Tracking #2007-01309
Final (permanent) adoption of emergency rules on 01/11/08
Emergency adoption 12/7/07, eff. 1/1/08 w/Tracking #2007-01390

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[I:/07102301.doc]

(2 CCR 503-1)

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Revisions to Section 16.714 were final (permanent) adoption of emergency rules at the 1/11/2008 State Board of Human Services rule-making session, with an effective date of 1/11/2008 (Rule-making# 07-10-23-1).  Statement of Basis Purpose and specific statutory authority for these revisions were incorporated by reference into the rule.  These materials are available for review by the public during normal working hours at the Colorado Department of Human Services, Office Human Resources, Compliance and Regulatory Affairs, Boards and Commissions Division, State Board Administration.
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16.714  COORDINATED SYSTEM OF PAYMENT [Rev. eff. 1/11/08]
A.  Funding Hierarchy
1.  Early intervention services shall be available at no cost to parent(s) of eligible infants and toddlers. 
2.  During development of the Individualized Family Service Plan, the service coordinator shall work with the family and team members to determine the appropriate funding source to pay for needed early intervention services that are identified in the Individualized Family Service Plan using the following ordering of funding sources: 
a.  At the discretion of the parent(s), use of private pay; then, 
b.  Private health insurance with the written consent of the parent(s); then, 
c.  Medicaid/Title XIX funding and Child Health Plan Plus; then, 
d.  Child welfare and Temporary Assistance to Needy Families (TANF); then, 
e.  Department of Education Part B and School for the Deaf and the Blind; then, 
f.  State General Funded early intervention services and other State or Federal sources; then, 
g.  Other local funds, as may be made available; then, 
h.  Traumatic Brain Injury Trust Fund; and then, 
i.  Federal Part C funds. 
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. 
B.  Early Intervention Service Brokers
1.  The Division for Developmental Disabilities shall designate one entity per Community Centered Board service area as the Early Intervention Service Broker for that region. 
2.  Community Centered Boards shall submit an application on a form determined by the Division for Developmental Disabilities for designation as an Early Intervention Service Broker. 
a.  If a Community Centered Board is unwilling to be the Early Intervention Service Broker for its service area, or the Division for Developmental Disabilities determines that the Community Centered Board does not meet the criteria established in Section 16.714, B, 3, then the Division for Developmental Disabilities shall accept applications from other entities. 
b.  If no Early Intervention Service Broker can be found, the Division for Developmental Disabilities may act as the Early Intervention Service Broker until such time as an Early Intervention Service Broker can be found. 
3.  Designation as an Early Intervention Service Broker shall be based on the following criteria: 
a.  Agency background and expertise in early intervention services; 
b.  Agency policies and procedures that ensure timely and accurate data entry as required by the Division for Developmental Disabilities; 
c.  Demonstrated ability to conform with generally accepted accounting and contracting practices; and, 
d.  Assurance to comply with State and Federal laws and regulations regarding early intervention services as defined in Section 16.710. 
e.  Failure to maintain ongoing compliance with the above criteria may result in de-designation as an Early Intervention Service Broker. 
4.  Upon designation, an Early Intervention Service Broker shall be responsible for the following: 
a.  Notifying a private health insurance carrier and, as appropriate, a Child Health Plan Plus Health Maintenance Organization (HMO), the county department of social/human services, and the Division for Developmental Disabilities within ten (10) working days that an infant or toddler covered under a public or private health insurance plan has been determined eligible for early intervention services. At a minimum, the notification shall include: 
1)  The child’s name; 
2)  The child’s date of birth; 
3)  The name of the private health insurance carrier; 
4)  The policy number; 
5)  The name of the primary policy holder; 
6)  A copy of the Individualized Family Service Plan; and, 
7)  The contact person at the Early Intervention Service Broker. 
b.  Establishing a registry of qualified early intervention service providers to provide early intervention services to eligible children in the designated service area; 
c.  Accepting and processing insurance claims using uniform forms and procedures for billing the costs of early intervention services to public medical assistance, as specified in the “Colorado Medical Assistance Act”, Articles 4 to 6 of Title 25.5, C.R.S., or the “Children’s Basic Health Plan Act”, Article 8 of Title 25.5, C.R.S., as appropriate, and private health insurance, as specified in Part 1 of Article 16 of Title 10, C.R.S., as necessary for those families with health insurance coverage for early intervention services; 
d.  Negotiating, within State and Federal defined parameters, for payment of early intervention services; 
e.  Ensuring payment for early intervention services rendered pursuant to an Individualized Family Service Plan; 
f.  Ensuring that Federal funds for early intervention are utilized as payor of last resort and are not co-mingled with State funds; 
g.  Using procedures and forms determined by the Division for Developmental Disabilities to document the provision or purchase of early intervention services; 
h.  Ensuring that all required demographic and billing information is entered into the community contract and management system for each child receiving services and is timely, valid, and accurate; 
i.  Participating in ongoing reviews of funding practices; and, 
j.  Providing the Division for Developmental Disabilities with timely, valid, and accurate information necessary for reporting purposes for the legislature or other funding sources. 
5.  Early Intervention Service Brokers may provide early intervention services directly or may subcontract the provision of services to other qualified providers on the registry. 
6.  Invoices or insurance claims for early intervention services shall be submitted based on the available funding source for each eligible child and the reimbursement rate for the appropriate federal, state, local, or private funding sources, including public medical assistance and private health insurance. 
7.  The Division for Developmental Disabilities shall establish reimbursement rates for Early Intervention Service Broker functions with input from Early Intervention Service Brokers. 
8.  Use of a certified Early Intervention Service Broker shall be voluntary. Qualified early intervention service providers may directly bill the appropriate program of public medical assistance or a participating provider, as defined in Section 10-16-102(28.5), C.R.S., may directly bill a private health insurance carrier for services rendered, unless the private health insurance carrier has elected to make payment through the trust fund. 
C.  Payment From Private Health Insurance Carriers
1.  Pursuant to Section 10-16-104, C.R.S., private health insurance carriers who are responsible to cover early intervention services for an eligible dependent child shall provide early intervention services as defined in the State Plan, except that non-emergency medical transportation, respite care, service coordination as defined in Federal law, and assistive technology shall be excluded, unless assistive technology is covered under an applicable insurance policy or service or indemnity contract as durable medical equipment. 
2.  Private health insurance carriers shall be responsible for payment of early intervention services that are authorized in a child’s Individualized Family Service Plan and case management services. 
Monthly payments for case management services for an eligible dependent child shall be made by the responsible private health insurance carrier directly to the certified Early Intervention Service Broker that has been designated by the State up to the annual maximum State appropriated amount. 
3.  Coverage required by private health insurance carriers shall be available annually to an eligible child from birth up to the child’s third birthday and shall be limited to five thousand seven hundred twenty-five dollars ($5,725), including case management costs, for early intervention services for each dependent child per calendar or policy year. 
a.  For policies or contracts issued or renewed on or after January 1, 2009, and on or after each January 1 thereafter, the limit shall be adjusted by the Division for Developmental Disabilities 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. 
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, 
2)  Services provided to a child who is not 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(1.7), C.R.S. 
4.  Coverage for families who elect to receive early intervention services under an Individualized Family Service Plan shall not be subject to deductibles or co-payments, and 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 in Section 10-16-104(1.3)(d), C.R.S., for high deductible plans. 
5.  A private health insurance carrier shall not be required to pay a reimbursement rate for early intervention services provided by a non-participating provider that exceeds the reimbursement rate allowed for comparable early intervention services provided by a participating provider, unless the carrier agrees prior to the provision of early intervention services to a different reimbursement rate. 
6.  The Division for Developmental Disabilities shall provide private health insurance carriers who are responsible pursuant to Section 10-16-104, C.R.S., to cover early intervention services for an eligible dependent child with the following choices for payment for early intervention services: 
a.  Direct payment to a qualified service provider who participates in the insurance carrier’s provider network; or, 
b.  Payment to an Early Intervention Service Broker as a third party vendor; or, 
c.  Payment to the State through use of a trust fund as defined in Section 16.714, D, 2. 
7.  Private health insurance carriers shall notify the family and the responsible Community Centered Board when a child’s coverage has reached the $5,725 limit, or the limit as adjusted pursuant to Section 16.714, C, 3, a. If additional early intervention services are still needed by the child prior to the end of the insurance plan year, the Early Intervention Service Broker shall coordinate with the Division for Developmental Disabilities to ensure that services continue. At the beginning of the new plan year, the private health insurance carrier shall be responsible for a new annual limit as established by Section 16.714, C, 3, a. 
8.  The Division for Developmental Disabilities shall notify private health insurance carriers within sixty (60) calendar days if a child is no longer eligible for early intervention services. 
D.  Trust Fund
1.  The Colorado Department of Human Services shall establish, pursuant to Section 27-10.5-706(1), C.R.S., a trust fund for the purpose of accepting deposits from private health insurance carriers for early intervention services to be provided on behalf of infants and toddlers under a participating insurance plan. 
2.  A private health insurance carrier who is responsible pursuant to Section 10-16-104, C.R.S., to cover early intervention services for an eligible dependent child may elect to deposit moneys into the trust fund. 
Payment shall be made as specified by the Department of Human Services in the amount of $5,725 per eligible dependent child per plan year. This payment amount shall be adjusted annually by the Division for Developmental Disabilities 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. 
3.  Moneys shall be deposited into the trust fund and expensed only for the child for whom the moneys were deposited. 
4.  The Division for Developmental Disabilities shall utilize the funds in the trust fund to contract with Early Intervention Service Brokers for early intervention services on behalf of the children for whom funds have been placed into the trust fund. 
5.  Funds in the trust fund shall be utilized for the following: 
a.  Early intervention services;
b.  A monthly case management (service coordination) fee based on the annual State appropriated rate; 
c.  A monthly Early Intervention Service Broker fee as defined by the Division for Developmental Disabilities, pursuant to Section 16.714, B, 7, shall be applied to each child’s account; and, 
d.  A monthly fee as determined by the Division for Developmental Disabilities to administer the trust fund shall be applied to each child’s account. 
6.  Upon termination from early intervention services or discontinuation of coverage by the private health insurance carrier, the Department of Human Services shall determine the amount of charges for the child for allowable early intervention services and return, within sixty (60) calendar days to the private health insurance carrier, moneys deposited in the trust fund on behalf of an eligible dependent child that are not expended on behalf of the child before the child became ineligible. 
7.  No later than March 1 of each year, the Department of Human Services shall provide private health insurance carriers with a report specifying the amount of benefits paid to Early Intervention Service Brokers or qualified providers for services provided to an eligible child during the prior calendar year, including the amount paid to each Early Intervention Service Broker or qualified provider and the services provided to an eligible child.