RELATES TO:
KRS
205.520,
314.011,
42 C.F.R.
438.2,
42 U.S.C.
1396s
NECESSITY, FUNCTION, AND CONFORMITY: 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 to qualify for federal
Medicaid funds. This administrative regulation establishes the reimbursement
provisions and requirements regarding services provided to Medicaid recipients
who are not enrolled with a managed care organization by individual advanced
practice registered nurses (APRNs) enrolled in the Medicaid program or APRN
provider groups enrolled in the Medicaid program.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
"APRN" is defined by KRS
314.011(7).
(2) "Department" means the Department for
Medicaid Services or its designated agent.
(3) "Managed care organization" means an
entity for which the Department for Medicaid Services has contracted to serve
as a managed care organization as defined by
42 C.F.R.
438.2.
(4) "Physician administered drug" or "PAD"
means any rebateable covered outpatient drug that is:
(a) Provided or administered to a Medicaid
recipient;
(b) Billed by a provider
other than a pharmacy provider through the medical benefit, including a
provider that is a physician office or another outpatient clinical setting;
and
(c) An injectable or
non-injectable drug furnished incident to provider services that are billed
separately to Medicaid.
(5) "Provider group" means a group of at
least two (2) individually licensed APRNs who:
(a) Are enrolled with the Medicaid program
individually and as a group; and
(b) Share the same Medicaid group provider
number.
(6) "Usual and
customary charge" means the uniform amount the provider charges in the majority
of cases for the service or procedure.
Section 2. Reimbursement.
(1) The department's reimbursement under this
administrative regulation shall be for a service or procedure:
(b) Provided by an APRN or APRN provider
group that:
1. Meets the condition of
participation requirements established in
907 KAR 1:102, Section 2;
and
2. Is the billing provider for
the service or procedure.
(2) Except as specified in subsection (3) of
this section or Section 3 of this administrative regulation, the department
shall reimburse for a service or procedure that is covered pursuant to
907 KAR 1:102 at the lesser of:
(a) The APRN's or APRN provider group's usual
and customary charge for the service or procedure;
(b) Seventy-five (75) percent of the amount
reimbursable to a Medicaid participating physician for the same service or
procedure pursuant to
907 KAR 3:010; or
(c) For anesthesia and related services
delivered by a certified registered nurse anesthetist, at one-hundred (100)
percent of the amount reimbursable to a Medicaid participating physician for
the same service or procedure pursuant to
907 KAR
3:010.
(3) The department's reimbursement for a
behavioral health service covered pursuant to
907 KAR 15:010 that is provided
by an APRN or APRN provider group that is the billing provider for the service
shall be pursuant to
907 KAR
15:015.
Section 3. Reimbursement Limitations.
(1) The department shall reimburse an APRN or
APRN provider group:
(a) A three (3) dollar
and thirty (30) cent fee for each vaccine administered to a Medicaid recipient
under the age of nineteen (19) up to a maximum of three (3) administrations per
APRN, per recipient, per date of service; and
(b) The cost of each vaccine administered in
accordance with paragraph (a) of this subsection, except as established in
subsection (2) of this section.
(2) The department shall not reimburse for
the cost of a vaccine that is available free through the Vaccines for Children
Program in accordance with 42 U.S.C.
1396s.
(3) The department shall reimburse for a PAD
in accordance with
907 KAR 23:020.
(4)
(a)
Payment for a cast or splint applied in conjunction with a surgical procedure
shall be included in the payment for the surgical procedure.
(b) Except as provided by paragraph (c) of
this subsection, the department shall not reimburse for a cast or splint
application for the same injury or condition within ninety (90) calendar days:
1. From the date of the surgical service;
or
2. If surgery is not performed,
from initial application of the cast or splint.
(c) The department shall reimburse for a
second cast or splint applied for a subsequent injury or condition within
ninety (90) calendar days of the first cast or splint application if the claim
contains documentation demonstrating that the injury or condition occurred
subsequent to the initial cast or splint application.
(d) Reimbursement for the application of a
cast or splint associated with a surgical procedure shall be considered to
include:
1. A temporary cast or splint, if
applied by the same physician who performed the surgical procedure;
2. The initial cast or splint applied during
or following the surgical procedure; and
3. A replacement cast or splint needed as a
result of the surgical procedure if:
a.
Provided within ninety (90) calendar days of the procedure by the same
physician; and
b. Applied for the
same injury or condition.
(5) Reimbursement for an anesthesia service
provided during a procedure shall include:
(a)
Preoperative and postoperative visits;
(b) Administration of the
anesthetic;
(c) Administration of
intravenous fluids, blood, or blood products incidental to the anesthesia or
surgery;
(d) Postoperative pain
management; and
(e) Monitoring
services.
(6) The
department's reimbursement for a laboratory service provided in an office
setting shall include the fee for collecting and analyzing a
specimen.
(7) A fee for a
laboratory test requiring an arterial puncture or a venipuncture shall include
the fee for the puncture.
Section
4. Not Applicable to Managed Care Organizations. A managed care
organization shall not be required to reimburse in accordance with this
administrative regulation for a service covered pursuant to:
(2) This administrative regulation.
Section 5. Federal Approval and
Federal Financial Participation. The department's reimbursement of services
pursuant to this administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 6. Appeal Rights. An appeal of a
negative action taken by the department regarding a Medicaid provider shall be
in accordance with
907 KAR 1:671.