State Structures for Part C Service Provision
and Implications for Accountability

Individual Provider Approach (see visual diagram (DOC: 26kb) ): The Individual Provider Approach usually includes entities at the regional or local level that serve as a point of entry conducting the initial evaluation/assessment, providing service coordination, and overseeing the implementation of the IFSP by state approved independent individual providers (not agencies). States typically set criteria for the minimum qualifications of the service providers, establish individual provider contracts, and maintain a current listing of approved providers for use by parents and service coordinators in arranging service delivery. Most states that use this approach require each approved provider in the provider pool to participate in state developed early intervention training.

This approach generally includes a fee for service and the provider is reimbursed following the provision of services. In some states, the provider is responsible for all billing of services to the appropriate payer, and in other states a central billing agency has been established to pay the provider a set fee and then bill the appropriate funding source for reimbursement. An authorization process, based upon IFSP services, is typically used for providers to receive reimbursement from the central billing agency.

Indiana, Illinois, Missouri, West Virginia, and Georgia are examples of states using this approach. Some of these states reorganized their system from a Provider Agency Approach (where provider agencies are primarily local counterparts to state agencies with some private-for-profit or private-non-profit agencies) in an attempt to increase compliance and improve services.

Some benefits that states have identified when using this approach include:

• A wide pool of providers are available and can usually serve the increasing number of children being referred;
• Providing services in natural environments is natural since individual providers usually work from their homes and do not have existing overhead facility costs;
• Central billing systems can form the basis for strong data systems, capable of tracking service authorization and delivery at the individual child level;
• Revenues can be maximized through fees and third party reimbursement;
• Families have choices among individual service providers.

Some challenges that states have identified when using this approach include:

• Employing sufficient state staff to ensure accountability, oversight and monitoring of individual provider contracts and entities serving as central points of contact (i.e., states have approximately 3,500 to over 7,000 individual provider contracts and can have 10 - 50 central points of entry contracts, which the state is responsible for overseeing);
• Ensuring delivery of quality services by individual providers that reflect the state's early intervention service delivery philosophy, current evidence-based practice, and related laws and regulations;
• Ensuring providers work as a coordinated team throughout the IFSP process rather than confuse families with conflicting approaches or overwhelm them with numbers of services and people;
• Establishing procedures that control costs and ensure that decisions related to IFSP services (including frequency and intensity) do not exceed the needs of children and families; and
• Establishing a strong technical assistance and training system that includes provider competencies, state developed training modules, numerous technical assistance supports, and strategies that ensure the provision of quality services (i.e., provider license on its own is not enough).

Several states with an Individual Provider Approach have shared copies of contracts they use to ensure accountability of service provision.

• Regional point of entry contracts:
• Illinois 2006-2007 CFC Contract (PDF: 36kb)

• Independent provider contracts:
• Georgia 2006-2007 Independent Provider Contracts for:
• Service Coordination (DOC: 60kb)
• Special Instruction (DOC: 53kb)
• Service Provision (DOC: 49kb)
• West Virginia Independent Provider Contract:
• CFO Payee Agreement (PDF: 229kb)
• Rider A (PDF: 223kb)
• Rider B (PDF: 231kb)
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Provider Agency (Program) Approach (see visual diagram (DOC: 29kb) ): Numerous states use a Provider Agency (Program) Approach for the provision of early intervention services. This approach usually includes the selection of approved agencies/programs by the state, based on an RFP or application process, which outlines standards/requirements that must be met. In this approach, a number of public and/or private agencies/programs within a region of the state may apply under the RFP or application process. In some states, approved provider agencies/programs receive most of the dollars up front and are subsequently held accountable for services provided. In other states, approved provider agencies/programs are reimbursed on a fee for service basis. The approved agencies/programs are usually the service provider for a specific area of the state and are responsible for all of the service provision.

Several states (e.g., Rhode Island, Massachusetts) that contract directly with programs/agencies have established a program certification process, including a set of standards that programs must meet to ensure that programs comply with federal and state regulations and provide quality services. The certification process and standards provide the basis for the lead agency determination of agencies'/programs' eligibility to participate in and receive payment for the provision of EI services. The standards typically mirror or are the state's procedures and requirements for EI services.

Examples of states that use a Provider Agency (Program) Approach include Texas, Connecticut, Rhode Island, Massachusetts, and Wyoming.

Some benefits states have identified from this approach include:

• Providing administrative and supervisory support to all service providers in a region under one entity, making it easier to support the provision of quality services;
• Having a limited number of state contracts or entities that the state is responsible for managing, monitoring, and ensuring accountability and compliance;
• Ensuring that the state is getting the best value for contracted services through a competitive procurement process for EI services on a regular basis (e.g., open competition among currently contracted agencies and others interested in becoming early intervention providers).
• Ensuring use of effective teaming approaches, including transdisciplinary or primary service provider models, since staff time in these activities is covered through overhead and/or rate structures; and
• Opportunities for staff development through reflective supervision, mentoring, and training are enhanced in salaried positions vs. individuals paid on a fee for service basis.
• Families have fewer choices of service providers, limiting confusion.

Some challenges states have identified when using this approach include:

• Less incentive to maximize resources and pursue all available funding sources if funds are paid up front. Strategies need to be incorporated into contracts or monitoring to address this;
• An insufficient number of providers to handle the increasing referrals states are encountering and to meet the needs of children who are eligible for services. Procedures that enable additional service providers (e.g., individuals or new agencies) to be added to the system between RFPs/applications need to be developed; and
• Limited family choice of service providers to those employed through the agency that serves the geographic region where the family resides.

• CT 2006-2007 Provider Agency Contract (DOC: 456kb)

Regional (District/Local) Administrative Approach (see visual diagram (DOC: 28kb) ): The Regional (District/Local) Administrative Approach is a third approach that states have used for the provision of early intervention services. It is a combination of the Individual Provider and Provider Agency (Program) Approaches. The state contracts with regional or local agencies (e.g., local lead agency) to coordinate services in a specified area of the state (in some states the regional or local agencies are counterparts to the state lead agency). These regional (district/local) agencies usually retain some of the service delivery responsibilities including evaluation/assessment and service coordination functions as well as some service provision responsibilities. They also contract with individual providers or provider agencies (programs) in order to ensure availability of sufficient services and resources. Funding arrangements for this approach vary from state to state. Some states provide funding to regional (district/local) agencies up front, make payments on a monthly or quarterly basis, or reimburse following service delivery. In other states, funding arrangements include a combination of these methods.

Some benefits that states have identified from this approach include:

• Providing administrative and supervisory support through one entity per area/region/community to employed service providers and using contractual arrangements for other service providers to ensure quality services and accountability;
• Having a limited number of state contracts or entities that the state manages, oversees, and monitors for compliance and quality services;
• Having a pool of providers in each geographic area to serve the increasing number of children being referred;
• Having flexibility in the service system structure to meet diverse local needs, (e.g., rural vs. urban);
• Providing services in natural environments is natural since individual providers usually work from their homes and do not have existing overhead facility costs; and
• Providing family choice among service providers or service provider agencies.

Some challenges that states have identified when using this approach include:

• Ensuring that individual service provider or service provider agency contracts are consistently managed by the region/community agencies that are given oversight responsibilities by the state; and
• Determining which payment methods will be used for regional/community agencies and for service providers.

Several states using a combination approach have made available copies of their contracts for ensuring accountability in the provision of services.

• Virginia 2006-2007 Local Lead Agency Contract for Continuing Participation in Part C (PDF: 177kb) (Note: This contract is being revised for 2007-2008 and will most likely include expanded deliverables.)
• North Carolina 2006-2007 Service Provider Agreement:
• General Service Provider Agreement (DOC: 210kb)
• Service Provider Attachment (DOC: 95kb)