NYSAC EXPANDED FACT SHEET:
The SFY 2012 Governor's Budget Proposal for Children with Special Needs
Governor Cuomo’s 2012-13 Budget includes several reform measures for the Early Intervention health services and pre-school special education programs. If enacted these reform proposals would significantly streamline administrative of these programs, more efficiently align responsibility among payers reduce future costs to Counties, thereby reducing the burden that State mandates place on property taxes.
Early Intervention Program
New York State’s Early Intervention (EI) program provides many services to children under three years of age that have developmental delays or disabilities regardless of a family’s income. In 2010 the total expenditures for the EI program was approximately $650 million with the Counties required to spend $330 million under State law. Recent data revealed that Counties submit to third party insurers between $90-100 million in claims for eligible EI services of which only about two percent of claims are being reimbursed.
The Governor’s Reform Proposals
The Governor proposal includes several reform measures to the Early Intervention (EI) program that if enacted would:
· Reduce administrative burdens to counties, while also providing mandate relief;
· Improve access and quality of care by integrating EI services with other service systems including: Medicaid Managed Care (MMC); Child Health Plus (CHP); and Office for People with Developmental Disabilities (OPWDD) waiver programs;
· Increase revenues by aligning insurance claiming for EI services with claiming for health care services; and
· Achieve efficiencies and improve accountability in fiscal operations by establishing a centralized State fiscal agent.
Third Party (Insurance) Reforms
In order to ensure that insurance companies through out New York State provide “covered services” to children enrolled in the Early Intervention (EI) program the Governor’s proposal seeks to increase the amount of insurance reimbursement for eligible services provided under the EI program by closing many of the existing loopholes. Insurers would deliver appropriate and timely care to EI children as required under New York State Public Health Law and the Individuals with Disabilities Education Improvement Act (IDEA). Highlights of the insurance reform measures are:
· Insurers (including Medicaid and the Child Health Plus, CHP, Program) would no longer be able to deny coverage for “covered services” simply because they are receiving EI services;
· Insurers would be able to impose visitation limitations for covered EI services which is consistent to their current benefits package but they would not be able to count EI services against a child’s maximum annual or lifetime limits in the benefits package;
· Insurers would be required to have an adequate network of EI evaluators and service providers. The adequacy of the network will be based on geographically accessible providers, as well as, sufficiency of EI providers in each area of specialty practices;
· Insurers are required to demonstrate to the Department of Health that an adequate network of EI evaluators and service providers is available to deliver appropriate EI services;
· Insurers would also be required to make publicly available the names of the EI evaluators and service providers in their network. This list must be updated quarterly;
· In order to provide greater coordination of services, insurer would be allowed to have a representative participate in the IFSP meetings for the child receiving EI services;
· Insurers would be required to provide, to the municipalities and the EI service coordinators, information on the extent of benefits available to a child receiving EI services within 15 days of a request for this information; and
· In those instances when an out of network provider is required, whether due to lack of timely availability of an evaluator or provider, or the child needs a specialized provider, the rate of payment would be at the State established rate for services;
EI Provider Reforms
In an effort to improve access to EI services as well as the quality of care provided to the children, the Governor includes as part of this comprehensive reform proposal for the EI program several provisions for providers of EI services, which are highlighted below:
· Effective January 1, 2013, EI providers may be required to enter into agreements with the Department of Health in order to provide evaluations, service coordination or any other EI services. Under this proposal, providers would no longer enter into contracts with each individual county;
· EI program evaluators and service providers are required to participate in the development of networks with the insurance companies and are also required to negotiate rates of payments with the insurers;
· Payments made by insurers for EI services would be considered paid in full and providers would not be able to bill municipalities for additional payments;
· If third party insurance is not available or has been exhausted, providers would be reimbursed for EI services at rates established by the Department of Health;
· Providers whose claims are denied reimbursement by the insurers must exhaust all levels of appeals before seeking payments for EI services from the municipalities. The provider would not be able to delay or discontinue services to the EI children during the appeals process; and
· In an effort to ensure the integrity of the EI program and the services provided, while also providing services in a more coordinated, effective and efficient manner, an “Arms Length” relationship between the service coordinator, the EI evaluator, and the EI provider is created under the bill. Under this proposal the service coordinator, the EI evaluator, and the service provider would no longer be allowed to be employed by or under contract with the same organization or entity.
Creation of State Fiscal Agent
The Governor proposes to create a statewide fiscal agent, which would centralize the fiscal administration of the EI program. The reform measures include:
· Counties would no longer be responsible for contracting with EI providers, administering provider payments, and obtaining third party (insurance) reimbursements, notifying school districts or convening transition conferences, and would realize savings through administrative efficiencies;
· The State fiscal agent would be granted with sufficient authority to act on behalf of the Counties;
· Insurers and providers would be required to directly bill the State’s fiscal agent;
· Claiming and reporting functions would be managed by the State fiscal agent; and
· Counties would still be responsible for:
o accepting and managing referrals to the EI program, including designating the initial service coordinators and may also continue to provide service coordination if they are an approved provider to deliver coordination services;
o reviewing evaluations and eligibility determinations; participating in IFSP meetings and authorizing services as a result of the IFSP meetings; and
o ensuring that services are provided as authorized in the IFSP, resulting in EI services to eligible children being provided in a more coordinated and effective manner.
Pre-School Special Education Services
New York State pre-school special education programs provide essential services to special needs children between the ages of three and five and serves as a bridge between the EI program and a formal Individual Education Plan (IEP) in a school setting. In New York State, Counties currently pay 40.5 percent of the costs (approximately $450 million yearly), but have no program oversight.
Pre-School Special Education Reform
The SFY 2012-13 Governor’s proposal moves towards placing responsibility for this program in the education sector by requiring school districts to now participate in the financing of programs and services that they develop and provide to eligible students. It is believed that these reform measures would result in more coordinated and effective services for the children while ensuring greater fiscal responsibility and accountability. The Executive proposed changes include:
· Requiring school districts to participate in the cost for pre-school special education services for increases above the base year. Currently, the costs of pre-school special education are borne by the State and localities split 59.5% and 40.5 % respectively. Under this proposal, the Governor would now split any costs above the base year total equally between the State, counties and school districts.
· Authorizing the Commissioner of Education to reduce the amounts owed to school districts for summer school special education, in order to collect any amounts owed by the school districts for pre-school special education;
· Providing the Counties with a greater role in the decision making process when providers request an exception to existing payment rates;
· Requiring justification by the school districts in the instances when an out of area special education provider is chosen over closer and equally qualified providers; and
· Establishing an “Arms-Length” distance between the evaluator and the provider by prohibiting children from being evaluated by the same agency that provides the educational services.