Current through Register Vol. 49, No. 6, March 15, 2024
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.
*Original authority: 374.045, RSMo 1967, amended 1993, 1995
and 376.1218, RSMo 2005.