Early Intervention Part C Coverage

PURPOSE: This rule implements the requirements of section 376.1218, RSMo, with respect to the Missouri early intervention system and clarifies insurance carriers’ obligations under the new law. (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. 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. *Original authority: 374.045, RSMo 1967, amended 1993, 1995 and 376.1218, RSMo 2005.