376.1218. Insurance coverage for children enrolled in the Part C early intervention system (First Steps).
Insurance coverage for children enrolled in the Part C earlyintervention system (First Steps).
376.1218. 1. Any health carrier or health benefit plan that offers orissues health benefit plans, other than Medicaid health benefit plans, whichare delivered, issued for delivery, continued, or renewed in this state on orafter January 1, 2006, shall provide coverage for early intervention servicesdescribed in this section that are delivered by early intervention specialistswho are health care professionals licensed by the state of Missouri and actingwithin the scope of their professions for children from birth to age threeidentified by the Part C early intervention system as eligible for servicesunder Part C of the Individuals with Disabilities Education Act, 20 U.S.C.Section 1431, et seq. Such coverage shall be limited to three thousanddollars for each covered child per policy per calendar year, with a maximum ofnine thousand dollars per child.
2. As used in this section, "health carrier" and "health benefit plan"shall have the same meaning as such terms are defined in section 376.1350.
3. In the event that any health benefit plan is found not to be requiredto provide coverage under subsection 1 of this section because of preemptionby a federal law, including but not limited to the act commonly known as ERISAcontained in Title 29 of the United States Code, or in the event thatsubsection 1 of this section is found to be unconstitutional, then the leadagency shall be responsible for payment and provision of any benefit providedunder this section.
4. For purposes of this section, "early intervention services" meansmedically necessary speech and language therapy, occupational therapy,physical therapy, and assistive technology devices for children from birth toage three who are identified by the Part C early intervention system aseligible for services under Part C of the Individuals with DisabilitiesEducation Act, 20 U.S.C. Section 1431, et seq. Early intervention servicesshall include services under an active individualized family service plan thatenhance functional ability without effecting a cure. An individualized familyservice plan is a written plan for providing early intervention services to aneligible child and the child's family that is adopted in accordance with 20U.S.C. Section 1436. The Part C early intervention system, on behalf of itscontracted regional Part C early intervention system centers and providers,shall be considered the rendering provider of services for purposes of thissection.
5. No payment made for specified early intervention services shall beapplied by the health carrier or health benefit plan against any maximumlifetime aggregate specified in the policy or health benefit plan if thecarrier opts to satisfy its obligations under this section under subdivision(2) of subsection 7 of this section. A health benefit plan shall be billed atthe applicable Medicaid rate at the time the covered benefit is delivered, andthe health benefit plan shall pay the Part C early intervention system at suchrate for benefits covered by this section. Services under the Part C earlyintervention system shall be delivered as prescribed by the individualizedfamily service plan and an electronic claim filed in accordance with thecarrier's or plan's standard format. Beginning January 1, 2007, such claims'payments shall be made in accordance with the provisions of sections 376.383and 376.384.
6. The health care service required by this section shall not be subjectto any greater deductible, co-payment, or coinsurance than other similarhealth care services provided by the health benefit plan.
7. (1) Subject to the provisions of this section, payments made duringa calendar year by a health carrier or group of carriers affiliated by orunder common ownership or control to the Part C early intervention system forservices provided to children covered by the Part C early intervention systemshall not exceed one-half of one percent of the direct written premium forhealth benefit plans as reported to the department of insurance, financialinstitutions and professional registration on the health carrier's mostrecently filed annual financial statement.
(2) In lieu of reimbursing claims under this section, a carrier or groupof carriers affiliated by or under common ownership or control may, on behalfof all of the carrier's or carriers' health benefit plan or plans providingcoverage under this section, directly pay the Part C early intervention systemby January thirty-first of the calendar year an amount equal to one-half ofone percent of the direct written premium for health benefit plans as reportedto the department of insurance, financial institutions and professionalregistration on the health carrier's most recently filed annual financialstatement, or five hundred thousand dollars, whichever is less, and suchpayment shall constitute full and complete satisfaction of the health benefitplan's obligation for the calendar year. Nothing in this subsection shallrequire a health carrier or health benefit plan providing coverage under thissection to amend or modify any provision of an existing policy or planrelating to the payment or reimbursement of claims by the health carrier orhealth benefit plan.
8. This section shall not apply to a supplemental insurance policy,including a life care contract, specified disease policy, hospital policyproviding a fixed daily benefit only, Medicare supplement policy,hospitalization-surgical care policy, policy that is individually underwrittenor provides such coverage for specific individuals and members of theirfamilies, long-term care policy, or short-term major medical policies of sixmonths or less duration.
9. Except for health carriers or health benefit plans making paymentsunder subdivision (2) of subsection 7 of this section, the department ofinsurance, financial institutions and professional registration shall collectdata related to the number of children receiving private insurance coverageunder this section and the total amount of moneys paid on behalf of suchchildren by private health carriers or health benefit plans. The departmentshall report to the general assembly regarding the department's findings nolater than January 30, 2007, and annually thereafter.
10. Notwithstanding the provisions of section 23.253, RSMo, to thecontrary, the provisions of this section shall not sunset.
(L. 2005 S.B. 500, A.L. 2007 S.B. 112)