La. Admin. Code tit. 48 § IX-334

Current through Register Vol. 50, No. 11, November 20, 2024

Section IX-334 - System of Payments

A. The department shall have the authority to establish a statewide system of payments in accordance with 34 CFR part 303.

B. In implementing the system of payments:

1. the department establishes a schedule of monthly cost participation for early intervention services per qualifying family. Cost participation sh all be based on a sliding scale;

2. application of the familys cost share using the sliding scale will include the familys adjusted gross income, family size, financial hardship, extraordinary expenses associated with the eligible child, and Medicaid eligibility;

a. extraordinary expenses may include but are not limited to unreimbursed medical expenses, equipment, home modifications, or other costs associated with the child with a disability;

b. extraordinary expenses must have been incurred during the calendar year that the familys cost share for individualized family services plan (IFSP) services is applied;

c. the family will be required to produce invoices, receipts, or other documents which establish the costs and payment for these expenses;

d. the family may request a reassessment of their costs based on extraordinary expenses at any time if there are significant changes affecting the determination of the cost participation amount. The request will be in writing and submitted to the service coordinator;

e. the request for reassessment will be considered by the designated EarlySteps office for a determination of the familys request. The family and the service coordinator will receive the departments written response;

3. the sliding scale shall utilize the most recent federal poverty guidelines issued in the Federal Register by the United States Department of Health and Human Services as the basis for determining the income threshold based on family size for eligibility for cost participation;

4. the department shall not assess any fee or other charge through the cost participation schedule upon a family which has an annual income of less than 300 percent of the federal poverty level;

5. the department shall not assess fees or other charges through the cost participation schedule which totals more than 3 percent of the monthly income level for a family of

four, according to the federal poverty guideline schedule which will be updated annually;

6. once the familys income has been verified with the required documentation and the IFSP services have been determined by the IFSP team, the following will occur:

a. the system point of entry office will issue the cost participation statement to notify the family of their assessed costs which will be reviewed with the family and a copy provided;

b. following the submission of service claims by the childs provider, the Central Finance Office (CFO) will mail a monthly explanation of payment statement (EOP) to the family for payment. The EOP will include a notice of the familys right for reconsideration of their financial status and their right to apply for exemption from cost participation due to financial hardship;

c. families will remit reimbursement to the CFO at the address provided in the EOP;

7. when a family is not complying with the cost participation requirements and procedures for suspending services, the following will occur related to the status of the childs services;

a. a notice will be issued to the family, to the service coordinator and to the designated EarlySteps office;

b. the CFO will notify the department when the family is in arrears for a duration of three months at which time the service coordinator will discuss the familys options with the family and assist the department with its determination of the status of the childs IFSP services;

c. if the family provides its consent, a copy of the notice that the family is in arrears with payment for three months will be sent to the representative and senator in whose district the family resides;

d. the department will make a written determination regarding the status of the childs IFSP services following review of information provided by the service coordinator and the family. Families will be offered the option to continue to receive services available at no cost if they choose according to the no-cost provisions which follow;

e. the department shall not limit early intervention services for a child in any month if the cost for the services in that month exceeds the maximum contribution from the childs family.

C. Parents who have public insurance (Medicaid) and elect not to assign such right of recovery or indemnification to the department or choose not to release financial information will be assessed the cost for each early intervention service listed on the IFSP according to the most current service rate schedule and the cost participation schedule.

D. No-Cost Provision: the following services that a child is otherwise entitled to receive will have no costs assessed to the parents:

1. child find activities;

2. evaluation and assessment for eligibility and IFSP planning;

3. service coordination, administrative and coordinative activities related to the development review, and evaluation of the IFSP; and

4. implementation of procedural safeguards and other components of the statewide system related to §464 of Act 417.

E. The department will provide written, prior notification to families for use of Medicaid according to the requirements of 34 CFR 303.414. This notice includes a statement that there are no costs charged by the department for use of the eligible childs Medicaid. The notification also includes a statement of the process for resolutions of disputes regarding decisions related to use of Medicaid, failure to pay for services and/or the states determination of a familys ability to pay.

F. Dispute Resolution Process

1. The procedures used by the department to resolve such disputes will not delay or deny the parents rights or the childs ability to access timely services.

2. The dispute resolution process can be initiated by the parent according to OCDDs policy for handling system complaints when the parent wishes to contest the imposition of a fee or the departments determination of the parents ability to pay.

G . Parental Consent. The department will obtain parental consent prior to the use of the childs Medicaid according to the following.

1. EarlySteps will obtain written consent for the use of the childs Medicaid using its established consent for services form.

2. Parental consent will be obtained prior to the initial provision of an early intervention service in the IFSP.

3. Parental consent will be obtained when an increase in frequency, length, duration, or intensity of a service is determined in the childs IFSP.

4. If the parent does not provide consent for the use of the childs Medicaid, the department will make available only those early intervention services on the IFSP for which the parent has provided consent.

5. Parents may withdraw consent for use of their childs Medicaid at any time.

H. Determination of Family Cost. Families are liable for the costs of services that their child receives while enrolled in EarlySteps as follows:

1. The aggregate contributions made by the parent shall not exceed the aggregate cost of the early intervention services received by the child and family (factoring in any amount received from other sources for payment for that service).

2. At least annually, or at any time the department determines that a reassessment of the parents financial circumstances is warranted, the department shall conduct such reassessment of financial status.

3. The parent has the right to request a reassessment at any time if there are significant changes affecting the determination of the cost participation amount.

4. Families who have the ability to pay and choose not to pay may be determined as ineligible to continue to receive services until payment is made.

5. The inability of the family of the eligible infant or toddler will not result in a delay or denial of services if the family does not meet the cost participation income requirements or for services for which there are no costs.

La. Admin. Code tit. 48, § IX-334

Promulgated by the Department of Health and Hospitals, Office for Citizens with Developmental Disabilities, LR 41:147 (January 2015).

AUTHORITY NOTE: Promulgated in accordance with R.S. 28:821 et seq.