RELATES TO:
KRS
205.520,
42 U.S.C.
1396a(a)(10)(B),
1396a(a)(23),
1396a(a)(30)(A)
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has a 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 by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the reimbursement
provisions and requirements regarding Medicaid Program behavioral health
services provided by individual approved behavioral health practitioners who
are independently enrolled in the Medicaid Program, practitioners working for
or under the supervision of the individual approved behavioral health
practitioners, and approved behavioral health practitioners under supervision
working in behavioral health provider groups or in behavioral health
multi-specialty groups, to Medicaid recipients who are not enrolled with a
managed care organization.
Section 1.
General Requirements. For the department to reimburse for a service covered
under this administrative regulation, the service shall be:
(2) Billed to the department by an individual
approved behavioral health practitioner, behavioral health provider group, or
behavioral health multi-specialty group recognized as a Medi-caid Program
provider in accordance with
907
KAR 15:010.
Section 2. Reimbursement.
(1) One (1) unit of service shall be:
(a) Fifteen (15) minutes in length unless a
different unit of service exists for the service in the corresponding:
1. Current procedural terminology code;
or
2. Healthcare common procedure
coding system code; or
(b) The unit amount identified in the
corresponding:
1. Current procedural
terminology code if an amount is identified in the current procedural
terminology code; or
2. Healthcare
common procedure coding system code if an amount is identified in the
healthcare common procedure coding system code.
(2) Except as provided by subsection (3) of
this section, the rate per unit for a covered service shall be:
(a) Seventy-five (75) percent of the rate on
the Kentucky-specific Medicare Physician Fee Schedule for the service if
provided by a:
1. Physician; or
2. Psychiatrist;
(b) 63.75 percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by:
1. An advanced practice registered
nurse;
2. A licensed psychologist;
or
3. A physician
assistant;
(c) Sixty
(60) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Licensed professional clinical counselor;
2. Licensed clinical social worker;
3. Licensed psychological
practitioner;
4. Certified
psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist;
7. Licensed behavior
analyst; or
8. Licensed clinical
alcohol and drug counselor;
(d) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a:
1. Marriage and
family therapy associate;
2.
Licensed professional counselor associate;
3. Licensed psychological
associate;
4. Certified social
worker;
5. Licensed professional
art therapist associate;
6.
Licensed assistant behavior analyst;
7. Certified psychologist; or
8. Licensed clinical alcohol and drug
counselor associate; or
(e) Thirty-seven and five-tenths (37.5)
percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule
for the service if provided by a certified alcohol and drug
counselor.
(3)
Reimbursement shall be as established on the Kentucky Medicaid Behavioral
Health and Substance Abuse Services Outpatient (Non-facility) Fee Schedule and
this administrative regulation for those services that are eligible to be
provided by each individual approved behavioral health practitioner, behavioral
health provider group, or behavioral health multi-specialty group as
established pursuant to
907
KAR 15:010.
(4)
(a) The
department shall use the current version of the Kentucky-specific Medicare
Physician Fee Schedule for reimbursement purposes.
(b) For example, if the Kentucky-specific
Medicare Physician Fee Schedule currently published and used by the Centers for
Medicare and Medicaid Services for the Medicare Program is:
1. An interim version, the department shall
use the interim version until the final version has been published;
or
2. The final version, the
department shall use the final version.
(5) The department shall not reimburse for a
service billed by or on behalf of an entity or individual that is not a billing
provider.
Section 3. Not
Applicable to Managed Care Organizations. A managed care organization shall not
be required to reimburse in accordance with this administrative regulation for
a service covered pursuant to:
(2) This administrative regulation.
Section 4. Federal Approval and
Federal Financial Participation. The department's reimbursement for services
pursuant to this administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the reimbursement; and
(2) Centers for Medicare and Medicaid
Services' approval for the reimbursement.
Section 5. Incorporation by Reference.
(1) "Kentucky Medicaid Behavioral Health and
Substance Abuse Services Outpatient (Non-Facility) Fee Schedule", July 2019, is
incorporated by reference.
(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, 8:00 a.m. to 4:30 p.m.; or
