Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520(3),
205.560(2),
42 C.F.R.
416.164,
416.166,
416.172,
416.173, Part
441 Subpart E, F, 447.271
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services has responsibility to administer the Medicaid Program pursuant
to KRS
194A.030(2).
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with a requirement that may be
imposed or opportunity presented by federal law for the provision of medical
assistance to Kentucky's indigent citizenry. This administrative regulation
establishes the coverage provisions and method for establishing payment for an
ambulatory surgical center.
Section 1.
Scope of Coverage. The Medicaid Program shall cover medically necessary,
medically appropriate services rendered by a participating ambulatory surgical
center (ASC) licensed by its respective state and certified for Medicare
participation.
Section 2. Basis for
Reimbursement.
(1) Beginning with the
effective date of this administrative regulation, the Department for Medicaid
Services shall determine the ASC rates by:
(a)
Utilizing the most recent January 1 ASC Fee Schedule as published by the
Centers for Medicare and Medicaid Services (CMS) at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html
in accordance with 42 C.F.R.
416.173; and
(b) Adjusting them as follows:
1. Reimbursement for a procedure shall be the
rate specific to that procedure as assigned by CMS, adjusted by the wage index
utilized by CMS for the Cincinnati, OH, Core-Based Statistical Area, or its
equivalent, in accordance with
42 C.F.R.
416.172(c).
2. Procedure codes that are considered a
packaged service by CMS with a Medicare rate of $0 shall be reimbursed at a
rate of $0.
3. Medicaid covered
procedures not included on the Medicare fee schedule shall be reimbursed at
forty-five (45) percent of billed charges.
4. Bilateral procedures shall be reimbursed
at one hundred and fifty (150) percent of the rate established in subparagraphs
1 and 2 of this paragraph.
5.
a. Reimbursement shall follow applicable
Medicare rules for multiple endoscopy discounting and multiple procedure
discounting as established in:
(i) 42 C.F.R.
Part 416 ; and
(ii) The Medicare
Claims Processing Manual, Chapter 14, as published by the Centers for Medicare
and Medicaid Services (CMS) at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs
in accordance with 42 C.F.R.
416.173.
b. If both discounts apply to a single claim,
the multiple endoscopy discount shall be applied first.
(2) Ambulatory surgical
center coverage provisions shall be as established in 42 C.F.R. Part 416 ,
Subpart F, including 42
C.F.R. 416.164 and
416.166.
(3) Reimbursements shall be limited to the
lesser of billed charges or the amount established pursuant to subsection (1)
of this section.
Section
3. Reproductive Services.
(1) A
reproductive service shall be reimbursable if performed in compliance with this
administrative regulation and 42 C.F.R. Part 441 , Subpart E or F, as
relevant.
(2) The appropriate
certification form or forms shall be completed and signed by the physician,
MAP-235, MAP-250, or MAP-251. A copy of the completed form and an operative
report shall accompany each claim submitted for payment.
(3) If a sterilization is performed in
conjunction with another surgical procedure and federal requirements governing
payment for the sterilization in 42 C.F.R. Part 441, Subpart F have not been
met, the department shall only make payment for the covered non-sterilization
procedure.
(4) Claims for
unilateral or laparoscopic surgical procedures that could result in
sterilization shall be submitted with documentation verifying that the
recipient was not sterilized as a result of the performed procedure.
Section 4. Documentation
Requirements.
(1) All services reimbursed by
the department shall be:
(a) Medically
necessary;
(b) Medically
appropriate; and
(c) Related to the
diagnosis or treatment of:
1.
Illness;
2. Injury;
3. Impairment; or
4. Maternity care.
(2) Documentation in recipient
medical records shall support necessity and substantiate the level of service
billed.
(3) Medical necessity shall
be determined in accordance with
907 KAR 3:130.
(4) The department shall have the authority
to audit any:
(a) Claim;
(b) Medical record; or
(c) Documentation associated with any claim
or medical record.
Section
5. Federal Approval and Federal Financial Participation. The
cabinet's coverage and reimbursement of services pursuant to this
administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage and reimbursement; and
(2) Centers for Medicare and Medicaid
Services' approval of the coverage and reimbursement, as relevant.
Section 6. 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 this administrative regulation.
Section 7. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "Certification Form for Induced
Abortion or Induced Miscarriage", MAP-235, February 2000;
(b) "Consent for Sterilization", MAP-250,
April 2022; and
(c) "Hysterectomy
Consent Form", MAP-251, October 2010.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Cabinet for Health and
Family Services, Department for Medicaid Services, 275 East Main Street,
Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)
