NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A8316B
SPONSOR: Gottfried (MS)
 
TITLE OF BILL: An act to amend the public health law, the insurance
law and chapter 60 of the laws of 2014 amending the public health law
relating to payments submitted by early intervention providers to
certain third party payors, in relation to the financial responsibility
for and reimbursement of payment for early intervention services by the
state
 
PURPOSE OR GENERAL IDEA OF BILL: To clarify the role of the state's
early intervention (EI) fiscal agent and ensure timely payment to
providers so that infants and toddlers in New York State have timely
access to El services.
 
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 of the bill amends subdivision 1 of Section 2557 of the Public
Health Law to provide that El providers must be paid in full at the
State El rate by the State or the State Fiscal Agent (SFA) designated by
the New York State Department of Health (NYS DOH) at least quarterly for
claims other than Medicaid claims.
Section 2 of the bill adds a new subparagraph (i) to paragraph (a) of
subdivision (5) of Section 2557 of the Public Health to enumerate the
duties of the SFA including collaborating with EI providers to process
claims, facilitating the submission of subrogation notices to third
party payors, and issuing payments to providers.
Section 3 of the bill amends paragraph (a) of subdivision 3 of Section
2559 of the Public Health Law by adding a new subparagraph (iv) to
require the SFA to conduct a reconciliation of their third party
reimbursement at least quarterly.
Section 4 of the bill adds a new subdivision 3-a to Section 2559 of the
Public Health Law to authorize an EI provider to seek payment from the
SFA 90 days after initial-submission of a claim to a commercial health
insurance company that is not regulated by the State of New York if such
insurer has not made payment of the claim in whole or in part or
rendered a determination that it is not obligated to pay the claim.
Section 5 of the bill amends subsection c of Section 3235-a of the
Insurance Law to require insurance companies to make payments for EI
services to the provider who submits the claim, regardless of whether
the provider is in the insurer's network. In addition, it requires
remittance paperwork be transmitted to the SFA.
Section 6 of the bill amends paragraph (2) of subsection d of Section
3224-a of the Insurance Law to define El providers as providers for the
purpose of the existing Prompt Pay Law.
Section 7 amends section 19 of part A of chapter 60 of the laws of 2014,
which authorized the Department to pay providers for outstanding claims
filed between April 1, 2013 and June 30, 2013 using $3.9 million allo-
cated in the FY14 budget. Section 7 allows the Department to use any
money remaining from this pool to pay additional outstanding claims
dated after June 30, 2013.
Section 8 provides that the act shall take effect on January 1, 2015,
except for section 7 which shall take effect immediately, and shall
apply to claims other than those for the medical assistance program
submitted to third party payers after June 30, 2013.
 
JUSTIFICATION: The 2012-13 State Budget (Section 11 of Part A of
Chapter 56 of the Laws of 2012) transferred the responsibility for EI
billing from county government to an SFA under contract with NYS DOH,
effective April 1, 2013 in order to achieve a more efficient and effec-
tive process with the expectation that a larger proportion of EI claims
would be paid by third party insurance. This bill makes clarifying
amendments to ensure that the original intent of making a more efficient
and effective process is in fact realized.
Under the new system, providers are caught between patients, insurers
and the SFA awaiting decisions and information that are often out of
their control. As a result they are experiencing devastating payment
delays and administrative burdens which have made the El program fiscal-
ly unsustainable for some providers. Access to services for infants and
children who rely on this program for critical therapies may be serious-
ly jeopardized as providers leave the program. This was not the intended
consequence of the creation of a fiscal agent in the 2013-14 State Budg-
et.
 
PRIOR LEGISLATIVE HISTORY: None
 
FISCAL IMPLICATIONS: None. Delays and lack of access to preventative
services will actually increase long term costs for special education
services for school age children.
 
EFFECTIVE DATE: January 1, 2015, except for section 7 which shall
take effect immediately.
STATE OF NEW YORK
________________________________________________________________________
8316--B
2013-2014 Regular Sessions
IN ASSEMBLY
December 18, 2013
___________
Introduced by M. of A. GOTTFRIED, CAHILL, HEVESI, ABINANTI, BRAUNSTEIN,
BRONSON, BUCHWALD, FAHY, JACOBS, JAFFEE, LUPARDO, MARKEY, MILLER,
MILLMAN, O'DONNELL, OTIS, PAULIN, RAIA, ROBERTS, ROSA, SCHIMEL,
SEPULVEDA, SKARTADOS, SKOUFIS, STECK, STIRPE, SWEENEY, THIELE, WEISEN-
BERG, ZEBROWSKI, SCARBOROUGH, ROSENTHAL, COOK, GUNTHER, LIFTON, BENE-
DETTO, WEPRIN, ROZIC, GALEF, CLARK, TITONE, ROBINSON, RUSSELL, CUSICK,
SALADINO, LAVINE, COLTON, BARRETT, BROOK-KRASNY, McDONALD, BRINDISI,
GOODELL, MAGNARELLI -- Multi-Sponsored by -- M. of A. ARROYO, BRENNAN,
CROUCH, DUPREY, HEASTIE, KEARNS, LUPINACCI, MAYER, McDONOUGH, RA,
RODRIGUEZ, SIMANOWITZ, WALTER, WRIGHT -- 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 --
again reported from said committee with amendments, ordered reprinted
as amended and recommitted to said committee
AN ACT to amend the public health law, the insurance law and chapter 60
of the laws of 2014 amending the public health law relating to
payments submitted by early intervention providers to certain third
party payors, in relation to the financial responsibility for and
reimbursement of payment for early intervention services by the state
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subdivision 1 of section 2557 of the public health law, as
2 amended by section 4 of part C of chapter 1 of the laws of 2002, is
3 amended to read as follows:
4 1. The approved costs for an eligible child who receives an evaluation
5 and early intervention services pursuant to this title shall be a charge
6 upon the municipality wherein the eligible child resides or, where the
7 services are covered by the medical assistance program, upon the social
8 services district of fiscal responsibility with respect to those eligi-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD13146-11-4
A. 8316--B 2
1 ble children who are also eligible for medical assistance. All approved
2 costs shall be paid in full at the state approved early intervention
3 rate in the first instance and at least quarterly [by the appropriate
4 governing body or officer of the municipality upon vouchers presented
5 and audited in the same manner as the case of other claims against the
6 municipality] by the state or its designated fiscal agent on behalf of
7 the municipality for claims other than claims for medical assistance.
8 Notwithstanding the insurance law or regulations thereunder relating to
9 the permissible exclusion of payments for services under governmental
10 programs, no such exclusion shall apply with respect to payments made
11 pursuant to this title. Notwithstanding the insurance law or any other
12 law or agreement to the contrary, benefits under this title shall be
13 considered secondary to any plan of insurance or state government bene-
14 fit program under which an eligible child may have coverage. Nothing in
15 this section shall increase or enhance coverages provided for within an
16 insurance contract subject to the provisions of this title.
17 § 2. The opening paragraph of paragraph (a) of subdivision 5 of
18 section 2557 of the public health law is designated subparagraph (i) and
19 a new subparagraph (ii) is added to read as follows:
20 (ii) The fiscal agent's duties shall include, but not be limited to,
21 the following:
22 (1) Collaborating with providers to process payable claims with all
23 third party payors, including but not limited to, overseeing and facili-
24 tating the resubmission of claims when further information has been
25 requested by such third party payor;
26 (2) Facilitating the submission of subrogation notices by the provider
27 to third party payors;
28 (3) Processing and transmitting claims from the department's data
29 system for services that may be covered by a third party payor; and
30 (4) Issuing payment to providers for services not covered by a third
31 party payor in accordance with this title.
32 § 3. Paragraph (a) of subdivision 3 of section 2559 of the public
33 health law is amended by adding a new subparagraph (iv) to read as
34 follows:
35 (iv) The fiscal agent shall, at least quarterly, conduct a reconcil-
36 iation of third party reimbursement pursuant to this subdivision and
37 provide reimbursement at levels in accordance with this title to the
38 state and municipalities.
39 § 4. Section 2559 of the public health law is amended by adding a new
40 subdivision 3-a to read as follows:
41 3-a. Commencing on and after the effective date of this subdivision,
42 only for those third party payors who are not subject to the provisions
43 of section three thousand two hundred thirty-five-a of the insurance
44 law, if a parent provides consent to access coverage available under
45 such third party payor and the third party payor has not, within ninety
46 days of the initial submission of said claim, made payment of the claim
47 in whole or in part or rendered a determination that it is not obligated
48 to pay the claim, the provider shall be authorized to seek payment of
49 such claim from the municipality, through the fiscal agent under
50 contract with the department. If such third party payor makes payment of
51 the claim after the provider has received payment from the municipality
52 through the fiscal agent, the third party payment shall be reconciled
53 against future payments due to the provider from the municipality.
54 § 5. Subsection (c) of section 3235-a of the insurance law, as
55 amended by section 17 of part A of chapter 56 of the laws of 2012, is
56 amended to read as follows:
A. 8316--B 3
1 (c) Any right of subrogation to benefits which a municipality or
2 provider is entitled in accordance with paragraph (d) of subdivision
3 three of section twenty-five hundred fifty-nine of the public health law
4 shall be valid and enforceable to the extent benefits are available
5 under any accident and health insurance policy. The right of subrogation
6 does not attach to insurance benefits paid or provided under any acci-
7 dent and health insurance policy prior to receipt by the insurer of
8 written notice from the municipality or provider, as applicable. If an
9 insurer makes payment in whole or in part for a claim or bill for
10 services rendered under the early intervention program established in
11 title two-A of article twenty-five of the public health law, such
12 payment shall be made to the provider who submitted the claim and not to
13 the covered person regardless of whether such provider is in the insur-
14 er's network, and a remittance advice shall be transmitted to the
15 department of health's designated fiscal agent. The insurer shall
16 provide the municipality and service coordinator with information on the
17 extent of benefits available to the covered person under such policy
18 within fifteen days of the insurer's receipt of written request and
19 notice authorizing such release. The service coordinator shall provide
20 such information to the rendering provider assigned to provide services
21 to the child.
22 § 6. Paragraph 2 of subsection (d) of section 3224-a of the insurance
23 law, as amended by section 57-b of part A of chapter 56 of the laws of
24 2013, is amended to read as follows:
25 (2) "health care provider" shall mean an entity licensed or certified
26 pursuant to article twenty-eight, thirty-six or forty of the public
27 health law, a facility licensed pursuant to article nineteen or thirty-
28 one of the mental hygiene law, a fiscal intermediary operating under
29 section three hundred [sixty five-f] sixty-five-f of the social services
30 law, an individual or agency approved by the department of health pursu-
31 ant to title two-A of article twenty-five of the public health law, a
32 health care professional licensed, registered or certified pursuant to
33 title eight of the education law, a dispenser or provider of pharmaceu-
34 tical products, services or durable medical equipment, or a represen-
35 tative designated by such entity or person.
36 § 7. Section 19 of part A of chapter 60 of the laws of 2014 amending
37 the public health law relating to payments submitted by early inter-
38 vention providers to certain third party payors is amended to read as
39 follows:
40 § 19. For claims for payment submitted by early intervention providers
41 to third party payors between the period April 1, 2013 until June 30,
42 2013 in accordance with title 2-A of article 25 of the public health
43 law, for which the third party payor has not, on the effective date of
44 this section, made payment of the claim in whole or in part or rendered
45 a determination that it is not obligated to pay the claim, the provider
46 shall be authorized to seek payment of such claim from the municipality,
47 through the fiscal agent under contract with the department of health;
48 provided, however, that the provider shall continue to render any
49 assistance needed, and provide any information and documentation
50 requested by the third party payor to facilitate payment of the claim
51 even if the provider has already received payment from the municipality.
52 If such third party payor makes payment of the claim after the provider
53 has received payment from the municipality, the third party payment
54 shall be reconciled against future payments due the provider from the
55 municipality. This section shall only apply to claims submitted by
56 approved early intervention providers to third party payors during the
A. 8316--B 4
1 period April 1, 2013 until June 30, 2013 for which no payment or deter-
2 mination has been made, as specified in this section, on April 1, 2014.
3 Provided, however, in the event that funds appropriated for the purpose
4 of this section exceed the amounts necessary to pay state reimbursement
5 to municipalities for such claims, the period set forth herein shall be
6 expanded, as determined by the department of health subject to the
7 availability of funding, to include additional claims submitted on or
8 after April 1, 2013 by early intervention providers to third party
9 payors for which the third party payor has not, on the effective date of
10 this section, made payment of the claim in whole or in part or rendered
11 a determination that it is not obligated to pay such claim; provided,
12 further that all other provisions of this section shall apply to such
13 claims to be paid by a municipality in accordance with this section.
14 Payment shall be made on the forty-fifth day after this act shall take
15 effect. The provisions in subdivision 2 of section 2557 of the public
16 health law that prohibit state reimbursement from being paid prior to
17 April first of the year in which the approved costs are paid by the
18 municipality shall not apply to the municipal payments made under this
19 section.
20 § 8. This act shall take effect immediately; except that sections one
21 through six of this act shall take effect January 1, 2015, and shall
22 apply to all claims for payment, other than claims for medical assist-
23 ance, submitted by an early intervention provider to third party payors
24 after June 30, 2013; provided, however, that the commissioner of health
25 is authorized and directed to promulgate regulations and take all
26 actions necessary and appropriate to implement the provisions of this
27 act on its effective date.