RELATES TO:
KRS
205.520
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 has
responsibility to administer the program of Medical Assistance.
KRS
205.520(3) empowers 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 administrative
regulation sets forth the conditions under which the Medicaid Program shall pay
for covered medical services furnished eligible recipients who are out of
state.
Section 1. General. Medicaid
services provided to an eligible Medicaid recipient who is a resident of
Kentucky while that resident is in another state shall be reimbursed in
accordance with Section 2 of this administrative regulation.
Section 2. Criteria for Coverage while Out of
State.
(1) Payment shall be made if covered
medical services are needed because of a medical emergency.
(2) Payment shall be made if medical services
are needed because the recipient's health would be endangered if he were
required to travel to Kentucky for the medical service. With regard to
long-term care patients, it shall be the policy of the cabinet to pay for the
medical services only until the time when the patient's medical condition has
stabilized so the patient return to Kentucky; it is expected that the period of
coverage shall be sixty (60) days or less; continuation of payment shall be
contingent upon presentation of medical evidence acceptable to the cabinet
which justifies an additional stay in a facility outside the state.
(3) Payment shall be made when the state
determines, on the basis of medical advice, that the needed medical services,
or necessary supplementary resources, are more readily available in the other
state; provided, however, that this provision shall not be construed or
interpreted in a manner which circumvents or negates the provisions and intent
of this administrative regulation.
(4) Payment shall be made when it is general
practice for recipients in a particular locality to use medical resources in
another state.
Section 3.
Exception. For individuals in long-term care out of state prior to the
effective date of this administrative regulation, and for whom the cabinet is
at that time paying for the cost of care, the cabinet may continue to pay for
the cost of care if the cabinet deems the payments to be appropriate. Children
in subsidized adoption or foster care status shall be exempt from the
restrictions shown in this administrative regulation.
Section 4. Cooperation with other States. The
cabinet shall facilitate the furnishing of medical services to individuals who
are present in Kentucky and are eligible for Medicaid under another state's
Medicaid plan.