RELATES TO:
KRS
205.520(3)
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 Medicaid program
service and coverage policies and requirements regarding specialty intermediate
care clinic services.
Section 1.
Definitions.
(1) "1915(c) home and community
based services waiver program" means a Kentucky Medicaid program established
pursuant to and in accordance with
42 U.S.C.
1396n(c).
(2) "Audiologist" is defined by
KRS
334A.020(5).
(3) "Behavior Analyst Certification Board"
means the nonprofit corporation:
(a)
Established in 1998; and
(b) Known
as the Behavior Analyst Certification Board, Inc.
(4) "Board certified behavior analyst" means
an individual who is currently certified by the Behavior Analyst Certification
Board as a certified behavior analyst.
(5) "Clinical laboratory" means a medical
laboratory pursuant to
KRS
333.020(3).
(6) "Department" means the Department for
Medicaid Services or its designee.
(7) "Developmental disability" means a severe
chronic disability which:
(a) Is attributable
to a mental or physical impairment or combination of mental and physical
impairments manifested before the person attains the age of twenty-two
(22);
(b) Is likely to continue
indefinitely;
(c) Results in
substantial limitations in three (3) or more areas of major life activity
including:
1. Self-care;
2. Receptive and expressive
language;
3. Learning;
4. Self direction;
5. Mobility; and
6. Capacity for independent living and
economic sufficiency; and
(d) Requires individually planned and
coordinated services of a lifelong or extended duration.
(8) "Enrollee" means an individual who is
enrolled with a managed care organization for the purposes of receiving
Medicaid program or KCHIP program covered services.
(9) "Epileptologist" means a physician who
specializes in treating patients who have epilepsy.
(10) "Federal financial participation" is
defined in
42 C.F.R.
400.203.
(11) "Functional assessment" means an
assessment performed using evidenced-based tools, direct observation, and
empirical measurement to obtain and identify functional relations between
behavioral and environmental factors.
(12) "Intellectual disability" means an
individual has:
(a) Sub-average intellectual
functioning;
(b) An intelligence
quotient of seventy (70) or below;
(c) Concurrent deficits or impairments in
present adaptive functioning in at least two (2) of the following areas:
1. Communication;
2. Self-care;
3. Home living;
4. Social or interpersonal skills;
5. Use of community resources;
6. Self-direction;
7. Functional academic skills;
8. Work;
9. Leisure; or
10. Health and safety; and
(d) Had an onset prior to eighteen
(18) years of age.
(13)
"Licensed psychological associate" means an individual who is currently
licensed in accordance with
KRS
319.064.
(14) "Licensed psychological practitioner"
means an individual who is currently licensed in accordance with
KRS
319.053.
(15) "Licensed psychologist" means an
individual who is currently licensed in accordance with
KRS
319.050.
(16) "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.
(17) "Medically necessary" means determined
by the department to be needed in accordance with
907
KAR 3:130.
(18) "Mental illness" is defined by
KRS
210.005(2).
(19) "Neurologist" means a physician who
specializes in neurology.
(20)
"Occupational therapist" is defined by
KRS
319A.010(3).
(21) "Occupational therapist assistant" is
defined by
KRS
319A.010(4).
(22) "Ophthalmic dispenser" means an
individual licensed to perform ophthalmic dispensing in accordance with
KRS
326.030.
(23) "Ophthalmic dispensing" is defined by
KRS
326.010(2).
(24) "Physical therapist" is defined by
KRS
327.010(2).
(25) "Physical therapist assistant" means a
skilled health care worker who:
(a) Is
certified by the Kentucky Board of Physical Therapy; and
(b) Performs physical therapy and related
duties as assigned by the supervising physical therapist.
(26) "Physical therapy" is defined by
KRS
327.010(1).
(27) "Physician" is defined by
KRS
311.550(12).
(28) "Physician services" means the practice
of medicine or osteopathy provided by a physician.
(29) "Positive behavior support specialist"
means an individual who:
(a) Provides:
1. Evidence-based individual interventions
that assist a recipient with acquiring or maintaining skills for community
living; and
2. Behavioral
intervention to reduce maladaptive behaviors;
(b) Has a master's degree in a behavioral
science and one (1) year of experience in behavioral programming; and
(c) Has at least one (1) year of direct
services with individuals with an intellectual or developmental
disability.
(30)
"Practice of medicine or osteopathy" is defined by
KRS
311.550(11).
(31) "Practice of psychology" is defined by
KRS
319.010(6).
(32) "Psychiatrist" is defined by
KRS
504.060(8).
(33) "Psychological services" means the
practice of psychology.
(34)
"Psychotropic medication" means a medication that is prescribed to treat the
symptoms of a psychiatric disorder.
(35) "Recipient" is defined by
KRS
205.8451(9).
(36) "Rural health clinic" is defined by
42 C.F.R.
405.2401(b).
(37) "Specialty intermediate care clinic" or
"specialty IC clinic" means a clinic licensed pursuant to
902 KAR
20:410.
(38) "Speech-language pathologist" is defined
by
KRS
334A.020(3).
Section 2. Conditions of Participation. A
specialty intermediate care clinic service shall be provided by an individual:
(1) Employed by a specialty intermediate care
clinic; or
(2) Working for a
specialty intermediate care clinic via a contractual agreement.
Section 3. Eligible Population.
(1) To be eligible to receive specialty IC
clinic services, an individual shall:
(a) Be a
recipient:
(b) Have a mental
illness, intellectual disability, or developmental disability; and
(c) Meet the patient status criteria
established in:
(2)
(a) A
recipient shall be eligible to receive services stated in Section 5 of this
administrative regulation:
1. In accordance
with the requirements established in Section 5 of this administrative
regulation if the recipient is:
a. Eligible
in accordance with subsection (1) of this section;
b. Receiving services via:
(i) A 1915(c) home and community services
waiver program; or
(ii) An
intermediate care facility for individuals with an intellectual disability;
and
2. Not
enrolled with a managed care organization; or
3. In accordance with Section 6(3) of this
administrative regulation.
(b) A recipient shall be eligible to receive
services stated in Section 6 of this administrative regulation and in
accordance with the requirements established in Section 6 of this
administrative regulation if the recipient is:
1. Eligible in accordance with subsection (1)
of this section;
2. Not receiving
services via:
a. A 1915(c) home and community
services waiver program; or
b. An
intermediate care facility for individuals with an intellectual disability;
and
3. Enrolled with a
managed care organization.
Section 4. General Requirements Regarding
Services.
(1)
(a) The department shall:
1. Reimburse for a specialty IC clinic
service if the service was:
a. Medically
necessary; and
b. Provided:
(i) By a specialty IC clinic; and
(ii) To an individual who is eligible to
receive specialty IC clinic services pursuant to Section 3(1) and either
Section 3(2)(a) or 6(3) of this administrative regulation; or
2. Not reimburse for a
specialty intermediate care clinic service if the service does not:
a. Meet the criteria established in
subparagraph 1. of this paragraph; or
b. Comply with subsection (2) of this section.
(b) A managed care organization
shall:
1. Reimburse for a specialty IC clinic
service if the service was:
a. Medically
necessary; and
b. Provided:
(i) By a specialty IC clinic; and
(ii) To an individual who is eligible to
receive specialty IC clinic services pursuant to Section 3(1) and (2)(b) of
this administrative regulation; or
2. Not reimburse for a specialty intermediate
care clinic service if the service does not:
a. Meet the criteria established in
subparagraph 1 of this paragraph; or
b. Comply with subsection (2) of this
section.
(2) Services provided at a specialty IC
clinic shall comply with the requirements established in
42 C.F.R.
440.90.
Section 5. Specialty Intermediate Care Clinic
Services for Recipients Who are Not Enrolled with a Managed Care Organization.
The following shall be the covered specialty intermediate care clinic services
for an individual who is not enrolled with a managed care organization and who
is eligible in accordance with Section 3(1) and (2)(a) of this administrative
regulation:
(1) Dental services provided:
(a) By an authorized practitioner in
accordance with
907
KAR 1:026; and
(2) Psychiatric services provided by a:
(a) Psychiatrist or physician in accordance
with the psychiatric service limit established in
907 KAR
3:005; or
(b) Advanced practice registered nurse in
accordance with the psychiatric service limit established in
907
KAR 1:104;
(3) Psychological services provided by a
licensed psychologist, licensed psychological practitioner, or licensed
psychological associate;
(4)
Psychotropic medication management provided by an advanced practice registered
nurse, physician, or psychiatrist;
(5) Neurology services provided by a
neurologist;
(6) Epileptology
services provided by an epileptologist;
(7) Preventive health care;
(8) Primary and sub-specialist medical
assessment and treatment;
(9)
Occupational therapy provided:
(a) By an
occupational therapist or occupational therapist assistant; and
(b) In accordance with the limits and
requirements established in Section 6 of this administrative
regulation;
(10) Physical
therapy provided:
(a) By a physical therapist
or physical therapist assistant; and
(b) In accordance with the limits and
requirements established in Section 6 of this administrative
regulation;
(11) Speech
therapy provided:
(a) By a speech-language
pathologist; and
(b) In accordance
with the limits and requirements established in Section 6 of this
administrative regulation;
(12) Nutritional or dietary
consultation;
(13) Mobility
evaluation or treatment;
(14)
Positive behavioral support services which shall:
(a) Be the systematic application of
techniques and methods to influence or change a behavior in a desired
way;
(b) Be provided to assist a
recipient to learn a new behavior that is directly related to existing
challenging behaviors or a functionally equivalent replacement behavior for
identified challenging behaviors;
(c) Include a functional assessment of the
recipient's behavior which shall include:
1.
An analysis of the potential communicative intent of the behavior;
2. The history of reinforcement for the
behavior;
3. The critical variables
that preceded the behavior;
4. The
effects of different situations on the behavior; and
5. A hypothesis regarding the motivation,
purpose, and factors which maintain the behavior;
(d) Include the development of a positive
behavioral support plan which shall:
1. Be
developed by a behavioral support specialist:
2. Be implemented by staff in all relevant
environments and activities;
3. Be
revised as necessary at least once every six (6) months;
4. Define the techniques and procedures
used;
5. Be designed to equip the
recipient to communicate his or her needs and to participate in age-appropriate
activities;
6. Include the
hierarchy of behavior interventions ranging from the least to the most
restrictive;
7. Reflect the use of
positive behavioral approaches; and
8. Prohibit the use of prone or supine
restraint, corporal punishment, seclusion, verbal abuse, or any procedure which
denies private communication, requisite sleep, shelter, bedding, food, drink,
or use of a bathroom facility;
(e) Include the provision of competency-based
training to other providers concerning implementation of the positive
behavioral support plan;
(f)
Include the monitoring of a recipient's progress which shall be accomplished
through:
1. The analysis of data concerning
the frequency, intensity, and duration of behavior; and
2. The reports of a provider involved in
implementing the positive behavioral support plan;
(g) Provide for the design, implementation,
and evaluation of systematic environmental modifications;
(h) Be provided by a behavioral support
specialist; and
(i) Be documented
by a detailed staff note which shall include:
1. The date of the service;
2. The beginning and end time; and
3. The signature, date of signature, and
title of the behavior support specialist;
(15) Audiology provided by an audiologist and
in accordance with the following:
(a) The
limits established in
907
KAR 1:038 for services provided to an individual under
the age of twenty-one (21) years shall be the limits for audiology services
provided in a specialty intermediate care clinic regardless of the recipient's
age; and
(b) The restriction
established in
907
KAR 1:038 of not covering audiology services for an
individual who is at least twenty-one (21) years of age shall not apply to
audiology services provided in a specialty intermediate care clinic;
(16) Ophthalmic dispensing
provided by an ophthalmic dispenser;
(18) Medication consultation;
(19) Medication management;
(20) Seizure management;
(21) Diagnostic services;
(22) Clinical laboratory services;
(23) Physician services in accordance with
the limits and requirements established in
907 KAR
3:005; or
(24) Laboratory services in accordance with
the limits and requirements established in
907
KAR 1:028.
Section 6. Specialty Intermediate Care Clinic
Services for Recipients Who are Enrolled with a Managed Care Organization.
(1) The following shall be the covered
specialty intermediate care clinic services for an individual who is enrolled
with a managed care organization and who is eligible in accordance with Section
3(1) and (2)(b) of this administrative regulation:
(a) Dental services provided in accordance
with
907
KAR 1:026 except that a dentist who is employed by or
under contract with a specialty IC clinic shall be authorized to provide the
services;
(b) Physician services
provided in accordance with
907 KAR
3:005 except that:
1. A physician who is employed by or under
contract with a specialty IC clinic shall be authorized to provide the
services; or
2. An advanced
practice registered nurse who is employed by or under contract with a specialty
IC clinic shall be authorized to provide the services;
(c) Psychiatric services provided in
accordance with
907 KAR
3:005 except that:
1.
A psychiatrist who is employed by or under contract with a specialty IC clinic
shall be authorized to provide the services;
2. A physician who is employed by or under
contract with a specialty IC clinic shall be authorized to provide the
services; or
3. An advanced
practice registered nurse who is employed by or under contract with a specialty
IC clinic shall be authorized to provide the services;
(d) Behavioral health services in accordance
with:
1.
907
KAR 1:054 except that:
a. A clinical psychologist who is employed by
or under contract with a specialty IC clinic shall be authorized to provide the
services; or
b. An advanced practice
registered nurse who is employed by or under contract with a specialty IC
clinic shall be authorized to provide the services;
2.
907
KAR 1:082 except that:
a. A clinical psychologist who is employed by
or under contract with a specialty IC clinic shall be authorized to provide the
services; or
b. An advanced practice
registered nurse who is employed by or under contract with a specialty IC
clinic shall be authorized to provide the services; or
3.
907
KAR 1:044 except:
a.
That:
(i) A clinical psychologist who is
employed by or under contract with a specialty IC clinic shall be authorized to
provide the services;
(ii) A
psychiatrist who is employed by or under contract with a specialty IC clinic
shall be authorized to provide the services; or
(iii) An advanced practice registered nurse
who is certified in the practice of mental health nursing and who is employed
by or under contract with a specialty IC clinic shall be authorized to provide
services as established in subsection (2)(b) of this section;
and
b. For the following
which shall not be covered if provided by a specialty IC clinic:
(i) Inpatient services;
(ii) Therapeutic rehabilitation services for
adults;
(iii) Therapeutic
rehabilitation services for children; or
(iv) Services in a detoxification
setting;
(e) Audiology services provided in accordance
with
907
KAR 1:038 except that an audiologist who is employed
by or under contract with a specialty IC clinic shall be authorized to provide
the services;
(f) Ophthalmic
dispensing provided by an ophthalmic dispenser in accordance with
907
KAR 1:038 except that an ophthalmologist who is
employed by or under contract with a specialty IC clinic shall be authorized to
provide the services;
(g) A
prescribed drug covered in accordance with
907 KAR
23:010 except that a pharmacist who is employed by or
under contract with a specialty IC clinic shall be authorized to provide the
services;
(h) Preventive health
care in accordance with
907 KAR
3:005 except that:
1. A physician who is employed by or under
contract with a specialty IC clinic shall be authorized to provide the
services; or
2. An advanced
practice registered nurse who is employed by or under contract with a specialty
IC clinic shall be authorized to provide the services;
(i) Occupational therapy in accordance with
907 KAR
3:005 except that an:
1. Occupational therapist who is employed by
or under contract with a specialty IC clinic shall be authorized to provide the
services; or
2. Occupational
therapy assistant who is employed by or under contract with a specialty IC
clinic shall be authorized to provide the services;
(j) Physical therapy in accordance with
907 KAR
3:005 except that a:
1. Physical therapist who is employed by or
under contract with a specialty IC clinic shall be authorized to provide the
services; or
2. Physical therapist
assistant who is employed by or under contract with a specialty IC clinic shall
be authorized to provide the services;
(k) Speech therapy in accordance with
907 KAR
3:005 except that a speech language pathologist who is
an employee of or under contract with a specialty IC clinic shall be authorized
to provide the services;
(l)
Diagnostic services in accordance with 907 KAR
1:014,
907
KAR 1:054,
907
KAR 1:082, or
907 KAR
3:005 except that:
1.
A physician who is employed by or under contract with a specialty IC clinic
shall be authorized to provide the services; or
2. An advanced practice registered nurse who
is employed by or under contract with a specialty IC clinic shall be authorized
to provide the services; or
(m) Laboratory services in accordance with
907
KAR 1:028 except that if a specialty IC clinic's
laboratory does not meet the requirements of
907
KAR 1:028, the specialty IC clinic shall be authorized
to provide the services via a contractual relationship with a laboratory which
meets the requirements of
907
KAR 1:028.
(2)
(a) The
use of prone or supine restraint, corporal punishment, seclusion, verbal abuse,
or any procedure which denies private communication, requisite sleep, shelter,
bedding, food, drink, or use of a bathroom facility shall be prohibited for any
behavioral health service.
(b) In
accordance with
907
KAR 1:044, an advanced practice registered nurse who
is certified in the practice of mental health nursing and who is employed by or
under contract with a specialty IC clinic shall be authorized to provide:
1. Chemotherapy services if the APRN meets
the requirements of
201
KAR 20:057, Section 2(1) and Sections 6(1) to (3);
or
2. Psychiatric evaluations and
testing if the APRN meets the requirements of
201
KAR 20:057, Section
2(1).
(3) The
department, rather than a managed care organization, shall reimburse for a
service that is:
(a)
1. Listed in Section 5 of this administrative
regulation; and
2. Not covered by a
managed care organization for an individual who is:
a. Eligible for the service in accordance
with Sections 3(1), (2)(b), and 4 of this administrative regulation; and
b. Enrolled with a managed care
organization; or
(b)
1.
Needed in excess of the limit for the service established in this
section;
2. Within the limit for
the service established in Section 5 of this administrative
regulation;
3. Medically necessary
as determined by the department pursuant to
907
KAR 3:130; and
4. For an individual who is:
a. Eligible for the service in accordance
with Sections 3(1), (2)(b), and 4 of this administrative regulation; and
b. Enrolled with a managed care
organization.
(4) In addition to other services, the
following shall be included in the scope of physician services:
(a) Neurology;
(b) Epileptology;
(c) Primary and sub-specialist medical
assessment and treatment;
(d)
Nutritional or dietary consultation;
(e) Mobility evaluation or
treatment;
(f) Medication
consultation;
(g) Medication
management; and
(h) Seizure
management.
Section
7. Therapy Limits.
(1) To be
reimbursable by the department, occupational therapy, physical therapy, or
speech therapy shall be limited to thirty (30) visits per twelve (12) months
for a recipient except as established in subsection (2) of this
section.
(2) The therapy limits
established in subsection (1) of this section shall:
(a) Not apply to a recipient under twenty-one
(21) years of age; and
(b) Be
overridden by the department if the department determines that an additional
visit or visits beyond the limit are medically necessary.
Section 8. No Duplication of
Service.
(1) The department shall reimburse
no more than one (1) provider for the provision of a given service to a
recipient on a given day.
(2) There
shall be no duplicate billing to the department regarding a given service
provided to a recipient on a given day.
Section 9. Federal Financial Participation. A
policy 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 policy; or
(2) Disapproves
the policy.
Section 10.
Appeal Rights.
(1) An appeal of a department
decision regarding a Medicaid recipient based upon an application of this
administrative regulation shall be in accordance with
907
KAR 1:563.
(2) An appeal of a department decision
regarding a Medicaid provider based upon an application of this administrative
regulation shall be in accordance with
907
KAR 1:671.