RELATES TO:
KRS
205.520,
205.560
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
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 policies and
requirements regarding the Department for Medicaid Services' enhanced
reimbursement for certain preventive services and wellness services provided to
Medicaid recipients who are not enrolled with a managed care
organization.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
"APRN" is defined by
KRS
314.011(7).
(2) "Currently enrolled with the Medicaid
Program" means:
(a) Currently enrolled with
the Medicaid Program pursuant to
907
KAR 1:672; and
(b) Currently participating with the Medicaid
Program pursuant to
907
KAR 1:671.
(3) "Department" means the Department for
Medicaid Services or its designee.
(4) "Federal financial participation" is
defined by
42 C.F.R.
400.203.
(5) "Managed care organization" or "MCO"
means an entity for which the Department for Medicaid Services has contracted
to serve as a managed care organization as defined in
42
C.F.R.
438.2.
(6) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(7) "Physician" is defined by
KRS
311.550(12).
(8) "Physician assistant" is defined by
KRS
311.840(3).
(9) "Provider group" means a group of at
least:
(a) Two (2) individually licensed
physicians who:
1. Are currently enrolled with
the Medicaid Program individually and as a group; and
2. Share the same Medicaid group provider
number;
(b) Two (2)
individually licensed APRNs who:
1. Are
currently enrolled with the Medicaid Program individually and as a group;
and
2. Share the same Medicaid
group provider number; or
(c) At least one (1) APRN and at least one
(1) physician who:
1. Are currently enrolled
with the Medicaid Program individually and as a group; and
2. Share the same Medicaid group provider
number.
(10)
"Recipient" is defined in
KRS
205.8451(9).
Section 2. Qualifying Requirements. To
qualify as a service to be reimbursed at the amount established on the Medicaid
Preventive and Wellness Enhanced Fee Schedule, the service shall:
(1) Be medically necessary;
(2) Meet the criteria established for the
service on the Medicaid Preventive and Wellness Enhanced Fee Schedule;
and
(3) Be provided:
(a) To a recipient who is not enrolled with a
managed care organization; and
(b)
By:
1. A physician who is:
a. Currently enrolled with the Medicaid
Program; or
b. Participating with a
provider group that is currently enrolled with the Medicaid Program;
2. An APRN who is:
a. Currently enrolled with the Medicaid
Program; or
b. Participating with a
provider group that is currently enrolled with the Medicaid Program;
or
3. A physician
assistant who is employed by or under contract with:
a. A physician who is currently enrolled with
the Medicaid Program;
b. An APRN
who is currently enrolled with the Medicaid Program; or
c. A provider group that is currently
enrolled with the Medicaid Program.
Section 3.
Enhanced Reimbursement for Preventive and Wellness Services.
(1) The department shall reimburse for a
preventive or wellness service listed on the Medicaid Preventive and Wellness
Enhanced Fee Schedule:
(a) If the service
meets the qualifying requirements established in Section 2 of this
administrative regulation;
(b) In
accordance with the requirements and limits established on the Medicaid
Preventive and Wellness Enhanced Fee Schedule; and
(c) The amount corresponding to the service
as listed on the Medicaid Preventive and Wellness Enhanced Fee
Schedule.
(2) The
department's reimbursement referenced in subsection (1)(c) of this section
shall:
(a) Apply to services rendered from
January 1, 2015 through June 30, 2016; and
(b) Not apply to services rendered July 1,
2016 going forward.
Section
4. Auditing Authority. The department shall have the authority to
audit any:
(1) Claim;
(2) Medical record; or
(3) Documentation associated with any claim
or medical record.
Section
5. Not Applicable to Managed Care Organizations. A managed care
organization shall not be required to implement the reimbursement established
in this administrative regulation.
Section
6. 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 7. Supersede. If any reimbursement
provision stated in
907 KAR
3:010 or
907
KAR 1:104 contradicts a provision stated in this
administrative regulation or in the Medicaid Preventive and Wellness Enhanced
Fee Schedule, the provision stated in this administrative regulation or in the
Medicaid Preventive and Wellness Enhanced Fee Schedule shall supersede the
provision stated in
907 KAR
3:010 or
907
KAR 1:104.
Section
8. Incorporation by Reference.
(1) The "Medicaid Preventive and Wellness
Enhanced Fee Schedule", April 2015, is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky, Monday through Friday, 8:00 a.m. to
4:30 p.m.; or