8 Colo. Code Regs. § 1405-1-5.107

Current through Register Vol. 47, No. 20, October 25, 2024

Section 8 CCR 1405-1-5.107 - COORDINATED SYSTEM OF PAYMENT

This rule is promulgated pursuant to sections 26.5-3-406, 26.5-3-407, 26.5-3-408, and 26.5-3-409, C.R.S.

A. Early intervention services are provided to an eligible child and family at no out-of-pocket costs to a parent or guardian, such that the parent or guardian is not responsible for a sliding fee for services or payment of deductibles and co-payments for any early intervention service on a child's Individualized Family Service Plan, but is responsible for payment of insurance premiums when:

1. Private or public health insurance is used to pay for early intervention services;

2. Medicaid or Child Health Plan Plus is used to pay for early intervention services; or

3. Use of private health insurance is required prior to the use of public insurance or benefits.

B. The Certified Early Intervention Service Broker shall ensure:

1. That the availability of public or private health insurance to pay for services shall not result in the delay or denial of early intervention services to a child or a child's family;

2. No early intervention service documented in an Individualized Family Service Plan shall be delayed or denied because of a dispute between agencies regarding financial or other responsibilities required under 34 C.F.R. Section 303.510, which is incorporated by reference in Rule 5.104(A)(5);

3. All early intervention services on a child's Individualized Family Service Plan shall be made available to the child and family whether consent to use insurance or Medicaid is required or provided; and

4. Each parent or guardian of a child receiving early intervention services shall be provided with the written policies that inform the parent or guardian of rights to mediation, due process, and the state complaint process under Rule 5.120, if the parent or guardian is charged for an early intervention service by a provider when the parent or guardian should not be.

C. Funding Hierarchy

1. The following order of funding sources shall be used when an Individualized Family Service Plan team determines the appropriate funding source(s) to pay for needed early intervention services and, where required, parental consent is provided to use the available funding source:

a. Use of private pay at the discretion of the parent or guardian; then,

b. Private health insurance; then,

c. TRICARE, a military health system; then,

d. Medicaid/Title XIX or Home and Community Based Services waivers, and Child Health Plan Plus; then,

e. Child Welfare and Temporary Assistance to Needy Families; then,

f. Other local, state, or federal funds, including mill levy funds, as may be made available; then,

g. State General Fund early intervention services; then,

h. Federal Part C of the Individuals with Disabilities Education Act funds.

2. Implementation of the funding hierarchy shall be in accordance with 34 C.F.R. Section 303.520, which is incorporated by reference in Rule 5.104(A)(5).

3. State and federal funds may be used in combination with other funding sources as necessary and appropriate, and within state and federal defined parameters, to ensure the provision of early intervention services.

4. Private health insurance, with written parental consent, shall be accessed prior to accessing public benefits or insurance.

5. The appropriate Medicaid billing codes for early intervention services shall be used for any service on an Individualized Family Service Plan that has Medicaid as the funding source and the early intervention services provider bills Medicaid.

D. To use public health insurance or benefits, the Certified Early Intervention Service Broker shall:

1. Provide written notification of the intent to use public benefits or insurance for payment of early intervention services to a parent or guardian or child who has public health insurance or benefits;

2. Obtain written parental consent to disclose a child's personally identifiable information to the public insurance agency for billing purposes;

3. Not require a parent or guardian to enroll him or herself or the parent or guardian's infant or toddler in a public benefits or insurance program as a condition of receiving early intervention services;

4. Obtain written parental consent prior to using the public benefits or insurance of a child or parent or guardian if that child or parent or guardian is not already enrolled in such a program; and

5. Obtain written parental consent to use a child or parent or guardian's public benefits or insurance to pay for early intervention services if that use would result in:

a. A decrease in the available lifetime coverage or any other insured benefit for a child or parent or guardian;

b. Payment for services that would otherwise be covered by the public benefits or insurance program;

c. Increases in premiums or discontinuation of public benefits or insurance for that child or parent or guardian as a result of such use; or

d. A risk of loss of eligibility for the child or parent or guardian for Medicaid Home and Community- Based waivers based on aggregate health expenses.

E. To use private health insurance, the Certified Early Intervention Service Broker shall:

1. Provide prior written notice of the intent to use the private health insurance for payment of early intervention services to a parent or guardian who has or whose child has private health insurance or benefits.

2. Obtain written parental consent:

a. To disclose a child's personally identifiable information to the private health insurance company for billing purposes, including the use of private health insurance when such use is a prerequisite for the use of public insurance or benefits; and

b. For a child whose private health coverage plan is not covered under section 10-16-104 (1.3), C.R.S., at the initiation of billing for early intervention services and any time there is an increase in frequency, duration, or intensity of a service on the child's Individualized Family Service Plan.

3. Provide the written coordinated system of payment and procedural safeguard policies each time consent is required that informs the parent or guardian there are no out-of-pocket costs associated with the use of private health insurance, except for:

a. Premiums which are the responsibility of the parent or guardian; and

b. For any child who has a private health coverage plan not covered under section 10-16-104 (1.3), C.R.S., when there may be long-term costs such as the loss of benefits for the child or family because of annual or lifetime health coverage caps under the insurance policy.

F. Payment from Early Intervention Services Trust Qualified Private Health Insurance Carriers

1. Subject to section 10-16-104 (1.3), C.R.S., qualified private health insurance carriers who are required to cover early intervention services for an eligible dependent child shall provide early intervention services. Non-emergency medical transportation and assistive technology, as defined in Rule 5.114, shall be excluded, unless assistive technology is covered under an applicable insurance policy or service or indemnity contract as durable medical equipment benefit provisions.

2. Coverage required by private health insurance carriers shall be available annually to an eligible infant or toddler from birth up to the third (3rd) birthday. As of January 1, 2013, the maximum annual benefit payable for early intervention services and service coordination for each dependent infant or toddler, per benefit plan year, shall be limited as required by sections 10-16-104 (1.3) and 26.5-3-409, C.R.S.

a. For policies or contracts issued or renewed on or after January 1, 2015, and on or after each January 1 thereafter, the limit shall be adjusted by the Department. This adjustment is based upon the consumer price index for the Denver- Boulder- Greeley metropolitan statistical area for the State Fiscal Year which ends in the preceding calendar year or by such additional amount to be equal to the increase by the General Assembly to the annual appropriated rate. This rate is based on service to one (1) child for one (1) fiscal year in the state-funded Early Intervention Program if that increase is more than the consumer price index increase.

b. The limit on the annual amount of coverage for early intervention services shall not apply to:

(1) Rehabilitation or therapeutic services that are necessary as the result of an acute medical condition or post-surgical rehabilitation;

(2) Services provided to a child who is participating in early intervention services that are not provided pursuant to an Individualized Family Service Plan; however, such services shall be covered at the level specified in section 10-16-104 (1.3), C.R.S.; or

(3) Assistive technology that is covered by the policy's durable medical equipment benefit provisions.

3. Any benefits paid under the coverage required by section 10-16-104 (1.3), C.R.S., shall not be applied to an annual or lifetime maximum benefit contained in the policy or contract, except as provided for high deductible plans in section 10-16-104 (1.3)(d), C.R.S.

4. A qualified early intervention services provider that receives reimbursement for services funded by the trust fund shall accept such reimbursement as payment in full for services under section 10-16-104 (1.3), C.R.S., and shall not seek additional reimbursement from either the eligible infant or toddler's family or the carrier.

5. If funds deposited into the trust are fully expended prior to the end of the insurance plan year, the Certified Early Intervention Service Broker, as defined in Rule 5.103, shall coordinate with the Department to ensure that services continue as designated in the Individualized Family Service Plan. At the beginning of the new plan year, the private health insurance carrier shall be required to deposit additional funds into the Early Intervention Services Trust as established by Rule 5.107(G)(1).

6. Private health insurance carriers shall be notified within ninety (90) calendar days if an infant or toddler is no longer eligible for early intervention services.

G. Use of Early Intervention Services Trust

1. A trust fund shall be established in accordance with section 26.5-3-409, C.R.S. for the purpose of accepting deposits from a participating public health insurance or benefits program, or from the required private health insurance carriers for early intervention services provided to infants and toddlers under a participating insurance plan.

2. Funds deposited in the trust fund shall be only utilized on behalf of each infant and toddler for whom funds have been placed into the trust fund for the following:

a. Early intervention services, with the exclusion of assistive technology services and transportation, as described in Rule 5.114(B);

b. Monthly case management (service coordination) fee as determined by the Department;

c. Monthly Certified Early Intervention Service Broker fee as defined by the Department; and

d. Monthly fee to administer the Early Intervention Services Trust to each child covered by a qualifying plan as determined by the Department.

3. Upon exit from early intervention services or discontinuation of coverage by the private health insurance carrier, a private health insurance carrier shall be notified of monies deposited in the Early Intervention Services Trust on behalf of an eligible dependent infant or toddler that are not expended and the funds shall be returned within ninety (90) calendar days.

4. No later than April 1 of each year, private health insurance carriers shall be provided with a report specifying the amount of benefits paid to each Certified Early Intervention Service Broker for services provided to eligible infants or toddlers during the prior calendar year.

8 CCR 1405-1-5.107

46 CR 01, January 10, 2023, effective 1/1/2023

46 CR 06, March 25, 2023, effective 4/14/2023

47 CR 13, July 10, 2024, effective 7/30/2024