RELATES TO: 42 C.F.R. 441 Subparts B, G,
42 U.S.C.
1396a,
1396b,
1396d,
1396n
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 Medicaid Program
reimbursement provisions and requirements regarding home and community based
waiver services version 1.
Section 1.
Definitions.
(1) "ADHC" means adult day
health care.
(2) "ADHC center"
means an adult day health care center that is:
(b) Certified for Medicaid participation by
the department.
(3)
"Cost report" means the Home Health and Home and Community Based Cost Report
and the Home Health and Home and Community Based Cost Report
Instructions.
(4) "DD" means
developmentally disabled.
(5)
"Department" means the Department for Medicaid Services or its
designee.
(6) "Fixed upper payment
limit" means the maximum amount the department shall reimburse for a unit of
service.
(7) "HCB" means home and
community based waiver.
(8) "Level
I reimbursement" means a reimbursement rate paid to an ADHC center for a basic
unit of service provided by the ADHC center to a participant.
(9) "Level II reimbursement" means a
reimbursement rate paid to an ADHC center for a basic unit of service provided
by the ADHC center to a participant, if the ADHC center meets the criteria
established in Sections 5 and 6 of this administrative regulation.
(10) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(11) "Occupational therapist" is defined by
KRS
319A.010(3).
(12) "Occupational therapy assistant" is
defined by KRS
319A.010(4).
(13) "Participant" means a recipient who
meets the:
(a) Nursing facility level of care
criteria established in
907 KAR 1:022; and
(b) Eligibility criteria for HCB services
established in
907 KAR 1:160, Section
4.
(14) "Physical
therapist" is defined by
KRS
327.010(2).
(15) "Physical therapist assistant" means a
skilled health care worker who:
(a) Is
certified by the Kentucky Board of Physical Therapy; and
(b) Performs physical therapy and related
duties as assigned by the supervising physical therapist.
(16) "Quality improvement organization" or
"QIO" is defined in 42
C.F.R.
475.101.
(17) "Speech-language pathologist" is defined
by KRS
334A.020(3).
Section 2. HCB Service
Reimbursement.
(1)
(a) Except as provided in Section 3, 4, or 5
of this administrative regulation, the department shall reimburse for a home
and community based waiver service provided in accordance with
907 KAR 1:160 at the lesser of;
1. Billed charges; or
2. The fixed upper payment limit for each
unit of service.
(b) The
unit amounts, fixed upper payment limits, and other limits established in the
following table shall apply:
Home and Community Based Waiver Service
|
Fixed Upper Payment Limit
|
Unit of Service
|
Assessment
|
$100.00
|
Entire assessment process
|
Reassessment
|
$100.00
|
Entire reassessment process
|
Case Management
|
$15.00
|
15 minutes
|
Home-making
|
$13.00
|
30 minutes
|
Personal Care
|
$15.00
|
30 minutes
|
Attendant Care
|
$11.50
|
1 hour (not to exceed 45 hours per week)
|
Respite
|
$2,000 per 6 months (January 1 through June 30 and
July 1 through December 31, not to exceed $4,000 per calendar year)
|
1 hour
|
Minor Home Adaptation
|
$500 per calendar year
|
|
(2) A service listed in subsection (1) of
this section shall not be subject to cost settlement by the department unless
provided by a local health department.
(3) A homemaking service shall be limited to
no more than four (4) units per week per participant.
Section 3. Local Health Department HCB
Service Reimbursement.
(1) The department
shall reimburse a local health department for HCB services:
(a) Pursuant to Section 2 of this
administrative regulation; and
(b)
Equivalent to the local health department's HCB services cost for a fiscal
year.
(2) A local health
department shall submit a cost report to the department at fiscal year's
end.
(3) The department shall
determine, based on a local health department's most recently submitted annual
cost report, the local health department's estimated costs of providing HCB
services by multiplying the cost per unit by the number of units provided
during the period.
(4) If a local
health department's HCB service reimbursement for a fiscal year is less than
its cost, the department shall make supplemental payment to the local health
department equal to the difference between:
(a) Payments received for HCB services
provided during a fiscal year; and
(b) The estimated cost of providing HCB
services during the same time period.
(5) If a local health department's HCB
service cost as estimated from its most recently submitted annual cost report
is less than the payments received pursuant to Section 2 of this administrative
regulation, the department shall recoup any excess payments.
(6) The department shall audit a local health
department's cost report if it determines an audit is necessary.
Section 4. Reimbursement for an
ADHC Service.
(1) Reimbursement for an ADHC
service shall:
(a) Be made:
1. Directly to an ADHC center; and
2. For a service only if the service was
provided on site and during an ADHC center's posted hours of
operation;
(b) If made
to an ADHC center for a service not provided during the center's posted hours
of operation, be recouped by the department; and
(c) Be limited to 120 units per calendar week
at each participant's initial review or recertification.
(2) Level I reimbursement shall be the lesser
of;
(a) The provider's usual and customary
charges; or
(b) Two (2) dollars and
fifty-seven (57) cents per unit of service.
(3) Level II reimbursement shall be the
lesser of:
(a) The provider's usual and
customary charges; or
(b) Three (3)
dollars and twelve (12) cents per unit of service.
(4) The department shall not reimburse an
ADHC center for more than twenty-four (24) basic units of service per day per
participant.
(5) An ADHC basic
daily service shall:
(a) Constitute care for
one (1) participant; and
(b) Not
exceed twenty-four (24) units per day.
(6) One (1) unit of ADHC basic daily service
shall equal fifteen (15) minutes.
(7) An ADHC center may request a Level II
reimbursement rate for a participant if the ADHC center meets the following
criteria:
(a) The ADHC center has an average
daily census limited to individuals designated as:
1. Participants;
2. Private pay; or
3. Covered by insurance; and
(b) The ADHC center meets the
requirements established in Section 5(2) of this administrative
regulation.
(8) If an
ADHC center does not meet the Level II reimbursement requirements established
in Section 5 of this administrative regulation, the ADHC center shall be
reimbursed at a Level I reimbursement rate for the quarter for which the ADHC
center requested Level II reimbursement.
(9) To qualify for Level II reimbursement, an
ADHC center that was not a Medicaid provider before July 1, 2000 shall:
(a) Have an average daily census of at least
twenty (20) individuals who meet the criteria established in subsection (7)(a)
of this section; and
(b) Have a
minimum of eighty (80) percent of its individuals meet the description of DD as
established in Section 5(2) of this administrative regulation.
(10) To qualify for reimbursement
as an ancillary therapy, a service shall be:
(a) Medically necessary;
(b) Ordered by a physician, a physician
assistant, or an advanced practice registered nurse; and
(c) Limited to:
1. Physical therapy provided by a physical
therapist or physical therapist assistant;
2. Occupational therapy provided by an
occupational therapist or occupational therapy assistant; or
3. Speech therapy provided by a
speech-language pathologist.
(11) Ancillary therapy service reimbursement
shall be:
(a) Per participant per encounter;
and
(b) The usual and customary
charges not to exceed the Medicaid upper limit of seventy-five (75) dollars per
encounter per participant.
(12) A respite service shall:
(a) Be provided on site in an ADHC center;
and
(13) One (1) respite service unit
shall equal one (1) hour to one (1) hour and fifty-nine (59) minutes.
(14) The length of time a participant
receives a respite service shall be documented.
(15) A covered respite service shall be
reimbursed as established in Section 2 of this administrative
regulation.
Section 5.
Criteria for DD ADHC Level II Reimbursement. To qualify for DD ADHC Level II
reimbursement:
(1) An ADHC center shall meet
the requirements established in Section 4 of this administrative regulation;
and
(2) Eighty (80) percent of its
ADHC service individuals shall have:
(a) A
substantial disability that shall have manifested itself before the individual
reaches twenty-two (22) years of age;
(b) A disability that is attributable to an
intellectual disability or a related condition, which shall include:
1. Cerebral palsy;
2. Epilepsy;
3. Autism; or
4. A neurological condition that results in
impairment of general intellectual functioning or adaptive behavior, such as an
intellectual disability, which significantly limits the individual in two (2)
or more of the following skill areas:
a.
Communication;
b.
Self-care;
c.
Home-living;
d. Social
skills;
e. Community use;
f. Self direction;
g. Health and safety;
h. Functional academics;
i. Leisure; or
j. Work; and
(c) An adaptive behavior limitation similar
to that of a person with an intellectual disability, including:
1. A limitation that directly results from or
is significantly influenced by substantial cognitive deficits; and
2. A limitation that is not attributable to
only a physical or sensory impairment or mental illness.
Section 6. The
Assessment Process for ADHC Level II Reimbursement.
(1)
(a) To
apply for Level II reimbursement, an ADHC center shall contact the QIO on the
first of the third month of the current calendar quarter.
(b) If the first of the month is on a weekend
or holiday, the ADHC center shall contact the QIO the next business
day.
(2) The QIO shall
be responsible for randomly determining the date each quarter for conducting a
Level II reimbursement assessment of an ADHC center.
(3) In order for an ADHC center to receive
Level II reimbursement:
(a) The ADHC center
shall:
1. Document on a MAP-1021, ADHC Payment
Determination Form that it meets the Level II reimbursement criteria
established in Section 5 of this administrative regulation;
2. Submit the completed MAP-1021, ADHC
Payment Determination Form to the QIO via facsimile or mail no later than ten
(10) working days prior to the end of the current calendar quarter in order to
be approved for Level II reimbursement for the following calendar quarter;
and
3. Attach to the MAP-1021, ADHC
Payment Determination Form a completed and signed copy of the Adult Day Health
Care Attending Physician Statement for each individual listed on the MAP-1021,
ADHC Payment Determination Form;
(b) The QIO shall review the MAP-1021, ADHC
Payment Determination Form submitted by the ADHC center and determine if the
ADHC center qualifies for Level II reimbursement; and
(c) The department shall review a sample of
the ADHC center's Level II assessments and validate the QIO's
determination.
(4) If
the department invalidates an ADHC center Level II reimbursement assessment,
the department shall:
(a) Reduce the ADHC
center's current rate to the Level I rate; and
(b) Recoup any overpayment made to the ADHC
center.
(5) If an ADHC
center disagrees with an invalidation of a Level II reimbursement
determination, the ADHC center may appeal in accordance with
907 KAR 1:671, Sections 8 and
9.
Section 7.
Applicability and Transition to Version 2.
(1) The provisions and requirements
established in this administrative regulation shall:
(a) Apply to HCB waiver services provided to
a participant pursuant to
907 KAR 1:160; and
(b) Not apply to individuals receiving HCB
waiver services version 2 pursuant to
907 KAR 7:010.
(2)
(a) The provisions and requirements
established in this administrative regulation shall become null and void at the
time that the next level-of-care determination has been performed regarding
each participant currently receiving services via this administrative
regulation.
(b) Next level-of-care
determinations shall occur in accordance with
907 KAR 7:010, Section
4(2).
Section
8. Appeal Rights. An HCB service provider may appeal a department
decision as to the application of this administrative regulation as it impacts
the provider's reimbursement in accordance with
907 KAR 1:671, Sections 8 and
9.
Section 9. Incorporation by
Reference.
(1) The following material is
incorporated by reference:
(a) "Map-1021, ADHC
Payment Determination Form", August 2000;
(b) "Adult Day Health Care Attending
Physician Statement", August 2000;
(c) "The Home Health and Home and Community
Based Cost Report", November 2007; and
(d) "The Home Health and Home and Community
Based Cost Report Instructions", November 2007.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at:
(a) The Department for Medicaid Services, 275
East Main Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to
4:30 p.m.; or