907 KAR 15:025 - Reimbursement provisions and requirements regarding behavioral health services provided by behavioral health service organizations

RELATES TO: KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 42 U.S.C. 1396a(a)(23), 18022(b)(1)(E)

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 behavioral health services organizations 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:

(1) Meet the requirements established in 907 KAR 15:020 or 907 KAR 15:022; and

(2) Be covered in accordance with 907 KAR 15:020 or 907 KAR 15:022.

Section 2. Reimbursement.

(1) One (1) unit of service shall be:

(a) Fifteen (15) minutes in length; or

(b) The unit amount identified in the corresponding:

1. Current procedural terminology code; or

2. Healthcare common procedure coding system code.

(2) The rates for covered services established pursuant to 907 KAR 15:020 and provided within a BHSO I 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. Licensed marriage and family therapist;

5. Licensed professional art therapist;

6. Certified psychologist with autonomous functioning; or

7. Licensed behavior analyst; or

(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 working under the supervision of a billing supervisor;

2. Licensed professional counselor associate working under the supervision of a billing supervisor;

3. Licensed psychological associate working under the supervision of a billing supervisor;

4. Certified social worker working under the supervision of a billing supervisor;

5. Certified psychologist; or

6. Licensed professional art therapist associate working under the supervision of a billing supervisor.

(3) The rates for covered services established pursuant to 907 KAR 15:022 and provided within a BHSO II 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. Licensed marriage and family therapist;

5. Licensed professional art therapist;

6. Certified psychologist with autonomous functioning; or

7. 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 working under the supervision of a billing supervisor;

2. Licensed professional counselor associate working under the supervision of a billing supervisor;

3. Licensed psychological associate working under the supervision of a billing supervisor;

4. Certified social worker working under the supervision of a billing supervisor;

5. Certified psychologist;

6. Licensed professional art therapist associate working under the supervision of a billing supervisor; or

7. 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.

(4) The rates for covered services established pursuant to 907 KAR 15:022 and provided within a BHSO III 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. Licensed marriage and family therapist;

5. Licensed professional art therapist;

6. Certified psychologist with autonomous functioning; or

7. 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 working under the supervision of a billing supervisor;

2. Licensed professional counselor associate working under the supervision of a billing supervisor;

3. Licensed psychological associate working under the supervision of a billing supervisor;

4. Certified social worker working under the supervision of a billing supervisor;

5. Certified psychologist;

6. Licensed professional art therapist associate working under the supervision of a billing supervisor; or

7. 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.

(5)

(a) Reimbursement for services provided by a BHSO I 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 within a BHSO I as established pursuant to 907 KAR 15:020.

(b) Reimbursement for services provided by a BHSO II 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 within a BHSO II as established pursuant to 907 KAR 15:022.

(c) Reimbursement for services provided by a BHSO III shall be as established on the Kentucky Medicaid Behavioral Health and Substance Abuse Services Facility Fee Schedule and this administrative regulation for those services that are eligible to be provided within a BHSO III as established pursuant to 907 KAR 15:022.

(6)

(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. A final version, the department shall use the final version.

(7) 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. No Duplication of Service.

(1) The department shall not reimburse for a service provided to a recipient by more than one (1) provider of any program in which the service is covered during the same time period.

(2) For example, if a recipient is receiving a behavioral health service from an independent behavioral health provider, the department shall not reimburse for the same service provided to the same recipient during the same time period by a behavioral health services organization.

Section 4. 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:

(1)

(a) 907 KAR 15:020; or

(b) 907 KAR 15:022; and

(2) This administrative regulation.

Section 5. 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 6. Incorporation by Reference.

(1) The following material is incorporated by reference:

(a) "Kentucky Medicaid Behavioral Health and Substance Abuse Services Outpatient (Non-Facility) Fee Schedule", July 2019; and

(b) "Kentucky Medicaid Behavioral Health and Substance Abuse Services Facility Fee Schedule", July 2019.

(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, Monday through Friday, 8:00 a.m. to 4:30 p.m.; or

(b) Online at the department's Web site at https://chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.

Notes

907 KAR 15:025

41 Ky.R. 700; 1398; 1656; eff. 2-6-2015; 46 Ky.R. 762, 1909; eff. 1-3-2020.

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)