DEPARTMENT OF REGULATORY AGENCIES
DIVISION OF INSURANCE
3 CCR 702-4
LIFE, ACCIDENT AND HEALTH
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
Section 2
Section 3
Section 4
Section 5
Section 6
Section 7
Section 8
Section 9
Section 10
Authority
Scope and Purpose
Applicability
Definitions
Rules
Severability
Enforcement
Incorporated Materials
Effective Date
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
Scope and Purpose
The purpose of this regulation is to provide health carriers the guidance necessary to implement House
Bill 1237 enacted in 2009 by the Colorado General Assembly to facilitate the payment of early intervention
services by private insurance sources. It replaces Emergency Regulation 09-E-01 in its entirety.
Section 3
Applicability
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 October 1, 2009 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 §10-16104(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:
C.
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.
Subject to paragraphs 1, 2 and 3 of this subsection C., carriers shall pay benefits into the trust
established by the Colorado Department of Human Services (CDHS) as provided in §27-10.5709(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 §1016-104(1.3), C.R.S.:
3.
D.
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;
Upon the receipt of a new IFSP for an eligible child not previously utilizing private health
coverage for reimbursement of early intervention services.
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 monthly 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, 2009, the maximum annual benefit payable for all eligible early
intervention and case management services is $5,935.00. 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 D:
5.
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.
When the trust is not utilized for early intervention services that were started prior to the
effective date of the amendment to this regulation, carriers 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 D.
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.
E.
The Division for Developmental Disabilities will notify the carrier within 90 days if a child is no
longer eligible for early intervention services.
F.
Short-term, accident, fixed indemnity, 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 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.