1. Private Insurance Reimbursement in the New York State – Early Intervention Program Brad Hutton, M.P.H., Part C Coordinator New York State Dept. of Health National Early Childhood Conference December 3, 2007

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9. 9 NYS Early Intervention Program  12/1/2006 child count = 30,988  58 municipalities – local programs  Serve between 2/year to 20,000/yr.  660 provider agencies  20,000 individual therapists  Racial/ethnic diversity  42% minority racial/ethnic groups  Materials in 19 languages

10. 10 Total Expenditures by Funding Source, 2005-06  $680 million in 2005-06  $277 million (40%) Medicaid  $195 million (29%) State  $195 million (29%) Counties  $11 million (2%) Private Insurance  Leading expense for counties after Medicaid  25% of Medicaid costs in NYS paid by counties with new cap enacted 2 years ago  40% of children in program have private insurance

11. 11 Payment Process  ISC obtains MA and insurance information, facilitates referral for enrollment in Medicaid, explains family protections  Rights subrogated to counties for claiming  County pays provider  County then required to:  Claim for Medicaid reimbursement  Claim for Private insurance  Claim for State reimbursement of 50% of unreimbursed costs within two years  $1 paid by private insurance equals 50c. savings to State and to counties

12. 12 Current Insurance Legislation in NYS for Early Intervention  Insurers prohibited from excluding coverage solely because services are early intervention program services  Does not include:  ERISAs  Self-insured  Contracts delivered outside of NYS

13. 13 County Private Insurance Claiming Experience, 2006  1,045,523 claims submitted for third party insurance reimbursement in 2006  69.5% were denied, many multiple times  Reasons for denial include:  22% service not covered  21% no response from insurer  11% not medically necessary  9% provider out of network  8% no preauthorization obtained  Also, location of services and duration of condition  Not just financial issue, but administrative burden with little revenue recovered

14. 14 Legislative Protections  Counties not obligated to bill if it will be applied to an annual or lifetime cap.  Public reimbursement of co-payments and deductibles  Services cannot reduce number of visits otherwise covered by plan (e.g., 10 PT visits per year)  Cannot have impact on premiums  Parents can refuse to provide insurance information and that cannot impact their eligibility or services in the program

15. 15 Administrative Efforts to Improve  Guidance Document on Commercial Insurance Claiming, 2003  Clarified claiming requirements for counties  Services that did not need to be claimed (e.g., special instruction and service coordination)  Process for appeal of denials  Prompt payment complaints – 45 days  Workgroup with counties and insurers  Likely resulted in increase from $5 million to $11 million paid per year

16. 16 Legislative History  Numerous unsuccessful attempts to modify statute to address flaws in mandate  Modification of Mandate – IFSPs shall meet all preauthorization, medical necessity, and coverage cannot be denied due to location, duration of conditions, provider out of network  Covered Lives Assessment – fee per covered lives for all insurers used to support publicly funded programs in NYS  $100 million increase proposed  Inclusion of ERISAs

17. 17 Conclusions  Funding from private insurers is essential for maintaining the financial security of programs  Insurance mandates can be effective, but the details are essential