205.536 Utilization review -- Prohibition against prospective or concurrent review

222 words·~1 min read·/ky/205-536

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

of prescription drug for alcohol or opioid use disorder.

(1)A Medicaid managed care organization shall have a utilization review plan, as

defined in KRS 304.17A-600, that meets the requirements established in 42 C.F.R.

pts. 431, 438, and 456. If the Medicaid managed care organization utilizes a private

review agent, as defined in KRS 304.17A-600, the agent shall comply with all

applicable requirements of KRS 304.17A-600 to 304.17A-633.

(2)In conducting utilization reviews for Medicaid benefits, each Medicaid managed

care organization shall use the medical necessity criteria selected by the Department

of Insurance pursuant to KRS 304.38-240, for making determinations of medical

necessity and clinical appropriateness pursuant to the utilization review plan

required by subsection

(1)of this section.

(3)To the extent consistent with the federal regulations referenced in subsection

(1)of

this section, the Department for Medicaid Services or any managed care

organization contracted to provide Medicaid benefits pursuant to KRS Chapter 205

shall not require or conduct a prospective or concurrent review, as defined in KRS

304.17A-600, for a prescription drug:

(a)That:

1. Is used in the treatment of alcohol or opioid use disorder; and

2. Contains Methadone, Buprenorphine, an opioid antagonist, or

Naltrexone; or

(b)That was approved before January 1, 2022, by the United States Food and

Drug Administration for the mitigation of opioid withdrawal symptoms.