RELATES TO:
KRS
205.520,
42 U.S.C.
1396a(a)(10)(B),
42 U.S.C.
1396a(a)(23)
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 targeted case management
services for individuals with a severe mental illness and children with a
severe emotional disability 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:
(1) Medically necessary;
(2) Provided:
(a) To a recipient;
(b) By a provider that meets the provider
participation requirements established in
907
KAR 15:060; and
(c) In accordance with the requirements
established in
907
KAR 15:060; and
Section 2. Reimbursement.
(1) The department shall reimburse a monthly
rate of $334 in total for all targeted case management services provided to a
recipient during the month.
(2)
Except as established in subsection (3) or (4) of this section, to qualify for
the reimbursement referenced in subsection (1) of this section, a targeted case
management services provider shall provide services to a recipient consisting
of at least four (4) targeted case management service contacts including:
(a) At least two (2) face-to-face contacts
with the recipient; and
(b) At
least two (2) additional contacts which shall be:
1.
a. By
telephone; or
b. Face-to-face;
and
2. With the recipient
or with another individual on behalf of the recipient.
(3) For a recipient who is under
the age of eighteen (18) years, the contacts that a targeted case management
services provider shall have shall include at least:
(a)
1. One
(1) face-to-face contact with the recipient; and
2. One (1) face-to-face contact with the
recipient's parent or legal guardian; and
(b) Two (2) additional contacts which shall
be:
1.
a. By
telephone; or
b. Face-to-face;
and
2. With the recipient
or with another individual or agency on behalf of the recipient.
(4) For a recipient who
is at least eighteen (18) years of age but under the age of twenty-one (21)
years, the contacts that a targeted case management services provider shall
have shall include:
(a)
1. At least two (2) face-to-face contacts
with the recipient; and
2. At least
two (2) additional contacts which shall be:
a.
(i) By
telephone; or
(ii) Face-to-face;
and
b. With the
recipient or with another individual or agency on behalf of the recipient;
or
(b)
1.
a. At
least one (1) face-to-face contact with the recipient; and
b. One (1) face-to-face contact with the
recipient's parent or legal guardian; and
2. At least two (2) additional contacts which
shall be:
a.
(i) By telephone; or
(ii) Face-to-face; and
b. With the recipient or with another
individual or agency on behalf of the recipient.
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 same service is covered during the same
time period.
(2) For example, if a
recipient is receiving targeted case management services from an independent
behavioral health provider, the department shall not reimburse for the targeted
case management services 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:
(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.
