NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A273A
SPONSOR: Paulin (MS) TITLE OF BILL:
An act to amend the public health law, in relation to funding early
intervention services
PURPOSE OR GENERAL IDEA OF BILL:
To provide a system that streamlines the process by which funds are
distributed to municipalities to finance early intervention programs,
thereby providing vital relief to the municipalities across the state,
and to improve their ability to more effectively administer early inter-
vention services to children who need such services.
SUMMARY OF SPECIFIC PROVISIONS:
Section one amends the public health law by adding a new section 2807-o
that provides definitions for terms used in this section of law. Section
one also provides that the commissioner of health shall make grants to
municipalities for the delivery of early intervention services. Such
grants shall be deemed reimbursements from third party payors to the
municipalities and the State and shall be a share of grants equal to the
proportionate share of the municipality and the State, as the case may
be, of the total approved statewide dollars not reimbursable. by the
medical assistance program paid by municipalities and the State to
providers of early intervention services in the last complete state
fiscal year for which such data is available.
Section two amends subdivision 6 of section 2807-s of the public health
law by adding two new paragraphs (g) and (h). Paragraph (g) provides
that a further gross statewide amount for two thousand seventeen shall
be one hundred fifteen million dollars. Paragraph (h) provides that the
one hundred fifteen million dollars specified in paragraph (g) shall be
allocated among the municipalities and the State based on the share of
each municipality and the State of early intervention program expendi-
tures not reimbursable by the medical assistance program for the latest
twelve month period for which such data is available.
Section three amends subdivision 7 of section 2807-s of the public
health law by adding a new paragraph (d) that provides that funds shall
be added to the funds collected by the commissioner for distribution in
accordance with section 2807-o, in the amount of one hundred fifteen
million dollars for the period January 1, 2017 through December 31,
2017.
Section four amends 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,
to delete the reference to a plan of insurance so that benefits under
this title shall be considered secondary only to any state government
benefit program under which an eligible child may have coverage, and to
delete the provision that nothing in this section shall increase or
enhance coverages provided for within an insurance contract subject to
the provisions of this title.
Section five amends section 2557 of the public health law by adding a
new subdivision 4 to require the commissioner to collect data, by muni-
cipality, on the early intervention program for purposes of improving
the efficiency, cost effectiveness and quality of the program. Data to
be collected shall include the number of children enrolled in the
program, the number of state-approved agencies and organizations provid-
ing early intervention services by service specialty and the number of
state-approved independent providers of early intervention services by
service specialty, the number of state-approved evaluators, the number
of children covered by the medical assistance program, the number of
claims submitted to the medical assistance program by municipality, the
percentage claims denied by medical assistance and the reasons for the
denials. The commissioner shall report for the period July 1, 2017 to
December 31, 2017 and for each calendar year thereafter, to the Governor
and the Legislature by March 1 of each year the information and analysis
required by this section.
Section six amends subdivision 2 of section 2557 of the public health
law, as amended by section 9-a of part A of chapter 56 of the laws of
2012, to provide that the department shall reimburse the approved costs
paid by a municipality other than those reimbursable by the medical
assistance program, eliminating the exclusion of costs reimbursable by
third party payors.
Section seven amends the section heading of section 2559 of the public
health law, as added by chapter 428 of the laws of 1992, to eliminate
the reference to third party insurance.
Section eight amends subdivision 3 of section 2559 of the public health
law, as added by chapter 428 of the laws of 1992, paragraphs (a), (c)
and (d) as amended by section 11 of part A of chapter 56 of the laws of
2012 and paragraph b as further amended by section 104 of Part A of
chapter 62 of the laws of 2011, to provide that providers shall first
seek payment from the medical assistance program rather than third party
payors including governmental agencies, prior to claiming payment from a
municipality for services rendered, though not when the insured is not
eligible for medical assistance pursuant to the social services law.
Section eight also deletes paragraphs (b) requiring the commissioner to
promulgate regulations providing public reimbursement for deductibles
and copayments imposed under an insurance policy or health benefit plan
to the extent that such deductibles and copayments are applicable to
early intervention services and (c) requiring that payments made for
early intervention services under an insurance policy or health benefit
plan provided as part of an IFSF shall not be applied against any maxi-
mum lifetime or annual limits specified in the policy or health benefit
plan. In addition, section eight provides that a municipality shall be
subrogated to the extent of its expenditures for early intervention
services furnished to eligible persons to the rights such person may
have from the medical assistance program rather than from third party
reimbursement. Except as provided in this article, no third party payor
other than the medical assistance program shall be required to reimburse
for early intervention services.
Section nine provides the effective date.
JUSTIFICATION:
The early intervention program was established under the Public Health
Law and the federal Individuals with Disabilities Education Act (IDEA)
to enhance the development of infants and toddlers from birth to age
three who have a significant developmental delay or disability, as well
as enhance the capacity of families to meet their children's special
needs. The program seeks to identify and evaluate as early as possible
those infants and toddlers whose healthy development is compromised and
to provide for appropriate therapeutic and supportive services. With
early intervention, we can reduce the number of children with disabili-
ties or reduce the severity of their disabling conditions.
All early intervention (El) services must be provided to eligible chil-
dren at no cost to their families. The EI program is financed through a
combination of state and county funds, Medicaid and commercial insur-
ance. Although Public Health Law and IDEA mandate that public and
private commercial insurance be maximized in financing El services,
reimbursement from third party payors, other than Medicaid, has been
minimal, leaving the cost of this entitlement to be paid by state and
municipal tax dollars.
In 2005 an aggregate 893,000 claims were submitted to commercial insur-
ers; 70% of the claims were denied. Further, according to a survey by
the New York State Association of County Health Officials, for the peri-
od July 2003 to June 2004, $75.5 million in claims for EI services were
filed with commercial insurers, of which $10.6 million, or 14%, was
paid. Counties, which are required by the State to finance and adminis-
ter the El program, are entitled to be reimbursed by the State for 50%
of their unreimbursed costs for EI services (36% for administration
costs). Counties have billed private insurers approximately $100
million, overshadowing the aggregate costs billed to Medicaid. The
partial funding by the State, combined with the low rate of recoupment
from third party insurers, has required municipalities to bear an esti-
mated 43% of the costs of providing EI services.
To require municipalities to bear such a significant portion of the
costs of the program where the number of children served as well as the
level of services provided continues to increase imposes a significant
strain on local budgets. In New York City alone, for the last six months
of 2005, an estimated $213.1 million was incurred for EI services, of
which $800,000 was paid by commercial insurance. Whereas in 1993 to
1994, the first year the EI program became effective, the costs of EI
services for the entire State was $40 million. Since a substantial
portion of municipal budgets must be spent on EI services, munici-
palities must face a shrinking balance of available funds, forcing them
to decrease or eliminate altogether other needed services.
Recognizing that the current structure of financing EI costs is inade-
quate, this bill provides a different approach to funding. The bill
would set up a statewide pool from which municipalities and the State
would be allocated funds to pay EI costs. For the first year, an amount
of $115M would be paid into the pool. This amount is based on the
approximate percentage commercial insurers pay of total EI program costs
(utilizing data from the 2012-13 program year) increased by the esti-
mated amount paid by commercial insurers related to mandated coverage
for autism spectrum disorder.
By allowing for the direct allocation of funds to municipalities from
the statewide pool, we will eliminate the unwieldy and inefficient step
of requiring municipalities (in the case where the insured is not eligi-
ble for medical assistance) to seek reimbursement of El costs first from
third party insurers and then, only upon denial or other disposition of
the claim, from the State. In cases where the insured is eligible for
medical assistance, municipalities will remain obligated to seek
reimbursement first from the medical assistance program.
Making funds readily available and streamlining the process by which the
funds are distributed to municipalities and the State will provide vital
relief to the State and the municipalities across the state that have
been struggling to finance the EI program and thereby improve their
ability to more effectively administer EI services to children who need
those services.
PRIOR LEGISLATIVE HISTORY:
A.6517-A, 2013 and 2014 referred to health.
A.812, 2011 and 2012 reported referred to ways and means.
A.4058-A, 2009 reported referred to ways and means and 2010 held for
consideration in ways and means.
A.6814-A, 2007 reported referred to ways and means and 2008 amended and
recommitted to ways and means.
FISCAL IMPLICATIONS:
This bill will have no fiscal impact to the State and will in fact
generate revenue to the State. The State currently bears approximately
97% of the total EI program costs, with commercial insurers paying 3%.
The bill contemplates that commercial insurers will pay into a fund 15%
of the program costs with the State and municipalities sharing such
funded amount.
EFFECTIVE DATE:
This act shall take effect on the thirtieth day after it shall become a
law; provided, however the amendments to section 2807-s of the public
health law made by sections two and three of this act shall not affect
the expiration of such section and shall be deemed to expire therewith.
STATE OF NEW YORK
________________________________________________________________________
273--A
2015-2016 Regular Sessions
IN ASSEMBLY(Prefiled)
January 7, 2015
___________
Introduced by M. of A. PAULIN, GOTTFRIED, CAHILL, CLARK, COOK, GALEF,
GUNTHER, JAFFEE, LIFTON, MARKEY, LAVINE, MAGNARELLI, DINOWITZ, BENE-
DETTO, LUPARDO, TITONE -- read once and referred to the Committee on
Health -- recommitted to the Committee on Health in accordance with
Assembly Rule 3, sec. 2 -- reported and referred to the Committee on
Ways and Means -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee
AN ACT to amend the public health law, in relation to funding early
intervention services
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. The public health law is amended by adding a new section
2 2807-o to read as follows:
3 § 2807-o. Early intervention services pool. 1. Definitions. The
4 following words or phrases as used in this section shall have the
5 following meanings:
6 (a) "Early intervention services" shall mean services delivered to an
7 eligible child, pursuant to an individualized family service plan under
8 the early intervention program.
9 (b) "Early intervention program" shall mean the early intervention
10 program for toddlers with disabilities and their families as created by
11 title two-A of article twenty-five of this chapter.
12 (c) "Municipality" shall mean any county outside of the city of New
13 York or the city of New York.
14 2. Grants for early intervention services. (a) The commissioner shall,
15 from funds allocated for such purpose under paragraph (g) of subdivision
16 six of section twenty-eight hundred seven-s of this article, make grants
17 to municipalities for the delivery of early intervention services. Such
18 grants shall be deemed reimbursement from third party payors to such
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD00282-03-6
A. 273--A 2
1 municipalities and the state of New York for the purposes of the early
2 intervention program.
3 (b) Grants under this subdivision shall be awarded to municipalities
4 by the commissioner. Each municipality and the state of New York shall
5 receive a share of such grants equal to its proportionate share of the
6 total approved statewide dollars not reimbursable by the medical assist-
7 ance program paid to providers of early intervention services by the
8 state and municipalities on account of early intervention services in
9 the last complete state fiscal year for which such data is available.
10 § 2. Subdivision 6 of section 2807-s of the public health law is
11 amended by adding two new paragraphs (g) and (h) to read as follows:
12 (g) A further gross statewide amount for two thousand seventeen shall
13 be one hundred fifteen million dollars.
14 (h) The amount specified in paragraph (g) of this subdivision shall be
15 allocated among the municipalities and the state of New York based on
16 each municipality's share and the state's share of early intervention
17 program expenditures not reimbursable by the medical assistance program
18 for the latest twelve month period for which such data is available.
19 § 3. Subdivision 7 of section 2807-s of the public health law is
20 amended by adding a new paragraph (d) to read as follows:
21 (d) funds shall be added to the funds collected by the commissioner
22 for distribution in accordance with section twenty-eight hundred seven-o
23 of this article, in the following amount: one hundred fifteen million
24 dollars for the period January first, two thousand seventeen through
25 December thirty-first, two thousand seventeen.
26 § 4. Subdivision 1 of section 2557 of the public health law, as
27 amended by section 4 of part C of chapter 1 of the laws of 2002, is
28 amended to read as follows:
29 1. The approved costs for an eligible child who receives an evaluation
30 and early intervention services pursuant to this title shall be a charge
31 upon the municipality wherein the eligible child resides or, where the
32 services are covered by the medical assistance program, upon the social
33 services district of fiscal responsibility with respect to those eligi-
34 ble children who are also eligible for medical assistance. All approved
35 costs shall be paid in the first instance and at least quarterly by the
36 appropriate governing body or officer of the municipality upon vouchers
37 presented and audited in the same manner as the case of other claims
38 against the municipality. Notwithstanding the insurance law or regu-
39 lations thereunder relating to the permissible exclusion of payments for
40 services under governmental programs, no such exclusion shall apply with
41 respect to payments made pursuant to this title. Notwithstanding the
42 insurance law or any other law or agreement to the contrary, benefits
43 under this title shall be considered secondary to any [plan of insurance
44 or] state government benefit program under which an eligible child may
45 have coverage. [Nothing in this section shall increase or enhance cover-
46 ages provided for within an insurance contract subject to the provisions
47 of this title.]
48 § 5. Section 2557 of the public health law is amended by adding a new
49 subdivision 4 to read as follows:
50 4. The commissioner shall collect data, by municipality, on the early
51 intervention program authorized under this title for purposes of improv-
52 ing the efficiency, cost effectiveness, and quality of such program.
53 Such municipality data collection shall include but not be limited to:
54 (a) The number and ages of children enrolled in the early intervention
55 program;
A. 273--A 3
1 (b) The total number of children, within a municipality, receiving a
2 single service, the percentage of those children by service type, and
3 the average frequency of visits per week for such service type;
4 (c) The total number of children, within a municipality, receiving
5 multiple services, the percentage of those children by service type, the
6 average frequency of visits per week for such service type and the aver-
7 age number of service types that each child receives;
8 (d) The number of New York state approved agencies, institutions, or
9 organizations providing early intervention services by service specialty
10 or specialties and the number of New York state approved independent
11 providers of early intervention services by service specialty or
12 specialties;
13 (e) The number and percentage of children receiving a single service
14 by type of New York state approved service provider, and the number and
15 percentage of children receiving multiple services by type of New York
16 state approved service provider;
17 (f) The overall number of New York state approved evaluators. The
18 number of approved evaluators who also provide services to early inter-
19 vention children they have evaluated;
20 (g) The number of families receiving family supportive services such
21 as family training, counseling, parent support groups, and respite;
22 (h) The types of clinical practice guidelines, evaluation tools and
23 testing instruments used by municipalities to establish eligibility or
24 need for early intervention services;
25 (i) Both service, cost and payment oversight mechanisms used by coun-
26 ties to ensure quality and efficient delivery of early intervention
27 services;
28 (j) The number of children that are covered by the medical assistance
29 program;
30 (k) The number of claims submitted to the medical assistance program
31 by municipality. The percentage of claims denied by the medical assist-
32 ance program. The reasons for the denials.
33 The commissioner shall collect and analyze such data elements to
34 determine service and utilization patterns and to enhance the depart-
35 ment's ongoing provision of program oversight and guidance. In addition,
36 the commissioner shall report for the period July first, two thousand
37 seventeen to December thirty-first, two thousand seventeen, and for each
38 calendar year thereafter, to the governor and the legislature, by March
39 first of each year, the information and analysis required by this subdi-
40 vision.
41 § 6. Subdivision 2 of section 2557 of the public health law, as
42 amended by section 9-a of part A of chapter 56 of the laws of 2012, is
43 amended to read as follows:
44 2. The department shall reimburse the approved costs paid by a munici-
45 pality for the purposes of this title, other than those reimbursable by
46 the medical assistance program [or by third party payors], in an amount
47 of fifty percent of the amount expended in accordance with the rules and
48 regulations of the commissioner; provided, however, that in the
49 discretion of the department and with the approval of the director of
50 the division of the budget, the department may reimburse municipalities
51 in an amount greater than fifty percent of the amount expended. Such
52 state reimbursement to the municipality shall not be paid prior to April
53 first of the year in which the approved costs are paid by the munici-
54 pality, provided, however that, subject to the approval of the director
55 of the budget, the department may pay such state aid reimbursement to
56 the municipality prior to such date.
A. 273--A 4
1 § 7. The section heading of section 2559 of the public health law, as
2 added by chapter 428 of the laws of 1992, is amended to read as follows:
3 [Third party insurance and medical] Medical assistance program
4 payments.
5 § 8. Subdivision 3 of section 2559 of the public health law, as added
6 by chapter 428 of the laws of 1992, paragraphs (a), (c) and (d) as
7 amended by section 11 of part A of chapter 56 of the laws of 2012 and
8 paragraph (b) as further amended by section 104 of part A of chapter 62
9 of the laws of 2011, is amended to read as follows:
10 3. (a) Providers of evaluations and early intervention services, here-
11 inafter collectively referred to in this subdivision as "provider" or
12 "providers", shall in the first instance and where applicable, seek
13 payment from [all third party payors including governmental agencies]
14 the medical assistance program prior to claiming payment from a given
15 municipality for evaluations conducted under the program and for
16 services rendered to eligible children, provided that, the obligation to
17 seek payment shall not apply [to a payment from a third party payor who
18 is not prohibited from applying such payment, and will apply such
19 payment, to an annual or lifetime limit specified in the insured's poli-
20 cy] where the insured is not eligible for medical assistance pursuant to
21 the social services law.
22 (i) Parents shall provide the municipality and service coordinator
23 information on any insurance policy, plan or contract under which an
24 eligible child has coverage.
25 (ii) Parents shall provide the municipality and the service coordina-
26 tor with a written referral from a primary care provider as documenta-
27 tion, for eligible children, of the medical necessity of early inter-
28 vention services.
29 (iii) providers shall utilize the department's fiscal agent and data
30 system for claiming payment for evaluations and services rendered under
31 the early intervention program.
32 (b) [The commissioner, in consultation with the director of budget and
33 the superintendent of financial services, shall promulgate regulations
34 providing public reimbursement for deductibles and copayments which are
35 imposed under an insurance policy or health benefit plan to the extent
36 that such deductibles and copayments are applicable to early inter-
37 vention services.
38 (c) Payments made for early intervention services under an insurance
39 policy or health benefit plan, including payments made by the medical
40 assistance program or other governmental third party payor, which are
41 provided as part of an IFSP pursuant to section twenty-five hundred
42 forty-five of this title shall not be applied by the insurer or plan
43 administrator against any maximum lifetime or annual limits specified in
44 the policy or health benefits plan, pursuant to section eleven of the
45 chapter of the laws of nineteen hundred ninety-two which added this
46 title.
47 (d)] A municipality, or its designee, and a provider shall be subro-
48 gated, to the extent of the expenditures by such municipality or for
49 early intervention services furnished to persons eligible for benefits
50 under this title, to any rights such person may have or be entitled to
51 from [third party reimbursement] the medical assistance program. The
52 provider shall submit notice to the insurer or plan administrator of his
53 or her exercise of such right of subrogation upon the provider's assign-
54 ment as the early intervention service provider for the child. The right
55 of subrogation does not attach to benefits paid or provided [under any
56 health insurance policy or health benefits plan] prior to receipt of
A. 273--A 5
1 written notice of the exercise of subrogation rights [by the insurer or
2 plan administrator providing such benefits]. Notwithstanding any incon-
3 sistent provision of this title, except as provided for herein, no third
4 party payor other than the medical assistance program shall be required
5 to reimburse for early intervention services provided under this title.
6 § 9. This act shall take effect on the thirtieth day after it shall
7 have become a law; provided, however the amendments to section 2807-s of
8 the public health law made by sections two and three of this act shall
9 not affect the expiration of such section and shall be deemed to expire
10 therewith.
