RELATES TO:
KRS
205.520, 42 C.F.R. 441, Subpart G, 447.272,
42 U.S.C.
1396a, b, d, n
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health
and Family Services, Department for Medicaid Services, is required 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
policies relating to home and community based waiver services provided to an
individual with an intellectual or developmental disability as an alternative
to placement in an intermediate care facility for an individual with an
intellectual disability.
Section 1.
Definitions.
(1) "Department" means the
Department for Medicaid Services or its de-signee.
(2) "Developmental disability" means a
disability that:
(a) Is manifested prior to
the age of twenty-two (22);
(b)
Constitutes a substantial disability to the affected individual; and
(c) Is attributable either to an intellectual
disability or a condition related to an intellectual disability:
1. Results in an impairment of general
intellectual functioning and adaptive behavior similar to that of a person with
an intellectual disability; and
2.
Is a direct result of, or is influenced by, the person's cognitive
deficits.
(3)
"Intellectual disability" or "ID" means a demonstration:
(a)
1. Of
significantly sub-average intellectual functioning and an intelligence quotient
(IQ) of approximately seventy (70) or below; and
2. Of concurrent deficits or impairments in
present adaptive functioning in at least two (2) of the following areas:
a. Communication;
b. Self-care;
c. Home living;
d. Social or interpersonal skills;
e. Use of community resources;
f. Self-direction;
g. Functional academic skills;
h. Work;
i. Leisure; or
j. Health and safety; and
(b) Which occurred prior
to the individual reaching eighteen (18) years of age.
(4) "North Carolina Support Needs Assessment
Profile" or "NC-SNAP" means a standardized tool used for the measurement of
supportive services needed by an individual with a disability.
(5) "Overall level of eligible support" means
the highest of three (3) scores from the daily living domain, health care
domain, or behavior domain, as established by the NC-SNAP.
(6) "Supports for community living services"
or "SCL services" means community-based waiver services for an individual with
an intellectual or developmental disability.
Section 2. Coverage.
(1) The department shall reimburse a
participating SCL provider for a covered service provided to a Medicaid
recipient who:
(a) Meets patient status
criteria for an intermediate care facility for individuals with intellectual
disabilities (ICF-IID) as established in
907
KAR 1:022; and
(b) Is authorized for an SCL service by the
department.
(2) In order
to be covered, a service shall be provided in accordance with the terms and
conditions specified in
907
KAR 1:145.
(3) The reimbursement provisions established
in this administrative regulation shall apply until the recipient transitions
to the new SCL waiver program established in
907
KAR 12:010 during the month of the recipient's next
birthday. After that transition, the reimbursement provisions established in
907
KAR 12:020 shall apply.
Section 3. SCL Reimbursement.
(1) Specialized medical equipment and
supplies shall:
(a) Be a unit of service in
which one (1) unit equals one (1) item as provided in Section 4 of this
administrative regulation;
(b) Be
reimbursed:
1. By a reduction of twenty (20)
percent of submitted costs for approved dental services; and
2. Based on the submission of three (3) price
estimates of which the lowest shall determine the amount of reimbursement;
and
(c) Not include
furniture, a recreational item, or a leisure item.
(2) A functional assessment to determine the
need for a behavior support plan shall be limited to a total of forty (40)
units per recipient per provider.
(3) A behavior support plan, if required,
shall be limited to a total of twenty-four (24) units per recipient per
provider.
(4) Monitoring a behavior
support plan shall be limited to twelve (12) units per week.
Section 4. Fixed Upper Payment
Limits.
(1) The following rates shall be the
fixed upper payment limits for the SCL services in conjunction with the
corresponding units of service:
Service
|
Unit of Service
|
Upper Payment Limit
|
Adult day training on-site
|
15 minutes
|
$2.50
|
Adult day training off-site
|
15 minutes
|
$3.00
|
Adult foster care
|
24 hours
|
$112.49
|
Assessment or reassessment
|
1 assessment or reassessment
|
$75.00
|
Behavior support
|
15 minutes
|
$33.25
|
Case management
|
1 month
|
$376.06
|
Children's day habilitation
|
15 minutes
|
$2.50
|
Community living supports
|
15 minutes
|
$5.54
|
Family home provider
|
24 hours
|
$112.49
|
Group home
|
24 hours
|
$126.35
|
Occupational therapy by occupational therapist
|
15 minutes
|
$22.17
|
Occupational therapy by certified occupational
therapy assistant
|
15 minutes
|
$22.17
|
Physical therapy by physical therapist
|
15 minutes
|
$22.17
|
Physical therapy by physical therapy assistant
|
15 minutes
|
$22.17
|
Psychological services
|
15 minutes
|
$38.79
|
Respite
|
15 minutes
|
$2.77
|
Specialized medical equipment and supplies
|
1 item
|
Based on submission of 3 price estimates and
reimbursed as described in Section 3 of this administrative regulation.
|
Speech therapy
|
15 minutes
|
$22.17
|
Staffed residence
|
24 hours
|
$168.46
|
Supported Employment
|
15 minutes
|
$5.54
|
(2)
Adult day training on-site and off-site shall be limited to:
(a) Forty (40) hours (160 units) per week;
and
(b) 255 days per calendar year
with the specific days established in the individual support plan and approved
by the department.
(3)
Children's day habilitation shall be limited to forty (40) hours (160 units)
per week.
Section 5.
Non-Level II Intensity Payment.
(1) In
addition to the rates specified in Section 4 of this administrative regulation,
a provider shall receive an intensity payment if the provider meets the
criteria established in subsection (2) of this section.
(2) A non-Level II intensity payment for a
unit of service shall be:
(a) Made if a
recipient has a score equal to five (5) on the NC-SNAP;
(b) Made for no more than ten (10) percent of
the total Medicaid SCL population; and
(c) For the following SCL services:
1. Staffed residence;
2. Community living supports;
3. Respite;
4. Family home provider;
5. Group home;
6. Adult foster care home;
7. Adult day training on-site;
8. Adult day training off-site; or
9. Children's day habilitation.
(3) A non-Level II
intensity payment for a unit of service shall be as follows:
Service
|
Intensity Payment
|
Adult day training on-site
|
$0.40
|
Adult day training off-site
|
$0.40
|
Children's day habilitation
|
$0.40
|
Staffed residence
|
$33.69
|
Community living
|
$0.83
|
Respite
|
$0.42
|
Family home provider
|
$16.87
|
Group home
|
$25.27
|
Adult foster care home
|
$16.87
|
Section
6. Level II Intensity Payment.
(1) The department shall reimburse an adult
day health care center which qualifies for Level II reimbursement pursuant to
907
KAR 1:170 with an intensity payment of fifty (50)
cents per unit for adult day training on-site or adult day training off-site
provided to an SCL recipient.
(2)
If an SCL recipient qualifies an adult day health care center for a non-Level
II intensity payment and a Level II intensity payment, the department shall pay
the Level II intensity payment.
Section 7. All-Inclusive Enhanced Rate.
(1) Effective September 1, 2006, the
department shall reimburse an all-inclusive rate of $125,000 per recipient per
year to a group home, staffed residence, family home provider, or adult foster
care home for SCL services that are provided, in accordance with
907
KAR 1:145, Section 4, to an individual who has
transitioned from an institutional setting to a community setting.
(2) The rate established in subsection (1) of
this section shall be paid for care to an individual who:
(a) Prior to the transition, expressed, or
whose legal guardian expressed, a desire to transition from the facility in
which he or she resided to a community placement; and
(b)
1. Prior
to the transition, resided in an ICF-IID for the entire two (2) year period,
with the period ending no earlier than July 1, 2006, immediately preceding
transitioning out of the ICF-IID and who was approved by the department for
transitioning;
2. Resided in an
ICF-IID for a period of less than two (2) years but more than six (6) months,
with the period ending no earlier than July 1, 2006, immediately preceding
transitioning out of the ICF-IID and who was approved for transitioning by the
department; or
3.
a. Transitioned from an institutional setting
other than an ICF-IID;
b. Had a
primary diagnosis of intellectual disability or developmental
disability;
c. Had resided in an
ICF-IID for a period of at least six (6) months within the preceding two (2)
years;
d. Had received prior SCL
funding; and
e. Had been reviewed
and approved for transitioning by the department.
(3) To be considered for
providing services to an individual meeting the criteria established in
subsection (2) of this section, a provider shall:
(a) Demonstrate its ability to ensure that
the potential recipient will have access to each service identified in his or
her individual support plan through:
1. The
provider's own operation; or
2. An
established network of providers that are:
a.
Enrolled in the Medicaid Program; or
b. Certified or licensed in accordance with
state law governing their specific area of practice;
(b) Notify the department in
writing:
1. Of the number of individuals it is
willing and able to accept;
2. The
date it will be able to accept an individual or individuals; and
3. That it is willing and able to provide
services to a minimum of one (1) individual who has scored at least five (5) on
the NC-SNAP; and
(c) Be
able to serve a minimum of three (3) individuals, regardless of funding source,
in the residence. A provider shall not be required to serve a minimum of three
(3) individuals referenced in subsection (2) of this section, but shall be able
to serve a minimum of three (3) individuals in the residence.
(4) To receive the rate
established in subsection (1) of this section, a provider shall submit
documentation to the department of each SCL service provided to the recipient
for whom the special rate is paid.
(5) The reimbursement established in
subsection (1) of this section:
(a) Shall
expire if approval from the Centers for Medicare and Medicaid Services ceases
and corresponding funding becomes unavailable; and
(b) Shall be all inclusive, meaning that it
shall cover residential as well as all other SCL services, in accordance with
907
KAR 1:145, Section 4, provided to the recipient for a
year.
(6) Recipient
freedom of choice provisions shall apply during an individual's transition from
an institution to a group home, staffed residence, family home provider, or
adult foster care home.
(7) An
individual may transition to a group home, staffed residence, family home
provider, or adult foster care home if:
(a)
The individual is eligible for SCL services pursuant to
907
KAR 1:145;
(b) The department determines that the group
home, staffed residence, family home provider, or adult foster care home
satisfies the requirements established in this section; and
(c) The group home, staffed residence, family
home provider, or adult foster care home meets the SCL provider requirements
established in
907
KAR 1:145.
(8)
(a) If a
group home, staffed residence, family home provider, or adult foster care home
declines to accept an individual referenced in subsection (2) of this section,
the provider, except as established in paragraph (b) of this subsection, shall
be ineligible to:
1. Provide services to any
future individual who meets the criteria established in subsection (2) of this
section; and
2. Receive the
corresponding rate referenced in subsection (1) of this section for care
provided to any future individual.
(b) If the department determines that a
provider who declines to accept an individual is not equipped to serve the
individual and that the placement would be inappropriate, the provider may be
considered for future placements and payments.
(c) Refusing to accept an individual
referenced in subsection (2) of this section shall not preclude a provider from
continuing to:
1. Serve an individual meeting
the criteria established in subsection (2) of this section who is already
residing in the provider's residence; or
2. Be reimbursed at the rate established in
subsection (1) of this section for services provided to an individual already
residing in the provider's residence.
Section 8. North Carolina Support Needs
Assessment Profile (NC-SNAP).
(1) A recipient
of an SCL waiver service shall have an NC-SNAP administered:
(a) By the department; and
(b) In accordance with the NC-SNAP
Instructor's Manual.
(2)
A new NC-SNAP shall be administered:
(a) At
the department's discretion; or
(b)
At the timely request of an SCL provider if a change in a recipient's
circumstances results in the need for increased or decreased supportive
services.
(3) A provider
shall be responsible for the cost of an NC-SNAP at the time administered:
(a) In accordance with subsection (2)(b) of
this section; or
(b) As a result of
an appeal filed in accordance with Section 11(1) of this administrative
regulation.
Section
9. Auditing and Reporting. An SCL provider shall maintain fiscal
records and incident reports in accordance with the requirements established in
907
KAR 1:145, Section 3(10).
Section 10. Transition to New SCL Waiver.
(1) The reimbursement policies established in
this administrative regulation shall:
(a)
Apply to an SCL waiver service provided to an SCL waiver service recipient
pursuant to
907
KAR 1:145; and
(b) Not apply to an SCL waiver service
provided to an SCL waiver service recipient pursuant to
907
KAR 12:010.
(2) An SCL waiver service provided to an SCL
waiver service recipient pursuant to
907
KAR 12:010 shall be reimbursed pursuant to
907
KAR 12:020.
(3) The policies established in this
administrative regulation shall become null and void at the time that:
(a) All SCL waiver service recipients receive
SCL waiver services pursuant to
907
KAR 12:010; and
(b) No SCL waiver recipient receives SCL
waiver services pursuant to
907
KAR 1:145.
Section 11. Appeal Rights.
(1) An appeal of an NC-SNAP score in
accordance with
907
KAR 1:671 shall not be allowed if the change in score
does not affect the provider's reimbursement level.
(2) An appeal of a department decision
regarding a Medicaid beneficiary shall be in accordance with
907
KAR 1:563.
(3) An appeal of a department decision
regarding the eligibility of an individual shall be in accordance with
907
KAR 1:560.
(4) A provider may appeal a department
decision regarding the application of this administrative regulation in
accordance with
907
KAR 1:671.
Section 12. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "MAP-95 Request for Equipment
Form", Department for Medicaid Services, September 2002 Edition;
(b) "North Carolina Support Needs Assessment
Profile (NC-SNAP)", 2000 Edition, copyright Murdoch Center Foundation;
and
(c) "NC-SNAP Instructor's
Manual", copyright 1999, Murdoch Center Foundation.
(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.