2559. Third party insurance and medical assistance program payments. 1. Nothing in this title shall be construed to permit the department or any other state agency or municipality to reduce medical assistance or other assistance or services available to eligible children.
2. Notwithstanding any other provisions of law, costs incurred for early intervention services that otherwise qualify as medical assistance that are furnished to an eligible child who is also eligible for benefits pursuant to title eleven of article five of the social services law are considered to be medical assistance for purposes of payments to providers and state reimbursement to the extent that federal financial participation is available therefor.
3. (a) Providers of evaluations and early intervention services, hereinafter collectively referred to in this subdivision as "provider" or "providers", shall in the first instance and where applicable, seek payment from all third party payors including governmental agencies prior to claiming payment from a given municipality for evaluations conducted under the program and for services rendered to eligible children, provided that, the obligation to seek payment shall not apply to a payment from a third party payor who is not prohibited from applying such payment, and will apply such payment, to an annual or lifetime limit specified in the insured's policy.
(i) Parents shall provide the municipality and service coordinator information on any insurance policy, plan or contract under which an eligible child has coverage.
(ii) Parents shall provide the municipality and the service coordinator with a written referral from a primary care provider as documentation, for eligible children, of the medical necessity of early intervention services.
(iii) providers shall utilize the department's fiscal agent and data system for claiming payment for evaluations and services rendered under the early intervention program.
(b) The commissioner, in consultation with the director of budget and the superintendent of financial services, shall promulgate regulations providing public reimbursement for deductibles and copayments which are imposed under an insurance policy or health benefit plan to the extent that such deductibles and copayments are applicable to early intervention services.
(c) Payments made for early intervention services under an insurance policy or health benefit plan, including payments made by the medical assistance program or other governmental third party payor, which are provided as part of an IFSP pursuant to section twenty-five hundred forty-five of this title shall not be applied by the insurer or plan administrator against any maximum lifetime or annual limits specified in the policy or health benefits plan, pursuant to section eleven of the chapter of the laws of nineteen hundred ninety-two which added this title.
(d) A municipality, or its designee, and a provider shall be subrogated, to the extent of the expenditures by such municipality or for early intervention services furnished to persons eligible for benefits under this title, to any rights such person may have or be entitled to from third party reimbursement. The provider shall submit notice to the insurer or plan administrator of his or her exercise of such right of subrogation upon the provider's assignment as the early intervention service provider for the child. The right of subrogation does not attach to benefits paid or provided under any health insurance policy or health benefits plan prior to receipt of written notice of the exercise of subrogation rights by the insurer or plan administrator providing such benefits.
4. Notwithstanding any other provision of law, the commissioner, pursuant to a memorandum of understanding with the commissioner of the office of mental retardation and developmental disabilities, shall develop and submit a medicaid home and community based services waiver, pursuant to section 1915c of the social security act, for the purpose of creating a waiver program to provide and finance services for children who qualify for the early intervention program. In further establishing eligibility criteria under the waiver program, the commissioner, in conjunction with the commissioner of the office of mental retardation and developmental disabilities, shall establish health, developmental and psycho-social criteria which shall permit the broadest eligibility based on criteria for the early intervention program and federal standards for participation in a waiver program. The waiver application shall be submitted pursuant to section 1915c of the social security act no later than January first, two thousand four.
5. Notwithstanding any law to the contrary, there is hereby established an early intervention demonstration project to be conducted in Albany, Montgomery, Rensselaer, Saratoga and Schenectady Counties. Such project shall be for the purposes of facilitating coverage eligibility determinations and claims submissions for early intervention services. The commissioner is hereby authorized and directed to facilitate and, within the amounts appropriated, shall award grant funds for the implementation and operation of such demonstration project which shall be conducted by an association representative of health maintenance organizations licensed under article forty-four of this chapter and article forty-three of the insurance law in conjunction with the commissioner and the counties specified in this subdivision.
Such demonstration shall include the development of an integrated web portal enabling access to health plan data bases to facilitate coverage eligibility, benefit determinations and claims submission and processing. Such access shall be subject to all federal and state laws for the confidentiality of personal and medical record information. The demonstration will develop technology solutions to facilitate coverage determinations and streamline and monitor claims processes and payment.
The association conducting the demonstration, the commissioner and participating counties shall submit a report to the temporary president of the senate and the speaker of the assembly, not later than one year following the commencement of the program's operation, describing the experiences, feasibility and advisability of replication, and any additional recommendations for continuation, modification or cessation of the program.
Last modified: February 3, 2019