RELATES TO:
KRS
205.520(3),
205.5375,
205.592,
45 C.F.R.
164,
42 U.S.C.
1396a(a)(47), r-1,
42 U.S.C.
9902
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) authorizes the
secretary to promulgate administrative regulations necessary to qualify for
federal funds by compliance with any requirement that may be imposed or
opportunity that may be presented by federal law.
KRS
205.5375(7) requires the
department to promulgate administrative regulations in accordance with KRS
Chapter 13A that are necessary to administer this statute, including a thorough
presumptive eligibility application form to be used by qualified hospitals when
making presumptive eligibility determinations using information provided and
attested to by an individual. This administrative regulation establishes
requirements for the determination of presumptive eligibility and the provision
of services to individuals deemed presumptively eligible for Medicaid-covered
services.
Section 1. Providers
Eligible to Grant Presumptive Eligibility.
(1)
A determination of presumptive eligibility regarding:
(a) A pregnant woman shall be made by a
qualified provider who is:
1. A family or
general practitioner;
2. A
pediatrician;
3. An
internist;
4. An obstetrician or
gynecologist;
5. A physician
assistant;
6. A certified nurse
midwife;
7. An advanced practice
registered nurse;
8. A
federally-qualified health care center;
9. A primary care center;
10. A rural health clinic; or
11. A local health department; or
(b) An individual whose income
standard for Medicaid eligibility purposes is a modified adjusted gross income
shall be made by an inpatient hospital participating in the Medicaid
Program.
(2) An
individual whose Medicaid eligibility is determined using the modified adjusted
gross income as an income standard shall be an individual identified in
907 KAR 20:100 as having a
modified adjusted gross income as the Medicaid income eligibility
standard.
Section 2.
Provider Responsibilities.
(1) A qualified
provider who determines that an individual is presumptively eligible for
Medicaid based on criteria established in Section 3 of this administrative
regulation shall:
(a) Complete the paper or
electronic application approved by the department pursuant to Section 8 of this
administrative regulation;
(b)
Enter the data into the department's Integrated Eligibility and Enrollment
System (IEES) self-service portal for a real-time eligibility
determination;
(c)
1. Inform the individual at the time the
determination is made that the individual is required to make an application
for Medicaid benefits through the individual's local DCBS office or via the
IEES self-service portal; and
2.
Inform the individual of any other requirements pursuant to
KRS
205.5375(2)(b);
(d) Inform the individual of the
location of the individual's local DCBS office;
(e) Issue presumptive eligibility
identification to the presumed eligible individual;
(f) Maintain a record of the presumptive
eligibility screening for each applicant for at least five (5) years;
and
(g) Complete and securely
submit the form described in Section 8(3) of this administrative regulation to
the department or the department's designee.
(2) If an individual is determined not to be
presumptively eligible, the qualified provider shall inform the individual of
the following in writing:
(a) The reason for
the determination;
(b) That the
individual may file an application for Medicaid if the individual wishes to
have a formal determination made; and
(c) The location of the individual's local
DCBS office.
(3) A
qualified provider shall, as appropriate, assist the patient with a full
Medicaid application pursuant to
KRS
205.5375(2)(e).
Section 3. Eligibility Criteria.
Presumptive eligibility shall be granted to:
(1) A woman if she:
(a) Is pregnant;
(b) Is a Kentucky resident;
(c) Does not have income exceeding 218
percent of the federal poverty level established annually by the United States
Department of Health and Human Services pursuant to
42 U.S.C.
9902(2) and as consistent
with
907 KAR 4:030;
(d) Does not currently have a pending
Medicaid application on file with the DCBS;
(e) Is not currently enrolled in
Medicaid;
(f) Has not been
previously granted presumptive eligibility for the current pregnancy;
and
(g) Is not an inmate of a
public institution, except as established in
907 KAR 20:005, Section 7(2);
or
(2) An individual
whose Medicaid income eligibility standard is a modified adjusted gross income
if the individual:
(a) Is a Kentucky
resident;
(b) Does not have income
exceeding:
1. 133 percent of the federal
poverty level established annually by the United States Department of Health
and Human Services pursuant to
42 U.S.C.
9902(2); or
2. 218 percent of the federal poverty level
established annually by the United States Department of Health and Human
Services pursuant to 42
U.S.C.
9902(2), if the
individual is a targeted low-income child, as consistent with
907 KAR 4:020;
(c) Does not currently have a
pending Medicaid application on file with the DCBS;
(d) Is not currently enrolled in Medicaid;
and
(e) Is not an inmate of a
public institution except as established in
907 KAR 20:005, Section
7(2).
Section
4. Presumptive Eligibility Period.
(1) Presumptive eligibility for an individual
shall begin on the date on which a qualified providerdetermines that the
individual is presumptively eligible based on the criteria specified in Section
3 of this administrative regulation.
(2) The presumptive eligibility period shall
end on:
(a) The day preceding the date the
presumptively-eligible individual is granted full eligibility in the Medicaid
Program by the DCBS; or
(b) The
last day of the month following the month in which a qualified provider made
the presumptive eligibility determination if the presumed eligible individual:
1. Does not apply for the full Medicaid
benefit package; or
2. Applies for
and is found ineligible for the full Medicaid benefit package.
(3) To illustrate the
presumptive eligibility period, if an individual became presumptively eligible
on July 7, 2014, the individual shall remain presumptively eligible through
August 31, 2014.
(4) For a woman
who gains presumptive eligibility by being pregnant, only one (1) presumptive
eligibility period shall be granted for each episode of pregnancy.
Section 5. Covered Services.
(1)
(a)
Payment for a covered service provided to a presumptively-eligible individual
shall be in accordance with the current Medicaid reimbursement policy for the
service unless the service is provided to an individual who is enrolled with a
managed care organization.
(b) A
managed care organization:
1. Shall not be
required to reimburse in the same manner or amount as the department reimburses
for a Medicaid-covered service provided to a presumptively eligible individual;
or
2. May elect to reimburse in the
same manner or amount as the department reimburses for a Medicaid-covered
service provided to a presumptively eligible individual.
(2) Covered services for a
presumptively-eligible:
(a) Pregnant woman
shall be limited to ambulatory prenatal care services delivered in an
outpatient setting and shall include:
1.
Services furnished by a primary care provider, including:
a. A family or general
practitioner;
b. A
pediatrician;
c. An
internist;
d. An obstetrician or
gynecologist;
e. A physician
assistant;
f. A certified nurse
midwife; or
g. An advanced practice
registered nurse;
5. Emergency room services provided in
accordance with
907 KAR 10:014;
6. Emergency and nonemergency transportation
provided in accordance with
907 KAR 1:060;
8. Services delivered by rural health clinics
provided in accordance with
907 KAR 1:082;
9. Services delivered by primary care
centers, federally-qualified health centers, and federally-qualified health
center look-alikes provided in accordance with
907 KAR 1:054; or
10. Primary care services delivered by local
health departments provided in accordance with
907 KAR 1:360; or
(b) Individual who is not a
pregnant woman shall include:
1. Services
furnished by a primary care provider, including:
a. A family or general
practitioner;
b. A
pediatrician;
c. An
internist;
d. An obstetrician or
gynecologist;
e. A physician
assistant;
f. A certified nurse
midwife; or
g. An advanced practice
registered nurse;
5. Emergency room services provided in
accordance with
907 KAR 10:014;
6. Emergency and nonemergency transportation
provided in accordance with
907 KAR 1:060;
8. Services delivered by rural health clinics
provided in accordance with
907 KAR 1:082;
9. Services delivered by primary care
centers, federally-qualified health centers, and federally-qualified health
center look-alikes provided in accordance with
907 KAR 1:054;
10. Primary care services delivered by local
health departments provided in accordance with
907 KAR 1:360; or
11. Inpatient or outpatient hospital services
provided by a hospital.
Section 6. Appeal Rights.
(1) The appeal rights of the Medicaid Program
shall not apply if an individual is:
(a)
Determined not to be presumptively eligible; or
(b) Determined to be presumptively eligible
but fails to file an application for Medicaid with the DCBS before the
individual's presumptive eligibility ends and therefore loses presumptive
eligibility at the end of the presumptive eligibility period.
(2) The appeal rights of the
Medicaid Program shall apply if an individual is:
(a) Determined to be presumptively eligible;
and
(b) Files an application with
the DCBS but is determined ineligible for Medicaid benefits.
(3) Except as specified in
subsection (1) of this section, an appeal of a negative action taken by the
department regarding a Medicaid recipient shall be in accordance with:
(a)
907 KAR 1:563 if the individual
is:
1. Not enrolled with a managed care
organization; or
2. Enrolled with a
managed care organization and the individual has exhausted the MCO internal
appeal process in accordance with
907 KAR 17:010 and requests an
appeal of an adverse decision by the MCO; or
(b)
907 KAR 17:010 if the individual
is enrolled with a managed care organization.
(4) Except as specified in subsection (1) of
this section, an appeal of a negative action taken by the department regarding
Medicaid eligibility of an individual shall be in accordance with
907 KAR 1:560.
(5) An appeal of a negative action regarding
a Medicaid provider shall be in accordance with
907 KAR 1:671.
Section 7. Quality Assurance and
Utilization Review.
(1) The cabinet shall
evaluate, on a continuing basis, access, continuity of care, health outcomes,
and services arranged or provided by a Medicaid provider to a presumptively
eligible individual in accordance with accepted standards of practice for
medical service.
(2) A hospital's
determination that an individual does not meet criteria for presumptive
eligibility shall be consistent with
KRS
205.5375 and Section 2 of this administrative
regulation.
Section 8.
Department Established Training and Presumptive Eligibility Form.
(1)
(a) As
required by KRS
205.5375, and in collaboration with the
Kentucky Hospital Association and each academic medical center, the department
shall institute and conduct a training at least once every twelve (12) months
that addresses current state and federal laws related to presumptive
eligibility for all qualified hospitals.
(b) The training may include a component that
demonstrates and clarifies use of the most current presumptive eligibility
application form that is designated by the department for use by the qualified
hospitals.
(c)
1. The training required pursuant to this
subsection shall be available in an on-demand format for review by all
interested qualified hospital staff.
2. At the request of the department, the
Kentucky Hospital Association, or any of the academic medical centers the
training may also be conducted virtually or in-person.
3. The most current on-demand version of the
training shall be hosted on the department's Web site at:
(2) The
department, in consultation with the Kentucky Hospital Association and any
academic medical center, shall establish a comprehensive and thorough
presumptive eligibility application form for use by each qualified hospital
when making presumptive eligibility determinations.
(a) The form shall be:
1. Updated within thirty (30) days of a
relevant or substantial change in applicable state and federal law relating to
presumptive eligibility;
2. A
current and comprehensive document that assists a hospital contractor,
employee, or volunteer in completing and making an accurate determination
relating to the presumptive eligibility status of an individual; and
3. Available on the department's Web site at:
(3)
(a) In accordance with
KRS
205.5375(2)(a), the
department, in consultation with the Kentucky Hospital Association and any
academic medical center, shall establish a notification form for a qualified
hospital to use to notify the department, or designee, of a determination that
an individual is presumptively eligible for Medicaid.
(b) The form shall be:
1. Updated within thirty (30) days of a
relevant or substantial change in applicable state and federal law relating to
notifications of presumptive eligibility; and
(4) The department and
a qualified hospital shall observe appropriate privacy and confidentiality
standards of state and federal law, including 45 C.F.R. Part
164 , in
transmitting a completed form that is determined to contain protected health
information. This may include:
(a) Use of
encrypted email;
(b) Use of other
encrypted electronic file transfer systems; or
(c) Any other department approved secure
method of sharing personally identifiable health information that is allowable
pursuant to state and federal law.
Section 9. Incorporation by Reference.
(1) "Presumptive Eligibility Hospital Patient
Information Form", February 2023, 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, Frankfort, Kentucky 40621, Monday
through Friday, 8 a.m. to 4:30 p.m. or at
www.chfs.ky.gov/agencies/dms/Pages/default.aspx.