RELATES TO:
KRS
205.520,
42 C.F.R.
447.53
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services has responsibility to administer the Medicaid Program.
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 to qualify for federal
Medicaid funds. This administrative regulation establishes provisions related
to Medicaid Program coverage of organ transplants for Medicaid recipients and
related to Department for Medicaid Services' reimbursement regarding organ
transplants provided to Medicaid recipients who are not enrolled with a managed
care organization.
Section 1.
Definitions.
(1) "Department" means the
Department for Medicaid Services or its designee.
(2) "Emergency" means that a condition or
situation requires an emergency service pursuant to
42 C.F.R.
438.114(a).
(3) "Enrollee" means a recipient who is
enrolled with a managed care organization.
(4) "Experimental" means that a procedure has
not previously been proven effective by the U.S. Food and Drug Administration
in treating a patient's health condition.
(5) "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.
(6) "Medical necessity" or "medically
necessary" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(7) "Nonemergency" means that a condition or
situation does not require an emergency service pursuant to
42 C.F.R.
438.114(a).
(8) "Recipient" is defined by
KRS
205.8451(9).
Section 2. Prior Authorization.
(1) Prior to coverage of an organ transplant
to a recipient who is not an enrollee, the transplant shall have been
determined by the department to be:
(a)
Medically necessary; and
(b)
Clinically appropriate pursuant to the criteria established in
907
KAR 3:130.
(2) The requirements established in
subsection (1) of this section shall not apply to an emergency
service.
Section 3.
General Coverage Criteria. A covered organ transplant shall meet the criteria
established in this section.
(1) A transplant
surgeon's opinion shall conclude that failure to perform the transplant would
create a life-threatening situation.
(2) The patient's prognosis shall indicate
that there is a reasonable expectation the transplant will be successful and
result in prolonged life of quality and dignity.
(3) The hospital where the transplant will
take place shall:
(a) Have a staffed and
functioning unit designed for and accustomed to performing the planned organ
transplant;
(b) Be accredited by
the Joint Commission on Accreditation of Healthcare Organizations;
and
(c) Be in good standing:
1. If it is an in-state hospital, with the
Cabinet for Health and Family Services; or
2. If it is an out-of-state hospital, with
that state's licensure authority.
(4) The physician performing the transplant
shall be recognized as competent by the medical community.
Section 4. Reimbursement for Organ
Transplants. For an organ transplant provided by a:
(1) Hospital to a recipient who is not an
enrollee, the department shall reimburse as established in:
(2) Physician to a recipient who
is not an enrollee, the department shall reimburse in accordance with
907 KAR
3:010.
Section 5. Noncovered Services. The
department shall not approve a request for an organ transplant if the requested
transplant:
(1) Fails to meet the criteria of
Sections 2 or 3 of this administrative regulation; or
(2) Is experimental in nature.
Section 6. Not Applicable to
Managed Care Organizations. A managed care organization shall not be required
to reimburse for an organ transplant according to this administrative
regulation.