Insurance. Declination and Exemption Forms

Transcription

1 Insurance Declination and Exemption Forms

2 Insurance Declination Forms 25 Count of forms submitted to CDHS FY FY FY FY Fiscal Year Source: Insurance Declination forms submitted by Community Centered Boards through October 30, 2012.

3 Family Exceptions Declined to provide info Non-qualifying plan 52 Public plan (CHP+ or Medicaid) Qualifying plan Source: Insurance Declination forms submitted by Community Centered Boards through October 30, 2012.

4 Community Connections DDRC Developmental Pathways Foothills Gateway Imagine! Mountain Valley Rocky Mtn Human Svcs North Metro TRE declined to provide health insurance info public health insurance (Medicaid or CHP+) non-qualifying plan qualifying plan Source: Insurance Declination forms submitted by Community Centered Boards through October 30, 2012.

5 System Exceptions 26% 4% 49% 21% No providers who will provide in accordance with IFSP. No providers who contract with insurance carrier. Coverage denied or IFSP service not a benefit. Cost of co-payment or deductible more costly. Source: Insurance Exemption forms submitted by Community Centered Boards from July 1, 2012 through October 30, 2012.

6 Starpoint Mountain Valley North Metro Rocky Mtn Human Svcs TRE Community Options Horizons Eastern Community Connections Blue Peaks DDRC Foothills Gateway Envision Imagine! Source: Insurance Exemption forms submitted by Community Centered Boards from July 1, 2012 through October 30, 2012.

7 How is the information being used? For reporting purposes for the Department, legislature or other funding sources To identify access barriers for any of the funding hierarchy levels To inform technical assistance activities, particularly as it relates to utilizing Medicaid and CHP+ To inform public awareness materials and general messaging related to funding Early Intervention Services

8 Time for a poll

9 Early Intervention Colorado An Overview of the Coordinated System of Payments and Early Intervention Services Rates

10 Point of Discussion Pursuant to 2 CCR 503-1, Section (B) and effective in FY , the Department shall implement a statewide upper rate limit for all Early Intervention Services. A third party contractor will be hired in early fall 2012 to facilitate the process. The contractor s role will be to analyze the early intervention rate structures in other states, provide recommendations and assist in the gathering of stakeholder input on the recommendations to the Department. Based on a final report, the Department shall revise fiscal policies and procedures in order to establish the upper limit for each of the Early Intervention Services that will go into effect on July 1, Source: Coordinated System of Payment Changes Communication Brief (August 7, 2012 )

11 Outcomes of the Discussion Become informed Have questions clarified Consider impact on whole system Contribute issues to be addressed in the Contractor s Request for Proposal Provide suggestions to ensure transparent communication to stakeholders

12 Overview Current System Background Information System Challenges Analysis Conducted to Date Direct Service Data from the 2012 ITCA Tipping Points Survey State Approaches to Rates

13 Overview of Current System All services are purchased through or provided by Community Centered Boards (CCBs) (n=20) CCBs either bill insurers (public and private) directly or billing is submitted by vendors Department of Human Services is payer of last resort (State General Funds and Federal Part C Funds) $34,605,067M* were expended for direct services in FY 11 *Preliminary Data: FY Early Intervention Revenue and Expenditure Reports

14 Who Paid: Direct Service Only, FY 11* Non-Qualifying Plans - $704,731 Trust $3,454,453 Other Local State or Federal Funds, including Mill Levy Funds - $2,036,786 Medicaid $7,274,629 State General Funds $14,670,699 ARRA - $33,466 Federal Part C Funds - $6,382,458 *Preliminary Data: FY Early Intervention Revenue and Expenditure Reports

15 15 Background Information Coordinated System of Payment Legislation, enacted in 2007, was intended to ensure the use of all available funding sources and to coordinate and streamline administrative procedures In January 2008 the Early Intervention Services Trust Fund was implemented Beginning in FY , criteria for projected Trust and Medicaid utilization were used in CCB allocation formulas In FY the Joint Budget Committee (JBC) required the CDHS to provide information on cost containment strategies to address case load growth and potential funding shortages

16 Direct Service Allocation Assumptions Medicaid - 40% of Average Monthly Enrolled (AME) (1,346) Trust Fund based on actual AME from previous year (780)

17 Early Intervention Services Rates The minimum, maximum and most frequently used rates are on file with the Department. Prior to FY 10 provided by CCBs through a self report survey process. Requirement to notify included in contract since FY 10. Each CCB shall: Not exceed the maximum rate limit on file for Early Intervention Services; and Notify the Department of any proposed change of reimbursement rates for all Early Intervention Services at least fifteen (15) calendar days prior to the use of such rates, including its rate setting methodology (2 CCR 503-1, Section (A)(6) and (B)) The maximum reimbursement rate is subject to restriction by the Department.

18 Year End Reporting Section (1) mandates that the Department report to the General Assembly by November 1 of each year the various funding sources used for Early Intervention Services Number of eligible children served The average service costs Prior to FY this data was submitted to the Department by CCBs using the Early Intervention Revenue and Expenditure Report and include each funding source by line item for: Service coordination Direct services Management fee, and Any other expense line item from the previous FY

19 Vendor versus Employed Provider* Most Utilized Early Intervention Services Vendor Provider Developmental Intervention (DI) 73% 27% Occupational Therapy (OT) 76% 24% Physical Therapy (PT) 84% 16% Speech Language Pathology (SLP) 84% 16% Total 81% 19% *Based on September 2011 Community Centered Board rate information on file with the Division for Developmental Disabilities. CCB Employed Provider

20 System Challenges

21 CCB EI Rates Compared to Medicaid Rates Rates currently paid by CCBs do not incentivize Medicaid utilization Federal match is lost and state has to cover the full expense in cases where Medicaid not used Costs may be higher due to same services (OT, PT, SLP) occurring in multiple settings (home health, clinic setting and home and community based setting) CPT or HCPCS Procedure Code Service Description Billable Unit* CO Medicaid Rate** CCB Range of MFP Rates SLP Per day $58 $40 - $ PT Per hour $43 $40 - $ OT Per hour $43 $40 - $123 *For the purposes of this report, all 15 minute billable units are presented as hourly rates. **Colorado Medicaid Fee Schedule July 1, 2012

22 CCB Rate Setting Methodology Varies by CCB Vendor rates are driven by providers in most service areas amount billed is what is paid Rate setting methodology of employed provider rates include overhead costs upwards of 60%

23 Physical Therapy Hourly Rate Comparison $ $ $ $ $ $50.00 $0.00 Purchased Service (Maximum Hourly Rate) FY Supplemental Audit Average Hourly Rate Billed CCB Provided (Maximum Hourly Rate)

24 Occupational Therapy Hourly Rate Comparison $ $ $ $ $ $ $50.00 $- Purchased Service (Maximum Hourly Rate) CCB Provided (Maximum Hourly Rate) FY Supplemental Audit Average Hourly Rate Billed

25 Analysis Conducted to Date

26 Recommendations Submitted January 2012 The upper rate limit for Early Intervention Services is determined by calculating the average of the most frequently used rates paid by each Early Intervention Service Broker (aka Community Centered Board). Rationale To implement 2 CCR 503-1, Section (A)(6) and (B) To establish a statewide cap on Early Intervention Services rates paid to providers as a strategy for managing caseload growth in the Early Intervention Services Program

27 Levels of Analysis Historical Early Intervention Services rates data (minimum, maximum and most frequently paid) Medicaid rates (not available for all Early Intervention Services) Bureau of Labor Statistics Data (not available for all professionals qualified to provide Early Intervention Services)

28 Options for Calculating the Early Intervention Services Upper Rate Limits Option 1: Implement two sets of upper rate limits for Early Intervention Services: Vendor Upper Rate Limit and Community Centered Board Provided Upper Rate Limit Most Utilized Early Intervention Services Developmental Intervention Hourly Upper Rate Limit for Contract Provider Hourly Upper Rate Limit for Employed Provider $ $ Occupational Therapy $ $ Physical Therapy $ $ Speech Language Pathology $ $ Average hourly rates calculated using the September 2011 Community Centered Board rates on file with the Division for Developmental Disabilities

29 Option 1: Projected Impact Most Utilized Early Intervention Services Total Costs/Savings Adjusted Costs/Savings Developmental Intervention $(417,789.96) $(280,418.63) Occupational Therapy $(206,276.95) $(139,862.63) Physical Therapy $(161,338.12) $(46,867.49) Speech Language Pathology $(594,527.11) $(329,635.62) Total $(1,379,932.14) $(796,784.37) *Adjusted projections are based on the assumption that all Community Centered Boards will raise the cost per unit for early intervention services to the upper rate limit. ** Utilization data extracted from the FY Division for Developmental Disabilities Early Intervention Audit Report. ***Analysis based on the current Community Centered Board rates on file with the Division for Developmental Disabilities. ****Total costs/savings projections do not include funding streams reported in the FY Division for Developmental Disabilities Early Intervention Audit Report that are not managed by the Division for Developmental Disabilities, such as Medicaid, non-qualifying private insurance plans under the Coordinated System of Payment legislation, and other funding sources.

30 Options for Calculating the Early Intervention Services Upper Rate Limits Option 2: Implement a single upper rate limit for each Early Intervention Service based on the vendor rate Most Utilized Early Intervention Services Hourly Upper Rate Limit for Vendors Developmental Intervention $ Occupational Therapy $ Physical Therapy $ Speech Language Pathology $ Average hourly rates calculated using the September 2011 Community Centered Board rates on file with the Division for Developmental Disabilities.

31 Option 2: Projected Impact Most Utilized Early Intervention Services Total Costs/Savings Adjusted Costs/Savings Developmental Intervention $(613,394.29) $(536,936.77) Occupational Therapy $(253,039.48) $(151,417.18) Physical Therapy $(167,712.14) $(61,659.26) Speech Language Pathology $(748,128.50) $(576,902.21) Total $(1,782,274.40) $(1,326,915.41) *Adjusted projections are based on the assumption that all Community Centered Boards will raise the cost per unit for early intervention services to the upper rate limit. ** Utilization data extracted from the FY Division for Developmental Disabilities Early Intervention Audit Report. ***Analysis based on the current Community Centered Board rates on file with the Division for Developmental Disabilities. ****Total costs/savings projections do not include funding streams reported in the FY Division for Developmental Disabilities Early Intervention Audit Report that are not managed by the Division for Developmental Disabilities, such as Medicaid, non-qualifying private insurance plans under the Coordinated System of Payment legislation, and other funding sources.

32 2012 ITCA Tipping Points Surveys 2012 Part C Implementation: State Challenges and Responses, Infant & Toddler Coordinator Association

33 As a result of state fiscal issues, what have you done in the past 12 months? Increased family fees, 1, 5% Narrowed eligibility, 6, 30% Required families to use private insurance or be placed on a fee schedule, 2, 10% Required prior approval for hours of service that exceed an identified amount, 4, 20% Reduced provider reimbursement, 7, 35%

34 Did any contractors/agencies decline to continue to provide direct services because of fiscal constraints? 4, 11% declined continued 31, 89%

35 What is the status of your provider reimbursement over the past three years? 3, 8% 1, 3% 2, 5% 23, 57% Rates stayed the same Decreased rates Will decrease rates Increased rates 11, 27% Will increase rates

36 State Approaches to Early Intervention Services Rates State established a single EI Rate State established rate based on discipline/service State established EI rate based on Medicaid rate Local program negotiated rate

37 Guiding Principles Early Intervention financing system must ensure Lead Agency and provider accountability, as well as, to provide reasonable support in a manner that is responsive to providers to ensure the delivery of quality, comprehensive services to meet the needs of children and families. Source: Infant & Toddler Coordination Association Reimbursement Paper October 2004

38 Guiding Principles Rates encourage and support service delivery to meet individualized child and family needs and are delivered within the context of the child s natural environment. Source: Infant & Toddler Coordination Association Reimbursement Paper October 2004

39 Guiding Principles The reimbursement structure should support early intervention philosophy and beliefs. Source: Infant & Toddler Coordination Association Reimbursement Paper October 2004

40 Guiding Principles The reimbursement structure should support early intervention philosophy and beliefs. Source: Infant & Toddler Coordination Association Reimbursement Paper October 2004

41 Guiding Principles The reimbursement structure should support best practice. Source: Infant & Toddler Coordination Association Reimbursement Paper October 2004

42 Guiding Principles The reimbursement structure should support the hiring and retention of qualified staff. Source: Infant & Toddler Coordination Association Reimbursement Paper October 2004

43 Outcomes of the Discussion Become informed Have questions clarified Consider impact on whole system Contribute issues to be addressed in the Contractor s Request for Proposal Provide suggestions to ensure transparent communication to stakeholders