RELATES TO:
KRS
205.520(3),
205.560(1)(j),
42 U.S.C.
1396r-8(d)
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 a requirement that may be
imposed, or opportunity presented, by federal law for the provision of medical
assistance to Kentucky's indigent citizenry.
KRS
205.560(1)(j) authorizes the
department to cover smoking cessation treatment interventions or programs. This
administrative regulation establishes the department's coverage and
reimbursement of tobacco cessation services.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
"APRN" is defined by
KRS
314.011(7).
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "FDA" means the United States Food and
Drug Administration.
(4) "Federal
financial participation" is defined by
42 C.F.R.
400.203.
(5) "Legend drug" means a drug:
(a) Defined by the United States Food and
Drug Administration as a legend drug; and
(b) Required to bear the statement: "Caution:
Federal law prohibits dispensing without prescription."
(6) "Medically necessary" means that a
covered benefit is determined by the department 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) "Recipient" is defined by
KRS
205.8451(9).
(10) "Supervising physician" is defined by
KRS
311.840(4).
(11) "Tobacco cessation medication" means:
(a) Nicotine replacement therapy:
1. Gum;
2. Lozenge;
3. Patch;
4. Inhaler; or
5. Spray; or
(b) A legend drug approved by the United
States Food and Drug Administration for tobacco cessation.
Section 2. Provider Requirements
for a Tobacco Cessation Assessment. A tobacco cessation assessment provider
shall be:
(1) A physician who is:
(a) Enrolled in the Medicaid Program pursuant
to
907
KAR 1:672; and
(b) Currently participating in the Medicaid
Program pursuant to
907
KAR 1:671;
(2) A physician assistant working under the
supervision of a supervising physician who is:
(a) Enrolled in the Medicaid Program pursuant
to
907
KAR 1:672; and
(b) Currently participating in the Medicaid
Program pursuant to
907
KAR 1:671;
(3) An APRN who is:
(a) Enrolled in the Medicaid Program pursuant
to
907
KAR 1:672; and
(b) Currently participating in the Medicaid
Program pursuant to
907
KAR 1:671; or
(4) Any of the following employed by a local
health department:
(a) A physician assistant
working under the supervision of a supervising physician;
(b) A physician; or
(c) An APRN.
Section 3. Tobacco Cessation Assessment and
Referral.
(1) The department shall reimburse
for a tobacco cessation assessment if:
(a)
The tobacco cessation assessment is provided:
1. By a provider listed in Section 2 of this
administrative regulation; and
2.
To a recipient; and
(b)
The department receives, from the provider, the completed Tobacco Cessation
Referral Form corresponding to the assessment.
(2) A tobacco cessation assessment shall:
(a) Be performed over a period of at least
ten (10) minutes;
(b) Be performed
face-to-face with the recipient;
(c) Include:
1. Asking the recipient about tobacco
use;
2. Advising the recipient to
quit using tobacco;
3. Assessing
the recipient's readiness to quit using tobacco;
4. Compiling a tobacco usage, medical, and
psychosocial history of the recipient;
5. Incorporating a review of the recipient's
coping skills and barriers to quitting; and
6. The provider's obtaining of a signed and
dated Tobacco Cessation Referral Form from the recipient declaring the
recipient's intent to quit using tobacco; and
(d) Be conducted once per course of
treatment.
(3)
(a) A provider shall complete a Tobacco
Cessation Referral Form with the recipient in accordance with the instructions
on the form.
(b) A provider and
recipient shall:
1. Choose one (1) of the
following tobacco cessation programs for the recipient:
a. The Cooper/Clayton Method;
b. Freedom from Smoking Online;
c. Kentucky's Tobacco Quitline;
d. GetQUIT Plan;
h. Another program designed to
offer support for tobacco cessation;
2. Determine that the recipient does not
require a support program; or
3.
Determine that a hardship exists that prevents the recipient from accessing a
tobacco cessation support program.
(c) The provider shall denote on the Tobacco
Cessation Referral Form the decision made by the provider and recipient
pursuant to paragraph (b) of this subsection.
(4) A provider shall:
(a) Submit a completed Tobacco Cessation
Referral Form to the department in accordance with the instructions on the
form; and
(b) Give a copy of the
completed Tobacco Cessation Referral Form to the recipient; and
(c) Maintain, for at least six (6) years from
the date a Tobacco Cessation Referral Form was completed, a:
1. Paper copy of the Tobacco Cessation
Referral Form; or
2. Readily
accessible electronically formatted copy of the Tobacco Cessation Referral
Form.
(5) The
department shall reimburse for no more than two (2) tobacco cessation
assessments per recipient per calendar year.
(6) If a recipient has a hardship which is
not revealed or denoted during an assessment, the department may:
(a) Determine that a hardship exists;
and
(b) Exempt the recipient from
the requirement to participate in a tobacco cessation program.
Section 4. Tobacco
Cessation Medication.
(1) If a physician,
APRN, or physician assistant working under a supervising physician as specified
in Section 2 of this administrative regulation prescribes a medically necessary
tobacco cessation medication for a recipient, the physician, APRN, or physician
assistant shall prescribe:
(a) An initial one
(1) month supply of the medication; and
(b) Up to two (2) refills of the
medication.
(2) The
department shall reimburse for a refill of a medication referenced in
subsection (1) of this section for a recipient if the requirements established
in this subsection are met.
(a) For a
recipient who is not participating in a tobacco cessation program:
1. The department shall have received, from
the provider or the recipient, a completed Tobacco Cessation Referral Form
corresponding to the recipient's assessment; and
2. The recipient shall have contacted the
department and requested the refill.
(b) For a recipient who is participating in a
tobacco cessation program:
1. The department
shall have received, from the provider or the recipient, a completed Tobacco
Cessation Referral Form corresponding to the recipient's assessment;
and
2. The recipient shall:
a. For the first refill:
(i) Have participated in the first month of a
tobacco cessation program; and
(ii)
Contacted the department to request a refill and to express the intent to
continue participating in the tobacco cessation program; or
b. For the second refill:
(i) Have participated in the second month of
a tobacco cessation program; and
(ii) Contacted the department to request a
refill and to express the intent to continue participating in the tobacco
cessation program.
Section 5. Tobacco Cessation Reimbursement.
(1) The department shall reimburse for a
tobacco cessation medication provided to a recipient if:
(a) The medication is:
1. Medically necessary;
2. Approved by the FDA for tobacco
cessation;
3. Prescribed for the
recipient in accordance with Section 4 of this administrative regulation;
and
4. If subject to prior
authorization, prior authorized by the department; and
(b) For a refill, the recipient has met the
requirements established in Section 4(2) of this administrative
regulation.
(2) The
department shall reimburse for no more than two (2) simultaneous tobacco
cessation medications.
(3) The
department shall reimburse for a tobacco cessation medication in accordance
with
907 KAR
1:018.
(4)
Reimbursement for a tobacco cessation medication shall be limited to two (2)
courses of treatment per recipient per calendar year.
(5) The department shall reimburse for a
tobacco cessation assessment provided by:
(a)
A physician, in accordance with
907 KAR
3:010, Section 2(2)(b);
(b) A physician assistant, in accordance with
907 KAR
3:010, Section 3(6) and (7)(a); or
Section
6. Reporting Requirements.
(1) A
recipient shall:
(a) Upon the department's
request, provide information to the department regarding the recipient's
success or failure at tobacco cessation as a result of receiving a service
reimbursed by the department; or
(b) Upon the provider's request, provide
information to the provider regarding the recipient's success or failure at
tobacco cessation as a result of receiving a service reimbursed by the
department.
(2) A
provider shall, upon the department's request, provide information to the
department in accordance with
907
KAR 1:672.
Section 7. Cost Sharing Exemption for Tobacco
Cessation Medications. The department shall not impose cost sharing for any
tobacco cessation medication prescribed for tobacco cessation purposes and
referenced in this administrative regulation.
Section 8. Federal Financial Participation. A
provision established in this administrative regulation shall be null and void
if the Centers for Medicare and Medicaid Services:
(1) Denies federal financial participation
for the provision; or
(2)
Disapproves the provision.
Section
9. Appeal. An appeal of a department decision regarding a Medicaid
recipient based upon an application of this administrative regulation shall be
conducted in accordance with
907
KAR 1:563.
Section
10. Incorporation by Reference.
(1) The "Tobacco Cessation Referral Form",
January 2011 edition, 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. and is also available at
http://www.chfs.ky.gov/dms/incorporated.htm.