20 CSR 400-2.170 - Early Intervention Part C Coverage
(1) Definitions: The terms used in this rule
or in section 376.1218, RSMo, shall have the
following meanings:
(A) "Assistive technology
device" means any item, piece of equipment, or product system, whether acquired
commercially off the shelf, modified, or customized, that is used to increase,
maintain or improve the functional capabilities of children with
disabilities.
(B) "Direct written
premium" means:
1. The total amount of premium
reported for health benefit plans, as defined in 376.1350, RSMo, on the Annual
Statement Supplement for the State of Missouri for health carriers required to
file this supplement; or
2. The
total amount of premium reported for health benefit plans, as defined in
376.1350, RSMo, on the Exhibit of Premiums, Enrollment, and Utilization for the
State of Missouri included in the health carrier's annual financial statement,
for all other health carriers not covered in paragraph (1)(B)1.
(C) "Early intervention services"
means medically necessary speech and language therapy, occupational therapy,
physical therapy, and assistive technology devices for children from birth to
age three (3) who are identified by the Part C early intervention system as
eligible for services under Part C of the Individuals with Disabilities
Education Act, 20 U.S.C.
Section 1431, et seq.
(D) "First Steps" refers to the Missouri
early intervention system under the federal Infant and Toddler Program, Part C
of the Individuals with Disabilities Act,
20 U.S.C. Section
1431, et seq.
(E) "Group of carriers affiliated by or under
common ownership or control" means health carriers with a common four (4)-digit
group code as assigned by the National Association of Insurance
Commissioners.
(F) "Health benefit
plan," "health care professional," and "health carrier" shall each have their
respective meanings as such terms are defined in 376.1350, RSMo.
(G) "Individualized family service plan"
means a written plan for providing early intervention services to an eligible
child and the child's family, that is adopted in accordance with
20 U.S.C. Section
1436.
(H) "Participating provider" means a provider
who, under a contract with the health carrier or with its contractor or
subcontractor, has agreed to provide health care services to enrollees with an
expectation of receiving payment, other than coinsurance, co-payments or
deductibles, directly or indirectly from the health
carrier.
(2) Health
benefit plans shall provide this coverage on the first date on or after January
1, 2006, on which the contract or certificate is delivered, issued for
delivery, continued or renewed in this state.
(3) Health Carriers to Recognize First Steps
as Provider.
(A) First Steps shall be
considered the rendering provider for all claims covered under section
376.1218, RSMo, and this
rule.
(B) First Steps shall be
considered a participating and/or network provider by all health carriers. All
health carriers shall use the Missouri standardized credentialing form or the
Federal W-9 tax form to establish network provider status for First Steps.
Health carriers shall take all necessary steps to assure that claims submitted
by First Steps are not denied, delayed, or reduced for reasons related to
network participation.
(4) Requirements for Acceptance and Payment
of Claims.
(A) Health carriers shall have the
option to pay claims for First Steps services in one (1) of three (3) ways:
1. A health carrier shall pay individual
claims submitted for each service to First Steps as the rendering provider, and
such coverage shall be limited to three thousand dollars ($3,000) for each
covered child per policy per calendar year, with a lifetime policy maximum of
nine thousand dollars ($9,000) per child. Such payments shall not exceed
one-half of one percent (0.5%) of the direct written premium for health benefit
plans; or
2. A health carrier and
all of its affiliates together shall submit a lump sum payment to First Steps
for one-half of one percent (0.5%) of the direct written premiums reported to
the Department of Commerce and Insurance on each health carrier's most recently
filed annual financial statement, per calendar year, which shall satisfy each
affiliated health carrier's payment obligation for First Steps services for
such calendar year; or
3. A health
carrier and all of its affiliates together shall make a lump sum payment of
five hundred thousand dollars ($500,000), per calendar year, to First Steps,
which shall satisfy the health carrier and its affiliates' payment obligation
for First Steps services for such calendar year.
4. As between paragraphs 2. and 3. of this
subsection, the health carrier shall pay whichever amount is less.
(B) Payment of individually
submitted claims under paragraph (4)(A)1. shall be subject to the requirements
of sections 376.383 and
376.384, RSMo, as of January 1,
2007.
(C) For health carriers
opting to make payments on individual claims under paragraph (4)(A)1.:
1. Such health carriers shall be responsible
for keeping records to determine when the maximum three thousand dollars
($3,000) per child, per policy, per calendar year has been reached. If there is
an irreconcilable discrepancy between a health carrier's records and Missouri
Department of Elementary and Secondary Education (DESE) records, DESE's records
shall prevail.
2. Such health
carriers shall amend their applicable coverage documents to reflect First Steps
benefits, and may do so by endorsement.
A.
Such documents shall contain the same or substantially the same benefit
description as stated in section
376.1218, RSMo, subsection
1.
3. Health carriers
shall receive and issue payment for First Steps claims.
A. All claim payments shall be sent to DESE's
designee.
B. Health carriers shall
submit all First Steps remittance advices to DESE's designee in an electronic
format consistent with federal administrative simplification standards, format
and content adopted pursuant to the Health Insurance Portability and
Accountability Act of 1996. Such remittance advices shall be submitted in a
format agreed to by DESE.
C. Health
carriers shall not deny, delay or reduce payment of First Steps claims based on
their own determination of medical necessity or diagnosis, but shall in all
cases defer to the services stated on the individual family service
plan.
D. Health carriers shall not
bundle claims for First Steps services.
E. For all adjustments on claim overpayments,
such health carriers shall submit to DESE's designee in an electronic format
consistent with federal administrative simplification standards, format and
content adopted pursuant to the Health Insurance Portability and Accountability
Act of 1996, remittance advices on a per claim adjustment reflecting the
individual and cumulative claim adjustment. Such remittance advices shall be
submitted in a format agreed to by DESE.
4. Coordination of benefits requirements.
A. All health benefit plans in effect during
a calendar year or any portion thereof, shall be obligated under the provisions
of section 376.1218, RSMo for reimbursement
of the early intervention services provided for any covered child entitled to
early intervention services as described in section
376.1218, RSMo up to the maximum
annual reimbursable amount of three thousand dollars ($3,000) with a nine
thousand dollar ($9,000)-lifetime maximum per child.
B. Failure of a parent or guardian to elect
to assign a right of recovery or indemnification to the First Steps program
shall not reduce claim payments to First Steps from secondary plans as defined
in 20 CSR
400-2.030.
C. Notification from DESE that a primary
plan, as defined in 20 CSR 400-2.030, has submitted
a lump sum payment under paragraphs (4)(A)2. or 3. shall be sufficient notice
to a secondary plan that such primary plan has fulfilled its payment
obligations for First Steps services for that year.
(D) Health carriers
shall accept and reimburse First Steps claims up to one (1) year after the date
of service. Health carriers that otherwise require participating providers to
submit claims in a shorter period of time than one (1) year shall waive this
requirement for First Steps claims.
1. Health
carriers that allow more than one (1) year for claims submission shall allow
the same amount of time for First Steps claims submissions.
(E) There will be a presumption
that the charges for First Steps services provided under section
376.1218, RSMo, and this rule,
are being billed at an applicable Medicaid rate for such services or assistive
technology devices.
(F) Health
carriers electing a lump sum payment under paragraphs (4)(A)2. or 3. will be
invoiced by DESE after January 1 of each year, with payments due no later than
January 31 of that year. The lump sum payment shall be due no later than
January 31 of each year regardless of the effective dates of the individual
insurance plans.
(G) Health
carriers that elect a lump sum payment under paragraphs (4)(A)2. or 3. and then
fail to make such payment no later than January 31 of that year, shall be
considered in violation of insurance law and be subjected to penalty, as
allowed under the insurance laws of the state of Missouri.
(H) Lump sum payments under paragraphs
(4)(A)2. and 3. shall not be credited against any health benefit plan lifetime
maximum aggregates.
(I) For health
carriers electing the lump sum payment option under paragraph (4)(A)2., the
amount of direct written premium used to determine such health carriers'
payment obligations for First Steps services will be the amount on record with
the Missouri Department of Commerce and Insurance on the most recently filed
annual financial statement and any filed amendments as of September 1 of each
year.
(5) Prior
Authorization.
(A) Health carriers shall not
require prior authorization for First Steps treatments and shall not deny,
delay or reduce claim payments for failure to obtain prior
authorization.
(6)
Transactions Affecting Affiliation of Health Carriers.
(A) In the event of a transaction affecting
affiliation of health carriers, the NAIC group code as of December 31 of the
preceding year that payment for First Steps claims is due will determine
affiliation of health carriers, and also, the total amount due to DESE if the
applicable health carriers elect a lump sum payment option under paragraphs
(4)(A)2. and 3.
Notes
AUTHORITY: sections 374.045, RSMo 2000 and 376.1218, RSMo Supp. 2005.* Emergency rule filed Dec. 20, 2005, effective Jan. 1, 2006, expired June 29, 2006. Original rule filed Dec. 20, 2005, effective June 30, 2006. Non-substantive change filed Sept. 11, 2019, published Oct. 31, 2019.
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