902 KAR 30:200. Coverage and payment for Services.

 

      RELATES TO: KRS 200.654, 200.672, 34 C.F.R. 303.520, 303.521, 20 U.S.C. 1438, 1440

      STATUTORY AUTHORITY: KRS 194A.050, 200.654, 200.660(3), (7), (8)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 200.660 requires the Cabinet for Health and Family Services to administer funds appropriated to implement the provisions of KRS 200.650 to 200.676, to enter into contracts with service providers, and to promulgate administrative regulations necessary to implement KRS 200.650 to 200.676. This administrative regulation establishes the provisions relating to early intervention services for which payment shall be made on behalf of eligible recipients.

 

      Section 1. Participation Requirements. An early intervention provider that requests to participate as an approved First Steps provider shall comply with the following:

      (1) Submit to an ongoing review by the Department for Public Health, or its agent, for compliance with 902 KAR Chapter 30;

      (2)(a) Meet the qualifications for a professional or paraprofessional established in 902 KAR 30:150; or

      (b) Employ or contract with a professional or paraprofessional who meets the qualifications established in 902 KAR 30:150;

      (3) Ensure that a professional or paraprofessional employed by the provider who provides a service in the First Steps Program shall attend training on First Steps' philosophy, practices, and procedures provided by First Steps representatives prior to providing First Steps services;

      (4) Agree to provide First Steps services as authorized by an individualized family service plan as required by 902 KAR 30:130;

      (5) Agree to maintain and to submit as requested by the Department for Public Health required information, records, and reports to ensure compliance with 902 KAR Chapter 30;

      (6) Establish a contractual arrangement with the Cabinet for Health and Family Services for the provision of First Steps services; and

      (7) Agree to provide upon request information necessary for reimbursement for services by the Cabinet for Health and Family Services in accordance with this administrative regulation, which shall include the tax identification number and usual and customary charges.

 

      Section 2. Reimbursement. The Department for Public Health shall reimburse a participating First Steps provider the lower of the actual billed charge for the service or the fixed upper limit established in this section for the service being provided. (1) A charge submitted to the Department for Public Health shall be the provider's usual and customary charge for the same service.

      (2) The fixed upper limit for services shall be as established in this subsection.

      (a) Initial evaluation. The developmental component of the initial evaluation for a child without an established risk condition shall be provided by face-to-face contact with the child and parent.

      1. In the office or center-based site, the fee shall be $270 per service event.

      2. In the home or community site, the fee shall be $270 per service event.

      (b) Five (5) Area Assessment. The developmental component of the initial evaluation for the child with an established risk condition shall be provided by face-to-face contact with the child and parent.

      1. In the office or center-based site, the fee shall be $175 per service event.

      2. In the home or community-based site, the fee shall be $175 per service event.

      (c) Annual or exit assessment. The annual or exit assessment conducted by the primary service provider shall be provided by face-to-face contact with the child and parent.

      1. In the office or center-based site, the fee shall be $175 per service event.

      2. In the home or community-based site, the fee shall be $175 per service event.

      (d) Discipline specific assessment. The discipline specific assessment conducted by a direct service provider shall be provided by face-to-face contact with the child and parent.

      1. In the office or center-based site, the fee shall be $175 per service event.

      2. In the home or community-based site, the fee shall be $175 per service event.

      (e) Record review. A record review shall be provided by a Department for Public Health approved team and paid at the contracted amount.

      (f) Intensive clinic evaluation. The intensive level evaluation shall be provided by a Department for Public Health approved team and shall include face-to-face contact with the child and parent.

      1. In the office or center-based site, which involves a board certified physician, the fee shall be $1,100 per service event.

      2. In the community site, which involves a board certified physician, the fee shall be $1,100 per service event.

      (g) Early intervention or collateral services in accordance with Section 3(1), (2), (4) and (5) of this administrative regulation shall have the fixed upper limits established in this paragraph.

      1. For an audiologist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      2. For a marriage and family therapist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) per hour of service.

      3. For a licensed psychologist, a licensed psychological practitioner, a licensed professional clinical counselor, or certified psychologist with autonomous functioning:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      4. For a licensed psychological associate or a certified psychologist:

      a. In the office or center-based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-one (61) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-one (81) dollars per hour of service.

      5. For a developmental interventionist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      6. For a registered nurse:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      7. For a dietitian:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      8. For an occupational therapist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      9. For an occupational therapy assistant:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be forty-six (46) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be seventy (70) dollars per hour of service.

      10. For an orientation and mobility specialist:

      a. In the office or center-based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      11. For a physical therapist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      12. For a physical therapist assistant:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be forty-six (46) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be seventy (70) dollars per hour of service.

      13. For a speech therapist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      14. For a social worker:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-one (61) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-one (81) dollars per hour of service.

      15. For a teacher of the deaf and hard of hearing:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      16. For a teacher of the visually impaired:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      17. For a physician or a nurse practitioner providing a collateral service in the office or center based site, the fee shall be seventy-six (76) dollars per hour of service. A physician or a nurse practitioner shall not receive reimbursement for early intervention.

      18. For an assistive technology specialist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-one (61) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-one (81) dollars per hour of service.

      19. For a sign language and cued language specialist:

      a. In the office or center based site, the fee for a collateral service or an early intervention service including cotreatment shall be sixty-three (63) dollars per hour of service; or

      b. In the home or community site, the fee for a collateral service or an early intervention service including cotreatment shall be eighty-nine (89) dollars per hour of service.

      20. For an optometrist or ophthalmologist providing collateral service in an office or center based site, the fee shall be sixty-three (63) dollars per hour of service. An optometrist or ophthalmologist shall not receive reimbursement for early intervention.

      (h) Respite shall be seven (7) dollars and sixty (60) cents per hour.

      (3)(a) For early intervention or collateral services, hours shall be determined using the beginning and ending time for a service.

      1. Services shall be documented in the First Steps data management system and shall include a list of all those present during the session, a description of each early intervention service provided, the child's response, and future action to be taken. Service documentation shall be entered within five (5) calendar days of the service delivery date.

      2. The hours shall be computed as follows:

      a. Fifteen (15) to twenty-nine (29) minutes shall equal 0.25 hours;

      b. Thirty (30) to forty-four (44) minutes shall equal 0.50 hours;

      c. Forty-five (45) to fifty-nine (59) minutes shall equal 0.75 hours; and

      d. Sixty (60) to seventy-four (74) minutes shall equal 1.00 hour.

      (b) For service coordination services, hours shall be determined using the beginning and ending time for a service documented in staff notes in accordance with paragraph (a) of this subsection.

      1. The hours shall be computed as follows:

      a. One (1) to twenty-two (22) minutes shall equal 0.25 hours;

      b. Twenty-three (23) to thirty-seven (37) minutes shall equal 0.50 hours;

      c. Thirty-eight (38) to fifty-two (52) minutes shall equal 0.75 hours; and

      d. Fifty-three (53) to sixty-seven (67) minutes shall equal 1.00 hour.

      2. Service coordination minutes spent over the course of a day on a child or family shall be accumulated at the end of the day in order to determine the total number of hours spent.

      (4) A payment for a discipline specific assessment, five (5) area assessment, annual or exit assessment, initial or intensive evaluation listed in subsection (2) of this section shall be based on a complete evaluation as a single unit of service. An individual provider shall not be reimbursed for participation on the intensive evaluation team.

      (5) Payment for assistive technology devices shall be made in accordance with 902 KAR 30:130, Section 3.

      (a) The total rental cost of an assistive technology device shall not exceed the purchase price of that device. The length of rental shall be based on the purchase price of the device and shall not exceed ten (10) months in length.

      (b) The total purchase cost of an assistive technology device shall include the actual cost of the item being purchased, all related shipping charges, and an administrative fee not to exceed ten (10) percent.

      (6) Payment for transportation shall be the lesser of the billed charge or:

      (a) For a commercial transportation carrier, an amount derived by multiplying one (1) dollar by the actual number of loaded miles using the most direct route;

      (b) For a private automobile carrier, an amount equal to twenty-five (25) cents per loaded mile transported; or

      (c) For a noncommercial group carrier, an amount equal to fifty (50) cents per eligible child per mile transported.

      (7) A payment for a group intervention service shall be thirty-two (32) dollars per child per hour of direct contact service for each child in the group with a limit of three (3) eligible children per professional or paraprofessional who can practice without direct supervision.

 

      Section 3. Limitations. (1) Service Assessments.

      (a) Payment for a discipline specific assessment shall be limited to three (3) assessments per discipline per child, unless additional hours are necessary based on the reasons listed in paragraph (b) and documented in accordance with 902 KAR 30:130, Section 1(7) from birth to the age of three (3) unless preauthorized by the Department for Public Health in accordance with Section 4 of this administrative regulation.

      (b)1. A service assessment payment shall not be made for the provision of routine early intervention services by a discipline in the general practice of that discipline.

      2. Payment for a service assessment shall be restricted to the need for additional testing due to new concerns or significant change in the child's status.

      3. Routine activity of assessing progress and outcomes shall be billed as early intervention.

      (2) For early intervention, unless prior authorized by the Department for Public Health in accordance with Section 4 of this administrative regulation, limitations for payment of services shall be as established in this subsection.

      (a) For office, center, or home and community sites:

      1. Payment shall be limited to no more than one (1) hour per day per child per discipline by a:

      a. Professional meeting the qualifications established in 902 KAR 30:150; or

      b. Paraprofessional meeting the qualifications established in 902 KAR 30:150.

      2. Payment shall be limited to no more than twenty-four (24) hours for a single discipline and thirty-six (36) hours for more than one (1) discipline during a six (6) month period and for group shall be limited to an additional forty-eight (48) hours during a six (6) month period.

      (b) For group:

      1. Children shall not be eligible for both group and individual early intervention services by the same discipline concurrently on the Individualized Family Services Plan.

      2. Group service shall be provided by enrolled First Steps providers in accordance with 902 KAR 30:150, Section 1(11). The ratio of staff to children in group early intervention shall be limited to a maximum of three (3) children per professional and paraprofessional per group.

      (c) Payment for siblings seen at the same time shall be calculated by dividing the total time spent by the number of siblings to get the amount of time to bill per child.

      (d) Payment for a service shall be limited to a service that is authorized by the IFSP team in accordance with 902 KAR 30:130, Section 3(3).

      (e) 1. Except as provided in subparagraph 2. of this paragraph, payment shall be limited to a service provided as a face-to-face contact with the child and either the child's parent or caregiver.

      2. Early intervention family services authorized by KRS 200.654(7) may be provided without the child present if the reason the child’s presence is clinically contraindicated is documented in the session note.

      (3) For respite, payment shall:

      (a) Be limited to no more than eight (8) hours of respite per month, per eligible child;

      (b) Not be allowed to accumulate beyond each month; and

      (c) Be limited to families in crisis, or strong potential for crisis without the provision of respite.

      (4) For collateral services, payment for collateral services shall be a billable service for First Steps providers, who are providing early intervention services for the eligible child through an IFSP and paid by the First Steps system.

      (a) The length of an IFSP meeting shall be limited to no more than one (1) hour.

      (b) Payment for attendance at one (1) Admissions and Release Committee (ARC) meeting held prior to a child's third birthday shall be limited to the service coordinator and primary service provider selected by the IFSP team.

      (c) Participation at an initial IFSP meeting by an initial evaluator shall be limited to an evaluator who conducted the initial evaluation in accordance with 902 KAR 30:120, Section 2(5)(a). Payment shall be at the collateral services rate for the discipline that the evaluator represents.

      (5) For cotreatment, payment shall be limited to three (3) disciplines providing services concurrently.

      (6) Unless prior authorized by the Department for Public Health due to a shortage of direct service providers, an initial evaluator shall not be eligible to provide early intervention to a child whom the evaluator evaluated and which resulted in the child becoming eligible.

 

      Section 4. Prior Authorization Process. (1) Authorization for payment for early intervention services beyond the limits established in Section 3 of this administrative regulation shall be submitted to the cabinet or its designee, as determined by the Department for Public Health, and approved prior to the service being delivered and shall include the following:

      (a) A service exception request completed in the First Steps data management system; and

      (b) The Record Review Supporting Documentation.

      (2) The record review team shall issue a written recommendation for the IFSP team to consider within ten (10) calendar days of receipt of the request.

      (3) If the IFSP team is not in agreement with the recommendation of the record review team:

      (a) A request for further review shall be submitted to the Department for Public Health; and

      (b) A three (3) person team from the Department for Public Health, Division of Maternal and Child Health, including the division director, shall render a recommendation.

      (4) If the IFSP team is not in agreement with the three (3) person team recommendation established in subsection (3)(b) of this section:

      (a) The child's IFSP team shall be asked to reconvene for an IFSP meeting with a representative from the record review team and a representative from the three (3) member team; and

      (b) If the IFSP team concludes at that IFSP meeting that the services are still needed, payment for the service shall be authorized for the duration of the current IFSP.

 

      Section 5. System of Payment and Fees. (1) All families enrolling in the First Steps system shall be assessed for the family’s ability to pay a participation fee for early intervention services in accordance with KRS 200.654(7)(f) to (m) and shall receive a copy of the Your Financial Responsibilities in First Steps brochure.

      (2) A charge to the family shall not be made for the following functions:

      (a) Child find;

      (b) Evaluation and assessment;

      (c) Service coordination; and

      (d) Administrative and coordinative activities including development, review, and evaluation of individualized family service plans, and the implementation of procedural safeguards.

      (3) Payment of fees shall be for the purpose of:

      (a) Maximizing available sources of funding for early intervention services; and

      (b) Giving families an opportunity to assist with the cost of services if there is a means to do so, in a family share approach.

      (4) The family share payment shall:

      (a) Be based on a sliding fee scale;

      (b) Be explained to the family by the service coordinator; and

      (c) Begin in the month of the IFSP, at the time early intervention services are authorized, and continue for the duration of participation in early intervention services.

      (5) The ability to pay shall:

      (a) Be based on the level of the family gross income identified on the last Federal Internal Revenue Service statement or check stubs from the four (4) most recent consecutive pay periods, as reported by the family; and

      (b) The level of income matched with the level of poverty, utilizing the federal poverty guidelines as published annually by the Federal Department of Health and Human Services, based on the following scale:

      1. Below 200 percent of poverty, there shall be no payment;

      2. From 200 percent of poverty to 299 percent, the payment shall be twenty (20) dollars per month of participation;

      3. From 300 percent of poverty to 399 percent, the payment shall be thirty (30) dollars per month of participation;

      4. From 400 percent of poverty to 499 percent, the payment shall be forty (40) dollars per month of participation;

      5. From 500 percent of poverty to 599 percent, the payment shall be fifty (50) dollars per month of participation; or

      6. From 600 percent of poverty and over, the payment shall be $100 per month of participation.

      (6) The family share participation fee shall not:

      (a) Exceed the cost of the actual monthly Part C service;

      (b) Apply to a family who receives only evaluation, assessment, service coordination services, or IFSP development in the initial calendar month of eligibility. The service coordinator shall notify the Department for Public Health First Steps Family Share Administrator immediately if the initial IFSP date is different than the month that early intervention services are started;

      (c) Apply to a family that does not receive services except those described in paragraph (b) of this subsection for at least one (1) month if prior authorized by the Department for Public Health First Steps Family Share Administrator in accordance with paragraph (d)1 and 2 of this subsection. A request shall not be submitted for a retroactive period unless an extenuating circumstance occurs such as an unexpected hospitalization; or

      (d) Prevent or delay a child from receiving services if the family shows to the satisfaction of the Department for Public Health an inability to pay, in accordance with the following:

      1. The service coordinator shall submit to the Department for Public Health First Steps Family Share Administrator, on behalf of the family, a waiver request to have the amount of the family share payment reduced or eliminated for a period not to exceed three (3) calendar months. A request shall not be submitted for a retroactive period unless extenuating circumstances, such as an unexpected hospitalization, occurs; and

      2. The family shall undergo a financial review by the Department for Public Health that may:

      a.(i) Adjust the gross household income by subtracting extraordinary medical costs, equipment costs, exceptional child care costs, and other costs of care associated with the child's other family members' disabilities; and

      (ii) Result in a calculation of a new family share payment amount based on the family's adjusted income compared to the percentage of the poverty level established in paragraph (b)2 of this subsection. If a recalculation is completed, the Department for Public Health shall conduct a review at least quarterly; or

      b. Suspend or reduce the family share payment, based on a verified financial crisis that would be exacerbated by their obligated family share payment. The Department for Public Health shall conduct a review at least quarterly.

      (7) In accordance with 902 KAR 30:180, the family may contest the imposition of a fee or the determination of their ability to pay by filing:

      (a) A request for mediation;

      (b) A request for a due process hearing;

      (c) An administrative complaint; or

      (d) An appeal to the Part C Coordinator for final resolution.

      (8) Income and insurance coverage shall be verified at six (6) month intervals, and more often if changes in household income will result in a change in the amount of the obligated family share payment.

      (9) A family that refuses to have its income verified shall be assessed a family share payment of $100 per month of participation.

      (10) If multiple children in a family receive early intervention services, the family share payment shall be the same as if there were one (1) child receiving services.

      (11)(a) If a family has the ability to pay the family share but refuses to do so for three (3) consecutive months, the family shall receive service coordination, IFSP development, procedural safeguards, and assessment services only until discharged from the program or the family share balance is paid in full, whichever occurs first.

      (b) The service coordinator shall provide the family a financial notice of action at thirty (30) calendar days prior to the suspension of ongoing IFSP services.

 

      Section 6. Use of Insurance. (1) Public Insurance.

      (a) The state lead agency shall be the enrolled Medicaid provider for early intervention services. A contracted provider or agency shall not bill Medicaid directly for early intervention services provided in accordance with the IFSP.

      (b) Written notification in accordance with 34 C.F.R. 303.520(3)(i)-(iv) shall be provided to the child’s parent or guardian before the use of public benefits or insurance to pay for early intervention services.

      (c) A parent or guardian shall not be required to sign up for or enroll in public benefits or insurance programs as a condition of receiving early intervention services.

      (2) Private Insurance.

      (a) Parent or guardian consent shall be obtained:

      1. For the use of private insurance to pay for the initial provision of an early intervention service on the IFSP; and

      2. Each time consent for services is required due to an increase in the frequency, length, duration, or intensity in the provision of service in the child’s IFSP.

      (b) A family who chooses to use private insurance for payment of a First Steps service shall not be responsible for payment of insurance deductibles or copayments related to this service.

      (c) The fee paid to the early intervention provider by KEIS shall include any co-pay or deductible associated with the services, bringing the total to the maximum rate for KEIS allowed by Section 2 of this administrative regulation. Families shall be responsible for payment of their insurance premiums and may incur a decrease in the annual cap for certain services under their policy.

      (d) A family who has the ability to pay and does not give consent for the use of private insurance shall receive only those services provided at no cost to the family as described in Section 5(2) of this administrative regulation.

      (e) If a family is assessed as having an inability to pay and does not give consent for the use of private insurance, this lack of consent shall not prevent or delay a child from receiving services.

      (f) If a family receives payment from insurance, these funds shall be surrendered to the early intervention provider for services rendered. Failure to surrender the payment shall result in the amount of the insurance payment being added to the family share balance due.

      (g) A provider shall bill a third-party insurance for an early intervention service prior to billing First Steps. Documentation regarding the billing, the third-party insurance representative’s response, and payment, if any, shall be maintained in the child’s record and submitted through the First Steps data management system.

 

      Section 7. Incorporation by Reference. (1) The following material is incorporated by reference:

      (a) "Record Review Supporting Documentation", July 2012; and

      (b) "Your Financial Responsibilities in First Steps", July 2012.

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Public Health, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (24 Ky.R. 811; Am. 1109; eff. 11-14-1997; 25 Ky.R. 672; 1420; 1663; eff. 1-19-1999; Recodified from 908 KAR 2:200, 10-25-2001; 29 Ky.R. 2795; 30 Ky.R. 330; 630; 893; eff. 8-20-2003; 31 Ky.R. 502; 1427; eff. 2-22-2005; 35 Ky.R. 2825; 36 Ky.R. 311; eff. 8-12-2009; Recodified from 911 KAR 2:200, 5-17-2010; 37 Ky.R. 542; 1282; 1685; eff. 2-4-2011; 39 Ky.R. 2428; eff. 10-16-2013.)