RELATES TO:
KRS
205.8453,
21
C.F.R. 1308.12,
1308.13,
1308.14,
42 C.F.R.
431.54,
433.111(b),
42 U.S.C.
1396(a),
1396(a)(2)
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) 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.
KRS
205.8453(4) and
205.6318(6)
direct the cabinet to promulgate administrative regulations to identify
misutilization of Medicaid services, to institute other measures necessary or
useful in controlling fraud and abuse. This administrative regulation
establishes the Medicaid lock-in provisions relating to recipient
overutilization of the Medicaid Services.
Section
1. Definitions.
(1) "Advanced
practice registered nurse" or "APRN" is defined by
KRS
314.011(7).
(2) "Cabinet" is defined by
KRS
205.010(1).
(3) "Controlled substance" means a drug or
substance identified in
21
C.F.R.
1308.12,
1308.13, or
1308.14.
(4) "Department" means the Department for
Medicaid Services or its designee.
(5) "Emergency medical condition" is defined
by
42
U.S.C.
1395dd(e)(1).
(6) "Emergency service" is defined by
42 C.F.R.
447.53.
(7) "Fraud" is defined by
KRS
205.8451(2).
(8) "Kentucky All Schedule Prescription
Electronic Reporting report" or "KASPER report" means a report displaying
information regarding:
(a) All the scheduled
prescriptions that an individual has had for the time period specified in the
report;
(b) The prescriber for each
prescription written for the individual during the time period specified in the
report; and
(c) The dispenser who
dispensed each prescription written for the individual during the time period
specified in the report.
(9) "Lock-in program" means a department
program which restricts a recipient to receiving Medicaid services from a
designated provider.
(10) "Lock-in
recipient" means a recipient enrolled in the lock-in program.
(11) "Medicaid Management Information System"
means the department's mechanized claims processing and information retrieval
system as defined by, and in accordance with,
42
C.F.R.
433.111(b).
(12) "Nonemergency care" means a service for
a nonemergency condition.
(13)
"Overutilization" means the receipt of a treatment, drug, medical supply, or
other Medicaid service from one (1) or more providers in an amount, duration,
or scope that exceeds the amount that would reasonably be expected to result in
a medical or health benefit to the recipient.
(14) "Physician" is defined by
KRS
311.550(12).
(15) "Physician assistant" or "PA" is defined
by
KRS
311.840(3).
(16) "Prescriber" means a health care
professional who:
(a) Within the scope of
practice under Kentucky licensing laws, has the legal authority to write or
order a prescription for the drug that is ordered;
(b) Is enrolled in the Medicaid Program
pursuant to
907
KAR 1:672; and
(c) Is currently participating in the
Medicaid Program pursuant to
907
KAR 1:671.
(d) Prescribes in accordance with his or her
current registration with the U.S. Department of Justice's Drug Enforcement
Administration.
(17)
"Primary care provider" means an advanced practice registered nurse, a
physician, or physician assistant.
(18) "Provider" is defined by
KRS
205.8451(7).
(19) "Provider abuse" is defined by
KRS
205.8451(8).
(20) "Recipient" is defined by
KRS
205.8451(9).
(21) "Recipient abuse" is defined by
KRS
205.8451(10)
(22) "Utilization review" means a department
review and analysis:
(a) Of Medicaid claims
for a twelve (12) consecutive month period including:
1. A recipient's medical conditions;
and
2. Medicaid services received
by the recipient; and
(b)
To determine if recipient overutilization has occurred.
Section 2. Review of Complaints.
(1)
(a) A
complaint relating to potential fraud, recipient abuse, provider abuse, or
overutilization shall be reported to the department or Cabinet for Health and
Family Services, Office of Inspector General via the Medicaid and Welfare Fraud
and Abuse hotline at 1-800-372-2970.
(b) The department may also review data
available to it to determine if potential fraud, recipient abuse, provider
abuse, or overutilization has occurred regardless of whether or not a complaint
was made regarding a given individual or provider.
(2) The department shall respond to a
complaint or data review referenced in subsection (1) of this section by
conducting a utilization review of the recipient.
(3) A utilization review of a recipient
referenced in subsection (2) of this section shall include a review of claims
using data collected from the Medicaid Management Information System or a
KASPER report to identify if the recipient:
(a) Utilized Medicaid services at a frequency
or amount which meets utilization criteria established in Section 4 of this
administrative regulation; and
(b)
1. Shall be restricted to receiving Medicaid
services from designated providers under the lock-in program.
2. Shall be excluded from the lock-in program
if the recipient:
b. Is under the age of eighteen (18)
years;
d. Utilized Medicaid services at a frequency
or amount which was medically necessary to treat a complex, life threatening
medical condition as determined by the department.
Section 3.
General Exemption. If the department determines that not enrolling a recipient
in the lock-in program is in the best interest of the recipient, the department
shall not enroll the recipient in the lock-in program.
Section 4. Lock-in Criteria.
(1) Except as established in Section 2(3)(b)2
and Section 3 of this administrative regulation, the department shall initiate
the lock-in process, as established in Section 5 of this administrative
regulation, for a recipient if in two (2) consecutive 180 calendar day periods,
the recipient:
(a)
1. Received services from at least five (5)
different providers;
2. Received at
least ten (10) different prescription drugs; and
3. Received prescriptions from at least three
(3) or more different pharmacies; or
(b)
1. Had
at least four (4) hospital emergency department visits for a condition that was
not an emergency medical condition; or
2. Received services from at least three (3)
different hospital emergency departments for a condition that was not an
emergency medical condition.
(2) A recipient shall be locked in to:
(a) One (1) primary care provider, one (1)
controlled substance prescriber, and one (1) pharmacy if the recipient meets
the criteria established in subsection (1)(a) of this section; or
(b) One (1) designated hospital for
nonemergency care, except for a screening to determine if an emergency medical
condition exists pursuant to
907
KAR 10:014, if the recipient meets the criteria
established in subsection (1)(b) of this section.
Section 5. Lock-in Process.
(1) Upon identification of a recipient who
shall be enrolled in the lock-in program in accordance with Section 2(3) of
this administrative regulation, the department shall:
(a) Send a written notification in accordance
with subsection (2) of this section; and
(b) Enroll the recipient in accordance with
subsection (3) of this section.
(2) The written notification sent to the
recipient shall include:
(a) The reason for
enrolling the recipient in the lock-in program;
(b) A description of the lock-in
program;
(c) The effective date of
lock-in program enrollment;
(d)
Identification of the recipient's designated providers as established in
subsection (2)(a) of this section;
(e) Information relating to the recipient's
right to a hearing as established in Section 9 of this administrative
regulation; and
(f) Contact
information of an individual who may be contacted in writing or by telephone
for information relating to the lock-in program.
(3) Except for a recipient who requests a
hearing relating to a department lock-in determination, the department shall
enroll the recipient in the lock-in program within thirty (30) days of sending
the written notification referenced in subsection (2) of this section.
(a) Once enrolled, the lock-in recipient
shall be restricted to receiving Medicaid services from designated providers
including:
1. One (1) primary care provider
who:
a. Shall be accessible to the recipient
within normal time and distance standards for the community in which the
recipient resides;
b. If the
lock-in recipient has a designated hospital, has admitting privileges to the
designated hospital;
c. Shall
provide services and manage the lock-in recipient's necessary health care
services;
d. If the lock-in
recipient needs a Medicaid-covered service other than the service of the
designated primary care provider, shall complete and forward a Lock-in
Recipient Referral to a referred provider;
e. Shall participate in the recipient's
periodic utilization review as identified in paragraph (c) of this subsection;
and
f. If the designated primary
care provider is a physician, may serve as the lock-in recipient's designated
controlled substance prescriber;
2. One (1) controlled substance prescriber
who shall serve as the sole prescriber and manager of controlled substances for
the lock-in recipient;
3. One (1)
pharmacy; and
4. If the recipient
meets the criteria established in Section 4(2)(b) of this administrative
regulation, one (1) hospital.
(b) The restrictions identified in paragraph
(a) of this subsection shall be maintained for at least twenty-four (24)
months.
(c) Following the initial
twenty-four (24) month period of lock-in enrollment as established in paragraph
(b) of this subsection, the department shall conduct a utilization review at
twelve (12) month intervals to:
1. Measure the
effectiveness of the recipient's enrollment in the lock-in program;
and
2. Determine if the recipient
shall:
a. Continue enrollment in the lock-in
program if the recipient continues to meet the criteria established in Section
4(1) of this administrative regulation; or
b. Be discharged from the lock-in program if
the recipient does not meet the criteria established in Section 4(1) of this
administrative regulation.
(d) The department shall provide the lock-in
recipient with a written notification, which shall include:
1. Findings of a utilization review as
identified in paragraph (c) of this subsection; and
2. A decision to maintain enrollment in or
discharge the recipient from the lock-in program.
Section 6. Designated
Providers.
(1) A designated provider as
identified in Section 5(2)(a) of this administrative regulation shall be the
designated provider of a lock-in recipient for at least twenty-four (24) months
except if:
(a) the designated provider submits
to the department a written request for a release from serving as the
recipient's designated provider. The provider shall continue to serve as the
recipient's designated provider until a comparable designated provider is
selected;
(b) The recipient
relocates outside of the designated provider's geographic area;
(c) The recipient submits a written request
to the department which:
1. Requests a
designated provider change; and
2.
Includes information to support cause or a necessary reason for the change,
including the recipient:
a. Was denied access
to a needed medical service;
b.
Received poor quality of care; or
c. Does not have access to a provider
qualified to treat the recipient's health care needs;
(d) The designated provider
withdraws or is terminated from participation in the Medicaid Program;
or
(e) The department determines
that it is in the best interest of the lock-in recipient to change the
designated provider.
(2)
A designated provider for a recipient shall:
(a) Be chosen by the department;
and
(b) Not be chosen by the
recipient.
(3) A
recipient shall not have more than one (1) change in a designated primary care
provider within a twenty-four (24) month period except as allowed in subsection
(1) of this section.
Section
7. Fees, Payments, and Nonpayments.
(1) On behalf of a lock-in recipient, the
department shall pay:
(a) At the beginning of
each month:
1. A fee of ten (10) dollars to a
designated primary care provider for the management of a lock-in recipient's
necessary health care; or
2. A fee
of five (5) dollars to a designated controlled substance prescriber, unless the
designated controlled substance prescriber is also the recipient's designated
primary care provider. If a designated controlled substance prescriber is also
the recipient's designated primary care provider, the department shall pay a
fee of ten (10) dollars in aggregate for being the recipient's designated
primary care provider; and
(b) For:
1.
A medical screening examination performed in the emergency department of a
hospital to determine if an emergency medical condition exists in accordance
with
907
KAR 10:014; and
2. An emergency
service.
(2) In
addition to the fee established in subsection (1)(a)1. of this section, the
department shall pay for necessary services provided to the recipient by the
recipient's designated primary care provider.
(3) Except for a service as established in
subsection (1)(b) of this section, the department shall not pay for a service
rendered by a provider other than the recipient's designated primary care
provider unless the designated primary care provider:
(a) Refers the recipient to the referred
provider for a necessary service; and
(b) Completes and forwards a copy of the
Lock-in Recipient Referral to the referred provider of the service.
Section 8. Lock-in
Recipient Requirements. A lock-in recipient:
(1) Shall be restricted to receiving
necessary nonemergency services from a designated provider as identified in
Section 5(3)(a) of this administrative regulation except for services rendered
by a referred provider in accordance with Section 7(3) of this administrative
regulation;
(2) Shall be
responsible for the payment of the charges for a service rendered by a provider
who:
(a) Is not the recipient's designated
primary care provider;
(b) Does not
have a Lock-in Recipient Referral from the recipient's designated primary care
provider; and
(c) Informs the
lock-in recipient that the recipient shall be responsible for the costs of the
provider's services before the service is rendered; and
(3) May request a change of a designated
provider in accordance with Section 6(1)(c) of this administrative regulation:
(a) Within ninety (90) days of the date of
the recipient notification letter as identified in Section 5(1) of this
administrative regulation; or
(b)
At least once in a twenty-four (24) month period following initial enrollment
in the lock-in program.
Section 9. Appeal Rights.
(1) A recipient who is notified of a
department decision to enroll or maintain enrollment of the recipient in the
lock-in program shall have the right to request a hearing in accordance with
this section.
(2) The subject of
the hearing shall be limited to whether or not the department had sufficient
evidence to support the department's decision.
(3) A request for a hearing shall be:
(a) In writing;
(b) Mailed to the department, to the
attention of the commissioner; and
(c) Received by the department within thirty
(30) calendar days from the date that the notice referenced in subsection (1)
of this section was received by the recipient.
(4) A copy of the request for a hearing shall
be mailed to and received by the department's Division of Program Integrity
within thirty (30) calendar days from the date that the notice referenced in
subsection (1) of this section was received by the recipient.
(5) If a request for a hearing which meets
the criteria established in subsection (3) of this section is:
(a) Received by the department within ten
(10) calendar days from the date that the recipient received a notice
referenced in subsection (1) of this section, the lock-in action shall be
delayed until a fair hearing has occurred; or
(b) Not received by the department within ten
(10) calendar days from the date that the recipient received a notice
referenced in subsection (1) of this section, the lock-in action shall not be
delayed.
(6) A fair
hearing shall be held in accordance with
907
KAR 1:563, Sections 6 through 15.
Section 10. Fraud and Abuse Referral. If
fraud, provider abuse, or recipient abuse is identified in the course of a
department utilization review for lock-in purposes, the department shall comply
with
KRS
205.8453(3).
Section 11. Incorporation by Reference.
(1) The "Lock-in Recipient Referral",
November 2010 edition, is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, 275 East Main Street, 6C-C, Frankfort, Kentucky 40601,
Monday through Friday, 8 a.m. to 4:30 p.m.