NY Pub Health L § 2559 (2021)
2021 New York Laws PBH - Public Health Article 25 - Maternal and Child Health Title 2-A - Early Intervention Program for Infants and Toddlers With Disabilities and Their Families 2559 - Third Party Insurance and Medical Assistance Program Payments.

§ 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  for  people  with  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   for   people   with   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.