RELATES TO:
KRS
205.6481 - 205.6497, 211.461 - 211.466,
281.010(25), 304.5-040, 304.17A-005(8), (14),
42 C.F.R.
435.403,
440.230, Part
457,
42 U.S.C.
1396,
1397aa,
9902(2)
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
205.6485 authorizes the cabinet, by
administrative regulations, to establish the Kentucky Children's Health
Insurance Program (KCHIP) to provide health care coverage and other coordinated
health care services to participant children of the Commonwealth who are
uninsured and otherwise not eligible for health insurance coverage. This
administrative regulation establishes the KCHIP Phase III eligibility criteria,
quality assurance and utilization review, covered services, the approval
process, grievance and appeal rights, and the requirements for delivery of
health services for providers who wish to participate with the Commonwealth to
provide health care coverage for KCHIP Phase III members through the provision
of a separate health insurance program under Title XXI.
Section 1. Definitions.
(1) "Cabinet" means the Kentucky Cabinet for
Health and Family Services or its designee.
(2) "Creditable coverage" is defined by
KRS
304.17A-005(8)(a) 1 through
3 and 5 through 10.
(3)
"Department" means the Department for Medicaid Services or its
designee.
(4) "Excepted benefits"
is defined by KRS
304.17A-005(14).
(5) "Health insurance" is defined by
KRS
304.5-040.
(6) "KCHIP" means the Kentucky Children's
Health Insurance Program in accordance with
42 U.S.C.
1397aa through
42 U.S.C.
1397jj.
Section 2. Eligibility Criteria.
(1) An individual shall be eligible for KCHIP
Phase III if the individual is a pregnant person who:
(a) Is a resident of Kentucky meeting the
conditions for determining state residency under
42 C.F.R.
435.403;
(b) Is an immigrant who is lawfully
present;
(c) Is not an inmate of a
public institution or a patient in an institution for mental
diseases;
(e)
1. Has
family income that does not exceed 213 percent of the federal poverty
guidelines updated annually in the Federal Register by the United States
Department of Health and Human Services under the authority of
42 U.S.C.
9902(2). A five (5) percent
income disregard shall be available consistent with the following:
a. If an eligibility determination indicates
that an individual's income exceeds 213 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), the
department shall apply an additional cushion of five (5) percent of the federal
poverty level toward the eligibility determination for the individual as
established pursuant to 42
U.S.C.
1396a(e)(14)(I)(i);
and
b. If after the five (5)
percent adjustment, the individual's income is under the adjusted income
threshold, the individual shall meet the modified adjusted gross income
standard;
2. Does not
have creditable coverage and may be covered by excepted benefits;
3. Provides to the department the information
required in Section 4(4) of this administrative regulation; and
4. Meets the continuing eligibility
requirements established in
907 KAR 20:010, Section
2.
(2) A
pregnant person's federal poverty level calculation pursuant to
42 U.S.C.
9902(2) shall be at least
two (2) and shall include the pregnant person and any unborn children of the
pregnant person. Other members of the household shall be calculated and
included consistent with KAR Title 907.
(3)
(a)
Eligibility for KCHIP Phase III shall be determined by the
department.
(b) Upon receipt of the
eligibility information established in subsection (1) of this section, the
department shall determine if a participant is eligible for benefits pursuant
to 42 U.S.C.
1396 or
1397bb.
Section 3. Covered Services.
(1) Health services shall be considered as
medically necessary in accordance with:
(2) The amount and duration of benefits
covered by KCHIP Phase III shall be as established in Title 907 KAR.
(3) A medical service shall be covered
through KCHIP Phase III if the individual is determined eligible for KCHIP
benefits in accordance with Section 2 of this administrative
regulation.
(4) Preventive and
remedial public health services shall be provided to KCHIP Phase III members in
accordance with
907 KAR 1:360.
(5) KCHIP Phase III shall be the payor of
last resort.
Section 4.
KCHIP Phase III Approval Process. The following information shall be required
from a participant or responsible party for KCHIP Phase III enrollment:
(1) A participant's demographics that shall
include:
(a) Name;
(b) Address;
(c) Sex;
(d) Date of birth;
(e) Race; and
(f) Social Security number;
(2) Monthly gross earned income,
if any, of a parent and a participant, for whom information is being submitted,
an employer type and address, if any, and frequency of income;
(3) The name and address of a health
insurance provider who currently provides creditable coverage;
(4) The creditable coverage policy number,
policy holder's name, Social Security number, and individuals covered by the
plan;
(5) Unearned income, if any,
received weekly, biweekly, bimonthly, quarterly, or annually;
(6) The name and age of a participant or
disabled adult for whom care is purchased in order for a parent or responsible
person to work; and
(7) The
signature, date, and telephone number of the person submitting the information
for a participant.
Section
5. Provider Participation Requirements. A provider's enrollment,
disclosure, and documentation for participation in KCHIP Phase III shall meet
the requirements established in:
Section 6. Complaint, Grievance and Appeal
Rights.
(1) If dissatisfied with an action
taken by the cabinet, the participant, the participant's parent, or the
participant's guardian shall be entitled to a complaint, grievance, or appeal
with the cabinet to be conducted in accordance with:
(2) If a service is provided by a managed
care organization, a dispute resolution between a provider and a participant,
the participant's parent, or the participant's guardian shall be in accordance
with:
(a)
KRS
211.461 through
211.466; and
(3) A KCHIP Phase III eligible
participant or a responsible party shall be informed in writing of the right to
and procedures for due process by the cabinet:
(a) At the time information to obtain KCHIP
Phase III approval is submitted;
(b) If there is a change in eligibility
status; or
(c) As required by
federal and state laws.
Section 7. Quality Assurance and Utilization
Review. The department shall evaluate the following on a continuing basis:
(1) Access to services;
(2) Continuity of care;
(3) Health outcomes; and
(4) Services arranged or provided as
established in 907 KAR Chapter 17.