in the plan • Services will still be at no cost to families • Families’ insurance will still only be billed if the child’s policy is regulated by the state, or with the parent’s consent 01/01/02

  22. What will change for children and families? 22 • If the service coordinator in consultation with the evaluator determine a child referred to EI may be eligible for OPwDD services, the service coordinator will notify the regional DDSO, with parent consent • Families of children found eligible for OPwDD services will have the option of • Entering the EIP and receiving “wrap around” services from OPwDD • Opting out of the EIP and receiving services for their children through the OPwDD system 01/01/02

  23. Changes for children and families 23 • For insured children referred to the EIP on or after January 1, 2013: • Parents will be required to select an approved evaluator in their insurer’s network • A representative from the child’s insurance plan will be invited to participate in IFSP meetings • IFSP meetings will not be delayed or cancelled if the insurer’s representative is not available to participate • If the insurer’s representative is unable to attend, arrangements may be made for other means of participation (e.g., by phone) • IFSP decisions are made by team consensus 01/01/02

  24. Changes for Children and Families 24 • Parents will be required to use EIP providers in their insurers’ network for covered EI services, except when • EI evaluations and services cannot be provided by an in-network provider in required timeframes • Insurance benefits have been exhausted • The insurer determines the child has a need for an evaluation or service that cannot be met by an in-network provider • If no in-network provider is available or appropriate, the child will receive services from an approved EI provider who can meet those needs • Payment to provider will at the State rate 01/01/02

  25. Will current protections for families’ insurance policies remain in place? 25 • Yes • Families will continue to receive EI services at no cost • The municipality and State, via the State Fiscal Agent, will pay any co-payments and deductibles required for use of insurance for EI services 01/01/02

  26. EI Reform Proposal – Fiscal Impact 26 01/01/02

  27. How will this proposal impact the State? 27 • New contract with Statewide Fiscal Agent • State savings will be accrued through increased commercial insurance reimbursement, to apply to mandate relief • Efficiencies in State EIP operations through the Fiscal Agent and consolidation of certain State-level functions, including approval of EIP providers under the Department’s authority • Streamlining of reporting requirements, with emphasis on performance-based measures 01/01/02

  28. Executive Order No: 38 28 • Limits State-funded Administrative and Executive Compensation • Requires Commissioners of Executive Agencies that provide State financial assistance or authorized payments to providers of services, including DOH, to promulgate regulations and take other actions to: • Address the extent and nature of a provider’s administrative costs and executive compensation eligible to be reimbursed with State funds 01/01/02

  29. Executive Order No: 38 29 • Each agency’s regulations must include requirements that providers of services that receive reimbursement directly, or indirectly, from the State must comply with the following restrictions: • No less than 75% of State payments to a provider for operating expenses must be direct to provide direct care servcies • Percentage increased by 5% each year until April 1, 2015, at which point the percentage will remain at 85% • State payments shall not be provided for compensation paid or given to any executive in the amount greater than $199,000 annually • Commissioners have discretion to adjust this figure annually based on appropriate factors, subject to DOB approval 01/01/02

  30. Executive Order No: 38 30 • A provider’s failure to comply with regulations may form the basis for termination or non-renewal of the agency’s contract with, or continued support of the provider • Waivers may be granted under appropriate circumstances and with good cause • Commissioners are required to regularly obtain data from providers that is needed to monitor compliance with these requirements • Report annually to DOB on the impact of these requirements on use of public funds 01/01/02

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