Sen. Mattie Hunter

Filed: 4/15/2013

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 626

2    AMENDMENT NO. ______. Amend Senate Bill 626 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. If and only if Senate Bill 2217 becomes law,
5the Illinois Insurance Code is amended by adding Section 367m
6as follows:
 
7    (215 ILCS 5/367m new)
8    Sec. 367m. Early intervention services. Parental consent
9is not required for the use of private insurance for early
10intervention services as defined in the Early Intervention
11Services System Act that are provided in this State pursuant to
12Part C of the federal Individuals with Disabilities Education
13Act. A policy of accident and health insurance that provides
14coverage for early intervention services must conform to the
15following criteria:
16        (1) The use of private health insurance to pay for

 

 

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1    early intervention services under Part C of the federal
2    Individuals with Disabilities Education Act may not count
3    towards or result in a loss of benefits due to annual or
4    lifetime insurance caps for an infant or toddler with a
5    disability, the infant's or toddler's parent, or the
6    infant's or toddler's family members who are covered under
7    that health insurance policy.
8        (2) The use of private health insurance to pay for
9    early intervention services under Part C of the federal
10    Individuals with Disabilities Education Act may not
11    negatively affect the availability of health insurance to
12    an infant or toddler with a disability, the infant's or
13    toddler's parent, or the infant's or toddler's family
14    members who are covered under that health insurance policy,
15    and health insurance coverage may not be discontinued for
16    these individuals due to the use of the health insurance to
17    pay for services under Part C of the federal Individuals
18    with Disabilities Education Act.
19        (3) The use of private health insurance to pay for
20    early intervention services under Part C of the federal
21    Individuals with Disabilities Education Act may not be the
22    basis for increasing the health insurance premiums of an
23    infant or toddler with a disability, the infant's or
24    toddler's parent, or the infant's or toddler's family
25    members covered under that health insurance policy.
 

 

 

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1    Section 10. If and only if Senate Bill 2217 becomes law,
2the Early Intervention Services System Act is amended by
3changing Sections 11, 13, 13.10, and 13.15 as follows:
 
4    (325 ILCS 20/11)  (from Ch. 23, par. 4161)
5    Sec. 11. Individualized Family Service Plans.
6    (a) Each eligible infant or toddler and that infant's or
7toddler's family shall receive:
8        (1) timely, comprehensive, multidisciplinary
9    assessment of the unique strengths and needs of each
10    eligible infant and toddler, and assessment of the concerns
11    and priorities of the families to appropriately assist them
12    in meeting their needs and identify supports and services
13    to meet those needs; and
14        (2) a written Individualized Family Service Plan
15    developed by a multidisciplinary team which includes the
16    parent or guardian. The individualized family service plan
17    shall be based on the multidisciplinary team's assessment
18    of the resources, priorities, and concerns of the family
19    and its identification of the supports and services
20    necessary to enhance the family's capacity to meet the
21    developmental needs of the infant or toddler, and shall
22    include the identification of services appropriate to meet
23    those needs, including the frequency, intensity, and
24    method of delivering services. During and as part of the
25    initial development of the individualized family services

 

 

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1    plan, and any periodic reviews of the plan, the
2    multidisciplinary team may seek consultation from the lead
3    agency's designated experts, if any, to help determine
4    appropriate services and the frequency and intensity of
5    those services. All services in the individualized family
6    services plan must be justified by the multidisciplinary
7    assessment of the unique strengths and needs of the infant
8    or toddler and must be appropriate to meet those needs. At
9    the periodic reviews, the team shall determine whether
10    modification or revision of the outcomes or services is
11    necessary.
12    (b) The Individualized Family Service Plan shall be
13evaluated once a year and the family shall be provided a review
14of the Plan at 6 month intervals or more often where
15appropriate based on infant or toddler and family needs. The
16lead agency shall create a quality review process regarding
17Individualized Family Service Plan development and changes
18thereto, to monitor and help assure that resources are being
19used to provide appropriate early intervention services.
20    (c) The initial evaluation and initial assessment and
21initial Plan meeting must be held within 45 days after the
22initial contact with the early intervention services system.
23The 45-day timeline does not apply for any period when the
24child or parent is unavailable to complete the initial
25evaluation, the initial assessments of the child and family, or
26the initial Plan meeting, due to exceptional family

 

 

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1circumstances that are documented in the child's early
2intervention records, or when the parent has not provided
3consent for the initial evaluation or the initial assessment of
4the child despite documented, repeated attempts to obtain
5parental consent. As soon as exceptional family circumstances
6no longer exist or parental consent has been obtained, the
7initial evaluation, the initial assessment, and the initial
8Plan meeting must be completed as soon as possible. With
9parental consent, early intervention services may commence
10before the completion of the comprehensive assessment and
11development of the Plan.
12    (d) Parents must be informed that early intervention
13services shall be provided to each eligible infant and toddler,
14to the maximum extent appropriate, in the natural environment,
15which may include the home or other community settings. Parents
16shall make the final decision to accept or decline early
17intervention services. A decision to decline such services
18shall not be a basis for administrative determination of
19parental fitness, or other findings or sanctions against the
20parents. Parameters of the Plan shall be set forth in rules.
21    (e) The regional intake offices shall explain to each
22family, orally and in writing, all of the following:
23        (1) That the early intervention program will pay for
24    all early intervention services set forth in the
25    individualized family service plan that are not covered or
26    paid under the family's public or private insurance plan or

 

 

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1    policy and not eligible for payment through any other third
2    party payor.
3        (2) That services will not be delayed due to any rules
4    or restrictions under the family's insurance plan or
5    policy.
6        (3) That the family may request, with appropriate
7    documentation supporting the request, a determination of
8    an exemption from private insurance use under Section
9    13.25.
10        (4) That responsibility for co-payments or
11    co-insurance under a family's private insurance plan or
12    policy will be transferred to the lead agency's central
13    billing office.
14        (5) That families will be responsible for payments of
15    family fees, which will be based on a sliding scale
16    according to the State's definition of ability to pay which
17    is comparing household size and income to the sliding scale
18    and considering out-of-pocket medical or disaster
19    expenses, and that these fees are payable to the central
20    billing office. Families who fail to provide income
21    information shall be charged the maximum amount on the
22    sliding scale.
23    (f) The individualized family service plan must state
24whether the family has private insurance coverage and, if the
25family has such coverage and parental consent has been
26obtained, must have attached to it a copy of the family's

 

 

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1insurance identification card or otherwise include all of the
2following information:
3        (1) The name, address, and telephone number of the
4    insurance carrier.
5        (2) The contract number and policy number of the
6    insurance plan.
7        (3) The name, address, and social security number of
8    the primary insured.
9        (4) The beginning date of the insurance benefit year.
10    (g) A copy of the individualized family service plan must
11be provided to each enrolled provider who is providing early
12intervention services to the child who is the subject of that
13plan.
14    (h) Children receiving services under this Act shall
15receive a smooth and effective transition by their third
16birthday consistent with federal regulations adopted pursuant
17to Sections 1431 through 1444 of Title 20 of the United States
18Code.
19(Source: P.A. 97-902, eff. 8-6-12; 09800SB2217eng.)
 
20    (325 ILCS 20/13)  (from Ch. 23, par. 4163)
21    Sec. 13. Funding and Fiscal Responsibility.
22    (a) The lead agency and every other participating State
23agency may receive and expend funds appropriated by the General
24Assembly to implement the early intervention services system as
25required by this Act.

 

 

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1    (b) The lead agency and each participating State agency
2shall identify and report on an annual basis to the Council the
3State agency funds utilized for the provision of early
4intervention services to eligible infants and toddlers.
5    (c) Funds provided under Section 633 of the Individuals
6with Disabilities Education Act (20 United States Code 1433)
7and State funds designated or appropriated for early
8intervention services or programs may not be used to satisfy a
9financial commitment for services which would have been paid
10for from another public or private source but for the enactment
11of this Act, except whenever considered necessary to prevent
12delay in receiving appropriate early intervention services by
13the eligible infant or toddler or family in a timely manner.
14"Public or private source" includes public and private
15insurance coverage.
16    Funds provided under Section 633 of the Individuals with
17Disabilities Education Act and State funds designated or
18appropriated for early intervention services or programs may be
19used by the lead agency to pay the provider of services (A)
20pending reimbursement from the appropriate State agency or (B)
21if (i) the claim for payment is denied in whole or in part by a
22public or private source, or would be denied under the written
23terms of the public program or plan or private plan, or (ii)
24use of private insurance for the service has been exempted
25under Section 13.25, or (iii) parental consent has not been
26obtained for the use of private insurance. Payment under item

 

 

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1(B)(i) may be made based on a pre-determination telephone
2inquiry supported by written documentation of the denial
3supplied thereafter by the insurance carrier.
4    (d) Nothing in this Act shall be construed to permit the
5State to reduce medical or other assistance available or to
6alter eligibility under Title V and Title XIX of the Social
7Security Act relating to the Maternal Child Health Program and
8Medicaid for eligible infants and toddlers in this State.
9    (e) The lead agency shall create a central billing office
10to receive and dispense all relevant State and federal
11resources, as well as local government or independent resources
12available, for early intervention services. This office shall
13assure that maximum federal resources are utilized and that
14providers receive funds with minimal duplications or
15interagency reporting and with consolidated audit procedures.
16    (f) The lead agency shall, by rule, create a system of
17payments by families, including a schedule of fees. No fees,
18however, may be charged for: implementing child find,
19evaluation and assessment, service coordination,
20administrative and coordination activities related to the
21development, review, and evaluation of Individualized Family
22Service Plans, or the implementation of procedural safeguards
23and other administrative components of the statewide early
24intervention system.
25    The system of payments, called family fees, shall be
26structured on a sliding scale based on the family's ability to

 

 

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1pay. The family's coverage or lack of coverage under a public
2or private insurance plan or policy shall not be a factor in
3determining the amount of the family fees.
4    Each family's fee obligation shall be established
5annually, and shall be paid by families to the central billing
6office in installments. At the written request of the family,
7the fee obligation shall be adjusted prospectively at any point
8during the year upon proof of a change in family income or
9family size. The inability of the parents of an eligible child
10to pay family fees due to catastrophic circumstances or
11extraordinary expenses shall not result in the denial of
12services to the child or the child's family. A family must
13document its extraordinary expenses or other catastrophic
14circumstances by showing one of the following: (i)
15out-of-pocket medical expenses in excess of 15% of gross
16income; (ii) a fire, flood, or other disaster causing a direct
17out-of-pocket loss in excess of 15% of gross income; or (iii)
18other catastrophic circumstances causing out-of-pocket losses
19in excess of 15% of gross income. The family must present proof
20of loss to its service coordinator, who shall document it, and
21the lead agency shall determine whether the fees shall be
22reduced, forgiven, or suspended within 10 business days after
23the family's request.
24    (g) To ensure that early intervention funds are used as the
25payor of last resort for early intervention services, the lead
26agency shall determine at the point of early intervention

 

 

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1intake, and again at any periodic review of eligibility
2thereafter or upon a change in family circumstances, whether
3the family is eligible for or enrolled in any program for which
4payment is made directly or through public or private insurance
5for any or all of the early intervention services made
6available under this Act. The lead agency shall establish
7procedures to ensure that payments are made either directly
8from these public and private sources, when parental consent
9has been obtained, instead of from State or federal early
10intervention funds, or as reimbursement for payments
11previously made from State or federal early intervention funds.
12(Source: P.A. 91-538, eff. 8-13-99; 92-10, eff. 6-11-01;
1392-307, eff. 8-9-01; 92-651, eff. 7-11-02; 09800SB2217.)
 
14    (325 ILCS 20/13.10)
15    Sec. 13.10. Private health insurance; assignment. The lead
16agency shall determine, at the point of new applications for
17early intervention services, and for all children enrolled in
18the early intervention program, at the regional intake offices,
19whether the child is insured under a private health insurance
20plan or policy. Parental consent must be obtained when the lead
21agency or enrolled provider who is providing a family with
22early intervention services seeks to use the child or parent's
23private insurance or benefits to pay for the initial provision
24of early intervention services in the Individualized Family
25Services Plan and anytime that an increase in frequency,

 

 

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1length, duration, or intensity is made to existing services in
2the child's Individualized Family Services Plan.
3(Source: P.A. 92-307, eff. 8-9-01; 09800SB2217.)
 
4    (325 ILCS 20/13.15)
5    Sec. 13.15. Billing of insurance carrier.
6    (a) Subject to the restrictions against private insurance
7use on the basis of material risk of loss of coverage, as
8determined under Section 13.25, each enrolled provider who is
9providing a family with early intervention services shall bill
10the child's insurance carrier for each unit of early
11intervention service for which coverage may be available and
12parental consent has been obtained. The lead agency may exempt
13from the requirement of this paragraph any early intervention
14service that it has deemed not to be covered by insurance
15plans. When the service is not exempted, providers who receive
16a denial of payment on the basis that the service is not
17covered under any circumstance under the plan are not required
18to bill that carrier for that service again until the following
19insurance benefit year. That explanation of benefits denying
20the claim, once submitted to the central billing office, shall
21be sufficient to meet the requirements of this paragraph as to
22subsequent services billed under the same billing code provided
23to that child during that insurance benefit year. Any time
24limit on a provider's filing of a claim for payment with the
25central billing office that is imposed through a policy,

 

 

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1procedure, or rule of the lead agency shall be suspended until
2the provider receives an explanation of benefits or other final
3determination of the claim it files with the child's insurance
4carrier.
5    (b) In all instances when an insurance carrier has been
6billed for early intervention services, whether paid in full,
7paid in part, or denied by the carrier, the provider must
8provide the central billing office, within 90 days after
9receipt, with a copy of the explanation of benefits form and
10other information in the manner prescribed by the lead agency.
11    (c) When the insurance carrier has denied the claim or paid
12an amount for the early intervention service billed that is
13less than the current State rate for early intervention
14services, the provider shall submit the explanation of benefits
15with a claim for payment, and the lead agency shall pay the
16provider the difference between the sum actually paid by the
17insurance carrier for each unit of service provided under the
18individualized family service plan and the current State rate
19for early intervention services. The State shall also pay the
20family's co-payment or co-insurance under its plan, but only to
21the extent that those payments plus the balance of the claim do
22not exceed the current State rate for early intervention
23services. The provider may under no circumstances bill the
24family for the difference between its charge for services and
25that which has been paid by the insurance carrier or by the
26State.

 

 

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1(Source: P.A. 97-813, eff. 7-13-12; 09800SB2217.)
 
2    Section 99. Effective date. This Act takes effect upon
3becoming law.".