Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
42
C.F.R. 440.40,
440.60,
447 Subpart B,
42 U.S.C.
1396a -d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has 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 Medicaid Program
reimbursement provisions and requirements for vision services provided to a
Medicaid recipient who is not enrolled in a managed care organization.
Section 1. Definitions.
(1) "CPT code" means a code used for
reporting procedures and services performed by medical practitioners and
published annually by the American Medical Association in Current Procedural
Terminology.
(2) "Department" means
the Department for Medicaid Services or its designee.
(3) "Enrollee" means a recipient who is
enrolled with a managed care organization.
(4) "Federal financial participation" is
defined by
42 C.F.R.
400.203.
(5) "Healthcare Common Procedure Coding
System" or "HCPCS" means a collection of codes acknowledged by the Centers for
Medicare and Medicaid Services (CMS) that represents procedures or
items.
(6) "Managed care
organization" means an entity for which the Department for Medicaid Services
has contracted to serve as a managed care organization as defined in
42
C.F.R. 438.2.
(7) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(8) "Ophthalmic dispenser" means an
individual who is qualified to engage in the practice of ophthalmic dispensing
in accordance with
KRS 326.030 or
326.040.
(9) "Optometrist" means an individual who is
licensed as an optometrist in accordance with KRS Chapter 320.
(10) "Provider" is defined by
KRS
205.8451(7).
(11) "Recipient" is defined by
KRS
205.8451(9).
(12) "Usual and customary charge" means the
uniform amount the provider charges in the majority of cases for the service or
item.
Section 2. General
Requirements.
(1) For the department to
reimburse for a vision service or item, the requirements established in
907
KAR 1:632 and this administrative regulation shall be
met.
(2)
(a) If a procedure is part of a comprehensive
service, the department shall:
1. Not
reimburse separately for the procedure; and
2. Reimburse one (1) payment representing
reimbursement for the entire comprehensive service.
(b) A provider shall not bill the department
multiple procedures or procedural codes if one (1) CPT code or HCPCS code is
available to appropriately identify the comprehensive service
provided.
(3)
(a) If a provider receives any duplicate
payment or overpayment from the department, regardless of reason, the provider
shall return the payment to the department.
(b) Failure to return a payment to the
department in accordance with paragraph (a) of this subsection may be:
1. Interpreted to be fraud or abuse;
and
2. Prosecuted in accordance
with applicable federal or state law.
(4) The department shall not reimburse for:
(a) A service with a CPT code that is not
listed on the Department for Medicaid Services Vision Program Fee Schedule;
or
(b) An item with an HCPCS code
that is not listed on the Department for Medicaid Services Vision Program Fee
Schedule.
Section
3. Reimbursement for Covered Procedures and Materials for
Optometrists.
(1) Except for a clinical
laboratory service, the department's reimbursement for a covered service or
covered item provided by a participating optometrist shall be the lesser of
the:
(a) Optometrist's usual and customary
charge for the service or item; or
(b) Reimbursement established on the
Department for Medicaid Services Vision Program Fee Schedule for the service or
item.
(2) The department
shall reimburse for a covered clinical laboratory service in accordance with
907
KAR 1:028.
Section 4. Maximum Reimbursement for Covered
Procedures and Materials for Ophthalmic Dispensers. The department's
reimbursement for a covered service or covered item provided by a participating
ophthalmic dispenser shall be the lesser of the:
(1) Ophthalmic dispenser's usual and
customary charge for the service or item; or
(2) Reimbursement established on the
Department for Medicaid Services Vision Program Fee Schedule for the service or
item.
Section 5.
Reimbursement Limitations.
(1) The department
shall not reimburse for:
(a) A telephone
consultation;
(b) Contact lenses,
except as established in
907
KAR 1:632, Section 5(1);
(c) Safety glasses unless proof of medical
necessity is documented;
(d) A
press-on prism; or
(e) A service
with a CPT code or item with an HCPCS code that is not listed on the Department
for Medicaid Services Vision Program Fee Schedule.
(2)
(a) The
department shall reimburse for no more than one (1) pair of eyeglasses per
recipient per calendar year unless:
1. The
recipient's eyeglasses are broken or lost during the calendar year;
or
2. The eyeglass prescription for
the recipient is changed during the calendar year.
(b) If an event referenced in paragraph (a)1
or 2 of this subsection occurs within the calendar year, the department shall
reimburse for one (1) additional pair of eyeglasses for the recipient during
the calendar year.
(3) A
prism, if medically necessary, shall be included in the cost of
lenses.
Section 6. Third
Party Liability.
(1) Nonduplication of
payments and third-party liability shall be in accordance with
907 KAR
1:005.
(2)
A provider shall comply with
KRS
205.622.
Section 7. Not Applicable to Managed Care
Organizations. A managed care organization shall not be required to reimburse
the same amount as established in this administrative regulation for an item or
service reimbursed by the department via this administrative
regulation.
Section 8. Federal
Approval and Federal Financial Participation. The department's reimbursement
for services pursuant to this administrative regulation shall be contingent
upon:
(1) Receipt of federal financial
participation for the reimbursement; and
(2) Centers for Medicare and Medicaid
Services' approval for the reimbursement.
Section 9. Appeal Rights. A provider may
appeal a department decision as to the application of this administrative
regulation in accordance with
907
KAR 1:671.
Section
10. Incorporation by Reference.
(1) "Department for Medicaid Services Vision
Program Fee Schedule", May 13, 2014, is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, 275 East Main Street, Frankfort, Kentucky, Monday through
Friday, 8 a.m. to 4:30 p.m. or online at the department's Web site at
http://www.chfs.ky.gov/dms/incorporated.htm.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)
