+
Utilizing
Private Insurance
in Supporting
Part C Services
Ron Benham
MA Part C Coordinator
Private Insurance Webinar
+
Objectives from the webinar on
public insurance:

Provide foundational background for learning about Private
Insurance

Introduce key types of Private Insurance and their components
related to Part C

Display private insurance information from the 2014 ITCA
Financial Survey and what forms of Private Insurance state
Part C systems are accessing

Highlight developments and directions in Private Insurance and
opportunities they may offer Part C systems
Private Insurance Webinar
+
Private Insurance Webinar
3

Early Intervention Services
Sec. 303.12

Payor of last resort
Sec. 303.510

Policies related to use of public
benefits or insurance or private
insurance to pay for Part C services
Sec. 303.520

System of payment and fees
Sec. 303.521
+
4
§ 303.510 Payor of last resort.
(a) Nonsubstitution of funds.
Except as provided in paragraph (b) of this section, funds
under this part may not be used to satisfy a financial
commitment for services that would otherwise have been
paid for from another public or private source, including any
medical program administered by the Department of
Defense, but for the enactment of part C of the Act.
Therefore, funds under this part may be used only for early
intervention services that an infant or toddler with a
disability needs but is not currently entitled to receive or
have payment made from any other Federal, State, local,
or private source (subject to §§ 303.520 and 303.521).
Private Insurance Webinar
+
5
ERISA and non-ERISA Policies
Employee Retirement Income Security Act of 1974

Non-ERISA : A fully insured group health plan under which the
benefits are provided by the sponsoring employer or union through
the purchase of health insurance coverage from an HMO or an
insurance company. In exchange for a premium, the HMO or the
insurance company bears full risk for the cost of the benefits
provided. Fully-insured plans are accountable to the your State
Department of Insurance.

ERISA: A self-insured (or self-funded) plan is a group health plan
under which the risk for the cost of the benefits provided is borne
by the sponsoring employer or union. The employer or union may
hire a third party administrator to perform such services as paying
claims, collecting premiums, or supplying other administrative
services), but the financial liability for the cost of the benefits
provided remains with the employer or union.
Private Insurance Webinar
+
6
Within ERISA and non-ERISA
Health plans: various delivery models
 Indemnity
 Fee
Plans
for Service
 Managed
Private Insurance Webinar
Care
+
7
Private Insurance
Utilization
Private Insurance Webinar
+
8
System of Payments (n=36)
Private Insurance Webinar
+
9
Statutory Language Related to Use
of Private Insurance (n=21)
Private Insurance Webinar
+
10
Statutory Cap on Insurance
Payment (n=21)
Private Insurance Webinar
+
11
Decrease in Insurance Revenue
from Family Refusing Access (n=21)
Private Insurance Webinar
+
12
Reported Revenue
 Private
Insurance:
 14
of the 21 states reporting use of private
insurance could provide revenue information.
 Total:
Private Insurance Webinar
$75,430,080
+
13
Part C Services included in the ACA
Essential Benefits(n=31)
Private Insurance Webinar
+
14
Infrastructure
Private
Insurance
(21)
State Personnel
1
Regional Personnel
1
Local Personnel
0
SICC
0
Child Find Public Awareness
2
Eligibility Determination
12
CSPD
0
Monitoring
0
Dispute Resolution
0
Data System
1
IFSP Development
5
Private Insurance Webinar
+
Private Insurance Webinar
Direct Services
15
Private
Insurance
(21)
Assistive Technology
15
Audiology
14
Family Training
11
Health
15
Medical (diagnostic)
15
Nursing
15
Nutrition
14
Occupational Therapy
17
Physical Therapy
17
Psychology
16
Service Coordination
10
Special Instruction
12
Speech Therapy
16
Sign or Cued Language
8
Social Work
11
Transportation
10
Vision
12
+
16
Massachusetts:
A State Example
Private Insurance Webinar
+
MA Medicaid Participation
as precursor to billing private insurance
1985 - present

Reimbursement model changed from cost reimbursement to unit
based

Currently 7 reimbursable services & current hourly rates (divisible by
15 minute increments for program based model:








Home Visits
Center Individual
Community Based Group
EI Only Group
Parent Group
Screening
Assessment
$ 81.80
68.60
31.40
23.88
30.68
95.60
109.72
DPH serves as gatekeeper to Medicaid
Private Insurance Webinar
17
+
18
MA Private Insurance Mandate

Bill introduced in 1986

Legislation passed in January 1990

Law took effect in April 1990

Fully in effect April 1991

“Medically Necessary” criteria

Service costs capped




Initial $2,400 yearly/ $7,200 aggregate
SFY- 97 - $3,200 yearly/$9,600 aggregate
SFY- 03 - $5,200 yearly/$15,600 aggregate
SFY-13 – Cap removed
Private Insurance Webinar
+

19
MA Use of Private Insurance
Legislation allowing access to a family’s private insurance coverage for
covered Part C services w/ consent
The dependent coverage of any such policy shall also provide coverage for
medically necessary early intervention services delivered by certified
early intervention specialists, as defined in the early intervention
operational standards by the department of public health and in
accordance with applicable certification requirements.
Private Insurance Webinar
+
20
MA Use of private insurance, cont.

Such medically necessary services shall be provided by early
intervention specialists who are working in early intervention
programs certified by the department of public health, as
provided in sections 1 and 2 of chapter 111G, for children from
birth until their third birthday. Reimbursement of costs for such
services shall be part of a basic benefits package offered by
the insurer or a third party…
Private Insurance Webinar
+
21
MA Use of private insurance, cont.

and shall not require co-payments, coinsurance or deductibles;
provided, however, that co-payments, coinsurance or
deductibles shall be required if the applicable plan is governed
by the Federal Internal Revenue Code and would lose its taxexempt status as a result of the prohibition on co-payments,
coinsurance or deductibles for these services.
Private Insurance Webinar
+
22
MA Use of Private Insurance, cont.

Family Co-Pay or Deductible

Historically, Massachusetts EI paid co-pays and deductibles of
families which allow greater access to private insurance
reimbursement

Paying insurance premiums for Part C enrolled children

Such payments may occur but this is not a widespread activity
Private Insurance Webinar
+
23
What has worked in MA

VISION, COMMITMENT, PERSISTENCE

Positive, cooperative working relationship with insurers and
Medicaid

Insurance/Health Plans with Early Intervention coordinators
work best

Insurers did not strongly oppose withdrawal of cap in SFY -13

Joint efforts related to billing/claims submission

Ongoing identification of systemic problems, programs, payers
Private Insurance Webinar
+
24
Strategies for Accessing Private
Insurance

Research and utilization of other state’s insurance
legislation:
Colorado
New Hampshire
Connecticut
New Mexico
Indiana
New York
Massachusetts
Rhode Island
Virginia
http://ectacenter.org/topics/finance/statelegis.asp

Determine the type of coverage you seek
discrete therapy
 program driven model
 service type vs. discipline specific
Private Insurance Webinar
+
25
Additional Strategies for Accessing
Private Insurance

Determine congruence between system design and what
insurers reimburse

Conduct a Circle of Influence (who will champion your effort?)

Get away from viewing Health Plans as “the enemy”

Understand the importance of meeting “medical necessity”
(what is your eligibility criteria?)

Draft cost saving arguments (Early Intervention vs.
rehabilitation services)
Private Insurance Webinar
+
Circles of Involvement:
26
Developing Key Relationships for Implementation
Circle of Possibility
Circle of Information Awareness
Circle of Champions
Circle of Engagement
Giving
Permission
Attending
Meetings
Core Circle
Bringing on
new leaders
Input
Planning
Financial
Support
The Strategic
Plan
Initiation
Adding Influence
Holding
Meetings
Doing the work
Decisions
Coordination
Advice
Technical
Support
Private Insurance Webinar
Adapted from “Creating a Framework
of Support and Involvement” originally
created by the Canadian Institute of
Cultural Affairs © 2002-2012
+
Circles of Involvement:
27
Developing Key Relationships for Implementation
More “External”
Private Sector:
Voluntary Sector:
Business, Media,
Investors/Funders
Faith Community, NonProfits, Associations
Public Sector:
Informal Sector:
Government, Education,
Public Figures
Kinship relations,
interest groups,
neighbors
The Strategic
Plan
Resource Partners:
“Who is providing resources?”
Supportive involvement,
program circle, suppliers,
networking
“Who is authorizing it?”
Management, the board,
framing
Beneficiaries:
“Who is benefiting from it?”
The “customer”, the
“stakeholder”, on whose
behalf it is being done,
those affected by it
Private Insurance Webinar
Policy Partners:
Practitioners:
“Who is doing it?”
Direct involvement, staff, mobilizing
More “Internal”
Adapted from “Creating a Framework
of Support and Involvement” originally
created by the Canadian Institute of
Cultural Affairs © 2002-2012
+
28
Other Considerations

Be aware of Maintenance of Effort (MOE) concerns – funding
accessed thru private insurance reimbursement does not count
for meeting federal MOE requirements (state and local public
funds).

The process of accessing private insurance isn’t necessarily
quick.

Legislation mandating coverage is most useful (utilize other
state examples).
Private Insurance Webinar
+
29
Additional Resources

A useful background link on insurance coverage in all states,
http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf412274

Examples of state insurance legislation for Early Intervention
http://ectacenter.org/topics/finance/statelegis.asp
Private Insurance Webinar
Thank you for your attention!
This is the third of four webinars in a series on Part C Finance
presented in 2014. Resources related to this call and other calls in the
series are available at the following URL:
http://ectacenter.org/~calls/2014/financepartc/financepartc.asp