Common use of Early Childhood Clause in Contracts

Early Childhood. Intervention (ECI) The MCO must ensure that Network Providers are educated regarding the federal laws on child find (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) and require Network Providers to identify and refer any Member birth through 35 months of age suspected of having a developmental disability or delay, or who is at risk of delay, to the designated ECI program for screening and assessment within two (2) Business Days from the day the Provider identifies the Member. The MCO must use written educational materials developed or approved by the Department of Assistive and Rehabilitative Services – Division for Early Childhood Intervention Services for these “child find” activities. Eligibility for ECI services will be determined by the local ECI program using the criteria contained in 40 T.A.C. §108.25. Note that, beginning on Operational Start Date, ECI Providers must submit claims for all physical, occupational, speech, and language therapy to the MCO. ECI Targeted Case Management services are Non-capitated Services, as described in Section 8.2.2.8. The MCO must contract with qualified ECI Providers to provide ECI Covered Services to Members birth through 35 months of age who have been determined eligible for ECI services. The MCO must permit Members to self refer to local ECI Service Providers without requiring a referral from the Member’s PCP. The MCO’s policies and procedures, including its Provider Manual, must include written policies and procedures for allowing such self-referral to ECI providers. The MCO will implement the Individual Family Service Plan (IFSP) and other services, including ongoing case management and other Covered Services required by the Member’s IFSP. Ongoing case management does not include ECI Targeted Case Management services. The IFSP is an agreement developed by the interdisciplinary team that consists of the MCO, ECI Case Manager/Service Coordinator, the Member/family, and other professionals who participated in the Member’s evaluation or are providing direct services to the Member. The interdisciplinary team may include the Member’s Primary Care Physician (PCP) with parental consent. The IFSP identifies the Member’s present level of development based on assessment, describes the services to be provided to the child to meet the needs of the child and the family, and identifies the person or persons responsible for each service required by the plan. The IFSP must be maintained by the MCO and, with parental consent, provided to the PCP to enhance coordination of the plan of care. The IFSP may be included in the Member’s medical record. The ECI program includes covering medical diagnostic procedures and providing medical records required to perform developmental assessments and developing the IFSP within the 45-day timeline established in federal rule (34 C.F.R. §303.342(a)). The MCO must require compliance with these requirements through Provider contract provisions. The MCO must not withhold authorization for the provision of such medical diagnostic procedures. The MCO must promptly provide relevant medical records available as needed. The MCO must require, through contract provisions, that all Medically Necessary health and Behavioral Health Services contained in the Member’s IFSP are provided to the Member in the amount, duration, scope and service setting established by the IFSP. The MCO must allow services to be provided by an Out-of-Network provider if a Network Provider is not available to provide the services in the amount, duration, scope and service setting as required by the IFSP. The MCO cannot create unnecessary barriers for the Member to obtain IFSP services, including requiring prior authorization for the ECI assessment.

Early Childhood. Intervention (ECI) The MCO HMO must ensure that Network Providers are educated regarding the their responsibility under federal laws on child find (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) and require Network Providers to identify and refer any Member birth through 35 months of age three (3) or under suspected of having a developmental disability or delay, or who is at risk of delay, to the designated ECI program for screening and assessment within two (2) Business Days working days from the day the Provider identifies the Member. The MCO HMO must use written educational materials developed or approved by the Department of Assistive and Rehabilitative Services – Division for Early Childhood Intervention Services for these “child find” activities. Eligibility for ECI services will be determined by the local ECI program using the criteria contained in 40 T.A.C. §108.25. Note that, beginning on Operational Start Date, ECI Providers must submit claims for all physical, occupational, speech, and language therapy to the MCO. ECI Targeted Case Management services are Non-capitated Services, as described in Section 8.2.2.8. The MCO HMO must contract with qualified ECI Providers to provide ECI Covered Services services to Members birth through 35 months of under age three who have been determined eligible for ECI services. The MCO HMO must permit Members to self refer to local ECI Service Providers without requiring a referral from the Member’s PCP. The MCOHMO’s policies and procedures, including its Provider Manual, must include written policies and procedures for allowing such self-referral to ECI providers. The MCO will implement HMO must coordinate and cooperate with local ECI programs in the development and implementation of the Individual Family Service Plan (IFSP) and other services), including ongoing on-going case management and other Covered Services non-capitated services required by the Member’s IFSP. Ongoing case management does not include ECI Targeted Case Management services. The IFSP is an agreement developed by the interdisciplinary team that consists of the MCO, ECI Case Manager/Service Coordinator, the Member/family, and other professionals who participated in the Member’s evaluation or are providing direct services to the Member. The interdisciplinary team , and may include the Member’s Primary Care Physician (PCP) with parental consent. The IFSP identifies the Member’s present level of development based on assessment, describes the services to be provided to the child to meet the needs of the child and the family, and identifies the person or persons responsible for each service required by the plan. The IFSP must shall be maintained transmitted by the MCO and, ECI Provider to the HMO and the PCP with parental consent, provided to the PCP consent to enhance coordination of the plan of care. The IFSP may be included in the Member’s medical record. The Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8 Version 1.7 Cooperation with the ECI program includes covering medical diagnostic procedures and providing medical records required to perform developmental assessments and developing the IFSP within the 45-day timeline established in federal rule (34 C.F.R. §303.342(a)). The MCO HMO must require compliance with these requirements through Provider contract provisions. The MCO HMO must not withhold authorization for the provision of such medical diagnostic procedures. The MCO HMO must promptly provide to the ECI program, relevant medical records available as neededto the HMO. The MCO interdisciplinary team will determine Medical Necessity for health and Behavioral Health Services as approved by the Member’s PCP. The HMO must require, through contract provisions, that all Medically Necessary health and Behavioral Health Services contained in the Member’s IFSP are provided to the Member in the amount, duration, scope and service setting established by the IFSP. The MCO HMO must allow services to be provided by an Outa non-of-Network network provider if a Network Provider is not available to provide the services in the amount, duration, scope and service setting as required by the IFSP. The MCO HMO cannot modify the plan of care or alter the amount, duration, scope, or service setting required by the Member’s IFSP. The HMO cannot create unnecessary barriers for the Member to obtain IFSP services, including requiring prior authorization for the ECI assessmentassessment or establishing insufficient authorization periods for prior authorized services.