RELATES TO:
KRS
314.011,
42 C.F.R.
440.70,
440.185,
42 U.S.C.
1396,
42 U.S.C.
1396n(c)
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, to qualify for federal Medicaid funds.
This administrative regulation establishes the service coverage and
reimbursement policies and requirements relating to Model Waiver II services
provided to a Medicaid-eligible recipient. These services are provided pursuant
to a 1915(c) home and community based waiver granted by the U. S. Department
for Health and Human Services in accordance with
42 U.S.C.
1396n(c).
Section 1. Definitions.
(1) "1915(c) home and community based waiver
program" means a Kentucky Medicaid program established pursuant to and in
accordance with 42 U.S.C.
1396n(c).
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "Federal financial participation" is
defined in 42 C.F.R.
400.203.
(4) "Home health agency" means an agency that
is:
(b) Medicare certified; and
(c) Medicaid certified.
(5) "Licensed practical nurse" is defined by
KRS
314.011(9).
(6) "Model Waiver II services" means 1915(c)
home and community based waiver program in-home ventilator services provided to
a Medicaid-eligible recipient who:
(a) Is
dependent on a ventilator; and
(b)
Would otherwise require a nursing facility level of care in a hospital based
nursing facility that will accept a recipient who is dependent on a
ventilator.
(8) "Participant" means a recipient who
qualifies for and is receiving Model Waiver II services in accordance with
Section 2 of this administrative regulation.
(9) "Person-centered service plan" means a
written individualized plan of services.
(10) "Private duty nursing agency" means a
facility licensed to provide private duty nursing services:
(a) By the Cabinet for Health and Family
Services, Office of Inspector General; and
(11) "Recipient" is defined by
KRS
205.8451(9).
(12) "Registered nurse" is defined by
KRS
314.011(5).
(13) "Registered respiratory therapist" is
defined by KRS
314A.010(3)(a).
(14) "Ventilator" means a respiration
stimulating mechanism.
(15)
"Ventilator dependent" means the condition or state of an individual who:
(a) Requires the aid of a ventilator for
respiratory function; and
(b) Meets
the high intensity nursing facility patient status criteria established in
907 KAR 1:022.
Section 2. Participant
Eligibility and Related Policies.
(1)
(a) To be eligible to receive Model Waiver II
services, an individual shall:
2. Require ventilator support for at least
twelve (12) hours per day; and
3.
Meet ventilator dependent patient status requirements established in
907 KAR 1:022.
(b) In addition to the individual
meeting the requirements established in paragraph (a) of this subsection:
1. The individual or a representative on
behalf of the individual shall:
a. Apply for
1915(c) home and community based waiver services via the MWMA;
b. Complete and upload into the MWMA a MAP -
115 Application Intake - Participant Authorization; and
c. Complete and upload into the MWMA a MAP -
116 Service Plan - Participant Authorization prior to or at the time the
person-centered service plan is uploaded into the MWMA; and
2. A registered nurse on behalf of
the individual applying for services shall:
a. Complete and upload into the MWMA:
(i) A MAP 350, Long Term Care Facilities and
Home and Community Based Program Certification Form;
(ii) A person-centered service plan;
and
(iii) A MAP-351A, Medicaid
Waiver Assessment; and
b. Upload a MAP-10, Waiver Services -
Physician's Recommendation, which shall be signed and dated by a
physician.
(c) An individual's eligibility for Model
Waiver II services shall begin upon receiving notification of approval from the
department.
(2) For an
individual to remain eligible for Model Waiver II services:
(a) The individual shall:
1. Maintain Medicaid eligibility requirements
established in
907 KAR 20:010; and
(b) A Model Waiver II level of
care determination confirming that the individual qualifies shall be performed
and submitted to the department every six (6) months; and
(c) A MAP-10, Waiver Services - Physician's
Recommendation shall be:
1. Signed and dated
by a physician every sixty (60) days on behalf of the individual; and
2. Uploaded into the MWMA after being signed
and dated in accordance with subparagraph 1 of this paragraph, every sixty (60)
days.
(3) A
Model Waiver II service shall not be provided to a recipient who is:
(a) Receiving a service in another 1915(c)
home and community based waiver program; or
(b) An inpatient of:
1. A nursing facility;
2. An intermediate care facility for
individuals with an intellectual disability; or
3. Another facility.
(4) The department shall not
authorize a Model Waiver II service unless it has ensured that:
(a) Ventilator dependent status has been met;
and
(b) The service:
1. Is available to the recipient;
2. Will meet the need of the recipient;
and
3. Does not exceed the cost of
traditional institutional ventilator care.
Section 3. Provider Participation
Requirements. To participate in the Model Waiver II program, a:
(1) Home health agency shall:
(a) Be a currently participating Medicaid
provider in accordance with
907 KAR 1:671;
(b) Be currently enrolled as a Medicaid
provider in accordance with
907 KAR 1:672; and
(c) Meet the home and community based waiver
service provider requirements established in:
(2) Private duty
nursing agency shall:
(a) Be a currently
participating Medicaid provider in accordance with
907 KAR 1:671;
(b) Be currently enrolled as a Medicaid
provider in accordance with
907 KAR 1:672; and
(c) Be a licensed private duty nursing agency
in accordance with
902 KAR 20:370.
Section 4. Covered
Services.
(1) The following shall be covered
Model Waiver II services:
(a) Skilled nursing
provided by:
1. A registered nurse;
or
2. A licensed practical nurse;
or
(b) Respiratory
therapy.
(2) Model
Waiver II services shall be provided by an individual employed by or under
contract through a private duty nursing agency or home health agency as a:
(a) Registered nurse;
(b) Licensed practical nurse; or
(c) Registered respiratory
therapist.
Section
5. Payment for Services. The department shall reimburse a
participating home health agency or private duty nursing agency for the
provision of covered Model Waiver II services as established in this section.
(1) Reimbursement shall be based on a fixed
fee for a unit of service provided for each covered service referenced in
Section 4 of this administrative regulation with one (1) hour equal to one (1)
unit of service.
(2) The fixed fee
for skilled nursing services provided by:
(a)
A registered nurse shall be thirty-one (31) dollars and ninety-eight (98) cents
for each unit of service;
(b) A
licensed practical nurse shall be twenty-nine (29) dollars and ten (10) cents
for each unit of service; and
(c) A
registered respiratory therapist shall be twenty-seven (27) dollars and
forty-two (42) cents for each unit of service.
(3) Reimbursement shall not exceed sixteen
(16) units of service per day.
(4)
Payment shall not be made for a service to an individual for whom it can
reasonably be expected that the cost of the 1915(c) home and community based
waiver program service furnished under this administrative regulation would
exceed the cost of the service if provided in a hospital-based nursing
facility.
Section 6.
Maintenance of Records.
(1) A Model Waiver II
service provider shall maintain:
(a) A
clinical record for each participant, which shall contain:
1. Pertinent medical, nursing, and social
history;
2. A person-centered
service plan;
3. A copy of the MAP
350, Long Term Care Facilities and Home and Community Based Program
Certification Form signed by the participant or the participant's legal
representative at the time of application or reapplication and each
recertification thereafter;
4.
Documentation of all level of care determinations;
5. All documentation related to prior
authorizations including requests, approvals, and denials;
6. Documentation that the participant or
legal representative was informed of the procedure for reporting complaints;
and
7. Documentation of each
service provided that shall include:
a. The
date the service was provided;
b.
The duration of the service;
c. The
arrival and departure time of the provider, excluding travel time, if the
service was provided at the participant's home;
d. Progress notes, which shall include
documentation of changes, responses, and treatments utilized to evaluate the
participant's needs; and
e. The
signature of the service provider;
(b) Each MAP-10, Waiver Services -
Physician's Recommendation submitted regarding the participant in accordance
with Section 2 of this administrative regulation; and
(c) Incident reports as required by Section 7
of this administrative regulation if an incident with the participant
occurs.
(2)
(a) Except as provided in paragraph (b) of
this subsection, a clinical record or incident report shall be retained for at
least six (6) years from the date that a covered service is provided.
(b) If the participant is a minor, a clinical
record or incident report shall be retained for three (3) years after the
participant reaches the age of majority under state law, if that is a longer
time period than the time period required by paragraph (a) of this
subsection.
(3) Upon
request, a provider shall make information regarding service and financial
records available to the:
(a)
Department;
(b) Cabinet for Health
and Family Services, Office of Inspector General or its designee;
(c) United States Department for Health and
Human Services or its designee;
(d)
General Accounting Office or its designee;
(e) Office of the Auditor of Public Accounts
or its designee; or
(f) Office of
the Attorney General or its designee.
Section 7. Incident Reporting.
(1)
(a)
There shall be two (2) classes of incidents.
(b) The following shall be the two (2)
classes of incidents:
1. An incident;
or
2. A critical
incident.
(2)
An incident shall be any occurrence that impacts the health, safety, welfare,
or lifestyle choice of a participant and includes:
(a) A minor injury;
(b) A medication error without a serious
outcome; or
(c) A behavior or
situation that is not a critical incident.
(3) A critical incident shall be an alleged,
suspected, or actual occurrence of an incident that:
(a) Can reasonably be expected to result in
harm to a participant; and
(b)
Shall include:
1. Abuse, neglect, or
exploitation;
2. A serious
medication error;
3.
Death;
4. A homicidal or suicidal
ideation;
5. A missing person;
or
6. Other action or event that
the provider determines may result in harm to the participant.
(4)
(a) If an incident occurs, the Model Waiver
II provider shall:
1. Report the incident by
making an entry into the MWMA that includes details regarding the incident;
and
2. Be immediately assessed for
potential abuse, neglect, or exploitation.
(b) If an assessment of an incident indicates
that the potential for abuse, neglect, or exploitation exists:
1. The incident shall immediately be
considered a critical incident;
2.
The critical incident procedures established in subsection (5) of this section
shall be followed; and
3. The Model
Waiver II provider shall report the incident to the participant's registered
nurse and participant's guardian, if the participant has a guardian, within
twenty-four (24) hours of discovery of the incident.
(5) If a critical incident occurs,
the:
(a) Individual who witnessed the critical
incident or discovered the critical incident shall immediately:
1. Act to ensure the health, safety, and
welfare of the at-risk participant; and
2. Report the critical incident by making an
entry in the MWMA portal including details of the incident; and
(b) Model Waiver II provider
shall:
1. Conduct an immediate investigation
and involve the participant's registered nurse in the investigation;
and
2. Prepare a report of the
investigation, which shall be recorded in the MWMA portal and shall include:
a. Identifying information of the participant
involved in the critical incident and the person reporting the critical
incident;
b. Details of the
critical incident; and
c. Relevant
participant information including:
(i) A
listing of recent medical concerns;
(ii) An analysis of causal factors;
and
(iii) Recommendations for
preventing future occurrences.
(6) If a critical incident does
not require reporting of abuse, neglect, or exploitation, the critical incident
shall be reported via the MWMA within eight (8) hours of discovery.
(7) If a death of a participant occurs, a
Model Waiver II provider shall submit to the MWMA mortality data documentation
within fourteen (14) days of the death including:
(a) The participant's person-centered service
plan at the time of death;
(b) Any
current assessment forms regarding the participant;
(c) The participant's medication
administration records from all service sites for the past three (3) months
along with a copy of each prescription;
(d) Progress notes regarding the participant
from all service elements for the past thirty (30) days;
(e) The results of the participant's most
recent physical exam;
(f) All
incident reports, if any exist, regarding the participant for the past six (6)
months;
(g) Any medication error
report, if any exists, related to the participant for the past six (6)
months;
(h) A full life history of
the participant including any update from the last version of the life
history;
(i) Names and contact
information for all staff members who provided direct care to the participant
during the last thirty (30) days of the participant's life;
(j) Emergency medical services notes
regarding the participant if available;
(k) The police report if available;
(l) A copy of:
1. The participant's advance directive,
medical order for scope of treatment, living will, or health care directive if
applicable; and
2. The
cardiopulmonary resuscitation and first aid card for any provider's staff
member who was present at the time of the incident that resulted in the
participant's death;
(m)
A record of all medical appointments or emergency room visits by the
participant within the past twelve (12) months; and
(n) A record of any crisis training for any
staff member present at the time of the incident that resulted in the
participant's death.
(8)
A Model Waiver II provider shall report a medication error by making an entry
into the MWMA.
Section
8. Use of Electronic Signatures. The creation, transmission,
storage, and other use of electronic signatures and documents shall comply with
the requirements established in
KRS
369.101 to
369.120.
Section 9. Federal Financial Participation.
The department's coverage of and reimbursement for Model Waiver II services
pursuant to this administrative regulation shall be contingent upon:
(1) Federal financial participation for the
coverage and reimbursement; and
(2)
Centers for Medicare and Medicaid Services' approval for the coverage and
reimbursement.
Section
10. Appeal Rights.
(1) An appeal
of a negative action regarding a Medicaid recipient shall be appealed in
accordance with
907 KAR 1:563.
(2) An appeal of a negative action regarding
a Medicaid beneficiary's eligibility shall be appealed in accordance with
907 KAR 1:560.
(3) An appeal of a negative action regarding
a Medicaid provider shall be appealed in accordance with
907 KAR 1:671.
Section 11. Incorporation by
Reference.
(1) The following material is
incorporated by reference:
(a) "MAP - 115
Application Intake - Participant Authorization", June 2015;
(b) "MAP 350, Long Term Care Facilities and
Home and Community Based Program Certification Form", June 2015
(c) "MAP-10 Waiver Services - Physician's
Recommendation", June 2015;
(d)
"MAP - 116 Service Plan - Participant Authorization", June 2015; and
(e) MAP-351A, Medicaid Waiver Assessment",
July 2015.
(2) This
material may be inspected, copied, or obtained, subject to applicable copyright
law:
(a) At the Department for Medicaid
Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through
Friday, 8 a.m. to 4:30 p.m.; or