RULE 054.00.95-007 - Reg. 45 - Children's Preventive Health Care Reimbursement Levels

RULE 054.00.95-007. Reg. 45 - Children's Preventive Health Care Reimbursement Levels

Section 1. Purpose

The purpose of this Regulation is to implement Arkansas Code Annotated § 23-79-141, as amended by Act 685 of 1995, effective July 28, 1995.

Section 2. Authority

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.

Section 3. Applicability and Scope

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"), 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.

Section 4. Effective Date

The effective date of this Rule is January 1, 1996, upon signature of the Commissioner and statutory filing.

Section 5. Definitions

A. Anticipatory Guidance

Anticipatory guidance shall include such things as visual evaluation (titmus machine or other ophth.almologi.cal testing not required), hearing evaluation (machine audiology test not required), dental inspection for children under two years of age, and a nutritional assessment.

B. Children's Preventive Health Care Services

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.

C. Developmental Assessment

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.

D. Lab Test/Immunizations

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).

E. Medical History

A medical history is to be obtained from the parent, legal guardian, or other responsible adult who is familiar with the child1s health history. The child's height and weight should also be recorded and compared with the ranges considered normal for children of that age.

F. Periodic Preventive Care Visits

Routine tests and procedures performed for the purpose of detection of abnormalities or malfunctions of bodily -systems and parts according to accepted medical practice.

G. Physical Examination

A physical examination is to be performed to note obvious physical defects including orthopedic, genital, skin, and other observable deviations.

Section 6. Reimbursement Levels

A. Pursuant to Ark. Code Ann. 23-79-141(f), as amended by Act 685 of 1995, reimbursements levels not exceeding current Arkansas Medicaid reimbursement levels shall be provided for the services mandated under this section of the Insurance Code. For any-pharmaceutical products for which reimbursement levels are not established under the Medicaid Program in the State of Arkansas, benefits shall be reimbursed at levels equal to the "Average Wholesale Price" for said pharmaceutical products, as defined in the most current edition of the Drug Topics Annual Redbook.

B.

(1) Each disability insurance policy, contract, certificate or plan providing benefits for children's preventive health care services on a periodic basis shall include twenty (20) visits at approximately the following age intervals: birth, 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years, 8 years, 10 years, 12 years, 14 years, 16 years and 18 years. A disability insurance policy, contract, certificate or plan may provide that children1s preventive health care services which are rendered during a periodic review shall only be covered to the extent that these services are provided by or under the supervision of a single physician during the course of one (1) visit.

(2) Benefits for recommended immunization services shall be exempt from any co-payment, coinsurance, deductible or dollar limit provisions in the disability insurance policy. Insurers and HMO's and other licensees required to comply with this Rule shall explicitly state in their policy and subscriber contracts that all other children's preventive health care services shall be subject to co-payment, coinsurance, deductible, or dollar limit provisions in the policy or contract. In this regard, insurers, HMO's and other licensees required to obtain the Department's prior approval of forms and endorsements under Ark. Code Ann. § 23-79-109 and other applicable laws shall make form or endorsement filings with this Department to ensure current Arkansas policies and contracts are in compliance with this Rule and Regulation by January 1, 1996.

C. On and after January 1, 1996, insurers, HMO's and self-insured plans shall adhere to the Medicaid reimbursement levels as outlined in Section 6 (A). Upon any subsequent decrease of Medicaid's reimbursement levels, insurers, HMO's and self-insured plans shall immediately adjust their reimbursement levels so as not to exceed Medicaid's reimbursement levels for the State of Arkansas. Upon any subsequent increase in Medicaid's reimbursement levels for the State of Arkansas, insurers, HMO's, and self-insured plans may adjust their reimbursement levels accordingly, or may maintain reimbursement levels specified by the Arkansas Medicaid program as of July 28, 1995. Upon any adjustment of 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.

Section 7. Periodic Screening Guidelines

The following is a part of the Arkansas Department of Health & Human Services' Early and Periodic Screening Diagnosis & Treatment ("EPSDT") Manual. The procedures outlined below are considered the minimum elements for proper periodic screening:

General Schedule for Medical/Dental Screen and Immunizations For Infants and Children***

AGE

PREPARATION AND EXAMINATION

Birth to 6 months

EPSDT Screening and Dental

Inspection* Oral Polio Vaccine

DPT

6 Months to 1 year

EPSDT Screening and Dental Inspection* Oral Polio Vaccine DPT

1 through 2 years

EPSDT Screening and Dental

Inspection*/Examination (See Section 213.60) Oral Polio Booster DPT Booster

3 through 4 years

EPSDT Screening and Dentist Examination **

5 through 6 years

Pre-School EPSDT Screening and Dental Examination DPT Booster Oral Polio Vaccine Booster

8 years

EPSDT Screening and Dental Examination

10 through 12 years

EPSDT Screening and Dental Examination

14 years

EPSDT Screening and Dental Examination Tetanus and Diphtheria Toxoids, Adult Type

16-18 years

EPSDT Screening and Dental Examination

* Routine Dental Inspection only for obvious dental problems.

** The last dose of polio vaccine, DPT, DT or TD must have been after the child's 4th birthday.

*** For all mandated visits not specifically addressed in this chart, services rendered shall include, at a minimum, an EPSDT Screening and Dental Examination.

Proper and timely application of the EPSDT Schedule and procedures described in these guidelines 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.

Section 8. Severability

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.

(12/13/1995)

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