Robbing Peter to Pay Paul

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Robbing Peter to Pay Paul

• Creative Approaches to Funding Providing Early
  Intervention Services

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Presentation ByPatti Rawding-Anderson MA,
MSPTDirector of Program Development for Early
Childhood Services Easter Seals
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Overview of Methods

• Actual Revenues
• Building Community Capacity
• Helping others to do what we cant
• Partnerships
• Sharing the load
• Decision Making
• The hard choices

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Actual Revenues

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

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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
• Childrens Care Management Collaborative
• Continuous Improvement and Focused Monitoring
  (QA)
• Family Resource Connection
• To a small degree, direct services

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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

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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)

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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

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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

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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 90s 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.

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Insurance Reimbursement

• In the late 90s, 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

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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 childs third birthday)
• Services for OT / PT / SLP only
• Consistent with the Massachusetts model which was
  state mandated

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Insurance Reimbursement

• In the early 2000s, 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

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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

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And if all that still doesnt work?

• Despite efforts, EI funding remains a concern in
  NH
• In 2004, NHs 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

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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

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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

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Philanthropic Dollars

• Grants
• United Way
• Individualized fund development activities
• Fund raisers
• Partnerships with Businesses

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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)

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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)

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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.

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NOW ITS YOUR TURN

• Ideas
• Innovative Funding Sources
• Creative Activities from the Field?