MOTOR VEHICLE SELF-INSURANCE - Colorado



Department of regulatory agencies

DIVISION OF INSURANCE

3 CCR 702-4

LIFE, ACCIDENT AND HEALTH

NEW 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 and 27-10.5-704(2), C.R.S.

Section 2 Background Scope and Purpose

The purpose of this regulation is to provide health carriers the guidance necessary to implement SenateHouse Bill 041237 enacted in 20079 by the Colorado General Assembly to facilitate the payment of early intervention services by private insurance sources. It replaces Emergency Regulation 079-E-0301 in its entirety.

Section 3 Applicability and Scope

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 JanuaryOctober 1, 20089 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 §10-16-102(8), C.R.S.

B. “Case management services” are the service coordination activities as defined in 34 CFR 303.23.

C. “Certified early intervention service broker” or “broker” means 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 Developmental Disabilities acting as the broker for any service area until another broker has been designated.

D. “Division for Developmental Disabilities” is a division of the Colorado Department of Human Services.

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

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

G. “Health benefit plan” shall have the same meaning as set forth in §10-16-102(21), C.R.S.

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

I. "Limited benefit health insurance" means 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”.

J. “Registry” means 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.

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, 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. A managed care plan does not have to pay a reimbursement rate for non-participating providers that exceeds its reimbursement rate for comparable early intervention services provided by a participating provider unless it agrees to do so prior to the provision of early intervention services or unless it does not have participating providers available to provide the required services.

D. Managed care plans must ensure that they have an adequate network of providers for all early intervention services or they must contract with a community center board or other entity to ensure that providers are available to provide these services to each eligible child.

EC. Subject to paragraphs 1, 2 and 3 of this subsection C., Ccarriers can, in-lieu of paying benefits directly to brokers or qualified early intervention service providers, shall pay benefits into the trust established by the Colorado Department of Human Services (CDHS) as provided in §27-10.5-7069(1), C.R.S., within 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 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;

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;

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

FD. Carrier payment guidelines.

1. Eligible early intervention services do not include:

a. Non-emergency medical transportation;

b. Respite care;

c. Service coordination other than case management services; and

d. 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 Mmonthly 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.

3. As of January 1, 20089, the maximum annual benefit payable for all eligible early intervention and case management services will beis $5,725.005,935.00. 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.

4. Any covered benefit payable for the following services shall not be subject to the maximum annual benefit specified in paragraph 3. of this subsection FD:

a. Rehabilitation or therapeutic services that 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, Ccarriers 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 FD.

6. Qualified early intervention service providers that receive reimbursement in accordance with paragraph 5 of this subsection D. 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.

GE. The Division for Developmental Disabilities will notify the carrier within 690 days if a child is no longer eligible for early intervention services.

HF. Short-term, accident, fixed indemnity, or 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.

G. 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 fines, issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority. 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 303.23 of Title 34 (Early Intervention Program for Infants and Toddlers with Disabilities), Code of Federal Regulations.

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 March1, 2008 October 1, 2009.

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.

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