A bill aimed at making it easier for parents to get Early Intervention services for their children without complications from the health insurance industry passed both houses of the Legislature during the last days of session last month It is now on its way to Governor Andrew Cuomo’s desk for his veto or approval signature.
Insurers have often been accused of stalling or refusing to pay for these services. The Early Intervention services are made possible by companies, known as providers, who offer physical therapy, occupational therapy and speech therapy, among other services.
“When an Early Intervention service provider renders services, they must bill the health insurance company first. Typically, insurance companies reject over 85 percent of claims, which means providers do not get paid,” said the bill’s sponsor, Assemblymember Amy Paulin (D-Scarsdale, Westchester County).
“In New York State, Early Intervention services are guaranteed for children under the age of three by state law and so any claims unpaid by insurance companies are ultimately paid by New York State, which charges local counties for the cost of the services. This process can take weeks, months, or even years to sort out and often means that providers do not receive reimbursement in a timely manner. This also results in counties and municipalities paying for tens of millions of dollars in services that are ultimately paid for by the local taxpayer.
“It is critical that children with developmental delays and special needs receive the early intervention services they need, as soon as possible. Streamlining the reimbursement process will help these families. At the same time, it will provide relief to property taxpayers by requiring insurance companies to pay their fair share and reduce the costs to the counties and state,” Paulin added.
During the floor debate on the bill, Assemblyman Kevin Cahill (D-Kingston, Ulster County), chairman of the Assembly Insurance Committee, pointed out that the insurance companies are not always at fault for delaying payments.
“Low-wage (program) providers are required to file claims,” Cahill said. “When they file claims they don’t always know what they’re doing. They often file claims for things that are not covered by benefits. They often file claims wrong. They often file claims late. In those instances they go through a claims appeal process. At the end they go through an external review process. It’s not the insurance company that decides who pays. It is the external review process that has decided that insurance companies will pay only $15 million instead of $80 million worth of claims. It is not the insurance companies. It is clear that some of those claims should have been paid if they were timely filed and properly filed.”
During his closing remarks of the debate, Cahill asserted that the bill is really a $40 million tax on taxpayers in New York State.
The plan raises $40 million by expanding the Covered Lives Assessment fee on health insurance policies, improving a funding stream in place since 2013 that has caused extensive delays in reimbursements to providers. This led many Early Intervention service providers to shut their doors.
“This new funding mechanism will ensure that providers receive reimbursement payments directly from the state via a fund paid for in advance by the health insurance industry,” according to Paulin.
“We have an awful lot of little kids, babies, who are not receiving the services they are supposed to get because the providers have left the field, because they were supposed to be collecting from the insurance companies,” argued Assemblyman Thomas Abinanti (D-Greenburgh, Westchester County), who has a son, Justin, with autism. “Imagine being a provider and figuring out which rejected claims they should contest and which ones they shouldn’t.” he said. “That’s what they’re facing. This bill is saying …let’s just assess the insurance companies an appropriate amount, let them kick into the system, they don’t need the paperwork and certainly the providers don’t need the paperwork.”
In the state Senate, Anthony Palumbo (R-New Suffolk, Suffolk County) spoke out against the measure, saying, “Simply taking the cost, adding a $40 million tax, in the overall scheme of things it’s not a huge percentage of the entire plan but these are numbers that are only eventually going to be passed off to the consumers. My concern is for the insurer and to strike that proper balance. So even though this is a laudable goal, this isn’t the means or the way we can achieve it.
While defending the measure, the bill’s sponsor, Senator Elijah Reichlin-Melnick (D-Nyack, Rockland County), admitted that the bill is not the final step and that additional tweaks may be needed.
“My bill will create a statewide Early Intervention pool that will use the Covered Lives Assessment to contribute to the state and county cost of the Early Intervention program,” said Reichlin-Melnick. “This bill will provide savings to state and county governments which currently pay the cost of denied insurance reimbursement by third party payers. …This bill will help support the Early Intervention program and providers by addressing significant changes made back in 2013 to the manner in which Early Intervention providers were paid.
Reichlin-Melnick admitted that if the bill is passed and implemented, the health insurance companies would probably institute a slight rate increase to recover its lost revenue.
“We are not talking about a significant increase and we’re talking about something that is going to make a meaningful difference in the lives of thousands of kids around New York and their families. … The current system is not working.
Assemblyman Richard Gottfried (D-Midtown Manhattan), chairman of the Assembly Health Committee, said, “Health plans should pay for health care. Early Intervention is health care.
“This is really the only practical mechanism we have to make sure that health plans in New York do pay for this critically important piece of health care. This measure solves a serious problem that has been torturing infants and toddlers and the professionals who try to serve them and its torture that has been going on primarily to serve the stockholders of insurance companies. It’s time for a change.”
Gottfried continued: “We will take $40 million, which is roughly what they ought to be paying for Early Intervention, we’ll just take that from this fund called the Covered Lives Assessment.”
Assemblywoman Melissa “Missy” Miller put a personal twist on the debate as she told her colleagues she has two children who benefited from the Early Intervention program. She called it “the gold standard.” Miller’s oldest daughter, Melanie, died at age seven from a rare genetic disease. She and her husband, Brandon, have raised two other children, Oliver and Katy, both with complicated medical issues. Oliver, 21, suffered a stroke before he was born and continues to endure severe seizures.
“Not being able to get the necessary services ultimately means that these kids in need that don’t get the services and resources become bigger burdens later in life,” Miller (R-Atlantic Beach, Nassau County), said. “These kids have a chance to catch up. They have a chance to be less needy and to get some kids back on track even. The early push was recognized as critical if we get to these kids early in their first three years. It seems to have lost its value to the current administration.
Advocacy groups were quick to commend the legislation and urge the governor to sign it into law.
“Too many private health insurers refuse to pay their fair share for these services, passing the buck on to taxpayers,” said Stephen Acquario, executive director of the New York State Association of Counties. “This legislation is a massive step forward in reforming and strengthening the Early Intervention program so that more children can get the help they need, when they need it. The legislation will ensure children with special needs have access to the services that allow them to reach their fullest potential.”