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Department of regulatory agencies

DIVISION OF INSURANCE

3 CCR 702-4

LIFE, ACCIDENT AND HEALTH

Proposed Amended Regulation 4-2-28

CONCERNING THE PAYMENT OF EARLY INTERVENTION SERVICES FOR CHILDREN ELIGIBLE FOR BENEFITS UNDER PART C OF THE FEDERAL “INDIVIDUALS WITH DISABILITIES EDUCATION ACT”

Section 1 Authority

Section 2 Scope and Purpose

Section 3 Applicability

Section 4 Definitions

Section 5 Rules

Section 6 Severability

Section 7 Enforcement

Section 8 Incorporated Materials

Section 9 Effective Date

Section 10 History

Section 1 Authority

This regulation is being promulgated and adopted by the Commissioner of Insurance under the authority of §§ 10-1-109, 10-16-104(1.3) and 27-10.5-7049(2), C.R.S. (2012).

Section 2 Scope and Purpose

The purpose of this regulation is to provide health carriers the guidance necessary to implement House Bill 1237 enacted in 2009 by the Colorado General Assembly to facilitate the payment of early intervention services by private insurance sources and to incorporate the changes made to those payments by House Bill 13-1266. It replaces Emergency Regulation 09-E-01 in its entirety.

Section 3 Applicability

This amended regulation applies to all individual and group sickness and accident insurance policies and all service or indemnity contracts issued or renewed on or after October 1, 2009 January 1, 2014, by entities subject to Part 2, Part 3 and Part 4 of Article 16 of Title 10 of the Colorado Revised Statutes, which provide coverage for health care services.

Section 4 Definitions

A. “Carrier” shall have the same meaning as set forth in found at § 10-16-102(8), C.R.S.

B. “Case management services” means, for the purposes of this regulation, are the service coordination activities as defined in 34 CFR 303.2334.

C. “Certified early intervention service broker” or “broker” means, for the purposes of this regulation, a community centered board or other entity designated by the Colorado Department of Human Services to perform the specified duties and functions in a particular designated service area and may include the Division for of Developmental Disabilities Community and Family Support acting as the broker for any service area until another broker has been designated.

D. “Division for Developmental Disabilities of Community and Family Supportmeans, for the purposes of this regulation, is a division of the Colorado Department of Human Services.

E. “Early intervention services” shall have the same meaning as set forth in found at § 10-16-104(1.3)(a)(II), C.R.S., and include a monthly case management service costs and fees.

F. “Eligible child” shall have the same meaning as set forth in found at § 10-16-104(1.3)(a)(III), C.R.S.

G. “Grandfathered health benefit plan” shall have the same meaning as found at § 10-16-102(31), C.R.S.

GH. “Health benefit plan” shall have the same meaning as set forth in found at § 10-16-102(2132), C.R.S.

HI. “Individualized family service plan” or “IFSP” shall have the same meaning as set forth in found at § 10-16-104(1.3)(a)(IV), C.R.S.

IJ. "Limited benefit health insurance" means, for the purposes of this regulation, a health policy, contract or certificate offered or marketed on an individual or group basis as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments or coinsurance amounts not covered by a health benefit plan. “Limited benefit health insurance” does not include short-term limited duration health insurance policies, contracts or certificates; high deductible plans; or catastrophic health policies, contracts or certificates. Such non-supplemental plans are included under the term “health benefit plan”.

JK. “Registry” means, for the purposes of this regulation, a listing of early intervention service providers established by the designated area’s certified early intervention service broker. The broker may provide early intervention services directly or may subcontract the provision of services to other qualified providers in the registry.

L. “Qualified early intervention service provider” or “qualified provider” shall have the same meaning as found at § 10-16-104(1.3)(a)(VI), C.R.S.

Section 5 Rules

A. Eligible early intervention services specified in the eligible child’s IFSP shall be considered to meet the carrier’s test of medically necessary services. Therefore, carriers shall arrange for the payment of claims for early intervention services provided to an eligible child received from qualified early intervention service providers listed in the registry.

B. The certified early intervention service broker will notify the carrier within ten (10) days of determining that a child, up to age three (3), is eligible for early intervention services. This notification will include, at a minimum:

1. The eligible child’s name;

2. The eligible child’s date of birth;

3. The policy number; and

4. The name of the primary insured or policyholder.

C. Trust Payments.

1. Upon the receipt of a new IFSP for an eligible child, carriers shall pay an amount equal to the annual benefit published in a bulletin by the Colorado Division of Insurance Subject to paragraphs 1, 2 and 3 of this subsection C., carriers shall pay benefits into the trust established by the Colorado Department of Human Services (CDHS) as provided in § 27-10.5-709(1), C.R.S., within thirty 30 days of receipt of an invoice issued by CDHS,. as follows:

1. For an eligible child identified after the effective date of the amendment of this regulation;

2. For an eligible child covered by a plan subject to the requirements of section 5.E.1: already receiving early intervention services in accordance with § 10-16-104(1.3), C.R.S.:

a. Upon the first day of the policy’s new calendar year or benefit year, as applicable, after the effective date of the amendment of this regulation; If funds remain in the trust after benefits have been paid for the required number of visits and associated case management costs and fees, the trust will refund the balance to the carrier when it performs its reconciliation for the eligible child.

b. Payment into the trust is not required prior to the policy’s new calendar year or benefit year, as applicable; therefore, the carrier’s payment of the services may continue as initially established; If the funds deposited are not enough to cover the services billed for the required number of visits and associated case management costs and fees, the carrier will deposit an additional amount in increments of $1,000, as needed, until all required services and fees have been paid. Remaining funds will be refunded in accordance with section 5.C.2.a.

3. Upon the receipt of a new IFSP for an eligible child not previously utilizing private health coverage for reimbursement of early intervention services.

D. Carrier payment guidelines.

1. Eligible early intervention services do not include:

a1. Non-emergency medical transportation;

b2. Respite care;

c3. Service coordination other than case management services; and

d4. Assistive technology. However, assistive technology may be covered by the policy’s durable medical equipment benefit provisions.

2. If the payment is not made into the trust, then monthly case management service fees shall be paid directly to the certified early intervention service broker that has been designated by the State until the maximum annual benefit has been paid.

E. Benefit and payment requirements.

1. For plans issued or renewed on or after January 1, 2014, except as allowed by section 5.E.2, coverage must be provided for no less than forty-five (45) visits annually for early intervention services and associated case management costs and fees, with no dollar limit imposed upon those visits.

2. For grandfathered health benefit plans, the maximum annual monetary benefit payable for all eligible early intervention and case management costs and fees will be published in a bulletin by the Colorado Division of Insurance and shall be adjusted annually based on:

a. The consumer price index for the Denver-Boulder-Greeley metropolitan statistical area for the state fiscal year that ends in the preceding calendar year; or

b. By such additional amount to be equal to the increase by the General Assembly to the annual appropriated rate to serve one child for one fiscal year in the state-funded early intervention program if that increase is more than the consumer price index increase.

3. As of January 1, 2009, the maximum annual benefit payable for all eligible early intervention and case management services is $5,935.00. Thereafter, on January 1 of each year, the maximum annual benefit payable shall be adjusted based on the consumer price index for the Denver-Boulder-Greeley metropolitan statistical area for the state fiscal year that 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 to serve one child for one fiscal year in the state-funded early intervention program if that increase is more than the consumer price index increase. The new maximum annual benefit amount will be published in a bulletin by the Colorado Division of Insurance.

43. Any covered benefit payable for the following services shall not be subject to the maximum annual benefit specified for in paragraphs 3. of this subsection D 1. and 2. of this subsection E:

a. Rehabilitation or therapeutic services thatwhich are necessary as the result of an acute medical condition or post-surgical rehabilitation;

b. Services provided to a child who is not participating in Part C and services that are not provided pursuant to an IFSP; and

c. Assistive technology that is covered by the policy’s durable medical equipment benefit provisions.

5. When the trust is not utilized for early intervention services that were started prior to the effective date of the amendment to this regulation, carriers shall notify the policyholder and the certified early intervention service broker when the maximum annual benefit has been paid. At the beginning of the new plan year, the carrier shall be responsible for paying benefits up to the maximum annual benefit as established in accordance with paragraph 3. of this subsection D.

64. Qualified early intervention service providers that receive reimbursement in accordance with paragraphs 51. and 2. of this subsection DE. shall accept such reimbursement as payment in full for services provided under § 10-16-104(1.3), C.R.S. and shall not seek additional reimbursement from either the covered person or the carrier.

EF. The Division for Developmental Disabilities of Community and Family Support will notify the carrier within ninety 90 days if a child is no longer eligible for early intervention services.

FG. Short-term, accident, fixed indemnity, specified disease policies, disability income contracts, limited benefit health insurance plans, credit disability insurance and Medicare supplement policies are not required to provided the benefits set forth in § 10-16-104(1.3), C.R.S.

GH. The carrier shall return requests for verification of eligibility of coverage of the eligible child to the certified early intervention service broker within five (5) business days of receipt.

Section 6 Severability

If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected.

Section 7 Enforcement

Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties fines, issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority license, subject to the requirements of due process. Among others, the penalties provided for in § 10-3-1108, C.R.S., may be applied.

Section 8 Incorporated Materials

The following is hereby incorporated by reference as written on or before the effective date of this regulation:

Section 303.2334 of Title 34 (Early Intervention Program for Infants and Toddlers with Disabilities), Code of Federal Regulations. published by the Government Printing Office shall mean Section 303.34 of Title 34 as published on the effective date of this regulation and does not include later amendments to or editions of Section 303.34 of Title 34. A copy of Section 303.34 of Title 34 may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado, 80202. A certified copy of Section 303.34 of Title 34 may be requested from the Rulemaking Coordinator, Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202. A charge for certification or copies may apply. A copy may also be obtained online at www.ecfr.gov.

This rule does not include later amendments to or editions of the incorporated material. A copy of this reference may be examined at any state publications depository library. For additional information regarding how to obtain a copy, please contact the Rulemaking Coordinator, Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202.

Section 9 Effective Date

This regulation shall become effective on October November 15, 200913.

Section 10 History

Emergency regulation 07-E-3 is effective December 3, 2007.

New regulation effective March 1, 2008.

Emergency regulation 09-E-01 is effective June 15, 2009.

Amended regulation effective October 1, 2009.

Amended regulation effective November 15, 2013.



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