Robbing Peter to Pay Paul

1. Robbing Peter to Pay Paul Creative Approaches to Funding & Providing Early Intervention Services

2. Presentation By:Patti Rawding-Anderson MA, MSPTDirector of Program Development for Early Childhood ServicesEaster Seals

3. Overview of Methods • Actual Revenues • $$$$$$$ • Building Community Capacity • Helping others to do what we can’t • Partnerships • Sharing the load • Decision Making • The hard choices

4. Actual Revenues • Part C Dollars • BDS • Medicaid Bundle • Medicaid Case Management • Insurance Reimbursement • Family Cost Share • Other Funding Sources • Philanthropic Dollars

5. Part C & Bureau of Developmental Services (BDS)Dollars NH receives the least amount of Part C Dollars based on the national formula for state size. This combined with the BDS state dollars: • Accounts for roughly 23% of EI moneys (20% Part C & 3% BDS) • Supports the Part C infrastructure and: • Area Agencies - CSPD activities • ICC - MICE • EEIN, - Mentorship • Technical assistance grants e.g. Autism Protocol • Children’s Care Management Collaborative • Continuous Improvement and Focused Monitoring (QA) • Family Resource Connection • To a small degree, direct services

6. Medicaid BundleMedicaid Case Management NH has a unique Early Intervention agreement with the state Medicaid system through a contract with EDS which began in September of 1993. • Medicaid Bundle for services and evaluations • Targeted EI Case Management

7. Medicaid Bundle The Medicaid Bundle allows for all health related services mandated by then Part H and now Part C. This was a set rate of $137.07 per week per child regardless of the number of services provided. In 2002, the rate was increased to $200 per week per child / family. Seven Services were included: 1. Assistive Technology Support (not equipment) 2. OT 3. PT 4. SLP 5. Social Work 6. Special Instruction 7. Family / Child training and counseling services (except by psychologists or psychiatrists)

8. Medicaid Bundle The Medicaid Bundle also reimburses for assessments / evaluations / screenings at a rate of $200 per activity except those conducted by service providers outside the bundle – This category is primarily to determine eligibility

9. Medicaid Case Management Targeted Medicaid Case Management $8.41 per day per child / family for every day of the month in which that child / family is enrolled in the EI system as long as at least one case management contact has been made

10. Medicaid Funding This stream applies only to those children receiving NH Medicaid which in NH is called the Healthy Kids Gold Plan. As long as Medicaid enrollment is up, this is a vital funding stream to support EI. When Medicaid enrollment is down which is currently the case in NH , this funding stream is compromised. In the mid 90’s the percentage of children with Medicaid receiving EI services was ~ 42%. Today, it hovers around 31% but varies considerably geographically. This is a huge loss of revenues to the system.

11. Insurance Reimbursement In the late 90’s, NH recognized a significant funding concern on the horizon. Thus a strong push for insurance revenue recovery was implemented. • Programs were encouraged to bill private insurance • Parent fees were established and recommended • Insurance denial data was collected to determine if legislation could be introduced to mandate insurance coverage for EI services • Discussions began with some of the larger insurance companies to introduce a voluntary EI benefit

12. Insurance Reimbursement Results of efforts varied across programs: • Some programs billed insurance - others did not • Few programs implemented parent fees • Legislation was not introduced as it was not perceived as likely to pass • However, an agreement was establish with Anthem BC / BS to implement a voluntary benefit for EI services ($3200 per year per child up to a maximum of $9600 for three years not to extend beyond a child’s third birthday) • Services for OT / PT / SLP only • Consistent with the Massachusetts model which was state mandated

13. Insurance Reimbursement In the early 2000’s, revenue projections indicated that within 6 years, the EI system would be in extreme financial crisis. • Insurance billing by programs became mandatory with a set of revenue expectations projected for each region • Eligibility criteria changed from a 25% to 33% delay in one area • Intake coordinators were trained on how better to inform parents about EI funding and more successfully engage their permission to allow programs to bill insurance • Technical Assistance was provided to EI programs to increase capacity to bill insurance (funded by Part C) • Insurance billing practices / responsibilities became part of the initial state wide training for all new service coordinators

14. Insurance Reimbursement • An insurance TA support group was established to network EI billing staff and administrators • Topical trainings were provided on coding, electronic billing, referral / authorization practices, and insurance billing protocols • Trainings were facilitated so that the major insurance carriers in NH could educate EI Programs about their respective policies and practices. Also to build relationships of understanding around billing practices between EI and insurers • A strong relationship was built with the NH state Insurance Commission with training to EI staff about their role and support structure • A delegate from the Insurance Commission was appointed to the ICC • Outreach was made to pre-service education programs to build insurance billing practices into their curriculums

15. And if all that still doesn’t work? Despite efforts, EI funding remains a concern in NH In 2004, NH’s ICC decided to prioritize EI funding and implemented a strategic planning process Steps: • Brainstorming all potential ways to optimize funding • Critical review of the Federal Part C rules to ensure compliance without supplemental activities • Review of the current EI funding structure and implementation practices • Revisiting proposed legislation to mandate insurance reimbursement of EI services • Negotiations with other insurance carriers for a voluntary EI benefit and avoid a legislative mandate

16. Family Cost Share NH is currently reviewing all other states’ family cost share practices including: • Mandated EI insurance access for all children / parents • Mandated parent fees • Combination of both • Parent contribution in non-financial ways

17. Other Funding Sources • Traditional Medicaid billing for medically necessitated services outside the bundle • Family Support funding for families with extraordinary circumstances (DD funding) • Respite dollars for families (DD funding) • Bureau of Special Medical Services for families with children with significant developmental disabilities – NH DHHS • Partners In Health Funding for families with children with significant health care needs • Part B / 619 resources to help with transition support, exiting evaluations, provision of summer services when a child turns three prior to Sept., or Child Find activities • Parent contributions (financial / inkind) • Adult DD services system (robbing the adult system to pay for the EI system through Area Agency budgets as EI is an entitlement and Adult services are not – not optimal) • EI vendors - generated revenues in a variety of ways

18. Philanthropic Dollars • Grants • United Way • Individualized fund development activities • Fund raisers • Partnerships with Businesses

19. Building Community Capacity Teaching Developmental Screening (ELOA / Baby Steps) • Primary Health Care • Childcare • Child Protective Services (County Incentive funds) • Maternal and Child Health Programs (Healthy Families HV) • Parent generated screening via access to Ages & Stages Parent Questionnaires (Early Connections Project / FRC) Access to Information • Family Resource Connection (state wide I & R for children, families, & providers) • Libraries (Early Connections / ELOA) • Newsletters & Collaborative Events (Parent Information Center, EEIN, SERESC, PTAN, Mentorship Program, UNH Cooperative Extension Program, IMH teams) • Public / Cable networks (NH Public Television, Parenting NH)

20. Partnerships Joint Activities • School Districts • Early Head Start • Family Resource Centers • Parenting Programs • Home Visiting Programs Delegation of Activities • Community based services (therapists) • Program sharing staff / contracts with other EI or PS / school programs • External Evaluation Services (Child Development clinics, hospitals, and private treatment services)

21. Decision Making Changing Standards of Practice • Making eligibility criteria more stringent • Reduction in frequency or scope of professional services • Reducing resource intensive activities • Creating efficient use of resources • Requiring parent cost participation • Developing alternative programs for children not eligible to reduce risk of entry into system later • Service delivery practice changes (greater use of paraprofessionals, transdisciplinary practice, use of professional consultation to home visitors rather than weekly professional services, etc.

22. NOW IT’S YOUR TURN Ideas Innovative Funding Sources Creative Activities from the Field?