Insurance
Insurance Declination Forms
17 16 21 19 0 5 10 15 20 25 FY 2009 - 10 FY 2010 - 11 FY 2011 - 12 FY 2012 - 13 C ou nt o f f or m s su bm itt ed to C D HS Fiscal YearSource: Insurance Declination forms submitted by Community Centered Boards through October 30, 2012.
Family Exceptions
52 12 3 6 Declined to provide info Non-qualifying plan Public plan (CHP+ or Medicaid) Qualifying planSource: Insurance Declination forms submitted by Community Centered Boards through October 30, 2012.
3 4 3 17 2 21 1 1 1 2 3 1 4 1 1 1 1 2 1 2 1 0 5 10 15 20 25 Community
Connections DDRC Developmental Pathways Gateway Foothills Imagine! Mountain Valley Rocky Mtn Human Svcs North Metro TRE declined to provide health insurance info non-qualifying plan
public health insurance (Medicaid or CHP+) qualifying plan
System Exceptions
21%49% 26%
4% 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.
29 7 79 79 2 21 18 2 24 34 99 63 3 2 Imagine! Envision Foothills Gateway DDRC Blue Peaks Community Connections Eastern Horizons Community Options TRE Rocky Mtn Human Svcs North Metro Mountain Valley Starpoint 0 20 40 60 80 100 120
Source: Insurance Exemption forms submitted by Community Centered Boards from July 1, 2012 through October 30, 2012.
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
Early Intervention
Colorado
An Overview of the Coordinated System of Payments and Early Intervention Services Rates
Point of Discussion
Pursuant to 2 CCR 503-1, Section 16.911(B) and
effective in FY 2013-14, 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, 2013.
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
Overview
Current System
Background Information System Challenges
Analysis Conducted to Date
Direct Service Data from the 2012 ITCA Tipping
Points Survey
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
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
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 2009-10, criteria for projected Trust
and Medicaid utilization were used in CCB allocation formulas
In FY 2009-10 the Joint Budget Committee (JBC)
required the CDHS to provide information on cost containment strategies to address case load
growth and potential funding shortages
Direct Service Allocation
Assumptions
Medicaid - 40% of Average Monthly Enrolled (AME) (1,346) Trust Fund – based on actual AME from previous year (780)
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 16.911(A)(6) and (B))
The maximum reimbursement rate is subject to restriction
Year End Reporting
Section 27-10.5-710 (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 2011-12 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
Vendor versus Employed Provider*
Most Utilized Early Intervention
Services
Vendor
Provider
CCB Employed
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.
System
Challenges
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
92507 SLP Per day $58 $40 - $150
97110 PT Per hour $43 $40 - $123
97530 OT Per hour $43 $40 - $123
*For the purposes of this report, all 15 minute billable units are presented as hourly rates.
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%
$0.00 $50.00 $100.00 $150.00 $200.00 $250.00 $300.00
Physical Therapy Hourly Rate Comparison
Purchased Service (Maximum Hourly Rate) CCB Provided (Maximum Hourly Rate) FY 09 - 10 Supplemental Audit Average Hourly Rate Billed
$- $50.00 $100.00 $150.00 $200.00 $250.00 $300.00 $350.00
Occupational Therapy Hourly Rate Comparison
Purchased Service (Maximum Hourly Rate) CCB Provided (Maximum Hourly Rate) FY 09 - 10 Supplemental Audit Average Hourly Rate Billed
Analysis
Conducted to
Date
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 16.911(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
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)
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 Hourly Upper Rate Limit for Contract Provider Hourly Upper Rate Limit for Employed Provider
Developmental Intervention $ 62.52 $ 87.68 Occupational Therapy $ 75.84 $ 84.88 Physical Therapy $ 78.44 $ 82.16 Speech Language Pathology $ 72.40 $ 94.12
Average hourly rates calculated using the September 2011 Community Centered Board rates on file with the Division for Developmental Disabilities
Option 1: Projected Impact
*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 2009 - 10 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 2009 - 10 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.
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)
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 $ 62.52 Occupational Therapy $ 75.84 Physical Therapy $ 78.44 Speech Language Pathology $ 72.40
Average hourly rates calculated using the September 2011 Community Centered Board rates on file with the Division for Developmental Disabilities.
Option 2: Projected Impact
*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 2009 - 10 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 2009 - 10 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.
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)
2012 ITCA Tipping
Points Surveys
2012 Part C Implementation: State Challengesand Responses, Infant & Toddler Coordinator Association
As a result of state fiscal
issues, what have you done
in the past 12 months?
Increased family fees, 1, 5% Required families to use private insurance or be placed on a fee schedule, 2, 10% Reduced provider reimbursement, 7, 35% Required prior approval for hours of service that exceed an identified amount, 4, 20% Narrowed eligibility, 6, 30%
Did any contractors/agencies
decline to continue to provide
direct services because of fiscal
constraints?
4, 11%
31, 89%
declined continued
What is the status of your
provider reimbursement
over the past three years?
23, 57%11, 27% 1, 3%
3, 8% 2, 5% Rates stayed the
same Decreased rates Will decrease rates Increased rates Will increase rates
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
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.
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.
Guiding Principles
The reimbursement structure should support early intervention philosophy and beliefs.
Guiding Principles
The reimbursement structure should support early intervention philosophy and beliefs.
Guiding Principles
The reimbursement structure should support best practice.
Guiding Principles
The reimbursement structure should support the hiring and retention of qualified staff.
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