IV. Reimbursement Mechanisms for Screening and Evaluation
Screenings and evaluations, as defined in EIP regulations at 10 NYCRR §69-4.1 and performed in accordance with EIP regulations at 10 NYCRR §69-4.8, are reimbursable at rates set by the Department with the approval of the New York State Division of Budget.
Multidisciplinary evaluations, including screenings performed in the course of an evaluation, must be conducted by approved evaluators under contract with municipalities and selected by parents to determine initial, and when indicated, ongoing eligibility for the EIP. Only one claim can be submitted for the screening, regardless of the number of visits required to complete a screening.49 Up to two screenings may be conducted in a twelve-month period, starting with the date of the child's referral to the EIP. Reimbursement is not available for screenings conducted after a child has been found eligible for early intervention services (i.e., when developmental delays consistent with the State definition of developmental delay have been substantiated or when a diagnosed condition with a high probability of developmental delay has been established).
Multidisciplinary evaluations performed in accordance with programmatic procedures described in Section II are reimbursed as either a core evaluation, or a core and one or more supplemental evaluations, depending on the nature and extent of the concerns about the child's development.50 Evaluators can only submit one claim for one core or one supplemental evaluation, regardless of the number of visits required to complete the core or supplemental evaluation. Reimbursement regulations at 10 NYCRR §69-4.30(c)(2)(iii)(a) allow for reimbursement of one core evaluation and up to four different supplemental evaluations within a twelve-month period in conjunction with the initial development or annual evaluation of IFSPs.
A core evaluation must include a developmental assessment; a review of pertinent records and the parent interview; and, at the option of the family, a family assessment. The developmental assessment completed for the core evaluation must be conducted by qualified personnel, with sufficient expertise in early childhood development and who are trained in the use of professionally accepted methods and procedures to evaluate each of the five developmental domains: physical development, cognitive development, communication development, social or emotional development, and adaptive development. If there is a specific concern about an area of the child's development at the time a child is referred, the qualified personnel who conduct the core evaluation should have sufficient expertise to assess that developmental area. The family assessment must also be conducted by qualified personnel who are trained in the use of professionally accepted methods and procedures to assist the family in identifying their concerns, priorities, and resources related to the development of their child.51 A core evaluation is required for all children who receive an evaluation to determine eligibility under the EIP. In many instances, the core evaluation will be sufficient to establish children's eligibility for the EIP and to initiate the development of an IFSP. The need for additional in-depth assessments can be identified as part of the IFSP team meeting, and can be accomplished through supplemental evaluations included in the child's IFSP.
Supplemental evaluations are provided at the recommendation of the multidisciplinary team conducting the core evaluation; or, after the child's initial multidisciplinary evaluation, in accordance with a child's IFSP. There are two types of supplemental evaluations: physician and non-physician supplemental evaluations.52 Supplemental non-physician evaluations are performed by qualified personnel, with specialized expertise, for the purpose of assessing specific child needs in one or more of the five developmental domains. Information obtained from supplemental evaluations must provide direction as to the specific early intervention services that may be required for the child.53 Supplemental non-physician evaluations must be performed by qualified personnel with specific expertise and training in the area of the child's development or condition that requires an in-depth assessment.54
Supplemental physician evaluations must be provided by a licensed physician for the purpose of assessing specific child needs in one or more developmental domains (including physical development) or for the purpose of providing specific medical information regarding physical or mental conditions that may impact on the growth and development of the child.55
It is important to note that supplemental evaluations are not intended to be routinely provided to all children in the EIP. The following are circumstances under which supplemental evaluations may be used in conjunction with a core evaluation for reimbursement of the child's initial multidisciplinary evaluation to establish a child's eligibility for the EIP, and as necessary to complete the development of an initial IFSP:
- If the multidisciplinary team that is conducting the core evaluation identifies the need for an in-depth assessment of a child's strengths and needs in a specific area of development, a supplemental evaluation may be recommended to the parent and provided with the parent's consent. The supplemental evaluation must be necessary to provide direction as to the specific early intervention services that may be needed by the child. Parent consent for the supplemental evaluation must be obtained, even when all evaluations for a child are being performed by professionals employed or under contract with a single agency.
- If, at the time of referral, the child has no established primary health care provider, a supplemental physician evaluation, or a non-physician evaluation by a qualified health practitioner working within the scope of his/her profession (e.g., a nurse practitioner or physician's assistant), may be used to complete the health assessment required as part of the evaluation of the child's physical development. The parent must agree to and provide consent for the supplemental physician evaluation or non-physician supplemental evaluation.
- If, at the time of referral, a child is suspected of having a diagnosed condition with a high probability of developmental delay, which necessitates the involvement of an expert qualified to evaluate and diagnose the condition, a non-physician or physician supplemental evaluation can be used to provide an evaluation by a psychologist, developmental pediatrician, psychiatrist, nurse practitioner, or other professional qualified to conduct an in-depth assessment resulting in a diagnosis.
- If, as the result of completing a core evaluation, a diagnosed condition with a high probability of developmental delay is suspected, for which the multidisciplinary team does not have sufficient expertise to conduct an in-depth assessment of the child's strengths and needs in that area, or to make a diagnosis, the multidisciplinary evaluation may recommend and the parent may agree to a supplemental evaluation. For example, if the multidisciplinary evaluation team has completed an evaluation of the child's communication development, and suspects that the child may have a hearing problem, the team may recommend that an audiologic evaluation be conducted to assess the child for possible hearing loss. The parent must agree and provide consent for this supplemental evaluation, and the evaluator selected by the parent to complete the core evaluation is responsible for assisting the parent in arranging the supplemental evaluation.
Subsequent to the child's initial multidisciplinary evaluation to establish eligibility and facilitate development of an initial IFSP, certain evaluation and assessment procedures may be repeated, with parent consent, if deemed necessary and appropriate by the Early Intervention Official. Specifically, evaluation and assessment procedures may be performed or repeated in conjunction with the annual evaluation of the IFSP:
- when an observable change in the child's developmental status indicates the need for modification of the IFSP;
- when an observable change in the child's developmental status indicates a change in the child's eligibility status; and,
- when the parent, early intervention official or service coordinator, or service provider(s) request a re-assessment at the six-month review of the IFSP.56
See Section VII for additional information on ongoing eligibility.
Core and/or supplemental evaluations provided subsequent to the child's initial IFSP must be authorized by the EIO. Reimbursement regulations at NYCRR §69-4.30(c)(2)(iii)(a) allow for reimbursement of one core evaluation and up to four supplemental evaluations in a twelve-month period in conjunction with the annual evaluation of IFSPs. After a child's initial multidisciplinary evaluation, any supplemental evaluations must be stated in the child's IFSP and must include the type of supplemental evaluation and the date and evaluator if known.57
As mentioned above, all evaluations performed under the EIP must be conducted by State-approved evaluators under contract with the municipality in which the child resides. In addition to licensure and certification within specific disciplines, individuals that perform evaluations should be experienced and trained in the use of the standardized instruments and clinical evaluation procedures. The six clinical practice guidelines developed by the Department EIP offer specific recommendations on the training and experience of professionals involved in evaluation and assessment procedures.
The Department EIP currently offers training sessions on the two published clinical practice guidelines (autism/pervasive developmental disorders and communication disorders), and is in the process of finalizing training curricula on the four guidelines currently in press (Down syndrome, motor disorders, vision impairment, and hearing loss). In addition, the Department EIP has a plan in place to develop training curricula and offer training sessions on standards and procedures for evaluations, evaluation reimbursement, and eligibility requirements and determination under the EIP. In the future, as these training sessions become available, all evaluators will be required to participate in Department EIP-sponsored training in these specific content areas.
49 10 NYCRR §69-4.30(c)(1)
50 10 NYCRR §69-4.30(c)(2)
51 10 NYCRR §69-4.30(c)(2)
52 10 NYCRR §69-4.30(c)(2)(ii)
53 10 NYCRR §69-4.30(c)(2)(ii)(b)
54 10 NYCRR §69-4.30(c)(2)(ii)(b)
55 10 NYCRR §69-4.30(c)(2)(ii)(a)
56 10 NYCRR §69-4.8(a)(12)
57 10 NYCRR §69-4.8 (a)(13); 10 NYCRR §69-4.30(c)(2)(iii)(b)