§469. System of payments; authority of the Louisiana Department of Health; cost participation schedule

A. The department is hereby authorized to establish a statewide system of payments in accordance with the provisions of 34 CFR Part 303.

B.(1) In implementing the system of payments, the department shall promulgate rules for the reimbursement of services from all third-party payers, both private and public.

(2) The department or its designee shall seek payment from all third-party payers prior to claiming payment from the IDEA-Part C early intervention system of this state for services rendered to eligible children.

(3) The department or its designee may pay directly to a provider any required deductible, copayment, coinsurance, or other out-of-pocket expense for a child who is eligible for services from the IDEA-Part C early intervention system of this state.

C.(1)(a) The department shall promulgate rules in accordance with the Administrative Procedure Act that establish a schedule of monthly cost participation for early intervention services per qualifying family. Cost participation shall be based on a sliding scale and shall consider elements including but not limited to adjusted gross income, family size, financial hardship, extraordinary expenses associated with the child, and Medicaid eligibility. The department shall be subject to all of the following limitations and requirements relative to the cost participation schedule:

(i) The department shall utilize the most recent federal poverty guidelines published in the Federal Register by the United States Department of Health and Human Services, referred to hereafter in this Subsection as the "federal poverty guidelines", as the basis for determining the income threshold based on family size for eligibility for cost participation.

(ii) 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 three hundred percent of the applicable federal poverty guideline.

(iii) In any month, the department shall not assess fees or other charges through the cost participation schedule which total more than three percent of the monthly income level for a family of four, according to the federal poverty guideline schedule.

(iv) The department shall not assess a fee or other charge through the cost participation schedule for any service provided for in Item (c)(ii) of this Paragraph.

(b) Parents who have public or private insurance and elect not to assign such right of recovery or indemnification to the department or choose not to release financial information shall be assessed the cost for each early intervention service listed on the individualized family service plan according to the most current service rate schedule and cost participation schedule promulgated by the department.

(c) The cost participation schedule promulgated by the department shall provide all of the following:

(i) Procedures by which a service provider may notify the department that a family is not complying with the cost participation requirements and procedures for suspending services.

(ii) A statement of assurance that fees are not charged for services which a child is otherwise entitled to receive at no cost to parents, including child-find activities, evaluation and assessment for eligibility and individualized family service planning, service coordination, administrative and coordinative activities related to development review, evaluation of individualized family service plans, and implementation of procedural safeguards and other components of the statewide system provided for in R.S. 28:464.

(2)(a) The department shall provide prior notification in writing to families for use of public or private insurance according to the requirements of 34 CFR 303.414. Such notification shall include a statement of the general categories of costs that the parent would incur and a statement of the process for resolution of a dispute regarding decisions related to use of public or private insurance, failure to pay for services or the state's determination of a family's ability to pay.

(b) The department shall ensure that the procedures utilized to resolve such disputes will not delay or deny the parents' rights or the child's ability to access timely services.

(3) The aggregate contributions made by the parent shall not exceed the aggregate cost of the early intervention services received by the child and family, inclusive of any amount received from other sources of payment for a service.

(4)(a) At least annually, or at any time the department determines is warranted, the department shall conduct a reassessment of the parents' financial status. A parent may request such reassessment at any time when significant changes in financial circumstances may affect the calculation of the cost participation amount.

(b) The department shall not make any administrative decision regarding suspension or termination of services for a family prior to the family having been in arrears, with respect to fees or other charges assessed pursuant to cost participation, for a duration of three months.

(c) On at least a monthly basis, the department shall send to any family in arrears, with respect to fees or other charges assessed pursuant to cost participation, notice of the family's right for reconsideration of their financial status and the family's right to apply for exemption from cost participation due to financial hardship. A copy of the notice shall be sent to the representative and senator in whose district the family resides.

(5) The department shall not limit early intervention services for a child in any month if the cost of such services in that month exceeds the maximum monthly contribution from the child's family as provided in Item (1)(a)(iii) of this Subsection.

Acts 2013, No. 417, §1, eff. June 21, 2013; Acts 2018, No. 206, §1.