RELATES TO: 42 C.F.R. 441 Subparts B, G,
42 U.S.C.
1396a,
1396b,
1396d,
1396n
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, is required 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 Medicaid Program
reimbursement requirements and provisions for home and community based waiver
services version 2.
Section 1.
Definitions.
(1) "ADHC" means adult day
health care.
(2) "ADHC center"
means an adult day health care center that is:
(b) Certified for Medicaid participation by
the department.
(3)
"Department" means the Department for Medicaid Services or its
designee.
(4) "Fixed upper payment
limit" means the maximum amount the department shall reimburse per
unit.
(5) "HCB" means home and
community based waiver.
(6)
"Participant" means a recipient who:
(a) Meets
the nursing facility level of care criteria established in
907 KAR 1:022; and
(b) Meets the eligibility criteria for HCB
services established in
907 KAR
7:010.
(7) "Recipient" is defined by
KRS
205.8451(9).
Section 2. HCB Service Reimbursement.
(1)
(a)
Except as provided in Section 3, 4, or 5 of this administrative regulation, the
department shall reimburse for a home and community based waiver service or
item at the lesser of the billed charges or the fixed upper payment limit for
each unit.
(b) The fixed upper
payment limits, unit amounts, and reimbursement maximums established in the
following table shall apply:
Service
|
Fixed Upper Payment Limit
|
Unit Amount
|
Maximum
|
PDS coordination
|
$162.50 per unit
|
|
Two (2) units per month
|
Case management
|
$100.00
|
One (1) month
|
One (1) unit per month
|
Attendant care not as a PDS
|
$24.00 per hour
|
One (1) hour
|
$200 per day alone or in combination with ADHC
services. Travel to and from the participant's residence shall be
excluded
|
Home and community supports
|
$2.88 per unit
|
Fifteen (15) minutes
|
Forty-five (45) hours per week; Maximum of $200 per
day alone or in combination with ADHC services; Travel to and from the
participant's residence shall be excluded
|
Non-specialized respite
|
$2.75 per unit
|
Fifteen (15) minutes
|
$200 per day alone or in combination with specialized
respite. Non-specialized respite alone or in combination with specialized
respite shall not exceed $4,000 per level of care year.
|
Goods and services
|
$3,500 per level of care year
|
Level of care year
|
$3,500 per level of care year; shall not be covered
unless prior authorized
|
Home delivered meals
|
$7.50 per hot meal
|
One (1) hot meal
|
One (1) hot meal per day and five (5) hot meals per
week
|
Adult day health care services
|
$2.83 per unit for Level I services; $3.43 per unit
for Level II services except for specialized respite, which shall be $10.00 per
unit for Level II
|
Fifteen (15) minutes
|
200 units per week
|
Specialized respite
|
$4.00 per unit for Level I; $10.00 per unit for Level
II
|
Fifteen (15) minutes
|
$200 per day alone or in combination with
non-specialized respite. Specialized respite alone or in combination with
non-specialized respite shall not exceed $4,000 per level of care year.
|
Environmental or minor home adaptation
|
$2,500 per level of care year
|
One (1) level of care year
|
$2,500 per level of care year; shall not be covered
unless prior authorized
|
(2)
(a)
Reimbursement for a service provided as a PDS shall not exceed the department's
allowed reimbursement for the same service as established in the table in
subsection (1) of this section.
(b)
Participants receiving services through the PDS option shall have three (3)
months from the date of level of care recertification to comply with the
reimbursement limit established in paragraph (a) of this subsection.
(3)
(a) Three (3) quotes from a prospective
provider shall be required for:
1. An
environmental or minor home adaptation; or
2. Goods and services.
(b) Documentation justifying the need for the
following shall be uploaded into the MWMA:
1.
An environmental or minor home adaptation; or
2. Goods and services.
(4) A service listed in subsection
(1) of this section shall not be subject to cost settlement by the department
unless provided by a local health department.
Section 3. Local Health Department HCB
Service Reimbursement.
(1) The department
shall reimburse a local health department for HCB services:
(a) Pursuant to Section 2 of this
administrative regulation; and
(b)
Equivalent to the local health department's HCB services cost for a fiscal
year.
(2) A local health
department shall:
(a) Each year complete a
Home Health and Home and Community Based Cost Report completed in accordance
with the Home Health and Home and Community Based Cost Reporting Instructions;
and
(b) Submit the Home Health and
Home and Community Based Cost Report to the department at fiscal year's
end.
(3) The department
shall determine, based on a local health department's most recently submitted
annual Home Health and Home and Community Based Cost Report, the local health
department's estimated costs of providing HCB services by multiplying the cost
per unit by the number of units provided during the period.
(4) If a local health department's HCB
service reimbursement for a fiscal year is less than its cost, the department
shall make supplemental payment to the local health department equal to the
difference between:
(a) Payments received for
HCB services provided during a fiscal year; and
(b) The estimated cost of providing HCB
services during the same time period.
(5) If a local health department's HCB
service cost as estimated from its most recently submitted annual Home Health
and Home and Community Based Cost Report is less than the payments received
pursuant to Section 2 of this administrative regulation, the department shall
recoup any excess payments.
(6) The
department shall audit a local health department's Home Health and Home and
Community Based Cost Report if it determines an audit is necessary.
Section 4. Reimbursement for an
ADHC Service.
(1) Reimbursement for an ADHC
service shall:
(a) Be made:
1. Directly to an ADHC center; and
2. For a service only if the service was
provided on site and during an ADHC center's posted hours of
operation;
(b) If made to
an ADHC center for a service not provided during the center's posted hours of
operation, be recouped by the department; and
(c) Be limited to 200 units per calendar week
per participant.
(2)
Level I reimbursement shall be the lesser of:
(a) The provider's usual and customary
charges; or
(b) Two (2) dollars and
eighty-three (83) cents per unit of service.
(3)
(a)
Except as established in paragraph (b) of this subsection, Level II
reimbursement shall be the lesser of:
1. The
provider's usual and customary charges; or
2. Three (3) dollars and forty-three (43)
cents per unit of service.
(b)
1. The
department shall pay a Level II reimbursement for specialized respite provided
by a:
a. Registered nurse; or
b. Licensed practical nurse under the
supervision of a registered nurse.
2. The Level II reimbursement for specialized
respite shall be the lesser of:
a. The ADHC
center's usual and customary charges; or
b. Ten (10) dollars per unit of
service.
(c) An
ADHC center's reimbursement for Level II services shall be:
1. Per participant; and
2. Based upon the participant's assessed
level of care and most recent person-centered service plan.
(4) An ADHC basic daily
service shall constitute care for one (1) participant.
(5) One (1) unit of ADHC basic daily service
shall equal fifteen (15) minutes.
(6) The level of and reimbursement rate for
any ADHC service provided to a participant shall be determined by an assessment
of the participant using the Kentucky Home Assessment Tool (K-HAT).
Section 5. Criteria for High
Intensity Level II Reimbursement and Home Health Level II Reimbursement.
(1) Any ADHC service provided to a
participant by an ADHC center shall qualify for Level II reimbursement if the
participant meets the Level II High Intensity criteria established in the
Kentucky Home Assessment Tool (K-HAT).
(2)
(a)
Specialized respite care provided to a participant by a home health agency
shall qualify for Level II reimbursement if:
1. The participant meets the Level II High
Intensity criteria established in the Kentucky Home Assessment Tool (K-HAT);
and
2. Provided by a:
a. Registered nurse; or
b. Licensed practical nurse under the
supervision of a registered nurse.
(b) The Level II reimbursement for
specialized respite provided by a home health agency shall be the reimbursement
established in Section 4(3)(b) of this administrative
regulation.
(3) If a
participant's assessment determines that:
(a)
ADHC services to the participant do not qualify for Level II reimbursement, the
department shall reimburse the Level I rate to the ADHC center for services
provided to the participant; or
(b)
Specialized respite care to the participant does not qualify for Level II
reimbursement, the department shall reimburse the Level I rate to the ADHC
center or home health agency for the specialized respite care
service.
Section
6. Applicability. The reimbursement provisions and requirements
established in this administrative regulation shall:
(1) Apply to services or items provided to
individuals who receive home and community based services version 2 pursuant to
907 KAR 7:010; and
(2) Not apply to services or items provided
to individuals receiving home and community based services version 1 pursuant
to
907 KAR
1:160.
Section 7. Appeal Rights. An HCB service
provider may appeal a department decision as to the application of this
administrative regulation as it impacts the provider's reimbursement in
accordance with
907 KAR 1:671, Sections 8 and
9.
Section 8. Incorporation by
Reference.
(1) The following material is
incorporated by reference:
(a) "Kentucky Home
Assessment Tool (K-HAT)", July 1, 2015;
(b) "The Home Health and Home and Community
Based Cost Report", November 2007; and
(c) "The Home Health and Home and Community
Based Cost Report Instructions", November 2007.
(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 40601, Monday through Friday, 8 a.m.
to 4:30 p.m.; or