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Public Act 92-0307
SB461 Enrolled LRB9207772DJmb
AN ACT in relation to children.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Early Intervention Services System Act is
amended by changing Sections 3, 4, 5, 11, 13, and 15 and
adding Sections 13.5, 13.10, 13.15, 13.20, 13.25, 13.30,
13.32, and 13.50 as follows:
(325 ILCS 20/3) (from Ch. 23, par. 4153)
Sec. 3. Definitions. As used in this Act:
(a) "Eligible infants and toddlers" means infants and
toddlers under 36 months of age with any of the following
conditions:
(1) Developmental delays as defined by the
Department by rule.
(2) A physical or mental condition which typically
results in developmental delay.
(3) Being at risk of having substantial
developmental delays based on informed clinical judgment.
(4) Either (A) having entered the program under any
of the circumstances listed in paragraphs (1) through (3)
of this subsection but no longer meeting the current
eligibility criteria under those paragraphs, and
continuing to have any measurable delay, or (B) not
having attained a level of development in each area,
including (i) cognitive, (ii) physical (including vision
and hearing), (iii) language, speech, and communication,
(iv) psycho-social, or (v) self-help skills, that is at
least at the mean of the child's age equivalent peers;
and, in addition to either item (A) or item (B), (C)
having been determined by the multidisciplinary
individualized family service plan team to require the
continuation of early intervention services in order to
support continuing developmental progress, pursuant to
the child's needs and provided in an appropriate
developmental manner. The type, frequency, and intensity
of services shall differ from the initial individualized
family services plan because of the child's developmental
progress, and may consist of only service coordination,
evaluation, and assessments.
(b) "Developmental delay" means a delay in one or more
of the following areas of childhood development as measured
by appropriate diagnostic instruments and standard
procedures: cognitive; physical, including vision and
hearing; language, speech and communication; psycho-social;
or self-help skills.
(c) "Physical or mental condition which typically
results in developmental delay" means:
(1) a diagnosed medical disorder bearing a
relatively well known expectancy for developmental
outcomes within varying ranges of developmental
disabilities; or
(2) a history of prenatal, perinatal, neonatal or
early developmental events suggestive of biological
insults to the developing central nervous system and
which either singly or collectively increase the
probability of developing a disability or delay based on
a medical history.
(d) "Informed clinical judgment" means both clinical
observations and parental participation to determine
eligibility by a consensus of a multidisciplinary team of 2
or more members based on their professional experience and
expertise.
(e) "Early intervention services" means services which:
(1) are designed to meet the developmental needs of
each child eligible under this Act and the needs of his
or her family;
(2) are selected in collaboration with the child's
family;
(3) are provided under public supervision;
(4) are provided at no cost except where a schedule
of sliding scale fees or other system of payments by
families has been adopted in accordance with State and
federal law;
(5) are designed to meet an infant's or toddler's
developmental needs in any of the following areas:
(A) physical development, including vision and
hearing,
(B) cognitive development,
(C) communication development,
(D) social or emotional development, or
(E) adaptive development;
(6) meet the standards of the State, including the
requirements of this Act;
(7) include one or more of the following:
(A) family training,
(B) social work services, including
counseling, and home visits,
(C) special instruction,
(D) speech, language pathology and audiology,
(E) occupational therapy,
(F) physical therapy,
(G) psychological services,
(H) service coordination services,
(I) medical services only for diagnostic or
evaluation purposes,
(J) early identification, screening, and
assessment services,
(K) health services specified by the lead
agency as necessary to enable the infant or toddler
to benefit from the other early intervention
services,
(L) vision services,
(M) transportation, and
(N) assistive technology devices and services;
(8) are provided by qualified personnel, including
but not limited to:
(A) child development specialists or special
educators,
(B) speech and language pathologists and
audiologists,
(C) occupational therapists,
(D) physical therapists,
(E) social workers,
(F) nurses,
(G) nutritionists,
(H) optometrists,
(I) psychologists, and
(J) physicians;
(9) are provided in conformity with an
Individualized Family Service Plan;
(10) are provided throughout the year; and
(11) are provided in natural environments,
including the home and community settings in which
infants and toddlers without disabilities would
participate to the extent determined by the
multidisciplinary Individualized Family Service Plan.
(f) "Individualized Family Service Plan" or "Plan" means
a written plan for providing early intervention services to a
child eligible under this Act and the child's family, as set
forth in Section 11.
(g) "Local interagency agreement" means an agreement
entered into by local community and State and regional
agencies receiving early intervention funds directly from the
State and made in accordance with State interagency
agreements providing for the delivery of early intervention
services within a local community area.
(h) "Council" means the Illinois Interagency Council on
Early Intervention established under Section 4.
(i) "Lead agency" means the State agency responsible for
administering this Act and receiving and disbursing public
funds received in accordance with State and federal law and
rules.
(i-5) "Central billing office" means the central billing
office created by the lead agency under Section 13.
(j) "Child find" means a service which identifies
eligible infants and toddlers.
(k) "Regional intake entity" means the lead agency's
designated entity responsible for implementation of the Early
Intervention Services System within its designated geographic
area.
(l) "Early intervention provider" means an individual
who is qualified, as defined by the lead agency, to provide
one or more types of early intervention services, and who has
enrolled as a provider in the early intervention program.
(m) "Fully credentialed early intervention provider"
means an individual who has met the standards in the State
applicable to the relevant profession, and has met such other
qualifications as the lead agency has determined are suitable
for personnel providing early intervention services,
including pediatric experience, education, and continuing
education. The lead agency shall establish these
qualifications by rule filed no later than 180 days after the
effective date of this amendatory Act of the 92nd General
Assembly.
(Source: P.A. 90-158, eff. 1-1-98; 91-538, eff. 8-13-99.)
(325 ILCS 20/4) (from Ch. 23, par. 4154)
Sec. 4. Illinois Interagency Council on Early
Intervention.
(a) There is established the Illinois Interagency
Council on Early Intervention. The Council shall be composed
of at least 15 but not more than 25 members. The members of
the Council and the designated chairperson of the Council
shall be appointed by the Governor. The Council member
representing the lead agency may not serve as chairperson of
the Council. The Council shall be composed of the following
members:
(1) The Secretary of Human Services (or his or her
designee) and 2 additional representatives of the
Department of Human Services designated by the Secretary,
plus the Directors (or their designees) of the following
State agencies involved in the provision of or payment
for early intervention services to eligible infants and
toddlers and their families:
(A) Illinois State Board of Education;
(B) (Blank);
(C) (Blank);
(D) Illinois Department of Children and Family
Services;
(E) University of Illinois Division of
Specialized Care for Children;
(F) Illinois Department of Public Aid;
(G) Illinois Department of Public Health;
(H) (Blank);
(I) Illinois Planning Council on Developmental
Disabilities; and
(J) Illinois Department of Insurance.
(2) Other members as follows:
(A) At least 20% of the members of the Council
shall be parents, including minority parents, of
infants or toddlers with disabilities or children
with disabilities aged 12 or younger, with knowledge
of, or experience with, programs for infants and
toddlers with disabilities. At least one such
member shall be a parent of an infant or toddler
with a disability or a child with a disability aged
6 or younger;
(B) At least 20% of the members of the Council
shall be public or private providers of early
intervention services;
(C) One member shall be a representative of
the General Assembly; and
(D) One member shall be involved in the
preparation of professional personnel to serve
infants and toddlers similar to those eligible for
services under this Act.
The Council shall meet at least quarterly and in such
places as it deems necessary. Terms of the initial members
appointed under paragraph (2) shall be determined by lot at
the first Council meeting as follows: of the persons
appointed under subparagraphs (A) and (B), one-third shall
serve one year terms, one-third shall serve 2 year terms, and
one-third shall serve 3 year terms; and of the persons
appointed under subparagraphs (C) and (D), one shall serve a
2 year term and one shall serve a 3 year term. Thereafter,
successors appointed under paragraph (2) shall serve 3 year
terms. Once appointed, members shall continue to serve until
their successors are appointed. No member shall be appointed
to serve more than 2 consecutive terms.
Council members shall serve without compensation but
shall be reimbursed for reasonable costs incurred in the
performance of their duties, including costs related to child
care, and parents may be paid a stipend in accordance with
applicable requirements.
The Council shall prepare and approve a budget using
funds appropriated for the purpose to hire staff, and obtain
the services of such professional, technical, and clerical
personnel as may be necessary to carry out its functions
under this Act. This funding support and staff shall be
directed by the lead agency.
(b) The Council shall:
(1) advise and assist the lead agency in the
performance of its responsibilities including but not
limited to the identification of sources of fiscal and
other support services for early intervention programs,
and the promotion of interagency agreements which assign
financial responsibility to the appropriate agencies;
(2) advise and assist the lead agency in the
preparation of applications and amendments to
applications;
(3) review and advise on relevant regulations and
standards proposed by the related State agencies;
(4) advise and assist the lead agency in the
development, implementation and evaluation of the
comprehensive early intervention services system; and
(5) prepare and submit an annual report to the
Governor and to the General Assembly on the status of
early intervention programs for eligible infants and
toddlers and their families in Illinois. The annual
report shall include (i) the estimated number of eligible
infants and toddlers in this State, (ii) the number of
eligible infants and toddlers who have received services
under this Act and the cost of providing those services,
and (iii) the estimated cost of providing services under
this Act to all eligible infants and toddlers in this
State, and (iv) data and other information as is
requested to be included by the Legislative Advisory
Committee established under Section 13.50 of this Act.
The report shall be posted by the lead agency on the
early intervention website as required under paragraph
(f) of Section 5 of this Act.
No member of the Council shall cast a vote on or
participate substantially in any matter which would provide a
direct financial benefit to that member or otherwise give the
appearance of a conflict of interest under State law. All
provisions and reporting requirements of the Illinois
Governmental Ethics Act shall apply to Council members.
(Source: P.A. 91-357; eff. 7-29-99.)
(325 ILCS 20/5) (from Ch. 23, par. 4155)
Sec. 5. Lead Agency. The Department of Human Services
is designated the lead agency and shall provide leadership in
establishing and implementing the coordinated, comprehensive,
interagency and interdisciplinary system of early
intervention services. The lead agency shall not have the
sole responsibility for providing these services. Each
participating State agency shall continue to coordinate those
early intervention services relating to health, social
service and education provided under this authority.
The lead agency is responsible for carrying out the
following:
(a) The general administration, supervision, and
monitoring of programs and activities receiving
assistance under Section 673 of the Individuals with
Disabilities Education Act (20 United States Code 1473).;
(b) The identification and coordination of all
available resources within the State from federal, State,
local and private sources.;
(c) The development of procedures to ensure that
services are provided to eligible infants and toddlers
and their families in a timely manner pending the
resolution of any disputes among public agencies or
service providers.;
(d) The resolution of intra-agency and interagency
regulatory and procedural disputes.; and
(e) The development and implementation of formal
interagency agreements, and the entry into such
agreements, between the lead agency and (i) the
Department of Public Aid, (ii) the University of Illinois
Division of Specialized Care for Children, and (iii)
other relevant State agencies that:
(1) define the financial responsibility of
each agency for paying for early intervention
services (consistent with existing State and federal
law and rules, including the requirement that early
intervention funds be used as the payor of last
resort), a hierarchical order of payment as among
the agencies for early intervention services that
are covered under or may be paid by programs in
other agencies, and procedures for direct billing,
collecting reimbursements for payments made, and
resolving service and payment disputes; and
(2) include all additional components
necessary to ensure meaningful cooperation and
coordination.
Interagency agreements under this paragraph (e) must
be reviewed and revised to implement the purposes of this
amendatory Act of the 92nd General Assembly no later than
60 days after the effective date of this amendatory Act
of the 92nd General Assembly.
(f) The maintenance of an early intervention
website. Within 30 days after the effective date of
this amendatory Act of the 92nd General Assembly, the
lead agency shall post and keep posted on this website
the following: (i) the current annual report required
under subdivision (b)(5) of Section 4 of this Act, and
the annual reports of the prior 3 years, (ii) the most
recent Illinois application for funds prepared under
Section 637 of the Individuals with Disabilities
Education Act filed with the United States Department of
Education, (iii) proposed modifications of the
application prepared for public comment, (iv) notice of
Council meetings, Council agendas, and minutes of its
proceedings for at least the previous year, (v) proposed
and final early intervention rules, (vi) requests for
proposals, and (vii) all reports created for
dissemination to the public that are related to the early
intervention program, including reports prepared at the
request of the Council, the General Assembly, and the
Legislative Advisory Committee established under Section
13.50 of this Act. Each such document shall be posted on
the website within 3 working days after the document's
completion.
(Source: P.A. 90-158, eff. 1-1-98.)
(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) (a) timely, comprehensive, multidisciplinary
assessment of the unique 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 services to meet
those needs; and
(2) (b) 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 shall consult the lead
agency's therapy guidelines and its 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.
(c) The evaluation and initial assessment and initial
Plan meeting must be held within 45 days after the initial
contact with the early intervention services system. 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, at their discretion,
early intervention services shall be provided to each
eligible infant and toddler 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 income, and that these fees are payable to
the central billing office, and that if the family
encounters a catastrophic circumstance, as defined under
subsection (f) of Section 13 of this Act, making it
unable to pay the fees, the lead agency may, upon proof
of inability to pay, waive the fees.
(f) The individualized family service plan must state
whether the family has private insurance coverage and, if the
family has such coverage, 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.
(Source: P.A. 91-538, eff. 8-13-99.)
(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. 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. 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, may also 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 family income. 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
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.)
(325 ILCS 20/13.5 new)
Sec. 13.5. Other programs.
(a) When an application or a review of eligibility for
early intervention services is made, and at any eligibility
redetermination thereafter, the family shall be asked if it
is currently enrolled in Medicaid, KidCare, or the Title V
program administered by the University of Illinois Division
of Specialized Care for Children. If the family is enrolled
in any of these programs, that information shall be put on
the individualized family service plan and entered into the
computerized case management system, and shall require that
the individualized family services plan of a child who has
been found eligible for services through the Division of
Specialized Care for Children state that the child is
enrolled in that program. For those programs in which the
family is not enrolled, a preliminary eligibility screen
shall be conducted simultaneously for (i) medical assistance
(Medicaid) under Article V of the Illinois Public Aid Code,
(ii) children's health insurance program (KidCare) benefits
under the Children's Health Insurance Program Act, and (iii)
Title V maternal and child health services provided through
the Division of Specialized Care for Children of the
University of Illinois.
(b) For purposes of determining family fees under
subsection (f) of Section 13 and determining eligibility for
the other programs and services specified in items (i)
through (iii) of subsection (a), the lead agency shall
develop and use, within 60 days after the effective date of
this amendatory Act of the 92nd General Assembly, with the
cooperation of the Department of Public Aid and the Division
of Specialized Care for Children of the University of
Illinois, a screening device that provides sufficient
information for the early intervention regional intake
entities or other agencies to establish eligibility for those
other programs and shall, in cooperation with the Illinois
Department of Public Aid and the Division of Specialized Care
for Children, train the regional intake entities on using the
screening device.
(c) When a child is determined eligible for and
enrolled in the early intervention program and has been
found to at least meet the threshold income eligibility
requirements for Medicaid or KidCare, the regional intake
entity shall complete a KidCare/Medicaid application with the
family and forward it to the Illinois Department of Public
Aid's KidCare Unit for a determination of eligibility.
(d) With the cooperation of the Department of Public
Aid, the lead agency shall establish procedures that ensure
the timely and maximum allowable recovery of payments for all
early intervention services and allowable administrative
costs under Article V of the Illinois Public Aid Code and the
Children's Health Insurance Program Act and shall include
those procedures in the interagency agreement required under
subsection (e) of Section 5 of this Act.
(e) For purposes of making referrals for final
determinations of eligibility for KidCare benefits under the
Children's Health Insurance Program Act and for medical
assistance under Article V of the Illinois Public Aid Code,
the lead agency shall require each early intervention
regional intake entity to enroll as a "KidCare agent" in
order for the entity to complete the KidCare application as
authorized under Section 22 of the Children's Health
Insurance Program Act.
(f) For purposes of early intervention services that may
be provided by the Division of Specialized Care for Children
of the University of Illinois (DSCC), the lead agency shall
establish procedures whereby the early intervention regional
intake entities may determine whether children enrolled in
the early intervention program may also be eligible for those
services, and shall develop, within 60 days after the
effective date of this amendatory Act of the 92nd General
Assembly, (i) the inter-agency agreement required under
subsection (e) of Section 5 of this Act, establishing that
early intervention funds are to be used as the payor of last
resort when services required under an individualized family
services plan may be provided to an eligible child through
the DSCC, and (ii) training guidelines for the regional
intake entities and providers that explain eligibility and
billing procedures for services through DSCC.
(g) The lead agency shall require that an individual
applying for or renewing enrollment as a provider of services
in the early intervention program state whether or not he or
she is also enrolled as a DSCC provider. This information
shall be noted next to the name of the provider on the
computerized roster of Illinois early intervention providers,
and regional intake entities shall make every effort to refer
families eligible for DSCC services to these providers.
(325 ILCS 20/13.10 new)
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. An application for early
intervention services shall serve as a right to assignment of
the right of recovery against a private health insurance plan
or policy for any covered early intervention services that
may be billed to the family's insurance carrier and that are
provided to a child covered under the plan or policy.
(325 ILCS 20/13.15 new)
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. 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 that 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.
(325 ILCS 20/13.20 new)
Sec. 13.20. Families with insurance coverage.
(a) Families of children with insurance coverage,
whether public or private, shall incur no greater or less
direct out-of-pocket expenses for early intervention services
than families who are not insured.
(b) Managed care plans.
(1) Use of managed care network providers. When a
family's insurance coverage is through a managed care
arrangement with a network of providers that includes
one or more types of early intervention specialists who
provide the services set forth in the family's
individualized family service plan, the regional intake
entity shall require the family to use those network
providers, but only to the extent that:
(A) the network provider is immediately
available to receive the referral and to begin
providing services to the child;
(B) the network provider is enrolled as a
provider in the Illinois early intervention system
and fully credentialed under the current policy or
rule of the lead agency;
(C) the network provider can provide the
services to the child in the manner required in the
individualized service plan;
(D) the family would not have to travel more
than an additional 15 miles or an additional 30
minutes to the network provider than it would have
to travel to a non-network provider who is available
to provide the same service; and
(E) the family's managed care plan does not
allow for billing (even at a reduced rate or reduced
percentage of the claim) for early intervention
services provided by non-network providers.
(2) Transfers from non-network to network
providers. If a child has been receiving services from a
non-network provider and the regional intake entity
determines, at the time of enrollment in the early
intervention program or at any point thereafter, that the
family is enrolled in a managed care plan, the regional
intake entity shall require the family to transfer to a
network provider within 45 days after that determination,
but within no more than 60 days after the effective date
of this amendatory Act of the 92nd General Assembly, if:
(A) all the requirements of subdivision (b)(1)
of this Section have been met; and
(B) the child is less than 26 months of age.
(3) Waivers. The lead agency may fully or
partially waive the network enrollment requirements of
subdivision (b)(1) of this Section and the transfer
requirements of subdivision (b)(2) of this Section as to
a particular region, or narrower geographic area, if it
finds that the managed care plans in that area are not
allowing further enrollment of early intervention
providers and it finds that referrals or transfers to
network providers could cause an overall shortage of
early intervention providers in that region of the State
or could cause delays in families securing the early
intervention services set forth in individualized family
services plans.
(4) The lead agency, in conjunction with any
entities with which it may have contracted for the
training and credentialing of providers, the local
interagency council for early intervention, the regional
intake entity, and the enrolled providers in each region
who wish to participate, shall cooperate in developing a
matrix and action plan that (A) identifies both (i) which
early intervention providers and which fully credentialed
early intervention providers are members of the managed
care plans that are used in the region by families with
children in the early intervention program, and (ii)
which early intervention services, with what
restrictions, if any, are covered under those plans, (B)
identifies which credentialed specialists are members of
which managed care plans in the region, and (C)
identifies the various managed care plans to early
intervention providers, encourages their enrollment in
the area plans, and provides them with information on how
to enroll. These matrices shall be complete no later than
7 months after the effective date of this amendatory Act
of the 92nd General Assembly, and shall be provided to
the Early Intervention Legislative Advisory Committee at
that time. The lead agency shall work with networks that
may have closed enrollment to additional providers to
encourage their admission of early intervention
providers, and shall report to the Early Intervention
Legislative Advisory Committee on the initial results of
these efforts no later than February 1, 2002.
(325 ILCS 20/13.25 new)
Sec. 13.25. Private insurance; exemption.
(a) The lead agency shall establish procedures for a
family, whose child is eligible to receive early intervention
services, to apply for an exemption restricting the use of
its private insurance plan or policy based on material risk
of loss of coverage as authorized under subsection (c) of
this Section.
(b) The lead agency shall make a final determination on
a request for an exemption within 10 business days after its
receipt of a written request for an exemption at the regional
intake entity. During that 10 days, no claims may be filed
against the insurance plan or policy. If the exemption is
granted, it shall be noted on the individualized family
service plan, and the family and the providers serving the
family shall be notified in writing of the exemption.
(c) An exemption may be granted on the basis of material
risk of loss of coverage only if the family submits
documentation with its request for an exemption that
establishes (i) that the insurance plan or policy covering
the child is an individually purchased plan or policy and has
been purchased by a head of a household that is not eligible
for a group medical insurance plan, (ii) that the policy or
plan has a lifetime cap that applies to one or more specific
types of early intervention services specified in the
family's individualized family service plan, and that
coverage could be exhausted during the period covered by the
individualized family service plan, or (iii) proof of another
risk that the lead agency, in its discretion, may have
additionally established and defined as a ground for
exemption by rule.
(d) An exemption under this Section based on material
risk of loss of coverage may apply to all early intervention
services and all plans or policies insuring the child, may be
limited to one or more plans or policies, or may be limited
to one or more types of early intervention services in the
child's individualized family services plan.
(325 ILCS 20/13.30 new)
Sec. 13.30. System of personnel development. The lead
agency shall provide training to early intervention providers
and may enter into contracts to meet this requirement. If
such contracts are let, they shall be bid under a public
request for proposals that shall be posted on the lead
agency's early intervention website for no less than 30 days.
This training shall include, at minimum, the following types
of instruction:
(a) Courses in birth-to-3 evaluation and treatment of
children with developmental disabilities and delays (1) that
are taught by fully credentialed early intervention providers
or educators with substantial experience in evaluation and
treatment of children from birth to age 3 with developmental
disabilities and delays, (2) that cover these topics within
each of the disciplines of audiology, occupational therapy,
physical therapy, speech and language pathology, and
developmental therapy, including the social-emotional domain
of development, (3) that are held no less than twice per
year, (4) that offer no fewer than 20 contact hours per year
of course work, (5) that are held in no fewer than 5 separate
locales throughout the State, and (6) that give enrollment
priority to early intervention providers who do not meet the
experience, education, or continuing education requirements
necessary to be fully credentialed early intervention
providers; and
(b) Courses held no less than twice per year for no
fewer than 4 hours each in no fewer than 5 separate locales
throughout the State each on the following topics:
(1) Practice and procedures of private insurance
billing.
(2) The role of the regional intake entities;
service coordination; program eligibility determinations;
family fees; Medicaid, KidCare, and Division of
Specialized Care applications, referrals, and
coordination with Early Intervention; and procedural
safeguards.
(3) Introduction to the early intervention program,
including provider enrollment and credentialing, overview
of Early Intervention program policies and regulations,
and billing requirements.
(4) Evaluation and assessment of birth-to-3
children; individualized family service plan development,
monitoring, and review; best practices; service
guidelines; and quality assurance.
(325 ILCS 20/13.32 new)
Sec. 13.32. Contracting. The lead agency may enter into
contracts for some or all of its responsibilities under this
Act, including but not limited to, credentialing and
enrolling providers; training under Section 13.30;
maintaining a central billing office; data collection and
analysis; establishing and maintaining a computerized case
management system accessible to local referral offices and
providers; creating and maintaining a system for provider
credentialing and enrollment; creating and maintaining the
central directory required under subsection (g) of Section 7
of this Act; and program operations. If contracted, the
contract shall be subject to a public request for proposals
as described in the Illinois Procurement Code,
notwithstanding any exemptions or alternative processes that
may be allowed for such a contract under that Code, and, in
addition to the posting requirements under that Code, shall
be posted on the early intervention website maintained by the
lead agency during the entire bid period. Any of these listed
responsibilities currently under contract or grant that have
not met these requirements shall be subject to public bid
under this request for proposal process no later than July 1,
2002 or the date of termination of any contract in place.
(325 ILCS 20/13.50 new)
Sec. 13.50. Early Intervention Legislative Advisory
Committee. No later than 60 days after the effective date of
this amendatory Act of 92nd General Assembly, there shall be
convened the Early Intervention Legislative Advisory
Committee. The majority and minority leaders of the General
Assembly shall each appoint 2 members to the Committee. The
Committee's term is for a period of 2 years, and the
Committee shall publicly convene no less than 4 times per
year. The Committee's responsibilities shall include, but not
be limited to, providing guidance to the lead agency
regarding programmatic and fiscal management and
accountability, provider development and accountability,
contracting, and program outcome measures. During the life
of the Committee, on a quarterly basis, or more often as the
Committee may request, the lead agency shall provide to the
Committee, and simultaneously to the public, through postings
on the lead agency's early intervention website, quarterly
reports containing monthly data and other early intervention
program information that the Committee requests. The first
data report must be supplied no later than September 21,
2001, and must include the previous 2 quarters of data.
(325 ILCS 20/15) (from Ch. 23, par. 4165)
Sec. 15. The Auditor General of the State shall conduct
a follow-up an evaluation of the system established under
this Act, in order to evaluate the effectiveness of the
system in providing services that enhance the capacities of
families throughout Illinois to meet the special needs of
their eligible infants and toddlers, and provide a report of
the evaluation to the Governor and the General Assembly no
later than April 30, 2002 1993. Upon receipt by the lead
agency, this report shall be posted on the early intervention
website.
(Source: P.A. 87-680.)
Section 99. Effective date. This Act takes effect upon
becoming law.
Passed in the General Assembly May 31, 2001.
Approved August 09, 2001.
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