Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
205.622,
205.8451(7),
(9), Chapter 320, Chapter 326, 326.030,
326.040, 369.101 to 369.120, 42 C.F.R. 400.203,
431.17,
438.2,
440.40,
440.60,
447 Subpart B,
45 C.F.R.
147.126, Parts
160 and
164,
164.306,
164.316,
42 U.S.C. 1320d to 1320d-8,
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 the Kentucky
Medicaid Program provisions and requirements regarding the coverage of vision
services.
Section 1. Definitions.
(1) "Current procedural terminology code" or
"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) "Medicaid basis" means a scenario in
which:
(a) A provider provides a service to a
recipient as a Medicaid-participating provider in accordance with:
1.
907 KAR 1:671; and
2.
907 KAR 1:672;
(b) The Medicaid Program is the
payer for the service; and
(c) The
recipient is not liable for payment to the provider for the service.
(8) "Medically necessary" or
"medical necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(9) "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.
(10) "Optometrist" means an individual who is
licensed as an optometrist in accordance with KRS Chapter 320.
(11) "Provider" is defined by
KRS
205.8451(7).
(12) "Recipient" is defined by
KRS
205.8451(9).
Section 2. General Requirements
and Conditions of Participation.
(1)
(a) For the department to reimburse for a
vision service or item, the service or item shall be:
1. Provided:
a. To a recipient; and
b. By a provider who is:
(i) Enrolled in the Medicaid Program pursuant
to 907 KAR 1:672;
(ii) Except as provided in paragraph (b) of
this subsection, currently participating in the Medicaid Program pursuant to
907 KAR 1:671; and
(iii) Authorized by this administrative
regulation to provide the given service or item;
2. Covered in accordance with this
administrative regulation;
3.
Medically necessary;
4. A service
or item authorized within the scope of the provider's licensure; and
5. A service or item listed on the Kentucky
Medicaid Vision Fee Schedule.
(b) In accordance with
907 KAR 17:015, Section 3(3), a
provider of a service to an enrollee shall not be required to be currently
participating in the fee-for-service Medicaid Program.
(2)
(a) To
be recognized as an authorized provider of vision services, an optometrist
shall:
1. Be licensed by the:
a. Kentucky Board of Optometric Examiners;
or
b. Optometric examiner board in
the state in which the optometrist practices if the optometrist practices in a
state other than Kentucky;
2. Submit to the department proof of
licensure upon initial enrollment in the Kentucky Medicaid Program;
and
3. Annually submit to the
department proof of licensure renewal including the expiration date of the
license and the effective date of renewal.
(b)
1. To
be recognized as an authorized provider of vision services, an in-state
optician shall:
a. Hold a current license in
Kentucky as an ophthalmic dispenser;
b. Comply with the requirements established
in KRS Chapter 326;
c. Submit to
the department proof of licensure upon initial enrollment in the Kentucky
Medicaid Program; and d. Annually submit to the department proof of licensure
renewal including the expiration date of the license and the effective date of
renewal.
2. To be
recognized as an authorized provider of vision services, an out-of-state
optician shall:
a. Hold a current license in
the state in which the optician practices as an ophthalmic dispenser;
b. Submit to the department proof of
licensure upon initial enrollment in the Kentucky Medicaid Program;
and
c. Annually submit to the
department proof of licensure renewal including the expiration date of the
license and the effective date of renewal.
(c) A physician shall be an authorized
provider of vision services.
(3) A provider shall comply with:
(a)
907 KAR 1:671;
(b)
907 KAR 1:672;
(c) All applicable state and federal laws;
and
(d) The confidentiality of
personal records pursuant to 42 U.S.C. 1320d to
1320d-8 and
45 C.F.R. Parts 160 and
164.
(4)
(a) A provider shall:
1. Have the freedom to choose whether to
provide services to a recipient; and
2. Notify the recipient referenced in
paragraph (b) of this subsection of the provider's decision to accept or not
accept the recipient on a Medicaid basis prior to providing any services to the
recipient.
(b) A
provider may provide a service to a recipient on a non-Medicaid basis:
1. If the recipient agrees to receive the
service on a non-Medicaid basis; and
2. The service is not a Medicaid covered
service.
Section 3. Vision Service Coverage.
(1) Vision service coverage shall be limited
to a service listed with a CPT code or item with an HCPCS code on the Kentucky
Medicaid Vision Fee Schedule as available at:
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
(2) Vision service limits shall be as
established on the Kentucky Medicaid Vision Fee Schedule as available at:
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
(3) Vision service limits may be exceeded by
prior authorization for children under twenty-one (21) if medically
necessary.
Section 4.
Coverage of Eyeglasses and Frames.
(1) To be
eligible for eyeglasses covered by the department, a recipient shall have a
diagnosed visual condition that:
(a) Requires
the use of eyeglasses;
(b) Is
within one (1) of the following categories:
1.
Amblyopia;
2. Post surgical eye
condition;
3. Diminished or
subnormal vision; or
4. Other
diagnosis which indicates the need for eyeglasses; and
(c) Requires a prescription correction in the
stronger lens no weaker than:
1. +0.50, 0.50
sphere +0.50, or 0.50 cylinder;
2.
0.50 diopter of vertical prism; or
3. A total of two (2) diopter of lateral
prism.
(2)
Provisions regarding any limit on the number of eyeglasses covered shall be as
established in
907 KAR 1:631.
(3) For the department to cover:
(a) A frame, the frame shall be:
1. First quality;
2. Free of defects;
3. Deluxe; and
4. Have a manufacturer warranty of at least
one (1) year; or
(b) A
lens, the lens shall be:
1. First
quality;
2. Free of
defects;
3. Meet the United States
Food and Drug Administration's impact resistance standards;
4. Polycarbonate and scratch coated;
and
5. If medically necessary,
inclusive of prisms.
(4) The dispensing of eyeglasses shall
include:
(a) Single vision
prescriptions;
(b) Bi-focal vision
prescriptions;
(c) Multi-focal
vision prescriptions;
(d)
Progressive lens prescriptions;
(e)
Services to frames; or
(f) Delivery
of the completed eyeglasses which shall include:
1. Instructions in the use and care of the
eyeglasses; and
2. Any adjustment,
minor or otherwise, for a period of one (1) year.
(5) A provider shall be
responsible, at no additional cost to the department or the recipient, for:
(a) An inaccurately filled
prescription;
(b) Defective
material; or
(c) An improperly
fitted frame.
Section
5. Contact Lenses, Tint, and Plano Safety Glasses.
(1) The department shall reimburse for
contact lenses substituted for eyeglasses if a medical indication prevents the
use of eyeglasses.
(2) The
department's reimbursement for contact lenses shall include disposable daily
contact lenses.
(3) The department
shall not reimburse for tint unless the prescription specifically indicates a
diagnosis of photophobia.
(4) The
department shall not reimburse for plano safety glasses unless the glasses are
medically indicated for the recipient.
Section 6. Noncovered Services or Items. The
department shall not reimburse for:
(1)
Tinting if not medically necessary;
(2) Photochromics if not medically
necessary;
(3) Anti-reflective
coatings if not medically necessary;
(4) Other lens options which are not
medically necessary;
(5) Low vision
services;
(6) A press-on prism if
not medically necessary; or
(7) A
service with a CPT code or item with an HCPCS code that is not listed on the
Kentucky Medicaid Vision Fee Schedule.
Section 7. Required Provider Documentation.
(1)
(a) In
accordance with 42 C.F.R.
431.17, a provider shall maintain medical
records of a service provided to a recipient for the period of time currently
required by the United States Health and Human Services Secretary unless the
department requires a retention period, pursuant to
907 KAR 1:671, longer than the
period required by the United States Health and Human Services
Secretary.
(b) If, pursuant to
907 KAR 1:671, the department
requires a medical record retention period longer than the period required by
the United States Health and Human Services Secretary, the medical record
retention period established in
907 KAR 1:671 shall be the
minimum record retention period.
(c) A provider shall maintain medical records
of a service provided to a recipient in accordance with:
1.
45 C.F.R.
164.316; and
2.
45 C.F.R.
164.306.
(2) A provider shall maintain the following
documentation in a recipient's medical record:
(a) Any covered service or covered item
provided to the recipient;
(b) For
each covered service or covered item provided to the recipient:
1. A signature by the individual who provided
the service or item signed on the date the service or item was
provided;
2. The date that the
service or item was provided; and
3. Demonstration that the covered service or
covered item was provided to the recipient;
(c) The diagnostic condition necessitating
the service or item; and
(d) The
medical necessity as substantiated by an appropriate medical order.
Section 8. No
Duplication of Service.
(1) The department
shall not reimburse for a service provided to a recipient by more than one (1)
provider of any program in which the service is covered during the same time
period.
(2) For example, if a
recipient is receiving a speech-language pathology service from a
speech-language pathologist enrolled with the Medicaid Program, the department
shall not reimburse for the same service provided to the same recipient during
the same time period via the physician services program.
Section 9. Third Party Liability. A provider
shall comply with KRS 205.622.
Section 10. Auditing Authority. The
department shall have the authority to audit any claim, medical record, or
documentation associated with the claim or medical record.
Section 11. Use of Electronic Signatures.
(1) The creation, transmission, storage, and
other use of electronic signatures and documents shall comply with the
requirements established in
KRS
369.101 to
369.120.
(2) A provider that chooses to use electronic
signatures shall:
(a) Develop and implement a
written security policy that shall:
1. Be
adhered to by each of the provider's employees, officers, agents, or
contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the provider's
electronic signature policy;
2. The
signed consent form; and
3. The
original filed signature.
Section 12. 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 13. Appeal Rights. An appeal of a
department decision regarding a Medicaid recipient who is:
(1) Enrolled with a managed care organization
shall be in accordance with
907 KAR 17:010; or
(2) Not enrolled with a managed care
organization shall be in accordance with
907 KAR 1:563.
Section 14. Incorporation by
Reference.
(1) "Kentucky Medicaid Vision Fee
Schedule", April 2023, 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
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
Section 15. This administrative
regulation has been found deficient by the Administrative Regulation Review
Subcommittee on May 9, 2023.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
42 C.F.R.
441.30,
42 C.F.R.
441.56(c)(1)