054.00.96 Ark. Code R. 007
PROPOSED RULE AND REGULATION 45 CHILDREN'S PREVENTIVE HEALTH CARE REIMBURSEMENT LEVELS
The purpose of this Regulation is to implement and coordinate insurers' compliance with Arkansas Code § 23-79-141, as amended by Act 685 of 1995.
This Rule is issued pursuant to the authority vested in the Commissioner under Ark. Code Ann. §§ 23-61-108, 23-76-125, 23-79-141 as amended by Act 685 of 1995, and 25-15-203, and other applicable provisions of Arkansas law.
This Rule applies to every disability (health) insurer, hospital or medical service corporation, health maintenance organization ("HMO"), and fraternal benefit society licensed by the Arkansas Insurance Commissioner ("Commissioner'1), and to each self-insured plan transacting disability insurance or providing disability coverage in this State which delivers, issues for delivery in this State, or renews, extends, or modifies disability policies, contracts, certificates and plans providing hospital and medical coverage on an expense incurred, service, or prepaid basis and which contracts provide coverage for a family member of the insured person.
This Regulation does not apply to disability income, specified disease, medicare supplement, hospital indemnity, or accident only policies.
The effective date of this Rule is July 1, 1997, upon signature of the Commissioner and statutory filing.
Anticipatory guidance shall- include such things as visual evaluation (titmus machine or other ophthalmological testing not required), hearing evaluation (machine audiology test not required), dental inspection for children under two years of age, and a nutritional assessment.
This term means physician-delivered or physician-supervised services for eligible dependents from birth through age eighteen (18), with periodic preventive care visits, including medical history, physical examination, developmental assessment, anticipatory guidance and appropriate immunizations and laboratory tests, in keeping with prevailing medical standards for the purposes of this Rule and Regulation.
A developmental assessment should be obtained by history and observation of the child, or by one recognized developmental tests. This portion of the screening should include assessment of eye-hand coordination, gross motor function (walking, hopping, climbing), fine motor skills (use of finger dexterity and hand usage), speech development, daily living personal skills such as dressing, feeding and grooming oneself, behavioral development, and proofs of mind with body integration.
Laboratory procedures and immunizations should be performed as appropriate for the child's age. A hematocrit or hemoglobin test is recommended for children one (1) year of age and older and a urinalysis is recommended for children five (5) years of age and older. Other laboratory procedures are to be performed if it is deemed appropriate by the child's age and/or health history (i.e., lead toxicity, sickle cell, tuberculin, pap smear),
A medical history is to be obtained from the parent, legal guardian, or other responsible adult who is familiar with the child's health history. The child's height and weight should also be recorded and compared with the ranges considered normal for children of that age. '
Routine tests and procedures performed for the purpose of detection of abnormalities or malfunctions of bodily systems and parts according to accepted medical practice.
A physical examination is to be performed to note obvious physical defects including orthopedic, genital, skin, and other observable deviations.
Upon any subsequent increase in Medicaid's reimbursement levels for the State of Arkansas, insurers, HMO's, and self-insured plans may adjust their minimum reimbursement levels accordingly.
Upon any adjustment of minimum reimbursement levels necessitated by subsequent changes in Arkansas' Medicaid Program, insurers and HMO's shall comply with form, rate and/or rule filings required under the Arkansas Insurance Code to disclose such amendments.
For compliance with this Rule, insurers and others' shall adhere to standards for the most current and recommended Periodicity Schedule of the American Academy of Pediatrics, and to the most current and recommended immunization and vaccine schedule of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics and of the American Academy of Family Physicians for children and infants from birth to age 18 years.
Insurers and others shall refer to the most current edition of the Arkansas Department of Human Services' Early and Periodic Screening Diagnosis & Treatment ("EPSDT") Manual.
Proper and timely application of the most current EPSDT Schedule and procedures prescribed in this Rule should enable the Arkansas EPSDT Program to reduce substantially the incidence of child morbidity throughout the State and in the long run reduce the human and financial costs associated with neglected health care.
Any section or provision of this Rule held by a court to be invalid or unconstitutional will not affect the validity of any other section or provision of this Rule.
054.00.96 Ark. Code R. 007