SB0626sam001 98TH GENERAL ASSEMBLY

Sen. Mattie Hunter

Filed: 4/15/2013

09800SB0626sam001 LRB098 04441 RPM 44594 a

AMENDMENT TO SENATE BILL 626

AMENDMENT NO. ______. Amend Senate Bill 626 by replacing everything after the enacting clause with the following:

"Section 5. If and only if Senate Bill 2217 becomes law, the Illinois Insurance Code is amended by adding Section 367m as follows:

(215 ILCS 5/367m new)

Sec. 367m. Early intervention services. Parental consent is not required for the use of private insurance for early intervention services as defined in the Early Intervention Services System Act that are provided in this State pursuant to Part C of the federal Individuals with Disabilities Education Act. A policy of accident and health insurance that provides coverage for early intervention services must conform to the following criteria:

(1) The use of private health insurance to pay for early intervention services under Part C of the federal Individuals with Disabilities Education Act may not count towards or result in a loss of benefits due to annual or lifetime insurance caps for an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy.

(2) The use of private health insurance to pay for early intervention services under Part C of the federal Individuals with Disabilities Education Act may not negatively affect the availability of health insurance to an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members who are covered under that health insurance policy, and health insurance coverage may not be discontinued for these individuals due to the use of the health insurance to pay for services under Part C of the federal Individuals with Disabilities Education Act.

(3) The use of private health insurance to pay for early intervention services under Part C of the federal Individuals with Disabilities Education Act may not be the basis for increasing the health insurance premiums of an infant or toddler with a disability, the infant's or toddler's parent, or the infant's or toddler's family members covered under that health insurance policy.

Section 10. If and only if Senate Bill 2217 becomes law, the Early Intervention Services System Act is amended by changing Sections 11, 13, 13.10, and 13.15 as follows:

(325 ILCS 20/11) (from Ch. 23, par. 4161)

Sec. 11. Individualized Family Service Plans.

(a) Each eligible infant or toddler and that infant's or toddler's family shall receive:

(1) timely, comprehensive, multidisciplinary assessment of the unique strengths and needs of each eligible infant and toddler, and assessment of the concerns and priorities of the families to appropriately assist them in meeting their needs and identify supports and services to meet those needs; and

(2) a written Individualized Family Service Plan developed by a multidisciplinary team which includes the parent or guardian. The individualized family service plan shall be based on the multidisciplinary team's assessment of the resources, priorities, and concerns of the family and its identification of the supports and services necessary to enhance the family's capacity to meet the developmental needs of the infant or toddler, and shall include the identification of services appropriate to meet those needs, including the frequency, intensity, and method of delivering services. During and as part of the initial development of the individualized family services plan, and any periodic reviews of the plan, the multidisciplinary team may seek consultation from the lead agency's designated experts, if any, to help determine appropriate services and the frequency and intensity of those services. All services in the individualized family services plan must be justified by the multidisciplinary assessment of the unique strengths and needs of the infant or toddler and must be appropriate to meet those needs. At the periodic reviews, the team shall determine whether modification or revision of the outcomes or services is necessary.

(b) The Individualized Family Service Plan shall be evaluated once a year and the family shall be provided a review of the Plan at 6 month intervals or more often where appropriate based on infant or toddler and family needs. The lead agency shall create a quality review process regarding Individualized Family Service Plan development and changes thereto, to monitor and help assure that resources are being used to provide appropriate early intervention services.

(c) The initial evaluation and initial assessment and initial Plan meeting must be held within 45 days after the initial contact with the early intervention services system. The 45-day timeline does not apply for any period when the child or parent is unavailable to complete the initial evaluation, the initial assessments of the child and family, or the initial Plan meeting, due to exceptional family circumstances that are documented in the child's early intervention records, or when the parent has not provided consent for the initial evaluation or the initial assessment of the child despite documented, repeated attempts to obtain parental consent. As soon as exceptional family circumstances no longer exist or parental consent has been obtained, the initial evaluation, the initial assessment, and the initial Plan meeting must be completed as soon as possible. With parental consent, early intervention services may commence before the completion of the comprehensive assessment and development of the Plan.

(d) Parents must be informed that early intervention services shall be provided to each eligible infant and toddler, to the maximum extent appropriate, in the natural environment, which may include the home or other community settings. Parents shall make the final decision to accept or decline early intervention services. A decision to decline such services shall not be a basis for administrative determination of parental fitness, or other findings or sanctions against the parents. Parameters of the Plan shall be set forth in rules.

(e) The regional intake offices shall explain to each family, orally and in writing, all of the following:

(1) That the early intervention program will pay for all early intervention services set forth in the individualized family service plan that are not covered or paid under the family's public or private insurance plan or policy and not eligible for payment through any other third party payor.

(2) That services will not be delayed due to any rules or restrictions under the family's insurance plan or policy.

(3) That the family may request, with appropriate documentation supporting the request, a determination of an exemption from private insurance use under Section 13.25.

(4) That responsibility for co-payments or co-insurance under a family's private insurance plan or policy will be transferred to the lead agency's central billing office.

(5) That families will be responsible for payments of family fees, which will be based on a sliding scale according to the State's definition of ability to pay which is comparing household size and income to the sliding scale and considering out-of-pocket medical or disaster expenses, and that these fees are payable to the central billing office. Families who fail to provide income information shall be charged the maximum amount on the sliding scale.

(f) The individualized family service plan must state whether the family has private insurance coverage and, if the family has such coverage and parental consent has been obtained, must have attached to it a copy of the family's insurance identification card or otherwise include all of the following information:

(1) The name, address, and telephone number of the insurance carrier.

(2) The contract number and policy number of the insurance plan.

(3) The name, address, and social security number of the primary insured.

(4) The beginning date of the insurance benefit year.

(g) A copy of the individualized family service plan must be provided to each enrolled provider who is providing early intervention services to the child who is the subject of that plan.

(h) Children receiving services under this Act shall receive a smooth and effective transition by their third birthday consistent with federal regulations adopted pursuant to Sections 1431 through 1444 of Title 20 of the United States Code.

(Source: P.A. 97-902, eff. 8-6-12; 09800SB2217eng.)

(325 ILCS 20/13) (from Ch. 23, par. 4163)

Sec. 13. Funding and Fiscal Responsibility.

(a) The lead agency and every other participating State agency may receive and expend funds appropriated by the General Assembly to implement the early intervention services system as required by this Act.

(b) The lead agency and each participating State agency shall identify and report on an annual basis to the Council the State agency funds utilized for the provision of early intervention services to eligible infants and toddlers.

(c) Funds provided under Section 633 of the Individuals with Disabilities Education Act (20 United States Code 1433) and State funds designated or appropriated for early intervention services or programs may not be used to satisfy a financial commitment for services which would have been paid for from another public or private source but for the enactment of this Act, except whenever considered necessary to prevent delay in receiving appropriate early intervention services by the eligible infant or toddler or family in a timely manner. "Public or private source" includes public and private insurance coverage.

Funds provided under Section 633 of the Individuals with Disabilities Education Act and State funds designated or appropriated for early intervention services or programs may be used by the lead agency to pay the provider of services (A) pending reimbursement from the appropriate State agency or (B) if (i) the claim for payment is denied in whole or in part by a public or private source, or would be denied under the written terms of the public program or plan or private plan, or (ii) use of private insurance for the service has been exempted under Section 13.25, or (iii) parental consent has not been obtained for the use of private insurance. Payment under item (B)(i) may be made based on a pre-determination telephone inquiry supported by written documentation of the denial supplied thereafter by the insurance carrier.

(d) Nothing in this Act shall be construed to permit the State to reduce medical or other assistance available or to alter eligibility under Title V and Title XIX of the Social Security Act relating to the Maternal Child Health Program and Medicaid for eligible infants and toddlers in this State.

(e) The lead agency shall create a central billing office to receive and dispense all relevant State and federal resources, as well as local government or independent resources available, for early intervention services. This office shall assure that maximum federal resources are utilized and that providers receive funds with minimal duplications or interagency reporting and with consolidated audit procedures.

(f) The lead agency shall, by rule, create a system of payments by families, including a schedule of fees. No fees, however, may be charged for: implementing child find, evaluation and assessment, service coordination, administrative and coordination activities related to the development, review, and evaluation of Individualized Family Service Plans, or the implementation of procedural safeguards and other administrative components of the statewide early intervention system.

The system of payments, called family fees, shall be structured on a sliding scale based on the family's ability to pay. The family's coverage or lack of coverage under a public or private insurance plan or policy shall not be a factor in determining the amount of the family fees.

Each family's fee obligation shall be established annually, and shall be paid by families to the central billing office in installments. At the written request of the family, the fee obligation shall be adjusted prospectively at any point during the year upon proof of a change in family income or family size. The inability of the parents of an eligible child to pay family fees due to catastrophic circumstances or extraordinary expenses shall not result in the denial of services to the child or the child's family. A family must document its extraordinary expenses or other catastrophic circumstances by showing one of the following: (i) out-of-pocket medical expenses in excess of 15% of gross income; (ii) a fire, flood, or other disaster causing a direct out-of-pocket loss in excess of 15% of gross income; or (iii) other catastrophic circumstances causing out-of-pocket losses in excess of 15% of gross income. The family must present proof of loss to its service coordinator, who shall document it, and the lead agency shall determine whether the fees shall be reduced, forgiven, or suspended within 10 business days after the family's request.

(g) To ensure that early intervention funds are used as the payor of last resort for early intervention services, the lead agency shall determine at the point of early intervention intake, and again at any periodic review of eligibility thereafter or upon a change in family circumstances, whether the family is eligible for or enrolled in any program for which payment is made directly or through public or private insurance for any or all of the early intervention services made available under this Act. The lead agency shall establish procedures to ensure that payments are made either directly from these public and private sources, when parental consent has been obtained, instead of from State or federal early intervention funds, or as reimbursement for payments previously made from State or federal early intervention funds.

(Source: P.A. 91-538, eff. 8-13-99; 92-10, eff. 6-11-01; 92-307, eff. 8-9-01; 92-651, eff. 7-11-02; 09800SB2217.)

(325 ILCS 20/13.10)

Sec. 13.10. Private health insurance; assignment. The lead agency shall determine, at the point of new applications for early intervention services, and for all children enrolled in the early intervention program, at the regional intake offices, whether the child is insured under a private health insurance plan or policy. Parental consent must be obtained when the lead agency or enrolled provider who is providing a family with early intervention services seeks to use the child or parent's private insurance or benefits to pay for the initial provision of early intervention services in the Individualized Family Services Plan and anytime that an increase in frequency, length, duration, or intensity is made to existing services in the child's Individualized Family Services Plan.

(Source: P.A. 92-307, eff. 8-9-01; 09800SB2217.)

(325 ILCS 20/13.15)

Sec. 13.15. Billing of insurance carrier.

(a) Subject to the restrictions against private insurance use on the basis of material risk of loss of coverage, as determined under Section 13.25, each enrolled provider who is providing a family with early intervention services shall bill the child's insurance carrier for each unit of early intervention service for which coverage may be available and parental consent has been obtained. The lead agency may exempt from the requirement of this paragraph any early intervention service that it has deemed not to be covered by insurance plans. When the service is not exempted, providers who receive a denial of payment on the basis that the service is not covered under any circumstance under the plan are not required to bill that carrier for that service again until the following insurance benefit year. That explanation of benefits denying the claim, once submitted to the central billing office, shall be sufficient to meet the requirements of this paragraph as to subsequent services billed under the same billing code provided to that child during that insurance benefit year. Any time limit on a provider's filing of a claim for payment with the central billing office that is imposed through a policy, procedure, or rule of the lead agency shall be suspended until the provider receives an explanation of benefits or other final determination of the claim it files with the child's insurance carrier.

(b) In all instances when an insurance carrier has been billed for early intervention services, whether paid in full, paid in part, or denied by the carrier, the provider must provide the central billing office, within 90 days after receipt, with a copy of the explanation of benefits form and other information in the manner prescribed by the lead agency.

(c) When the insurance carrier has denied the claim or paid an amount for the early intervention service billed that is less than the current State rate for early intervention services, the provider shall submit the explanation of benefits with a claim for payment, and the lead agency shall pay the provider the difference between the sum actually paid by the insurance carrier for each unit of service provided under the individualized family service plan and the current State rate for early intervention services. The State shall also pay the family's co-payment or co-insurance under its plan, but only to the extent that those payments plus the balance of the claim do not exceed the current State rate for early intervention services. The provider may under no circumstances bill the family for the difference between its charge for services and that which has been paid by the insurance carrier or by the State.

(Source: P.A. 97-813, eff. 7-13-12; 09800SB2217.)

Section 99. Effective date. This Act takes effect upon becoming law.".