Insurance Circular Letter No. 6 (2022)

April 21, 2022

STATUTORY REFERENCES: N.Y. Public Health Law Article 25, Title 2-A, and § 2807-o; Chapter 820 of the Laws of 2021

I. Purpose

On December 30, 2021, Governor Kathy Hochul signed into law Chapter 820 of the Laws of 2021 (“Chapter 820”), which amended the Public Health Law and Insurance Law with regard to early intervention services. In relevant part, Chapter 820 added a new Public Health Law § 2807-o, which created an early intervention services pool, and repealed Insurance Law §§ 3216(i)(25)(F), 3221(l)(17)(F), 3235-a, and 4303(ee)(6). The amendments made by Chapter 820 took effect on January 1, 2022.

The purpose of this circular letter is to remind insurers authorized to write accident and health insurance in this state, Article 43 corporations, health maintenance organizations, student health plans certified pursuant to Insurance Law § 1124, municipal cooperative health benefit plans, and prepaid health services plans (collectively, “issuers”) of changes to the Early Intervention Program (“EIP”) in relation to comprehensive health insurance coverage. As of January 1, 2022, issuers are subject to an assessment to fund an early intervention services pool and are no longer required to reimburse EIP services provided pursuant to Public Health Law Article 25, Title 2-A on and after January 1, 2022.

II. Coverage of EIP Services Prior to January 1, 2022

The EIP, established under Public Health Law Article 2, Title 2-A, provides a child who has a confirmed disability or established developmental delay with access to a range of therapeutic and support services from birth to three years old at no cost to the child’s family. Prior to being repealed by Chapter 820, Insurance Law § 3235-a prohibited an issuer from excluding coverage for a service, otherwise covered under a health insurance policy or contract, solely on the basis that the service is provided under the EIP. Additionally, Insurance Law § 3235-a provided that the EIP service must not be applied against any annual or lifetime dollar limits, if applicable, in a health insurance policy or contract. Furthermore, any visit limits and other terms or conditions of the coverage could have been applied to EIP services; however, any visits used for EIP services could not have reduced the number of visits otherwise available to the child under a health insurance policy or contract.

Issuers must ensure that they are not denying claims for EIP services provided prior to January 1, 2022 and otherwise covered under a policy or contract, solely on the basis that the service was obtained through the EIP. Issuers should process all claims received from the Department of Health’s (“DOH”) State Fiscal Agent (“SFA”) for EIP services provided before January 1, 2022 and ensure that the claims are properly reimbursed for covered services.

III. Coverage of EIP Services On and After January 1, 2022

Since Chapter 820 repealed Insurance Law §§ 3216(i)(25)(F), 3221(l)(17)(F), 3235-a, and 4303(ee)(6) effective January 1, 2022, issuers are no longer required to reimburse EIP services provided pursuant to Public Health Law Article 2, Title 2-A on and after January 1, 2022. Instead, issuers are subject to a statewide assessment of $40 million beginning in fiscal year 2022 and each fiscal year thereafter. The EIP assessment will fund a pool from which municipalities and the state will be reimbursed for claims for EIP services, not reimbursable by any medical assistance program, pursuant to Public Health Law § 2807-o. As of March 22, 2022, DOH and the SFA ended the process of sending claims to issuers for EIP services. Due to the system changes, issuers may have received claims from the SFA for EI services provided on and after January 1, 2022. Issuers are not responsible for reimbursing these claims. Issuers that have already reimbursed claims for EIP services provided on and after January 1, 2022 should contact the SFA to initiate a return of payment. The SFA may be reached by telephone at (866) 315-3747 or by email at [email protected].

IV. Conclusion

The EIP provides vital services to young children in New York. Issuers must cover the cost of EIP services provided to children participating in the EIP when services were provided prior to January 1, 2022 and when a health insurance policy or contract otherwise provides coverage for the services. For the period of January 1, 2022 through March 22, 2022, issuers may have received claims for EIP services, but they are not responsible for reimbursing claims for EIP services provided on and after January 1, 2022.

Please direct any questions regarding this circular letter by email to [email protected].

Very truly yours,

Lisette Johnson
Chief, Health Bureau