RELATES TO:
KRS
205.520
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has a 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 the Medicaid Program
coverage provisions and requirements regarding occupational therapy services,
physical therapy services, and speech-language pathology services provided to
Medicaid recipients who are not enrolled with a managed care organization and
by adult day health care programs, rehabilitation agencies, special health
clinics, mobile health services, multi-therapy agencies, and comprehensive
outpatient rehabilitation facilities.
Section
1. Provider Participation. To be eligible to provide and be
reimbursed for services covered under this administrative regulation, a
provider shall meet the requirements established in
907 KAR 8:040.
Section 2. Reimbursement.
(1) To be reimbursable under this
administrative regulation, a service shall meet the coverage requirements
established in
907 KAR 8:040.
(2) The department shall reimburse:
(a) 63.75 percent of the rate listed on the
current Kentucky-specific Medicare Physician Fee Schedule for a service
provided by:
1. An occupational
therapist;
2. A physical therapist;
or
3. A speech-language
pathologist; or
(b) 37.5
percent of the rate listed on the current Kentucky-specific Medicare Physician
Fee Schedule for a service provided by:
1. An
occupational therapy assistant;
2.
A physical therapist assistant; or
3. A speech-language pathology clinical
fellow.
(3)
(a) The current Kentucky-specific Medicare
Physician Fee Schedule shall be the Kentucky-specific Medicare Physician Fee
Schedule used by the Centers for Medicare and Medicaid Services on the date
that the service is provided.
(b)
For example, if an occupational therapy service is provided on a date when the
Centers for Medicare and Medicaid Services':
1. Interim Kentucky-specific Medicare
Physician Fee Schedule for a given year is in effect, the reimbursement for the
service shall be the amount established on the interim Kentucky-specific
Medicare Physician Fee Schedule for the year; or
2. Final Kentucky-specific Medicare Physician
Fee Schedule for a given year is in effect, the reimbursement for the service
shall be the amount established on the final Kentucky-specific Medicare
Physician Fee Schedule for the year.
(4) The unit amount for a given service shall
be as established in the corresponding:
(a)
Current procedural terminology code for the service; or
(b) Healthcare common procedure coding system
code for the service or item.
Section 3. Not Applicable to Managed Care
Organizations. A managed care organization shall not be required to reimburse
in accordance with this administrative regulation for a service covered
pursuant to:
(2) This administrative
regulation.
Section 4.
Federal Approval and Federal Financial Participation. The department's coverage
of services pursuant to 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 for the coverage.
Section 5. Appeals. A provider may appeal an
action by the department as established in accordance with
907 KAR 1:671.
