RELATES TO: 42 C.F.R. Parts 430, 431, 432, 433, 435, 440, 442,
447, 455, 456,
42 U.S.C.
1396a, b, d
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
July 9, 2004, reorganized the Cabinet for Health Services and placed the
Department for Medicaid Services and the Medicaid Program under the Cabinet for
Health and Family Services. The Cabinet for Health and Family Services,
Department for Medicaid Services, has responsibility to administer the Medicaid
Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law for the provision of Medical
Assistance to Kentucky's indigent citizenry. This administration regulation
establishes the provisions relating to the review and approval of selected
therapies as ancillary services for Medicaid recipients in nursing
facilities.
Section 1. Definitions.
(1) "Adult recipient" means an individual who
is:
(a) Eligible to participate in Kentucky's
Medicaid Program; and
(b) Age
twenty-one (21) or over.
(2) "Ancillary service" means a direct
therapy service for which a separate charge is customarily made pursuant to
Section 2 of this administrative regulation.
(3) "Attending physician" means the physician
of record identified in the recipient's nursing facility medical
record.
(4) "Department" means the
Department for Medicaid Services or its designee.
(5) "Nursing facility" or "NF" means:
(a) A facility:
1. To which the state survey agency has
granted an NF license;
2. For which
the state survey agency has recommended to the department certification as a
Medicaid provider; and
3. To which
the department has granted certification for Medicaid participation;
or
(b) A hospital swing
bed that provides services in accordance with
42 U.S.C.
1395tt and
1396l,
if the swing bed is certified to the department as meeting requirements for the
provision of swing bed services in accordance with
42 U.S.C.
1396r(b), (c), (d),
42 C.F.R.
447.280 and
482.66.
(6) "Pediatric recipient" means an individual
who is:
(a) Eligible to participate in
Kentucky's Medicaid Program; and
(b) Under twenty-one (21) years of
age.
Section 2.
Covered Ancillary Services.
(1) Oxygen
therapy shall be a covered ancillary service if the department determines that
the therapy:
(a) Is medically necessary;
and
(b) Meets criteria pursuant to
Section 3 of this administrative regulation.
(2) The following therapies shall be covered
ancillary services if the department determines that the therapies meet the
criteria established in Section 3 of this administrative regulation:
(a) Physical therapy;
(b) Occupational therapy; or
(c) Speech therapy.
Section 3. On-site Review Approval
and Denial Criteria.
(1) The department shall
approve a therapy as an ancillary service if, through an on-site review, the
department determines that:
(a) The nature and
extent of functional deficiency requires a qualified therapist, as determined
through chart evaluation and resident contact;
(b) The care setting is appropriate for
treatment planned;
(c) The therapy
frequency, duration and intensity shall be reasonable and necessary for the
resident's current active diagnosis;
(d) The following documentation is complete:
1. Referral request;
2. Therapy assessment;
3. Action plan;
4. Progress report; and
5. Service discontinuance;
(e) The progress of the resident
can be verified against baseline and stated goals and time frames;
(f) The therapy is not duplicative of other
services that the resident is receiving;
(g) The condition of the resident requires a
registered therapist to:
1. Evaluate the
resident's active daily intervention program;
2. Supervise trained staff to carry out a
therapy regimen;
3. Use assistive
or adaptive equipment;
4. Train
staff to use assistive or adaptive equipment;
5. Train the resident to use assistive or
adaptive equipment during goal setting;
6. Supervise and certify a therapy assistant
who is participating in a treatment program;
7. Establish a nursing care plan program to
be performed by:
a. Nursing staff;
b. Restorative aide; or
c. A resident; and
8. Be responsible for the timely discharge of
a service level;
(h) A
therapist has a:
1. Specific
diagnosis;
2. Specific treatment
plan that relates to a condition of the resident;
3. Specific modality for intervention that
relates to a condition of the resident; and
4. Reasonable expectation for gain based on
reasonable goals and time frames; and
(i) A resident is:
1. An adult recipient who meets the approval
criteria of the "Technical Criteria for Reviewing Ancillary Services for
Adults"; or
2. A pediatric
recipient who meets the "Technical Criteria for Reviewing Ancillary Services
for Pediatrics".
(2) The department shall deny a request for a
therapy as an ancillary service pursuant to Section 2 of this administrative
regulation if, through an on-site review, the department determines that:
(a) Services of a registered therapist are
not needed on a daily basis because:
1. Lack
of progress of the patient;
2.
Goals have been met;
3. A patient
is unable to participate;
4. Lack
of ability of nursing staff or resident to conduct or perform care;
5. The Nursing care plan program has been
designed and will be performed by staff other than a therapist;
6. Nursing staff or the resident is able to
safely:
a. Perform the following:
(i) Repetitious exercise;
(ii) Nonrestorative exercise; or
(iii) Drills; and
b. Use equipment or
devices;
7. The frequency
or intensity of the services exceeds the benefits;
8. No further gains are reasonably
achievable; or
9. A resident is:
a. Independent; or
b. Needs only minimal assistance for
performance;
(b) The resident is:
1. An adult recipient who meets the
"Indication for Denial" criteria established in the "Technical Criteria for
Reviewing Ancillary Services for Adults"; or
2. A pediatric recipient who meets the
"Indication for Denial" criteria established in the "Technical Criteria for
Reviewing Ancillary Services for Pediatrics"; and
(c) If applicable, oxygen therapy is not
medically necessary.
Section
4. Certification and Recertification Process for a Therapy as an
Ancillary Service.
(1) Within two (2)
workdays of the date that a recipient's attending physician orders
administration of a therapy pursuant to Section 2 of this administrative
regulation, an NF shall:
(a) Notify the
department by telephone; and
(b)
Request an on-site review of the therapy.
(2) Within five (5) workdays of receipt of
notification pursuant to subsection (1) of this section, the department shall:
(a) Perform an on-site review pursuant to
Section 3 of this administrative regulation; and
(b) Render a certification
decision.
(3) The
department shall issue a written notice of approval or denial relating to:
(a) A request for oxygen therapy to the:
1.
a.
Resident; or
b.
Guardian;
2. NF;
and
3. Attending physician;
or
(b) A request for a
therapy pursuant to Section 2(2) of this administrative regulation to the
NF.
(4) If a therapy
pursuant to Section 2(2) of this administrative regulation is approved as an
ancillary service, the department shall establish a certification period that
includes:
(a) A start date of up to two (2)
workdays prior to the date of notification by an NF pursuant to subsection (1)
of this section; and
(b) An end
date that the department determines to be a reasonable time period for an
individual to meet goals established by an individualized therapy
program.
(5) Prior to
the last day of a certification period for an approved therapy as an ancillary
service, the department shall:
(a) Recertify a
therapy as an ancillary service for the extended period of time, if an
individual continues to meet criteria pursuant to Sections 2 and 3 of this
administrative regulation; and
(b)
Issue a written notice pursuant to subsection (3) of this
section.
(6) If the
department denies a request for certification or recertification of a therapy
as an ancillary service, the NF may request that the department reconsider a
request pursuant to Section 5 of this administrative
regulation.
Section 5.
Reconsideration and Appeal of a Denial of a Therapy as an Ancillary Service.
(1) The department shall reconsider its
decision to deny a request for oxygen therapy as an ancillary service if,
within thirty (30) days of the date on a notice of adverse action, a written
request for reconsideration is submitted to the department by the:
(a) Resident; or
(b) Resident's legal guardian.
(2) If the department receives a
request for reconsideration pursuant to subsection (1) of this section, the
department shall:
(a) Conduct a
reconsideration on-site review within three (3) workdays from the receipt of
the request;
(b) Employ a physician
who was not involved with the initial on-site review or determination to
conduct a reconsideration on-site review;
(c) Base its reconsideration decision solely
upon information that is:
1. Contained in the
resident's medical records; and
2.
Submitted with the written request pursuant to subsection (1) of this section;
and
(d) Issue a
notification of approval or denial within two (2) workdays of a reconsideration
on-site review.
(3) The
department shall reconsider its decision to deny a request for a therapy as an
ancillary service pursuant to Section 2(2) of this administrative regulation
if:
(a) Form MAP-703, "Request for
Reconsideration of Ancillary Therapy Billing" is submitted to the department by
an NF; and
(b) Form MAP-703 is
received by the department within seven (7) days of the date on the notice of
adverse action.
(4) If
the department receives a request for reconsideration pursuant to subsection
(3) of this section, the department shall:
(a)
Conduct a reconsideration on-site review within seven (7) workdays from receipt
of the request;
(b) Employ a
registered nurse who was not involved with the initial on-site review or
determination to conduct the reconsideration on-site review;
(c) Base its reconsideration decision solely
upon information that is:
1. Contained in the
resident's medical records; and
2.
Submitted with the request pursuant to subsection (3)(a) of this section;
and
(d) Issue a
notification of approval or denial within three (3) workdays of a
reconsideration on-site review.
(5) If an outcome of a reconsideration
on-site review results in the denial of a therapy as an ancillary service, the
department shall grant an appeal as follows:
(a) An appeal of the denial of oxygen therapy
as an ancillary service shall be granted pursuant to
907
KAR 1:563; and
(b) An appeal of the denial of a therapy
pursuant to Section 2(2) of this administrative regulation as an ancillary
service shall be granted pursuant to
907
KAR 1:671.
Section 6. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) The "Technical Criteria for
Reviewing Ancillary Services for Adults", Department for Medicaid Services,
November 2003 edition;
(b) The
"Technical Criteria for Reviewing Ancillary Services for Pediatrics",
Department for Medicaid Services, November 2003 edition; and
(c) Form "MAP-703, Request for
Reconsideration of Ancillary Therapy Billing", Department for Medicaid
Services, April 2000 edition.
(2) This material may be inspected, copied or
obtained, subject to applicable copyright law, at the Department for Medicaid
Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through
Friday, 8 a.m. to 4:30 p.m.