RELATES TO:
KRS
205.520,
205.622,
309.0831,
369.101-369.120,
20 U.S.C.
1400,
21 U.S.C.
823(g)(2),
29 U.S.C.
701,
42
U.S.C. 290ee-3,
1320d-2-1320
d-8, 1396a(a)(10)(B), 1396a(a)(23), 12101,
42 C.F.R. Part 2,
431.17,
435.1010,
45 C.F.R. 160, 164
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 coverage
provisions and requirements regarding Medicaid Program outpatient and inpatient
chemical dependency treatment center services.
Section 1. General Coverage Requirements.
(1) For the department to reimburse for a
service covered under this administrative regulation, the service shall be:
(a) Medically necessary; and
(b) Provided:
1. To a recipient; and
2. By a chemical dependency treatment center
that meets the provider participation requirements established in Section 2 of
this administrative regulation.
(2)
(a)
Direct contact between a practitioner and a recipient shall be required for
each service except for:
1. Collateral
outpatient therapy for a recipient under the age of twenty-one (21) years if
the collateral outpatient therapy is in the recipient's plan of care;
2. A family outpatient therapy service in
which the corresponding current procedural terminology code establishes that
the recipient is not present; or
3.
A psychological testing service comprised of interpreting or explaining results
of an examination or data to family members or others in which the
corresponding current procedural terminology code establishes that the
recipient is not present.
(b) A service that does not meet the
requirement in paragraph (a) of this subsection shall not be covered.
(3) A billable unit of service
shall be actual time spent delivering a service in an encounter.
(4) A service shall be:
(a) Stated in the recipient's plan of care;
and
(b) Provided in accordance with
the recipient's plan of care.
(5)
(a) A
chemical dependency treatment center shall establish a plan of care for each
recipient receiving services from a chemical dependency treatment
center.
(b) A plan of care shall
meet the treatment plan requirements established in
902
KAR 20:160.
Section 2. Provider Participation.
(1)
(a) To
be eligible to provide services under this administrative regulation, a
chemical dependency treatment center shall:
1. Be currently enrolled as a provider in the
Kentucky Medicaid Program in accordance with
907
KAR 1:672;
2. Except as established in subsection (2) of
this section, be currently participating in the Kentucky Medicaid Program in
accordance with
907
KAR 1:671;
3. Be licensed as a chemical dependency
treatment center to provide outpatient and inpatient behavioral health services
in accordance with
902
KAR 20:160; and
4.
Have:
a. For each service it
provides, the capacity to provide the full range of the service as established
in this administrative regulation;
b. Documented experience in serving
individuals with mental health, substance use, or co-occurring
disorders;
c. The administrative
capacity to ensure quality of services;
d. A financial management system that
provides documentation of services and costs; and
e. The capacity to document and maintain
individual health records.
(b) The documentation referenced in paragraph
(a)4.b. of this subsection shall be subject to audit by:
1. The department or its designee;
2. The Cabinet for Health and Family
Services, Office of Inspector General;
3. A managed care organization, if the
chemical dependency treatment center is enrolled in its network;
4. The Centers for Medicare and Medicaid
Services;
5. The Kentucky Office of
the Auditor of Public Accounts; or
6. The United States Department of Health and
Human Services, Office of the Inspector General.
(2) In accordance with
907
KAR 17:015, Section 3(3), a chemical dependency
treatment center that provides a service to an enrollee shall not be required
to be currently participating in the fee-for-service Medicaid
Program.
(3) A chemical dependency
treatment center shall:
(a) Agree to provide
services in compliance with federal and state laws regardless of age, sex,
race, creed, religion, national origin, handicap, or disability; and
(b) Comply with the Americans with
Disabilities Act (42 U.S.C.
12101 et seq.) and any amendments to the
act.
(4)
(a) Except as provided by paragraph (b) of
this subsection, a chemical dependency treatment center shall possess
accreditation, within one (1) year of initial enrollment, by one (1) of the
following:
1. The Joint Commission;
2. The Commission on Accreditation of
Rehabilitation Facilities;
3. The
Council on Accreditation; or
4. A
nationally recognized accreditation organization.
(b) The department shall grant a one (1) time
extension to a chemical dependency treatment center that requests a one (1)
time extension to complete the accreditation process, if the request is
submitted at least ninety (90) days prior to expiration of provider
enrollment.
Section
3. Covered Services.
(1)
Reimbursement shall not be available for services performed within a chemical
dependency treatment program by a:
(a)
Licensed behavior analyst;
(b)
Licensed assistant behavior analyst;
(c) Registered behavior technician;
or
(d) Community support
associate.
(2) The
services covered may be provided for a substance use disorder or for
co-occurring disorders.
(3) The
services listed in this subsection shall be covered under this administrative
regulation in accordance with the requirements established in this subsection.
(a) A screening shall:
1. Determine the likelihood that an
individual has a substance use disorder;
2. Not establish the presence or specific
type of disorder;
3. Establish the
need for an in-depth assessment;
4.
Be provided face-to-face or via telehealth as appropriate pursuant to
907
KAR 3:170; and
5. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section; or
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section.
(b) An assessment
shall:
1. Include gathering information and
engaging in a process with the individual that enables the practitioner to:
a. Establish the presence or absence of a
substance use disorder;
b.
Determine the individual's readiness for change;
c. Identify the individual's strengths or
problem areas that may affect the treatment and recovery processes;
and
d. Engage the individual in
developing an appropriate treatment relationship;
2. Establish or rule out the existence of a
clinical disorder or service need;
3. Include working with the individual to
develop a plan of care;
4. Not
include psychological or psychiatric evaluations or assessments;
5. Utilize a multidimensional assessment that
complies with the most current version of The ASAM Criteria to determine the
most appropriate level of care;
6.
Be provided face-to-face or via telehealth as appropriate pursuant to
907
KAR 3:170; and
7. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section; or
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section.
(c) Psychological
testing shall:
1. Include a psychodiagnostic
assessment of personality, psychopathology, emotionality, or intellectual
disabilities;
2. Include an
interpretation and a written report of testing results;
3. Be face-to-face or via telehealth as
appropriate pursuant to
907
KAR 3:170; and
4. Be provided by:
a. A licensed psychologist;
b. A certified psychologist with autonomous
functioning;
c. A licensed
psychological practitioner;
d. A
certified psychologist under supervision; or
e. A licensed psychological associate under
supervision.
(d) Crisis intervention:
1. Shall be a therapeutic intervention for
the purpose of immediately reducing or eliminating the risk of physical or
emotional harm to:
a. The recipient; or
b. Another individual;
2. Shall consist of clinical
intervention and support services necessary to provide integrated crisis
response, crisis stabilization interventions, or crisis prevention activities
for individuals;
3. Shall be
provided:
a. As an immediate relief to the
presenting problem or threat; and
b. In a one (1) on one (1) encounter between
the provider and the recipient, which is delivered either face-to-face or via
telehealth if appropriate pursuant to
907
KAR 3:170;
4. Shall be followed by a referral to
non-crisis services if applicable;
5. May include:
a. Further service prevention planning
including:
(i) Lethal means reduction for
suicide risk; or
(ii) Substance use
disorder relapse prevention; or
b. Verbal de-escalation, risk assessment, or
cognitive therapy; and
6. Shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section; or
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section.
(e) Mobile crisis
services shall:
1. Be available twenty-four
(24) hours per day, seven (7) days per week, every day of the year;
2. Be provided for a duration of less than
twenty-four (24) hours;
3. Not be
an overnight service;
4. Be a
face-to-face, or via telehealth as appropriate pursuant to the most current
version of The ASAM Criteria and
907
KAR 3:170, multi-disciplinary team-based intervention
in a home or community setting that ensures access to substance use disorder
services and supports to:
a. Reduce symptoms
or harm; or
b. Safely transition an
individual in an acute crisis to the appropriate least restrictive level of
care;
5. Involve all
services and supports necessary to provide:
a.
Integrated crisis prevention;
b.
Assessment and disposition;
c.
Intervention;
d. Continuity of care
recommendations; and
e. Follow-up
services;
6. Include
access to a board-certified or board-eligible psychiatrist twenty-four (24)
hours a day, seven (7) days a week, every day of the year; and
7. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section;
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section; or
c. A peer support specialist who:
(i) Is under the supervision of an approved
behavioral health practitioner, as limited by subsection (1) of this section;
and
(ii) Provides support services
for a mobile crisis service.
(f)
1. Day
treatment shall be a non-residential, intensive treatment program for an
individual under the age of twenty-one (21) years who has:
a. A substance use disorder; and
b. A high risk of out-of-home placement due
to a behavioral health issue.
2. Day treatment shall:
a. Be face-to-face, or via telehealth as
appropriate pursuant to the most current version of The ASAM Criteria and
907
KAR 3:170;
b. Consist of an organized, behavioral health
program of treatment and rehabilitative services;
c. Include:
(i) Individual outpatient therapy, family
outpatient therapy, or group outpatient therapy;
(ii) Behavior management and social skills
training;
(iii) Independent living
skills that correlate to the age and developmental stage of the recipient;
or
(iv) Services designed to
explore and link with community resources before discharge and to assist the
recipient and family with transition to community services after discharge;
and
d. Be provided:
(i) In collaboration with the education
services of the local education authority including those provided through
20 U.S.C.
1400 et seq. (Individuals with Disabilities
Education Act) or
29 U.S.C.
701 et seq. (Section 504 of the
Rehabilitation Act);
(ii) On school
days and during scheduled school breaks;
(iii) In coordination with the recipient's
individualized educational plan or Section 504 plan if the recipient has an
individualized educational plan or Section 504 plan; and
(iv) With a linkage agreement with the local
education authority that specifies the responsibilities of the local education
authority and the day treatment provider.
3. To provide day treatment services, a
chemical dependency treatment center shall have:
a. The capacity to employ staff authorized to
provide day treatment services in accordance with this section and to
coordinate the provision of services among team members; and
b. Knowledge of substance use disorders and
co-occurring disorders.
4. Day treatment shall not include a
therapeutic clinical service that is included in a child's individualized
education program or Section 504 plan.
5. Day treatment shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section;
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section; or
c. A peer support specialist who:
(i) Is under the supervision of an approved
behavioral health practitioner, as limited by subsection (1) of this section;
and
(ii) Provides support services
for a day treatment service.
(g)
1. Peer
support services shall:
a. Be emotional
support that is provided by:
(i) An
individual who has been trained and certified in accordance with
908 KAR
2:220 and who is experiencing or has experienced a
substance use disorder to a recipient by sharing a similar substance use
disorder in order to bring about a desired social or personal change;
(ii) A parent or other family member, who has
been trained and certified in accordance with
908 KAR
2:230, of a child having or who has had a substance
use disorder to a parent or family member of a child sharing a similar
substance use disorder in order to bring about a desired social or personal
change;
(iii) An individual who has
been trained and certified in accordance with
908 KAR
2:240 and identified as experiencing a substance use
disorder; or
(iv) A registered
alcohol and drug peer support specialist who has been trained and certified in
accordance with
KRS
309.0831 and is a self-identified consumer of
substance use disorder services who provides emotional support to others with
substance use disorder to achieve a desired social or personal
change;
b. Be an
evidence-based practice;
c. Be
structured and scheduled non-clinical therapeutic activities with an individual
recipient or a group of recipients;
d. Be provided face-to-face, or via
telehealth as appropriate pursuant to the most current version of The ASAM
Criteria and
907
KAR 3:170;
e. Promote socialization, recovery,
self-advocacy, preservation, and enhancement of community living skills for the
recipient;
f. Except for the
engagement into substance use disorder treatment through an emergency
department bridge clinic, be coordinated within the context of a comprehensive,
individualized plan of care developed through a person-centered planning
process;
g. Be identified in each
recipient's plan of care; and
h. Be
designed to contribute directly to the recipient's individualized goals as
specified in the recipient's plan of care.
2. To provide peer support services, a
chemical dependency treatment center shall:
a.
Have demonstrated:
(i) The capacity to provide
peer support services for the behavioral health population being served
including the age range of the population being served; and
(ii) Experience in serving individuals with
behavioral health disorders;
c. Use an approved behavioral health
practitioner to supervise peer support specialists;
d. Have the capacity to coordinate the
provision of services among team members;
e. Have the capacity to provide on-going
continuing education and technical assistance to peer support
specialists;
f. Require individuals
providing peer support services to recipients to provide no more than thirty
(30) hours per week of direct recipient contact; and
g. Require peer support services provided to
recipients in a group setting to not exceed eight (8) individuals within any
group at one (1) time.
(h)
1.
Intensive outpatient program services shall:
a. Be an alternative to or transition from a
higher level of care for a substance use disorder or for co-occurring
disorders;
b. Offer a multi-modal,
multi-disciplinary structured outpatient treatment program that is
significantly more intensive than individual outpatient therapy, group
outpatient therapy, or family outpatient therapy;
c. Meet the service criteria, including the
components for support systems, staffing, and therapies outlined in the most
current version of The ASAM Criteria for intensive outpatient level of care
services;
d. Be provided
face-to-face, or via telehealth as appropriate pursuant to the most current
version of The ASAM Criteria and
907
KAR 3:170;
e. Be provided at least three (3) hours per
day at least three (3) days per week for adults;
f. Be provided at least six (6) hours per
week for adolescents; and
g.
Include:
(i) Individual outpatient therapy,
group outpatient therapy, or family outpatient therapy unless
contraindicated;
(ii) Crisis
intervention; or
(iii)
Psycho-education related to identified goals in the recipient's treatment
plan.
2.
During psycho-education, the recipient or recipient's family member shall be:
a. Provided with knowledge regarding the
recipient's diagnosis, the causes of the condition, and the reasons why a
particular treatment might be effective for reducing symptoms; and
b. Taught how to cope with the recipient's
diagnosis or condition in a successful manner.
3. An intensive outpatient program services
treatment plan shall:
a. Be individualized;
and
b. Focus on stabilization and
transition to a lesser level of care.
4. To provide intensive outpatient program
services, a chemical dependency treatment center shall have:
a. Access to a board-certified or
board-eligible psychiatrist for consultation;
b. Access to a psychiatrist, physician, or
advanced practice registered nurse for medication prescribing and
monitoring;
c. Adequate staffing to
ensure a minimum recipient-to-staff ratio of ten (10) recipients to one (1)
staff person;
d. The capacity to
provide services utilizing a recognized intervention protocol based on
nationally accepted treatment principles; and
e. The capacity to employ staff authorized to
provide intensive outpatient program services in accordance with this section
and to coordinate the provision of services among team members.
5. Intensive outpatient program
services shall be provided by:
a. An approved
behavioral health practitioner, as limited by subsection (1) of this section;
or
b. An approved behavioral
health practitioner under supervision, as limited by subsection (1) of this
section.
(i)
Individual outpatient therapy shall:
1. Be
provided to promote the:
a. Health and
wellbeing of the recipient; and
b.
Restoration of a recipient to his or her best possible functional level from
substance use disorder or co-occurring disorders;
2. Consist of:
a. A face-to-face encounter or via telehealth
as appropriate pursuant to
907
KAR 3:170 that is a one (1) on one (1) encounter
between the provider and recipient; and
b. A behavioral health therapeutic
intervention provided in accordance with the recipient's identified plan of
care;
3. Be aimed at:
a. Reducing adverse symptoms;
b. Reducing or eliminating the presenting
problem of the recipient; and
c.
Improving functioning;
4. Not exceed three (3) hours per day alone
or in combination with any other outpatient therapy per recipient unless
additional time is medically necessary; and
5. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section; or
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section.
(j)
1. Group outpatient therapy shall:
a. Be a behavioral health therapeutic
intervention provided in accordance with a recipient's identified plan of
care;
b. Be provided to promote
the:
(i) Health and wellbeing of the
individual; and
(ii) Restoration of
a recipient to his or her best possible functional level from substance use
disorder or co-occurring disorders;
c. Consist of a face-to-face, or via
telehealth as appropriate pursuant to the most current version of The ASAM
Criteria and
907
KAR 3:170, behavioral health therapeutic intervention
provided in accordance with the recipient's identified plan of care;
d. Be provided to a recipient in a group
setting:
(i) Of nonrelated individuals except
for multi-family group therapy; and
(ii) Not to exceed twelve (12) individuals in
size;
e. Focus on the
psychological needs of the recipients as evidenced in each recipient's plan of
care;
f. Center on goals, including
building and maintaining healthy relationships, personal goals setting, and the
exercise of personal judgment;
g.
Not include physical exercise, a recreational activity, an educational
activity, or a social activity; and
h. Not exceed three (3) hours per day alone
or in combination with any other outpatient therapy per recipient unless
additional time is medically necessary.
2. The group shall have a:
a. Deliberate focus; and
b. Defined course of treatment.
3. The subject of group outpatient
therapy shall relate to each recipient participating in the group.
4. The provider shall keep individual notes
regarding each recipient within the group and within each recipient's health
record.
5. Group outpatient therapy
shall be provided by:
a. An approved
behavioral health practitioner, as limited by subsection (1) of this section;
or
b. An approved behavioral health
practitioner under supervision, as limited by subsection (1) of this
section.
(k)
1. Family outpatient therapy shall consist of
a face-to-face or appropriate telehealth, pursuant to
907
KAR 3:170, behavioral health therapeutic intervention
provided:
a. Through scheduled therapeutic
visits between the therapist and the recipient and at least one (1) member of
the recipient's family; and
b. To
address issues interfering with the relational functioning of the family and to
improve interpersonal relationships within the recipient's home
environment.
2. A family
outpatient therapy session shall be billed as one (1) service regardless of the
number of individuals (including multiple members from one (1) family) who
participate in the session.
3.
Family outpatient therapy shall:
a. Be
provided to promote the:
(i) Health and
well-being of the individual; or
(ii) Restoration of a recipient to his or her
best possible functional level from substance use disorder or co-occurring
disorders; and
b. Not
exceed three (3) hours per day alone or in combination with any other
outpatient therapy per recipient unless additional time is medically
necessary.
4. Family
outpatient therapy shall be provided by:
a. An
approved behavioral health practitioner, as limited by subsection (1) of this
section; or
b. An approved
behavioral health practitioner under supervision, as limited by subsection (1)
of this section.
(l)
1.
Collateral outpatient therapy shall:
a.
Consist of a face-to-face or appropriate telehealth, provided pursuant to
907
KAR 3:170, behavioral health consultation:
(i) With a parent or caregiver of a
recipient, household member of a recipient, legal representative of a
recipient, school personnel, treating professional, or other person with
custodial control or supervision of the recipient; and
(ii) That is provided in accordance with the
recipient's plan of care;
b. Not be reimbursable if the therapy is for
a recipient who is at least twenty-one (21) years of age; and
c. Not exceed three (3) hours per day alone
or in combination with any other outpatient therapy per recipient unless
additional time is medically necessary.
2. Written consent by a parent or custodial
guardian to discuss a recipient's treatment with any person other than a parent
or legal guardian shall be signed and filed in the recipient's health
record.
3. Collateral outpatient
therapy shall be provided by:
a. An approved
behavioral health practitioner, as limited by subsection (1) of this section;
or
b. An approved behavioral health
practitioner under supervision, as limited by subsection (1) of this
section.
(m)
1. Screening, brief intervention, and
referral to treatment for a substance use disorder shall:
a. Be provided face-to-face or via telehealth
as appropriate according to
907
KAR 3:170;
b. Be an evidence-based early-intervention
approach for an individual with non-dependent substance use to provide an
effective strategy for intervention prior to the need for more extensive or
specialized treatment; and
c.
Consist of:
(i) Using a standardized screening
tool to assess an individual for risky substance use behavior;
(ii) Engaging a recipient, who demonstrates
risky substance use behavior, in a short conversation and providing feedback
and advice; and
(iii) Referring a
recipient to additional substance use disorder services if the recipient is
determined to need additional services to address substance
use.
2. A
screening and brief intervention that does not meet criteria for referral to
treatment may be subject to coverage by the department.
3. A screening, brief intervention, and
referral to treatment for a substance use disorder shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section; or
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section.
(n)
1. Service planning shall:
a. Be provided face-to-face, or via
telehealth as appropriate pursuant to the most current version of The ASAM
Criteria and
907
KAR 3:170;
b. Involve assisting a recipient in creating
an individualized plan for services and developing measurable goals and
objectives needed for maximum reduction of the effects of substance use
disorder or co-occurring disorders;
c. Involve restoring a recipient's functional
level to the recipient's best possible functional level; and
d. Be performed using a person-centered
planning process.
2. A
service plan:
a. Shall be directed and signed
by the recipient;
b. Shall include
practitioners of the recipient's choosing; and
c. May include:
(i) A mental health advance directive being
filed with a local hospital;
(ii) A
crisis plan; or
(iii) A relapse
prevention strategy or plan.
3. Service planning shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsection (1) of this section; or
b. An approved behavioral health practitioner
under supervision, as limited by subsection (1) of this section.
(o)
1. Ambulatory withdrawal management services
shall:
a. Be provided face-to-face for
recipients with substance use disorder or co-occurring disorders;
b. Be incorporated into a recipient's care as
appropriate according to the continuum of care described in the most current
version of The ASAM Criteria; and
c.
Be in accordance with the most current version of The ASAM Criteria for
ambulatory withdrawal management levels in an outpatient setting.
2. A recipient who is receiving
ambulatory withdrawal management services shall:
a. Meet the most current version of
diagnostic criteria for substance withdrawal management found in the Diagnostic
and Statistical Manual of Mental Disorders; and
b. Meet the current dimensional admissions
criteria for withdrawal management level of care as found in the most current
version of The ASAM Criteria.
3. Ambulatory withdrawal management services
shall be provided by:
a. A
physician;
b. A
psychiatrist;
c. A physician
assistant;
d. An advanced practice
registered nurse; or
e. Any other
approved behavioral health practitioner with oversight by a physician, advanced
practice registered nurse, or a physician assistant, as limited by subsection
(1) of this section.
(p)
1.
Medication assisted treatment shall be provided by an authorized prescribing
provider who:
a. Is:
(i) A physician licensed to practice medicine
under KRS Chapter 311;
(ii) An
advanced practice registered nurse (APRN); or
(iii) A physician assistant licensed to
practice medicine under KRS Chapter 311;
c. Maintains a current waiver under
21 U.S.C.
823(g)(2) to prescribe
buprenorphine products, including any waiving or expansion of buprenorphine
prescribing authority by the federal government; and
d. Has experience and knowledge in addiction
medicine.
2. Medication
assisted treatment with behavioral health therapies shall:
a. Be co-located within the same practicing
site as the practitioner with a waiver pursuant to subparagraph 1.b. of this
paragraph or be conducted via telehealth as appropriate according to
907
KAR 3:170; or
b. Be conducted with agreements in place for
linkage to appropriate behavioral health treatment providers who specialize in
substance use disorders and are knowledgeable in bi-opsychosocial dimensions of
alcohol or other substance use disorder, such as:
(i) An approved behavioral health
practitioner, as limited by subsection (1) of this section; or
(ii) A multi-specialty group or behavioral
health provider group pursuant to
907
KAR 15:010.
3. A medication assisted treatment program
shall:
a. Assess the need for treatment
including:
(i) A full patient history to
determine the severity of the patient's substance use disorder; and
(ii) Identifying and addressing any
underlying or co-occurring diseases or conditions, as necessary;
b. Educate the patient about how
the medication works, including:
(i) The
associated risks and benefits; and
(ii) Overdose prevention;
c. Evaluate the need for medically
managed withdrawal from substances;
d. Refer patients for higher levels of care
if necessary; and
e. Obtain informed
consent prior to integrating pharmacologic or nonpharmacologic
therapies.
4. Medication
assisted treatment shall be provided by:
a. A
physician;
b. A
psychiatrist;
c. An advanced
practice registered nurse; or
d. An
approved behavioral health practitioner, as limited pursuant to subsection (1)
of this section, or approved behavioral health practitioner under supervision,
as limited pursuant to subsection (1) of this section, to provide counseling,
behavioral therapies, and other support components with experience and
knowledge in addiction medicine.
(q)
1. An
inpatient chemical dependency treatment program shall:
a. Be a structured inpatient program to
provide medical, social, diagnostic, and treatment services to individuals with
substance use disorder or co-occurring disorders;
b.
(i) If
being provided as an ASAM 3.7 level of care medically monitored intensive
inpatient service, be provided face-to-face, twenty-four (24) hours per day,
seven (7) days per week, 365 days a year with continuous nursing services and
under the medical direction of a physician; or
(ii) If being provided as an ASAM 3.5 level
of care clinically managed high intensity residential service, be provided
face-to-face, or via telehealth as appropriate pursuant to the most current
version of The ASAM Criteria and
907
KAR 3:170, twenty-four (24) hours per day, seven (7)
days per week, and 365 days a year; and
c. Meet the service criteria for medically
monitored intensive inpatient services using the most current version of The
ASAM Criteria, currently described by ASAM as a 3.7 level of care; and
d. Include the following services:
(i) Screening;
(ii) Assessment;
(iii) Service planning;
(iv) Psychiatric services;
(v) Individual therapy;
(vi) Family therapy;
(vii) Group therapy;
(viii) Peer support;
(ix) Medication assisted treatment;
(x) Clinically managed high intensity
residential services, as established pursuant to sub-paragraph 2. of this
paragraph; or
(xi) Medically
monitored inpatient withdrawal management, as established pursuant to
sub-paragraph 3. of this paragraph.
2. Clinically managed high intensity
residential services provided in an inpatient chemical dependency treatment
center shall:
a. Meet the service criteria for
clinically managed high intensity residential services using the current
version of The ASAM Criteria, currently described by ASAM as a 3.5 level of
care;
b. Have:
(i) A planned and structured regimen of
twenty-four (24) hour professionally directed evaluation, observation, clinical
management, and addiction treatment;
(ii) Twenty-four (24) hour access to nursing
care;
(iii) Twenty-four (24) hour
access to a psychiatrist; and
(iv)
Twenty-four (24) hour access to a physician; and
3. Medically monitored inpatient withdrawal
management services provided in an inpatient chemical dependency treatment
center shall:
a. Meet the service criteria
for medically monitored inpatient withdrawal management services using the
current version of The ASAM Criteria, currently described by ASAM as a 3.7
level of care; and
b. Have:
(i) A planned and structured regimen of
twenty-four (24) hour professionally directed evaluation, observation, medical
monitoring, and addiction treatment;
(ii) Twenty-four (24) hour nursing
care;
(iii) Twenty-four (24) hour
access to a psychiatrist; and
(iv)
Twenty-four (24) hour access to a physician; and
c. Comply with services pursuant to the
requirements of
902
KAR 20:160.
4. An inpatient chemical dependency treatment
program providing both ASAM 3.5 and ASAM 3.7 level of care services in the same
facility shall:
a. Provide the ASAM 3.7
services within a separate unit from the ASAM 3.5 level of care unit; and
b. Meet the requirements of
subparagraph 3. of this paragraph for all ASAM 3.7 level of care
services.
5. For a
recipient in an inpatient chemical dependency treatment program, care
coordination shall include at minimum:
a.
Facilitating medication assisted treatment for recipients as necessary, per
recipient choice;
b. Referral to
appropriate community services;
c.
Facilitation of medical and behavioral health follow ups; and
d. Linking the recipient to the appropriate
level of substance use treatment within the continuum to provide ongoing
supports.
6. Inpatient
chemical dependency treatment services shall be provided in accordance with
902
KAR 20:160, Sections 4 and 7.
7. Length-of-stay for chemical dependency
treatment services shall be person-centered and according to an individually
designed plan of care that is consistent with this administrative regulation
and the licensure of the facility and practitioner.
8.
a.
Except as established in clause b. or c. of this subparagraph, the physical
structure in which inpatient chemical dependency treatment services is provided
shall:
(i) Have between nine (9) and sixteen
(16) beds; and
(ii) Not be part of
multiple units comprising one (1) facility with more than sixteen (16) beds in
aggregate, except as allowed pursuant to subparagraphs 2., 3., and 4. of this
paragraph and by
902
KAR 20:160, as applicable.
b. If every recipient receiving services in
the physical structure is under the age of twenty-one (21) years or over the
age of sixty-five (65) years, the limit of sixteen (16) beds established in
clause a. of this subparagraph shall not apply.
c. The limit of sixteen (16) beds established
in clause a. of this subparagraph shall not apply if the facility possesses the
appropriate inpatient, or residential, as applicable, ASAM certification to
provide chemical dependency treatment center services, with the exception that:
(i) Each currently enrolled chemical
dependency treatment center shall be granted a one (1) time provisional
certification that expires July 1, 2022, unless extended by the department;
or
(ii) A federal waiver, or other
change to controlling federal law that allows for the availability of federal
financial participation, shall be available for this clause to be
operational.
9. Inpatient chemical dependency treatment
services shall not include:
a. Room and
board;
b. Educational
services;
c. Vocational
services;
d. Job training
services;
e. Habilitation
services;
f. Services to an inmate
in a public institution pursuant to
42 C.F.R.
435.1010;
g. Services to an individual residing in an
institution for mental diseases pursuant to
42 C.F.R.
435.1010;
h. Recreational activities;
i. Social activities; or
j. Services required to be covered
elsewhere in the Medicaid state plan.
10. To provide inpatient chemical dependency
treatment services, the program shall:
a. Have
the capacity to employ staff authorized to provide services in accordance with
this section and to coordinate the provision of services among team
members;
b. Be licensed as a
chemical dependency treatment services and facility in accordance with
902
KAR 20:160; and
c. After July 1, 2022, possess an appropriate
ASAM Level of Care Certification for medically monitored intensive inpatient
services in accordance with the most current version of The ASAM Criteria, and
possess an appropriate ASAM Level of Care Certification for clinically managed
high intensity residential services pursuant to the most current version of The
ASAM Criteria if providing that level of care.
11.
a.
Inpatient chemical dependency treatment shall be provided by:
(i) An approved behavioral health
practitioner, except as provided pursuant to subsection (1) of this section;
or
(ii) An approved behavioral
health practitioner under supervision, except as provided pursuant to
subsection (1) of this section.
b. Support services for inpatient chemical
dependency shall be provided by a peer support specialist under the supervision
of an approved behavioral health practitioner.
(4) The department shall not
reimburse for a service billed by or on behalf of an entity or individual who
is not a billing provider.
Section
4. Additional Limits and Non-covered Services or Activities.
(1)
(a)
Except as established in paragraph (b) of this subsection, unless a diagnosis
is made and documented in the recipient's health record within three (3)
visits, the service shall not be covered.
(b) The requirement established in paragraph
(a) of this subsection shall not apply to:
1.
Mobile crisis services;
2. Crisis
intervention;
3. A screening;
or
4. An assessment.
(2) The department
shall not reimburse for both a screening and a screening, brief intervention
and referral to treatment (SBIRT) provided to a recipient on the same date of
service.
(3) The following services
or activities shall not be covered under this administrative regulation:
(a) A service provided to:
1. A resident of:
a. A nursing facility; or
b. An intermediate care facility for
individuals with an intellectual disability;
2. An inmate of a federal, local, or state:
a. Jail;
b. Detention center; or
c. Prison; or
3. An individual with an intellectual
disability without documentation of an additional psychiatric
diagnosis;
(b) A
consultation or educational service provided to a recipient or to
others;
(c) A telephone call, an
email, a text message, or other electronic contact that does not meet the
requirements stated in the definition of "face-to-face" established in
907
KAR 15:005, Section 1(21). Contact that is not
reimbursable under this paragraph may be permissible if it is conducted in the
course of a telehealth service permitted pursuant to
907
KAR 3:170 or this administrative regulation, as
applicable;
(d) Travel
time;
(e) A field trip;
(f) A recreational activity;
(g) A social activity; or
(h) A physical exercise activity
group.
(4)
(a) A consultation by one (1) provider or
professional with another shall not be covered under this administrative
regulation except as established in Section 3(3)(l)1. of this administrative
regulation.
(b) A third-party
contract shall not be covered under this administrative regulation.
(5) A billing supervisor
arrangement between a billing supervisor and an approved behavioral health
practitioner under supervision shall not:
(a)
Violate the clinical supervision rules or policies of the respective
professional licensure boards governing the billing supervisor and the approved
behavioral health practitioner under supervision; or
(b) Substitute for the clinical supervision
rules or policies of the respective professional li-censure boards governing
the billing supervisor and the approved behavioral health practitioner under
supervision.
Section
5. 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
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 chemical dependency treatment
center.
Section 6.
Records Maintenance, Documentation, Protection, and Security.
(1) A chemical dependency treatment center
shall maintain a current health record for each recipient.
(2) A health record shall document each
service provided to the recipient including the date of the service and the
signature of the individual who provided the service.
(3) A health record shall:
(a) Include:
1. An identification and intake record
including:
a. Name;
b. Social Security number;
c. Date of intake;
d. Home (legal) address;
e. Health insurance or Medicaid participation
information;
f. If applicable, the
referral source's name and address;
g. Primary care physician's name and
address;
h. The reason the
individual is seeking help including the presenting problem and diagnosis;
i. Any physical health diagnosis,
if a physical health diagnosis exists for the individual, and information
regarding:
(i) Where the individual is
receiving treatment for the physical health diagnosis; and
(ii) The physical health provider's name;
and
j. The name of the
informant and any other information deemed necessary by the chemical dependency
treatment center in order to comply with the requirements of:
(i) This administrative regulation;
(ii) The chemical dependency treatment
center's licensure board;
(iii)
State law; or
(iv) Federal
law;
2.
Documentation of the:
a. Screening;
b. Assessment, if an assessment was
performed; and
c. Disposition, if a
disposition was performed;
3. A complete history including mental status
and previous treatment;
4. An
identification sheet;
5. A consent
for treatment sheet that is accurately signed and dated; and
6. The individual's stated purpose for
seeking services; and
(b) Be:
1.
Maintained in an organized central file;
2. Furnished upon request:
a. To the Cabinet for Health and Family
Services; or
b. For an enrollee, to
the managed care organization in which the recipient is enrolled or has been
enrolled in the past;
3.
Made available for inspection and copying by:
a. Cabinet for Health and Family Services'
personnel; or
b. Personnel of the
managed care organization in which the recipient is enrolled if
applicable;
4. Readily
accessible; and
5. Adequate for the
purpose of establishing the current treatment modality and progress of the
recipient if the recipient received services beyond a
screening.
(4)
Documentation of a screening shall include:
(a) Information relative to the individual's
stated request for services; and
(b) Other stated personal or health concerns
if other concerns are stated.
(5)
(a) A
chemical dependency treatment center's service notes regarding a recipient
shall:
1. Be made within forty-eight (48)
hours of each service visit;
2.
Indicate if the service was provided face-to-face or via telehealth for
outpatient services; and
3.
Describe the:
a. Recipient's symptoms or
behavior, reaction to treatment, and attitude;
b. Behavioral health practitioner's
intervention;
c. Changes in the
plan of care if changes are made; and
d. Need for continued treatment if deemed
necessary.
(b)
1. Any edit to notes shall:
a. Clearly display the changes; and
b. Be initialed and dated by the
person who edited the notes.
2. Notes shall not be erased or illegibly
marked out.
(c)
1. Notes recorded by an approved behavioral
health practitioner under supervision shall be co-signed and dated by the
supervising professional within thirty (30) days.
2. If services are provided by an approved
behavioral health practitioner under supervision, there shall be a monthly
supervisory note recorded by the supervising professional that reflects
consultations with the approved behavioral health practitioner working under
supervision concerning the:
a. Case;
and
b. Supervising professional's
evaluation of the services being provided to the recipient.
(6)
Immediately following a screening of a recipient, the practitioner shall
perform a disposition related to:
(a) A
provisional diagnosis;
(b) A
referral for further consultation and disposition, if applicable; or
(c)
1. If
applicable, termination of services and referral to an outside source for
further services; or
2. If
applicable, termination of services without a referral to further
services.
(7)
Any change to a recipient's plan of care shall be documented, signed, and dated
by the rendering practitioner and by the recipient or recipient's
representative.
(8)
(a) Notes regarding services to a recipient
shall:
1. Be organized in chronological
order;
2. Be dated;
3. Be titled to indicate the service
rendered;
4. State a starting and
ending time for the service; and
5.
Be recorded and signed by the rendering practitioner and include the
professional title (for example, licensed clinical social worker) of the
provider.
(b) Initials,
typed signatures, or stamped signatures shall not be accepted.
(c) Telephone contacts, family collateral
contacts not covered under this administrative regulation, or other
non-reimbursable contacts shall:
1. Be
recorded in the notes; and
2. Not
be reimbursable.
(9)
(a) A
termination summary shall:
1. Be required,
upon termination of services, for each recipient who received at least three
(3) service visits; and
2. Contain
a summary of the significant findings and events during the course of treatment
including the:
a. Final assessment regarding
the progress of the individual toward reaching goals and objectives established
in the individual's plan of care;
b. Final diagnosis of clinical impression;
and
c. Individual's condition upon
termination and disposition.
(b) A health record relating to an individual
who has been terminated from receiving services shall be fully completed within
ten (10) days following termination.
(10) If an individual's case is reopened
within ninety (90) days of terminating services for the same or related issue,
a reference to the prior case history with a note regarding the interval period
shall be acceptable.
(11)
(a) Except as established in paragraph (b) of
this subsection, if a recipient is transferred or referred to a health care
facility or other provider for care or treatment, the transferring chemical
dependency treatment center shall, within ten (10) business days of awareness
of the transfer or referral, transfer the recipient's records in a manner that
complies with the records' use and disclosure requirements as established in or
required by:
1.
a. The Health Insurance Portability and
Accountability Act;
c.45 C.F.R. Parts
160 and
164;
or
(b) If a
recipient is transferred or referred to a residential crisis stabilization
unit, a psychiatric hospital, a psychiatric distinct part unit in an acute care
hospital, a Level I psychiatric residential treatment facility, a Level II
psychiatric residential treatment facility, or an acute care hospital for care
or treatment, the transferring chemical dependency treatment center shall,
within forty-eight (48) hours of the transfer or referral, transfer the
recipient's records in a manner that complies with the records' use and
disclosure requirements as established in or required by:
1.
a. The
Health Insurance Portability and Accountability Act;
c.45 C.F.R. Parts
160 and
164;
or
(12)
(a) If
a chemical dependency treatment center's Medicaid Program participation status
changes as a result of voluntarily terminating from the Medicaid Program,
involuntarily terminating from the Medicaid Program, a licensure suspension, or
death of an owner or deaths of owners, the health records of the chemical
dependency treatment center shall:
1. Remain
the property of the chemical dependency treatment center; and
2. Be subject to the retention requirements
established in subsection (13) of this section.
(b) A chemical dependency treatment center
shall have a written plan addressing how to maintain health records in the
event of death of an owner or deaths of owners.
(13)
(a)
Except as established in paragraph (b) or (c) of this subsection, a chemical
dependency treatment center shall maintain a health record regarding a
recipient for at least six (6) years from the last date of the service or until
any audit dispute or issue is resolved beyond six (6) years.
(b) After a recipient's death or discharge
from services, a provider shall maintain the recipient's record for the longest
of the following periods:
1. Six (6) years
unless the recipient is a minor; or
2. If the recipient is a minor, three (3)
years after the recipient reaches the age of majority under state
law.
(c) If the
Secretary of the United States Department of Health and Human Services requires
a longer document retention period than the period referenced in paragraph (a)
of this subsection, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(14)
(a) A
chemical dependency treatment center shall comply with 45 C.F.R. Part
164.
(b) All information contained
in a health record shall:
1. Be treated as
confidential;
2. Not be disclosed
to an unauthorized individual; and
3. Be disclosed to an authorized
representative of:
a. The
department;
b. Federal government;
or
c. For an enrollee, the managed
care organization in which the enrollee is enrolled.
(c)
1. Upon request, a chemical dependency
treatment center shall provide to an authorized representative of the
department, federal government, or managed care organization if applicable,
information requested to substantiate:
a.
Staff notes detailing a service that was rendered;
b. The professional who rendered a service;
and
c. The type of service rendered
and any other requested information necessary to determine, on an individual
basis, whether the service is reimbursable by the department or the managed
care organization, if applicable.
2. Failure to provide information referenced
in subparagraph 1. of this paragraph shall result in denial of payment for any
service associated with the requested information.
Section 7. Medicaid
Program Participation Compliance.
(1) A
chemical dependency treatment center shall comply with:
(c) All applicable state and federal
laws.
(2)
(a) If a chemical dependency treatment center
receives any duplicate payment or overpayment from the department or a managed
care organization, regardless of reason, the chemical dependency treatment
center shall return the payment to the department or managed care organization
in accordance with
907
KAR 1:671.
(b) Failure to return a payment to the
department or managed care organization in accordance with paragraph (a) of
this subsection may be:
1. Interpreted to be
fraud or abuse; and
2. Prosecuted
in accordance with applicable federal or state law.
(3)
(a) When the department makes payment for a
covered service and the chemical dependency treatment center accepts the
payment:
1. The payment shall be considered
payment in full;
2. A bill for the
same service shall not be given to the recipient; and
3. Payment from the recipient for the same
service shall not be accepted by the chemical dependency treatment
center.
(b)
1. A chemical dependency treatment center may
bill a recipient for a service that is not covered by the Kentucky Medicaid
Program if the:
a. Recipient requests the
service; and
b. Chemical dependency
treatment center makes the recipient aware in writing in advance of providing
the service that the:
(i) Recipient is liable
for the payment; and
(ii)
Department is not covering the service.
2. If a recipient makes payment for a service
in accordance with subparagraph 1. of this paragraph, the:
a. Chemical dependency treatment center shall
not bill the department for the service; and
b. Department shall not:
(i) Be liable for any part of the payment
associated with the service; and
(ii) Make any payment to the chemical
dependency treatment center regarding the service.
(4)
(a) A chemical dependency treatment center
shall attest by the chemical dependency treatment center's staff's or
representative's signature that any claim associated with a service is valid
and submitted in good faith.
(b)
Any claim and substantiating record associated with a service shall be subject
to audit by the:
1. Department or its
designee;
2. Cabinet for Health and
Family Services, Office of Inspector General, or its designee;
3. Kentucky Office of Attorney General or its
designee;
4. Kentucky Office of the
Auditor for Public Accounts or its designee;
5. United States General Accounting Office or
its designee; or
6. For an
enrollee, managed care organization in which the enrollee is
enrolled.
(c)
1. If a chemical dependency treatment center
receives a request from the:
a. Department to
provide a claim, related information, related documentation, or record for
auditing purposes, the chemical dependency treatment center shall provide the
requested information to the department within the timeframe requested by the
department; or
b. Managed care
organization in which an enrollee is enrolled to provide a claim, related
information, related documentation, or record for auditing purposes, the
chemical dependency treatment center shall provide the requested information to
the managed care organization within the timeframe requested by the managed
care organization.
2.
a. The timeframe requested by the department
or managed care organization for a chemical dependency treatment center to
provide requested information shall be:
(i) A
reasonable amount of time given the nature of the request and the circumstances
surrounding the request; and
(ii) A
minimum of one (1) business day.
b. A chemical dependency treatment center may
request a longer timeframe to provide information to the department or a
managed care organization if the chemical dependency treatment center justifies
the need for a longer timeframe.
(d)
1. All
services provided shall be subject to review for recipient or provider fraud or
abuse, and compliance with this administrative regulation and state and federal
law.
2. Willful abuse by a chemical
dependency treatment center shall result in the suspension or termination of
the chemical dependency treatment center from Medicaid Program participation in
accordance with
907
KAR 1:671.
Section 8. Third Party Liability. A chemical
dependency treatment center shall comply with
KRS
205.622.
Section 9. Use of Electronic Signatures.
(1) 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.
(2) A chemical dependency treatment center
that chooses to use electronic signatures shall:
(a) Develop and implement a written security
policy that shall:
1. Be adhered to by each of
the chemical dependency treatment center's employees, officers, agents, or
contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the chemical
dependency treatment center's electronic signature policy;
2. The signed consent form; and
3. The original filed signature.
Section 10.
Auditing Authority. The department or managed care organization in which an
enrollee is enrolled shall have the authority to audit any:
(1) Claim;
(2) Health record; or
(3) Documentation associated with any claim
or health record.
Section
11. Federal Approval and Federal Financial Participation.
(1) The department's reimbursement of
services pursuant to this administrative regulation shall be contingent upon:
(a) Receipt of federal financial
participation for the coverage; and
(b) Centers for Medicare and Medicaid
Services' approval for the coverage.
(2) The reimbursement of services provided by
a licensed clinical alcohol and drug counselor or licensed clinical alcohol and
drug counselor associate shall be contingent and effective upon approval by the
Centers for Medicare and Medicaid Services.
Section 12. Appeals.
(1) An appeal of an adverse action by the
department regarding a service and a recipient who is not enrolled with a
managed care organization shall be in accordance with
907
KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with
907
KAR 17:010.907 KAR
15:080