907 KAR 1:190 - Payments for freestanding birth center services
RELATES TO: KRS 205.520
NECESSITY, FUNCTION, AND CONFORMITY: 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 establishes the Department for Medicaid Services' reimbursement provisions and requirements for freestanding birth center services provided to Medicaid recipients who are not enrolled with a managed care organization.
Section 1. Definitions.
(1) "Advanced practice registered nurse" is
defined by
KRS
314.011(7).
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "Enrollee" means a recipient who is
enrolled with a managed care organization.
(4) "Freestanding birth center" means a:
(a) Freestanding birth center as defined by
42
U.S.C. 1396d(l)(3)(B);
and
(b) Facility that is:
1. Licensed as an alternative birth center in
accordance with
902 KAR
20:150; and
2. Accredited by the Commission for the
Accreditation of Birth Centers.
(5) "Freestanding birth center services" is
defined by
42
U.S.C. 1396d(28) and
42
U.S.C.
1396d(l)(3)(A).
(6) "Managed care organization" means an
entity for which the Department for Medicaid Services has contracted to serve
as a managed care organization as defined in
42
C.F.R. 438.2.
(7) "Participating freestanding birth center"
means a freestanding birth center that is:
(a)
Currently enrolled in the Medicaid program pursuant to
907
KAR 1:672;
(b) Currently participating in the Medicaid
program pursuant to
907
KAR 1:671;
(c) Licensed in accordance with
902 KAR
20:150; and
(d) Authorized to provide the service in
accordance with
907 KAR
1:180.
(8) "Provider" is defined by
KRS
205.8451(7).
(9) "Recipient" is defined by
KRS
205.8451(9).
(10) "Registered nurse" is defined by
KRS
314.011(5).
(11) "Rendering provider" means a provider
who:
(a) Provides a service for which
reimbursement is:
1. Made to the provider;
and
2. Not made to a freestanding
birth center; and
(b) Is:
1. A physician who provides a service
associated with a freestanding birth center;
2. A physician assistant who provides a
service associated with a freestanding birth center;
3. An advanced practice registered nurse who
provides a service associated with a freestanding birth center; or
4. A registered nurse who provides a service
associated with a freestanding birth center.
Section 2. General Requirements.
For the department to reimburse for a freestanding birth center service, the
service shall meet the requirements established in
907 KAR
1:180, Section 2.
Section 3. Reimbursement.
(1)
(a) The
department shall reimburse a professional fee to a rendering provider for a
prenatal visit, a standby service, or a postnatal visit at the lesser of:
1. The rendering provider's usual and
customary charge for the service;
2. The reimbursement for the service pursuant
to
907 KAR
3:010 if the rendering provider is a physician;
or
3. Seventy-five (75) percent of
the reimbursement for the service pursuant to
907 KAR
3:010 if the rendering provider is:
a. An advanced practice registered
nurse;
b. A physician assistant;
or
c. A registered
nurse.
(b) The
department shall:
1. Reimburse for no more
than two (2) postnatal visits per recipient; and
2. Not reimburse for a postnatal visit that
occurs after six (6) weeks have lapsed since the delivery.
(c) The department's reimbursement of a
professional fee to a rendering provider referenced in this subsection shall be
separate from and in addition to the reimbursement referenced in subsection (2)
of this section.
(2)
(a) The department shall reimburse a
freestanding birth center:
1. Twenty-five (25)
dollars for referring a recipient to an inpatient hospital for delivery
services if the freestanding birth center determined before providing
delivery-related services that the recipient's delivery was complicated and
needed to be handled in an inpatient hospital;
2. $156 for:
a. Providing delivery-related services to a
recipient; and
b. Determining, after
providing delivery-related services to a recipient, that the recipient's
delivery was complicated and needed to be handled in an inpatient hospital;
or
3. $1,557 for services
related to a complete delivery that occurred at the freestanding birth
center.
(b) The
department's reimbursement to a freestanding birth center referenced in this
subsection shall be separate from and in addition to the reimbursement
referenced in subsection (1) of this section.
(3)
(a) The
department's reimbursement shall be considered payment in full for all
services, supplies, and devices provided to a recipient.
(b)
1. A
freestanding birth center shall not bill a recipient or party other than the
department for a service provided to the recipient if the service was covered
by the department.
2. A rendering
provider shall not bill a recipient or party other than the department for a
service provided to the recipient if the service was covered by the
department.
(4)
(a) A managed care organization's
reimbursement shall be considered payment in full for all services, supplies,
and devices provided to an enrollee.
(b)
1. A
freestanding birth center shall not bill an enrollee or party other than the
enrollee's managed care organization for a service provided to the enrollee if
the service was covered by the managed care organization.
2. A rendering provider shall not bill an
enrollee or party other than the managed care organization for a service
provided to the enrollee if the service was covered by the managed care
organization.
Section 4. Not Applicable to Managed Care
Organizations.
(1) A managed care organization
may elect to reimburse in accordance with this administrative regulation for a
service or item covered pursuant to
907 KAR
1:180 and this administrative regulation.
(2) A managed care organization shall not be
required to reimburse the same amount as established in this administrative
regulation for a service or item covered pursuant to
907 KAR
1:180 and this administrative
regulation.
Section 5.
Federal Financial Participation. A provision or requirement established in this
administrative regulation shall be null and void if the Centers for Medicare
and Medicaid Services:
(1) Denies federal
financial participation for the provision or requirement; or
(2) Disapproves the provision or
requirement.
Notes
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