RELATES TO:
KRS
309.460-309.464,
369.101-369.120
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
194A.030(2) requires the
Cabinet for Health and Family Services, Department for Medicaid Services 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. KRS
205.648 requires DMS to seek a state plan
amendment and implement covered services on behalf of community health workers.
This administrative regulation establishes community health worker services and
reimbursement.
Section 1. Definitions.
(1) "Certified community health worker" is
defined by KRS
309.460(2).
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "Medical intervention":
(a) Means a treatment, procedure, or other
action taken to prevent or treat disease, or improve health in other ways;
and
(b) Includes, but does not
require the direct application of medical care.
(4) "Ordering provider" means a provider that
is employed by or contracted with a sponsoring provider and who is:
(a) A physician;
(b) A physician assistant;
(c) An advanced practice registered nurse,
including a certified nurse midwife;
(d) A dentist;
(e) An optometrist; or
(f) Any other clinician type included by the
department.
(5)
"Sponsoring provider":
(a) Means a provider
listed or permitted to employ a certified community health worker pursuant to
KRS
205.648(2); and
(b)
1.
Includes a behavioral health multi-specialty group; or
2. Any other provider or facility that has
been approved pursuant to
KRS
205.648(2)(b)
10.
Section
2. Certified Community Health Worker Qualifications. In order to
be eligible for reimbursement, a certified community health worker shall:
(1) Be a legal United States
resident;
(2) Be employed as a
certified community health worker in the state of Kentucky;
(3) Be at least eighteen (18) years of
age;
(4) Meet and maintain the
certification or recertification requirements of
902 KAR 21:040;
(5) Provide services as approved by an
ordering provider who is associated with a sponsoring provider; and
(6) Provide services on behalf of a
sponsoring provider.
Section
3. Community Health Worker Services.
(1) A community health worker service shall
be related to a medical intervention that is outlined in the individual's care
plan.
(2) Community health worker
services shall include all services established within
KRS
205.648(3)(a)-(e).
(3) Consistent with federal approval, the
following services may be conducted by a certified community health worker. Any
services provided shall be consistent with established or recognized healthcare
standards:
(a) Health system navigation and
resource coordination, which may include:
1.
Helping a recipient find Medicaid providers to receive a covered
service;
2. Helping a recipient
make an appointment for a Medicaid covered service;
3. Arranging transportation to a medical
appointment;
4. Attending an
appointment with the recipient for a covered service; or
5. Helping a recipient find other relevant
community resources such as support groups.
(b) Health promotion and coaching, which may
include providing information or training to recipients that make positive
contributions to their health status, such as:
1. Cessation of tobacco use;
2. Reduction in the misuse of alcohol or
drugs;
3. Improvement in
nutrition;
4. Improvement of
physical fitness;
5. Family
planning;
6. Control of stress;
or
7. Pregnancy and infant care,
including prevention of fetal alcohol syndrome.
(c) Health education and training to train or
promote to recipients methods and measures that have been proven effective in
avoiding illness or lessening its effects, including:
1. Immunizations;
2. Control of high blood pressure;
3. Control of sexually transmittable
disease;
4. Prevention and control
of diabetes;
5. Control of toxic
agents;
6. Occupational safety and
health; or
7. Accident
prevention.
Section 4. Ordering and Delivery of Community
Health Worker Services. Community health worker services shall be:
(1) Ordered or approved by an ordering
provider; and
(2) Delivered
according to a care plan approved by the ordering provider.
Section 5. Documentation of
Community Health Worker Services. Community health worker services shall be:
(1) Signed and documented by the certified
community health worker;
(2)
Approved by the ordering provider of the sponsoring provider; and
(3) Recorded and kept in the patient medical
record.
Section 6.
Reimbursement for Community Health Worker Services. Reimbursement for community
health worker services shall be via appropriate codes that comply with relevant
existing rate methodologies utilized by the department and established by state
and federal law. As appropriate, billing and reimbursement information shall be
included in the Medicaid Physician Fee Schedule established in
907 KAR 3:010, available at:
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
Section 7. There shall not be reimbursement
under this administrative regulation available for a certified community health
worker:
(1) If performing a specific service
that is funded by a federal grant, and only for that specific federally
grant-funded service; or
(2) That
is directly employed by a managed care organization.
Section 8. A community health worker service,
by itself, shall not generate a wrap payment, including wrap payments for the
following provider types:
(1) Federally
qualified health center (FQHC);
(2)
Rural health clinic (RHC); or
(3)
Certified community behavioral health clinic (CCBHC).
Section 9. Use of Electronic Signatures. 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.
Section 10. Auditing Authority. The
department or the managed care organization in which an enrollee is enrolled
may audit any:
(1) Claim;
(2) Medical record; or
(3) Documentation associated with any claim
or medical record.
Section
11. Federal Approval and Federal Financial Participation. The
coverage provisions and requirements established in this administrative
regulation shall be contingent upon:
(1)
Receipt of federal financial participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval of the coverage.
Section 12. Appeal Rights. An appeal of a
department decision or adverse action regarding a Medicaid recipient who is:
(1) Enrolled with a managed care organization
shall be in accordance with
907 KAR 17:010; or
(2) Not enrolled with a managed care
organization shall be in accordance with
907 KAR
1:563.