205.560 Scope of care to be designated by administrative regulations --
2,453 words·~11 min read·
/ky/205-560A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Reimbursements mandated or prohibited -- Payments to community mental
health centers -- Participation of providers in Medical Assistance Program.
(1)The scope of medical care for which the Cabinet for Health and Family Services
undertakes to pay shall be designated and limited by regulations promulgated by the
cabinet, pursuant to the provisions in this section. Within the limitations of any
appropriation therefor, the provision of complete upper and lower dentures to
recipients of Medical Assistance Program benefits who have their teeth removed by
a dentist resulting in the total absence of teeth shall be a mandatory class in the
scope of medical care. Payment to a dentist of any Medical Assistance Program
benefits for complete upper and lower dentures shall only be provided on the
condition of a preauthorized agreement between an authorized representative of the
Medical Assistance Program and the dentist prior to the removal of the teeth. The
selection of another class or other classes of medical care shall be recommended by
the council to the secretary for health and family services after taking into
consideration, among other things, the amount of federal and state funds available,
the most essential needs of recipients, and the meeting of such need on a basis
insuring the greatest amount of medical care as defined in KRS 205.510 consonant
with the funds available, including but not limited to the following categories,
except where the aid is for the purpose of obtaining an abortion:
(a)Hospital care, including drugs, and medical supplies and services during any
period of actual hospitalization;
(b)Nursing-home care, including medical supplies and services, and drugs during
confinement therein on prescription of a physician, dentist, or podiatrist;
(c)Drugs, nursing care, medical supplies, and services during the time when a
recipient is not in a hospital but is under treatment and on the prescription of a
physician, dentist, or podiatrist. For purposes of this paragraph, drugs shall
include products for the treatment of inborn errors of metabolism or genetic,
gastrointestinal, and food allergic conditions, consisting of therapeutic food,
formulas, supplements, amino acid-based elemental formula, or low-protein
modified food products that are medically indicated for therapeutic treatment
and are administered under the direction of a physician, and include but are
not limited to the following conditions:
1. Phenylketonuria;
2. Hyperphenylalaninemia;
3. Tyrosinemia (types I, II, and III);
4. Maple syrup urine disease;
5. A-ketoacid dehydrogenase deficiency;
6. Isovaleryl-CoA dehydrogenase deficiency;
7. 3-methylcrotonyl-CoA carboxylase deficiency;
8. 3-methylglutaconyl-CoA hydratase deficiency;
9. 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMG-CoA lyase
deficiency);
10. B-ketothiolase deficiency;
11. Homocystinuria;
12. Glutaric aciduria (types I and II);
13. Lysinuric protein intolerance;
14. Non-ketotic hyperglycinemia;
15. Propionic acidemia;
16. Gyrate atrophy;
17. Hyperornithinemia/hyperammonemia/homocitrullinuria syndrome;
18. Carbamoyl phosphate synthetase deficiency;
19. Ornithine carbamoyl transferase deficiency;
20. Citrullinemia;
21. Arginosuccinic aciduria;
22. Methylmalonic acidemia;
23. Argininemia;
24. Food protein allergies;
25. Food protein-induced enterocolitis syndrome;
26. Eosinophilic disorders; and
27. Short bowel syndrome;
(d)Physician, podiatric, and dental services;
(e)Optometric services for all age groups shall be limited to prescription
services, services to frames and lenses, and diagnostic services provided by an
optometrist, to the extent the optometrist is licensed to perform the services
and to the extent the services are covered in the ophthalmologist portion of the
physician's program. Eyeglasses shall be provided only to children under age
twenty-one (21);
(f)Drugs on the prescription of a physician used to prevent the rejection of
transplanted organs if the patient is indigent; and
(g)Nonprofit neighborhood health organizations or clinics where some or all of
the medical services are provided by licensed registered nurses or by
advanced medical students presently enrolled in a medical school accredited
by the Association of American Medical Colleges and where the students or
licensed registered nurses are under the direct supervision of a licensed
physician who rotates his services in this supervisory capacity between two
(2)or more of the nonprofit neighborhood health organizations or clinics
specified in this paragraph.
(2)Payments for hospital care, nursing-home care, and drugs or other medical,
ophthalmic, podiatric, and dental supplies shall be on bases which relate the amount
of the payment to the cost of providing the services or supplies. It shall be one
of the functions of the council to make recommendations to the Cabinet for Health
and Family Services with respect to the bases for payment. In determining the rates
of reimbursement for long-term-care facilities participating in the Medical
Assistance Program, the Cabinet for Health and Family Services shall, to the extent
permitted by federal law, not allow the following items to be considered as a cost to
the facility for purposes of reimbursement:
(a)Motor vehicles that are not owned by the facility, including motor vehicles
that are registered or owned by the facility but used primarily by the owner or
family members thereof;
(b)The cost of motor vehicles, including vans or trucks, used for facility business
shall be allowed up to fifteen thousand dollars ($15,000) per facility, adjusted
annually for inflation according to the increase in the consumer price index-u
for the most recent twelve
(12)month period, as determined by the United
States Department of Labor. Medically equipped motor vehicles, vans, or
trucks shall be exempt from the fifteen thousand dollar ($15,000) limitation.
Costs exceeding this limit shall not be reimbursable and shall be borne by the
facility. Costs for additional motor vehicles, not to exceed a total of three
per facility, may be approved by the Cabinet for Health and Family Services if
the facility demonstrates that each additional vehicle is necessary for the
operation of the facility as required by regulations of the cabinet;
(c)Salaries paid to immediate family members of the owner or administrator, or
both, of a facility, to the extent that services are not actually performed and
are not a necessary function as required by regulation of the cabinet for the
operation of the facility. The facility shall keep a record of all work actually
performed by family members;
(d)The cost of contracts, loans, or other payments made by the facility to owners,
administrators, or both, unless the payments are for services which would
otherwise be necessary to the operation of the facility and the services are
required by regulations of the Cabinet for Health and Family Services. Any
other payments shall be deemed part of the owner's compensation in
accordance with maximum limits established by regulations of the Cabinet for
Health and Family Services. Interest paid to the facility for loans made to a
third party may be used to offset allowable interest claimed by the facility;
(e)Private club memberships for owners or administrators, travel expenses for
trips outside the state for owners or administrators, and other indirect
payments made to the owner, unless the payments are deemed part of the
owner's compensation in accordance with maximum limits established by
regulations of the Cabinet for Health and Family Services; and
(f)Payments made to related organizations supplying the facility with goods or
services shall be limited to the actual cost of the goods or services to the
related organization, unless it can be demonstrated that no relationship
between the facility and the supplier exists. A relationship shall be considered
to exist when an individual, including brothers, sisters, father, mother, aunts,
uncles, and in-laws, possesses a total of five percent (5%) or more of
ownership equity in the facility and the supplying business. An exception to
the relationship shall exist if fifty-one percent (51%) or more of the supplier's
business activity of the type carried on with the facility is transacted with
persons and organizations other than the facility and its related organizations.
(3)No vendor payment shall be made unless the class and type of medical care
rendered and the cost basis therefor has first been designated by regulation.
(4)The rules and regulations of the Cabinet for Health and Family Services shall
require that a written statement, including the required opinion of a physician, shall
accompany any claim for reimbursement for induced premature births. This
statement shall indicate the procedures used in providing the medical services.
(5)The range of medical care benefit standards provided and the quality and quantity
standards and the methods for determining cost formulae for vendor payments
within each category of public assistance and other recipients shall be uniform for
the entire state, and shall be designated by regulation promulgated within the
limitations established by the Social Security Act and federal regulations. It shall
not be necessary that the amount of payments for units of services be uniform for
the entire state but amounts may vary from county to county and from city to city,
as well as among hospitals, based on the prevailing cost of medical care in each
locale and other local economic and geographic conditions, except that insofar as
allowed by applicable federal law and regulation, the maximum amounts
reimbursable for similar services rendered by physicians within the same specialty
of medical practice shall not vary according to the physician's place of residence or
place of practice, as long as the place of practice is within the boundaries of the
state.
(6)Nothing in this section shall be deemed to deprive a woman of all appropriate
medical care necessary to prevent her physical death.
(7)To the extent permitted by federal law, no medical assistance recipient shall be
recertified as qualifying for a level of long-term care below the recipient's current
level, unless the recertification includes a physical examination conducted by a
physician licensed pursuant to KRS Chapter 311 or by an advanced practice
registered nurse licensed pursuant to KRS Chapter 314 and acting under the
physician's supervision.
(a)If payments made to community mental health centers, established pursuant to
KRS Chapter 210, for services provided to the intellectually disabled exceed
the actual cost of providing the service, the balance of the payments shall be
used solely for the provision of other services to the intellectually disabled
through community mental health centers.
(b)Except as provided in KRS 210.370(4) and (5)(c), if a community mental
health center, established pursuant to KRS Chapter 210, provides services to a
recipient of Medical Assistance Program benefits outside of the community
mental health center's regional service area, as established in KRS 210.370,
the community mental health center shall not be reimbursed for such services
in accordance with the department's fee schedule for community mental
health centers but shall instead be reimbursed in accordance with the
department's fee schedule for behavioral health service organizations.
(c)As used in this subsection, "community mental health center" means a
regional community services program as defined in KRS 210.005.
(9)No long-term-care facility, as defined in KRS 216.510, providing inpatient care to
recipients of medical assistance under Title XIX of the Social Security Act on July
15, 1986, shall deny admission of a person to a bed certified for reimbursement
under the provisions of the Medical Assistance Program solely on the basis of the
person's paying status as a Medicaid recipient. No person shall be removed or
discharged from any facility solely because they became eligible for participation in
the Medical Assistance Program, unless the facility can demonstrate the resident or
the resident's responsible party was fully notified in writing that the resident was
being admitted to a bed not certified for Medicaid reimbursement. No facility may
decertify a bed occupied by a Medicaid recipient or may decertify a bed that is
occupied by a resident who has made application for medical assistance.
(10)Family-practice physicians practicing in geographic areas with no more than one
(1)primary-care physician per five thousand (5,000) population, as reported by the
United States Department of Health and Human Services, shall be reimbursed one
hundred twenty-five percent (125%) of the standard reimbursement rate for
physician services.
(11)The Cabinet for Health and Family Services shall make payments under the
Medical Assistance Program for services which are within the lawful scope of
practice of a chiropractor licensed pursuant to KRS Chapter 312, to the extent the
Medical Assistance Program pays for the same services provided by a physician.
(a)The Medical Assistance Program shall use the appropriate form and
guidelines for enrolling those providers applying for participation in the
Medical Assistance Program, including those licensed and regulated under
KRS Chapters 311, 312, 314, 315, and 320, any facility required to be
licensed pursuant to KRS Chapter 216B, and any other health care practitioner
or facility as determined by the Department for Medicaid Services through an
administrative regulation promulgated under KRS Chapter 13A. A Medicaid
managed care organization shall use the forms and guidelines established
under KRS 304.17A-545(5) to credential a provider. For any provider who
contracts with and is credentialed by a Medicaid managed care organization
prior to enrollment, the cabinet shall complete the enrollment process and
deny, or approve and issue a Provider Identification Number
(PID)within
fifteen
(15)business days from the time all necessary completed enrollment
forms have been submitted and all outstanding accounts receivable have been
satisfied.
(b)Within forty-five
(45)days of receiving a correct and complete provider
application, the Department for Medicaid Services shall complete the
enrollment process by either denying or approving and issuing a Provider
Identification Number
(PID)for a behavioral health provider who provides
substance use disorder services, unless the department notifies the provider
that additional time is needed to render a decision for resolution of an issue or
dispute.
(c)Within forty-five
(45)days of receipt of a correct and complete application for
credentialing by a behavioral health provider providing substance use disorder
services, a Medicaid managed care organization shall complete its contracting
and credentialing process, unless the Medicaid managed care organization
notifies the provider that additional time is needed to render a decision. If
additional time is needed, the Medicaid managed care organization shall not
take any longer than ninety
(90)days from receipt of the credentialing
application to deny or approve and contract with the provider.
(d)A Medicaid managed care organization shall adjudicate any clean claims
submitted for a substance use disorder service from an enrolled and
credentialed behavioral health provider who provides substance use disorder
services in accordance with KRS 304.17A-700 to 304.17A-730.
(e)The Department of Insurance may impose a civil penalty of one hundred
dollars ($100) per violation when a Medicaid managed care organization fails
to comply with this section. Each day that a Medicaid managed care
organization fails to pay a claim may count as a separate violation.
(13)Dentists licensed under KRS Chapter 313 shall be excluded from the requirements
of subsection
(12)of this section. The Department for Medicaid Services shall
develop a specific form and establish guidelines for assessing the credentials of
dentists applying for participation in the Medical Assistance Program.