(1) The department will provide financial assistance for a CSHS-eligible CYSHCN with a covered condition:

(a) if the benefit is not covered by another payment source, with the exception of the Indian health service (IHS), which is a payer of last resort;

(b) if the department has sufficient federal funds to provide the benefit;

(c) up to a maximum of $2,000 per eligibility year;

(d) up to the maximum of $2,000 for speech, physical, nutritional, occupational, or respiratory therapy related to a covered condition. For a CYSHCN under age three, CSHS will pay after the early intervention program, part C, of the disabilities services division; and

(e) after all third parties, if any, have paid the provider, in which case the department pays any balance remaining for services to the lower of the insurance allowed amount or the CSHS allowed amount for the services in question.

(2) The department will pay providers directly for CSHS-eligible services and will not reimburse clients.

(3) The department will pay eligible providers after the department receives a signed authorization, claim form, and requested documentation that the care has been provided.

(4) Any individual who erroneously or improperly receives payment from the department must promptly refund that payment to the department.

(5) A provider who accepts the CSHS level of payment for covered services may not seek additional payment from a CSHS client or their family.

(6) The department will pay up to the following limits for orthodontia care:

(a) Payment for orthodontia for CSHS clients who have cleft or craniofacial conditions requiring orthodontia due to a medical condition with orthodontic implications will be subject to the maximum allowable payment as set forth in CSHS rule.

(b) Payment will be based on a treatment plan submitted by the provider that meets the requirements of the department's orthodontic coverage and reimbursement guidelines and that includes, at a minimum, a description of the plan of treatment, the provider's estimated usual and customary charge, and a time line for treatment. The maximum payable amount for any one phase of treatment is 85%. The department will reimburse 40% of the CSHS allowed amount upon initial billing for each phase of treatment, the remainder being paid in monthly installments as determined by the time line established in the provider's treatment plan for completing orthodontic care. Payment is also subject to any insurance coverage a client may have.

(7) For services to a CSHS client, a provider will be paid 85% of the actual submitted charge. If the CSHS client has third-party coverage, the department will pay the remaining balance for services to the lower of the insurance allowed amount or the CSHS allowed amount of the approved services.

(8) Hospitals and surgicenters will be paid 85% of the actual submitted charge, or after all third-party payers, if any, have paid the provider, in which case the department pays any balance remaining for services to the lower of the insurance allowed amount or the CSHS allowed amount for the services in question for the date of occurrence for inpatient and outpatient services.

(9) Dentists will be paid 85% of billed charges, or after all third-party payers, if any, have paid the provider, in which case the department pays any balance remaining for services to the lower of the insurance allowed amount or the CSHS allowed amount for an annual dental exam and dental extractions related to active or anticipated orthodontic treatment.

(10) In addition to the above, the department will pay:

(a) the lesser of either the actual charge for drugs and other prescribed supplies, or the wholesale price cited, less 15%, plus a dispensing fee on the Medicaid point-of-sale system;

(b) 85% of the cost of durable medical equipment to the appropriate amount when allowing financial assistance, or to the maximum amount set by the program for the federal fiscal year;

(c) 85% of the cost of specialized formula and foods and prescriptive or nonprescriptive medications prescribed by a physician for inborn errors of metabolism; and

(d) 85% of the cost of syringes and disposable medical equipment for the treatment of covered conditions.

(11) A CYSHCN who attends interdisciplinary pediatric specialty clinics, supported by CSHS, is not responsible for copays, deductibles, or coinsurance, nor will they be balance-billed.