Missouri Senate

Senate Committee Substitute

The structure for the delivery of first steps services will be on a regional basis, with the regions to be determined by the lead agency through a bidding process. The bidding process must establish criteria for allowing regions to implement models that will serve the unique needs of their community. The process shall also encourage agreements between bidding organizations and other state and local governmental entities providing similar services to infants and toddlers, including the department of mental health's division of mental retardation and developmental disability centers and with established quality early intervention providers in the region (Section 160.910).

Each agency shall include in their proposal assurances and documentation of their plan to provide for those functions specifically identified under state and federal regulations, ensure provider oversight, include family oriented, transdisciplinary and coaching approaches as necessary, utilize multiple funding sources, and implement a system to ritualize and oversee assistive technology services (Section 160.915).

The lead agency in the first instance and where applicable, will seek payment from all third party payers prior to claiming payment from the state program (Section 160.920.5).

The lead agency shall also pay required deductibles, copayments, or other out-of-pocket expenses for an eligible child directly to the provider. A health carrier shall apply any payments made by the lead agency to the health benefit plan's deductibles, copayments, or other out-of-pocket expenses according to the terms and conditions of the health benefit plan (Section 160.920.6).

A schedule of monthly cost participation fees for services per qualifying family will be established by the lead agency for services per family regardless of the number of children participating or the amount of services provided. These fees shall not include services to be provided to the family at no cost as established by the IDEA(Section 160.920.7).

Fees shall be based on a sliding scale to become effective October 1, 2005, and will take into account the following elements:

- adjusted gross income, family size, financial hardship, and Medicaid eligibility with the fee implementation beginning at two hundred percent of the federal poverty guidelines;

- a minimum monthly fee amount of five dollars to the maximum of one hundred dollars;

- an increased fee schedule for parents who have insurance and elect not to use the insurance,

- the effect of procedures for notifying regional offices if a family is not paying the cost participation and suspension of services, and

- the effect of procedures for determining waivers for the cost participation based on significant financial hardship or medicaid eligibility (Section 160.920.7).

The lead agency shall provide regional offices with the necessary financial data to assist regional offices in monitoring their expenditures and the cost of direct services (Section 160.910).

Nothing in this act will permit any other state agency that provides medically related services to reduce medical assistance to eligible children (Section 160.920).

All amounts generated by family cost participation, including insurance and Medicaid reimbursements, will be deposited to the first steps fund created in Section 160.925 (Section 160.920).

This act also provides that the Department of Social Services shall recognize the first steps established under this act, and shall pay all claims for reimbursement for Medicaid-eligible children to the first steps system. The Department of Social Services shall seek insurance reimbursement for those eligible children having other private insurance (Section 208.144).

This act also provides that each health carrier that offers or issues health benefit plans which are issued on or after January 1, 2006, shall provide coverage for medically necessary early intervention services for children in the first steps program. Such coverage shall be limited to three thousand dollars per covered child per policy per calendar year, with a maximum of nine thousand dollars per child (Section 376.1218.1).

The first steps system, on behalf of its contracted regional first steps centers and providers, shall be considered the rendering provider of services for purposes of this act and shall comply with all of the terms and conditions of the carrier’s contracts with similarly situated health care providers (Section 376.1218.2).

Prescribed insurance benefits shall be billed at the current Medicaid reimbursement rate for each specified eligible service and shall be reimbursed by the carrier at that rate or at the carrier usual reimbursement rate (Section 376.1218.3).

The health care service required by this section shall not be subject to any greater deductible or copayment than other similar health care services provided by the health benefit plan (Section 376.1218.4).

A health carrier subject to the provisions of this act shall also provide reimbursement to the department of social services for claims filed on behalf of eligible children under the first steps program (Section 376.1218.5).

Payments made during a calendar year by a health carrier subject to the provisions of this act to the lead agency entitled to payment for services provided by the first steps program shall not exceed one-half of one percent of the health carrier’s net direct written health care premium, less premium earned from policies or contracts from supplemental insurance policies (Section 376.1218.6).

Instead of reimbursing claims, a carrier may directly pay the lead agency by January 31 of the calendar year one-half of one percent of the amount of its capped liability or five hundred thousand dollars, whichever is less. The payment shall constitute full and complete satisfaction of the carrier's obligation for the calendar year (Section 376.1218.6).

Certain carriers have the right to audit claims payments made to the lead agency. The lead agency or Department of Social Services shall refund any paid claim for reimbursement that fails to meet the terms of the health benefit plan (Section 376.1218.7).

This act shall not apply to supplemental insurance policies, including a life care contract, specified disease policies, hospital policy providing a fixed daily benefit only, Medicare supplement policy, hospitalization-surgical care policy, long-term care policy, or short-term major medical policies of six months or less duration (Section 376.1218.8).

In addition, current law expresses that school districts may coordinate with public, private, and private not-for-profit agencies for the delivery of efficient early childhood special education (Section 162.700). This act changes the aforementioned "may" to "shall".

This act requires school districts providing early childhood special education to give consideration to the value of continuing services with Part C providers for the remainder of a school year when developing an individualized education program for a student who has received services pursuant to Part C of the Individuals with Disabilities Education Act and reaches the age of three years during a regular school year. Further, the act removes language from the section which specifies that preference shall be given to the continuation of services with the student's private provider unless the cost exceeds the average per student cost of early childhood education in the district (Section 162.700).

This act has an emergency clause.

ADRIANE CROUSE