CABINET FOR HEALTH AND FAMILY SERVICES

Department for Public Health

Division of Maternal and Child Health

(Amendment)

 

      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 complete[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[serviceor] 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. 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 one (1) hour.

      2. Services shall be documented in the First Steps data management system and shall include:

      a. A service note describing the intervention provided during the session;

      b. A list of participants present during the early intervention session;

      c. The caregiver’s report of the child’s progress since the last session, including any modifications to the suggested intervention or barriers to implementing the intervention;

      d. The child's response to intervention that describes the skill level of the child and if the skill has increased, decreased, or stayed the same and the method used to measure progress; and

      e. The plan for the next visit, based on the child’s response to intervention and the IFSP outcome[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].

      (b) Service documentation shall be entered within ten (10)[five (5)] calendar days of the service delivery date. Documentation entered after ten (10) days from the date of service shall be immediately disapproved for payment.

      (c) Once the provider has entered a corrected service log, a payment adjustment shall be made. Payment shall be prorated on the following scale:

      1. Correction entered within one (1) to five (5) days, claim paid at a three (3) dollar reduction;

      2. Correction entered within six (6) to ten (10) days, claim paid at an eight (8) dollar reduction;

      3. Correction entered within eleven (11) to fifteen (15) days, claim paid at a twenty-five (25) dollar reduction;

      4. Correction entered within sixteen (16) to thirty (30) days, claim paid at one half the maximum KEIS payment; and

      5. Correction entered after thirty (30) days or beyond shall be disapproved and not adjusted for payment[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].

      (d)[(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 902 KAR 30:110, Section 2(10)[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 one (1)[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 that impacts the early intervention services authorized on the IFSP.

      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). Families with private or public insurance shall not be charged disproportionately more than families without insurance[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 activities;

      (b) Evaluation and assessment of the child and family;

      (c) Service coordination;[and]

      (d) Administrative and coordinative activities including development, review, and evaluation of individualized family service plans;[,] and

      (e) The implementation of procedural safeguards.

      (3) Families shall receive a copy of the First Steps System of Payment notice during the intake meeting, at the initial IFSP meeting and each subsequent IFSP meeting.

      (4) 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.

      (5)[(4)] The family share payment shall:

      (a) Be based on a sliding fee scale;

      (b) Be explained to the family by the POE staff[service coordinator]; and

      (c) Begin with the provision of an[in the month of the IFSP, at the time] early intervention service[services are authorized], and continue for the duration of participation in early intervention services.

      (6)[(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 249 percent of poverty, there shall be no payment;

      2. From 250 percent of poverty to 299 percent, the payment shall be five (5) dollars per month of participation;

      3. From 300 percent of poverty to 349 percent, the payment shall be ten (10) dollars per month of participation;

      4. From 350 percent of poverty to 399 percent, the payment shall be twenty-five (25) dollars per month of participation;

      5. From 400 percent of poverty to 449 percent, the payment shall be seventy-five (75) dollars per month of participation;

      6. From 450 percent of poverty to 499 percent, the payment shall be $150 per month of participation;

      7. From 500 percent of poverty to 549 percent, the payment shall be $200 per month of participation;

      8. From 550 percent of poverty to 599 percent, the payment shall be $300 per month of participation; and

      9. From 600 percent of poverty and above, the payment shall be $400 per month of participation[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].

      (7)[(6)] The family share participation fee shall not:

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

      (b) Apply to a family whose child is covered by public insurance benefits (Medicaid); or

      (c)[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.

      (8) The family may request a reduction or waiver of the family share fee if the family shows to the satisfaction of the Department for Public Health an inability to pay, in accordance with the following:

      (a)[1.] The service coordinator shall submit to the Department for Public Health First Steps Family Share Administrator, on behalf of the family, a Family Share Extraordinary Expenses Worksheet (FS-24)[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

      (b)[2.] The family shall undergo a financial review by the Department for Public Health that may:

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

      2.a.[(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 subsection (6)(b) of this section[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.

      (9)[(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.

      (10)[(8)] Income[and insurance coverage] shall be verified during the intake process and 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.

      (11)[(9)] A family that refuses to have its income verified shall be assessed a family share payment of $400[$100] per month of participation.

      (12)[(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.

      (13)[(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 be the full reimbursement from KEIS and the provider shall not charge the family[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].

      (d) 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].

      (e) Federal Part C funds may be used to pay the cost of insurance premiums when obtaining insurance for the child is the most cost effective method for KEIS to pay for early intervention services;

      (f) A family who has the ability to pay and gives consent for the use of private insurance may waive the family share fee. If the consent to bill private insurance is revoked by the family, the family shall be assessed the corresponding family share fee;

      (g) A family who has the ability to pay and does not give consent for the use of private insurance shall be assessed a family share fee[receive only those services provided at no cost to the family] as described in Section 5(6)(b)[(2)] of this administrative regulation.

      (h)[(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.

      (i)[(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.

      (j)[(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. Use of funds. Consistent with 34 C.F.R. 303.120 through 303.122 and 303.220 through 303.226, the state lead agency may use the federal Part C funds for activities or expenses that are reasonable and necessary for implementing the Kentucky Early Intervention System program for infants and toddlers with disabilities including:

      (1) For direct early intervention services for infants and toddlers with disabilities and their families that are not otherwise funded through other public or private sources;

      (2) To expand and improve services for infants and toddlers with disabilities and their families; and

      (3) To strengthen the statewide system by initiating, expanding, or improving collaborative efforts related to at-risk infants and toddlers, including establishing linkages with appropriate public and private community-based organizations, service, and personnel for the purposes of:

      (a) Identifying and evaluating at-risk infants and toddlers;

      (b) Making referrals for the infants and toddlers identified and evaluated under paragraph (a) of this subsection; and

      (c) Conducting periodic follow-up on each referral, to determine if the status of the infant or toddler involved has changed with respect to eligibility of the infant or toddler for services.

 

      Section 8. Incorporation by Reference. (1) The following material is incorporated by reference:

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

      (b) "System of Payment Notice", April 2014; and

      (c) "Family Share Extraordinary Expenses Worksheet", December 2013["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.

 

STEPHANIE MAYFIELD GIBSON, MD, FCAP, Commissioner

AUDREY TAYSE HAYNES, Secretary

      APPROVED BY AGENCY: May 7, 2014

      FILED WITH LRC: May 9, 2014 at 2 p.m.

      PUBLIC HEARING AND PUBLIC COMMENT PERIOD: A public hearing on this administrative regulation shall, if requested, be held on May 21, 2014, at 9:00 a.m. in the Auditorium, Health Services Building, First Floor, 275 East Main Street, Frankfort, Kentucky. Individuals interested in attending this hearing shall notify this agency in writing by May 14, 2014, five (5) workdays prior to the hearing, of their intent to attend. If no notification of intent to attend the hearing is receive by that date, the hearing may be canceled. The hearing is open to the public. Any person who attends will be given an opportunity to comment on the proposed administrative regulation. A transcript of the public hearing will not be made unless a written request for a transcript is made. If you do not wish to attend the public hearing, you may submit written comments regarding this proposed administrative regulation. You may submit written comments on the proposed administrative regulation until June 2, 2014. Send written notification of intent to attend the public hearing or written comments on the proposed administrative regulation to:

      CONTACT PERSON: Tricia Orme, Office of Legal Services, 275 East Main Street 5 W-B, Frankfort, Kentucky 40621, phone 502-564-7905, fax 502-564-7573, email tricia.orme@ky.gov.

 

REGULATORY IMPACT ANALYSIS AND TIERING STATEMENT

 

Contact Person: Paula Goff

      (1) Provide a brief summary of 902 KAR 30:200:

      (a) What this administrative regulation does: This administrative regulation establishes the rates to be paid to providers for the provision of approved services (i.e. Physical Therapy, Occupational Therapy), sets forth limitations for billable services, and establishes processes for requesting services beyond set parameters, for assessing and collecting family participation payments, and the use of public and private insurance to cover the cost of early intervention services.

      (b) The necessity of this administrative regulation: 902 KAR 30:200 is necessary because the First Steps program operates on a fee-for-service system requiring the establishment of rates for covered services.

      (c) How this administrative regulation conforms to the content of the authorizing statute: KRS 200.660 assigns the Cabinet for Health and Family Services the duty of appropriately administering all funds related to the implementation of the First Steps program. Further, KRS 200.660 directs the Cabinet for Health and Family Services to develop and implement a sliding fee scale in accordance with federal regulation, and contract with providers to provide First Steps services.

      (d) How this administrative regulation currently assists in the effective administration of the statutes: This administrative regulation describes the rate structure used by the Cabinet for Health and Family Services when contracting with service providers as well as the sliding fee scale.

      (2) If this is an amendment to an existing administrative regulation, provide a brief summary of:

      (a) How the amendment will change the existing administrative regulation: The amendment to this administrative regulation revises the family share participation fees to incentivize the use of private insurance to help cover the cost of early intervention services. It sets sanctions of the provider who fails to follow the service provider agreement and it outlines the permissive use of federal funds.

      (b) The necessity of the amendment to this administrative regulation: The revisions to this administrative regulation are necessary to bring the program into full compliance with the federal regulations as required by the federal grant application.

      (c) How the amendment conforms to the content of the authorizing statute: KRS 200.660 assigns the Cabinet for Health and Family Services the duty of appropriately administering all funds related to the implementation of the First Steps program. Further, KRS 200.660 directs the Cabinet for Health and Family Services to develop and implement a sliding fee scale in accordance with federal regulation, and contract with providers to provide First Steps services. KRS 200.650(6) and KRS 200.652(3) require a statewide comprehensive early intervention system that is in compliance with federal statute and regulation.

      (d) How the amendment will assist in the effective administration of the statutes: These amendments will help to assure appropriate compensation to First Steps service provider and will assure that the Cabinet for Health and Family Services is administering the sliding fee scale in a manner consistent with federal regulation and intent.

      (3) List the type and number of individuals, businesses, organizations, or state and local governments affected by the administrative regulation: Approximately 1,500 early intervention providers, including Point of Entry staff, will be affected by these regulations. Over 6,000 eligible children and their families will be affected by the service changes related to the regulations. No state or local governments are affected by the administrative regulation.

      (4) Provide an analysis of how the entities identified in question (3) will be impacted by either the implementation of this administrative regulation, if new, or by the change, if it is an amendment, including:

      (a) List the actions that each of the regulated entities identified in question (3) will have to take to comply with this administrative regulation or amendment: Point of Entry staff will need to fully understand the financial assessment of the family’s ability to pay and the requirements for the consent for the use of private insurance; as well as, when a family will not be charged a family share participation fee. Early intervention providers will need to understand when they are required to bill private insurance before submitting a bill to KEIS for payment. Families will need to understand the incentives available to them by giving consent to bill insurance so they can make an informed decision.

      (b) In complying with this administrative regulation or amendment, how much will it cost each of the entities identified in question (3): The Kentucky Early Intervention System currently costs approximately $40 million dollars. The revisions to this administrative regulation do not cost the entities affected by the amended regulations any additional dollars.

      (c) As a result of the compliance, what benefits will accrue to the entities identified in question (3): The amended regulations will benefit early intervention providers, including service coordinators by providing needed clarity so that they are more effective in their roles within the system.

      (5) Provide an estimate of how much it will cost to implement this regulation:

      (a) Initially: No new costs are incurred in implementing this regulation.

      (b) On a continuing basis: No new costs are incurred in implementing this regulation.

      (6) What is the source of the funding that will be used for the implementation and enforcement of the administrative regulation: Federal Part C funds and state general funds will be used to implement this administrative regulation.

      (7) Provide an assessment of whether an increase in fees or funding will be necessary to implement this administrative regulation, if new, or by change if it is an amendment: No increase in fees or funding is necessary to implement this administrative regulation or its amendments.

      (8) State whether or not this administrative regulation establishes any fees or directly or indirectly increases any fees: There is no direct or indirect increase in fees.

      (9) TIERING: Is tiering applied? Tiering is not applied because First Steps regulations apply consistently across all children and families participating in the First Steps program as well as all providers participating in the First Steps program.

 

FISCAL NOTE ON STATE OR LOCAL GOVERNMENT

 

      1. What units, parts or divisions of state or local government (including cities, counties, fire departments, or school districts) will be impacted by this administrative regulation? This administrative regulation impacts the fifteen (15) local Point of Entry, approx. 1,500 direct service providers, families receiving early intervention services, as well as the state administrative office that governs the First Steps program.

      2. Identify each state or federal statute or federal regulation that requires or authorizes the action taken by the administrative regulation. 20 U.S.C. 1438, 1440, 34 C.F.R. Part 303, KRS 194A.050, KRS 200.650-676

      3. Estimate the effect of this administrative regulation on the expenditures and revenues of a state or local government agency (including cities, counties, fire departments, or school districts) for the first full year the administrative regulation is to be in effect.

      (a) How much revenue will this administrative regulation generate for the state or local government (including cities, counties, fire departments, or school districts) for the first year? There will be no revenue generated by this administrative regulation for the first year.

      (b) How much revenue will this administrative regulation generate for the state or local government (including cities, counties, fire departments, or school districts) for subsequent years? There will be no revenue generated by this administrative regulation during subsequent years.

      (b) How much will it cost to administer this program for the first year? There will be no new expenditures to implement this administrative regulation during the first year.

      (c) How much will it cost to administer this program for subsequent years? There will be no new expenditures to implement this administrative regulation during the subsequent years.

      Note: If specific dollar estimates cannot be determined, provide a brief narrative to explain the fiscal impact of the administrative regulation.

      Revenues (+/-):

      Expenditures (+/-):

      Other Explanation: There is no fiscal impact on local or state government for this administrative regulation.

 

FEDERAL MANDATE ANALYSIS COMPARISION

 

      1. Federal statute or regulation constituting the federal mandate. 34 C.F.R. 303.500 through 303.521 outlines the federal policies and procedures related to financial matters. It states that First Steps must be the payor of last resort. It also provides provisions for charging a family participation fee. This amendment ensures full compliance with the provisions under that part.

      2. State compliance standards. KRS 200.674 charges the Cabinet for Health and Family Services, Department for Public Health in the use of early intervention funds.

      3. Minimum or uniform standards contained in the federal mandate. By revising this administrative regulation, Kentucky is in full compliance with the federal requirements to ensure First Steps is the payor of last resort for early intervention services.

      4. Will this administrative regulation impose stricter requirements, or additional or different responsibilities or requirements, than those required by the federal mandate? This amendment does not impose stricter than federal requirements.

      5. Justification for the imposition of stricter standard, or additional or different responsibilities or requirement. This amendment does not impose stricter than federal requirements.