Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
216B.020(4), (5)
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
July 9, 2004, reorganized the Cabinet for Health Services and placed the
Department for Medicaid Services and the Medicaid Program under the Cabinet for
Health and Family Services. The Cabinet for Health and Family Services,
Department for Medicaid Services has the responsibility for administering the
Kentucky Medicaid Program in an efficient, cost-effective manner, consonant
with the funds that are available, and consistent with the objectives of the
Program. One (1) of these objectives is for recipients to have reasonable
access to health care and services under the Medicaid Program, taking into
account such factors as geographic location, travel time, choice of providers,
and utilization rates. This administrative regulation establishes the process
and criteria relating to Medicaid participation for dual-licensed acute care
hospital beds that were converted to nursing facility beds pursuant to
KRS
216B.020(4), and supplements
applicable provisions for provider enrollment in Section 2 of
907
KAR 1:672 and the administrative hearing process in
907
KAR 1:671.
Section
1. Definitions.
(1)
"Administrative process" means meeting, review, investigation, hearing, appeal,
deliberation or exchange of documents or information between the provider and
the department.
(2) "Applicant"
means a person or entity who submits an application to become a Medicaid
provider.
(3) "Applicant's
geographic area" means the county in which the applicant's converted
dual-licensed hospital-based nursing facility beds are located and contiguous
Kentucky counties.
(4)
"Application" means a request for Medicaid certification for beds that were
converted to hospital-based nursing facility beds pursuant to
KRS
216B.020(4).
(5) "Certificate of need" is defined in
KRS
216B.015(8).
(6) "Converted" means a bed that was
previously a dual-licensed acute care hospital bed that, pursuant to
KRS
216B.020(4) and (5), changed
a dual-licensed acute care bed to a hospital-based nursing facility bed and is
not presently participating in the Medicaid Program.
(7) "Provider" is defined in
KRS
205.8451(7).
(8) "State Health Plan" is defined in
KRS
216B.015(19).
Section 2. Enrollment Process for Converted
Dual-Licensed Hospital-Based Nursing Facility Beds Participation in Medicaid.
(1) An application for converted
dual-licensed hospital-based nursing facility beds which are not presently
participating in the Medicaid Program, but requesting participation, shall be
submitted to the Commissioner of the Department for Medicaid Services.
(a) The application shall be in writing in
the form, content and manner required by the department in accordance with this
administrative regulation and
907
KAR 1:672. The application shall contain the
following, with pertinent information and supporting documentation:
1. The total number, each room number and bed
designation of:
a. Dual-licensed acute care
beds that were converted to hospital-based nursing facility beds and licensed
pursuant to
KRS
216B.020(4);
b. Converted beds already participating in
Medicaid;
c. Converted
hospital-based nursing facility beds applying for Medicaid certification;
and
d. Licensed hospital-based
nursing facility beds.
2.
Data that demonstrates a need for additional not presently participating
Medicaid certified beds in the applicant's geographic area in accordance with
the factors listed in Section 3 of this administrative regulation;
3. The requested date for Medicaid
certification of the converted beds; and
(b) Information in the application shall be
current, presented clearly and precisely.
(2) The department shall:
(a) Review the application for completeness;
and
(b) Review the notification
from the Division of Licensing and Regulation of the Office of Inspector
General recommending Medicaid certification for the converted beds.
(3) Upon receipt of notification
from the Division of Licensing and Regulation, along with a complete and
accurate application, with all requested documentation, the department shall
determine:
(a) The number of licensed
hospital-based nursing facility beds the applicant has available for
certification; and
(b) Whether the
application establishes a need for additional Medicaid certified beds in the
applicant's geographic area in accordance with Section 3 of this administrative
regulation.
(4) Except as
provided in subsection (9) of this section, the department shall make a
decision regarding the application within thirty (30) days of the receipt of
information specified in subsection (3) of this section. The department shall:
(a) Grant, in whole or in part, the requested
Medicaid certification; or
(b) Deny
the request.
(5) The
department shall notify the applicant, in writing, of the decision, and the
basis for denial if applicable.
(6)
If an applicant wishes to appeal an adverse determination, the appeal shall be
in accordance with Sections 4 and 5 of this administrative
regulation.
(7) Except as provided
in subsection (8) of this section, if an application for Medicaid certification
of converted beds is fully or partially granted and the applicant is not
currently a Medicaid certified nursing facility provider, the applicant shall:
(a) Follow the enrollment procedures
delineated in
907
KAR 1:672; and
(b) Include a copy of the department's
decision granting certification in its enrollment packet.
(8) If the applicant is currently a Medicaid
certified nursing facility provider:
(a) All
converted beds that may be certified by the department shall be included under
the existing provider number; and
(b) The provider shall comply with licensing
requirements established in
902 KAR
20:300 and
902 KAR
20:310.
(9) Subsection (4) of this section shall:
(a) Apply to a request for new participation
in the Medicaid Program; and
(b)
Not apply to a bed previously approved by the
department.
Section
3. Enrollment Criteria for Converted Dual-Licensed Hospital-Based
Nursing Facility Beds Requesting Participation in Medicaid.
(1) Based on data submitted in the
application, relevant factors in the applicant's geographic area shall be
considered to assess the need for Medicaid certification of converted beds and
shall include:
(a) The total number of
free-standing and hospital-based nursing facility beds.
(b) The total number of the following:
1. Medicaid certified nursing facility beds;
and
2. Medicaid certified
hospital-based nursing facility beds;
(c) Survey data reported to the cabinet by
providers for the two (2) calendar years preceding the date of receipt of the
application, and data collected by the cabinet in accordance with
902 KAR
20:008 for licensed nursing facility beds in the
applicant's geographic area relating to:
1.
The occupancy percentage for each of the two (2) preceding calendar years;
and
2. The number of admissions,
discharges or deaths;
(d)
The impact of the cost of the converted beds on the Medicaid budget;
(e) The current State Health Plan "nursing
facility bed need calculations by county and state" maintained by the Cabinet
for Health and Family Services, Office of the Certificate of Need;
and
(f) Other documentation
included in the application that demonstrates the need for Medicaid
certification of a converted bed.
(2) The department may consider the following
when making a determination of need:
(a) The
most current Medicaid nursing facility financial data; and
(b) Other information, including relevant
information that the department may have requested from:
1. The applicant;
2. Another provider in the applicant's
geographic area; or
3. A medical
services trend report.
Section 4. Resolution of Applicant Disputes
Prior to an Administrative Hearing.
(1) If an
applicant disagrees with the department's determination regarding Medicaid
certification, the applicant may:
(a) Request
a resolution meeting pursuant to subsections (2), (3), and (4) of this section;
or
(b) Submit additional
information for consideration in lieu of a request pursuant to subsection (5)
of this section.
(2) A
written request for a resolution meeting shall be received by the Director of
the Department's Division of Long-term Care within thirty (30) calendar days of
the date of the department's notice of decision. The request shall:
(a) Identify the disputed issue or
issues;
(b) State the basis of the
challenge to the department's decision;
(c) Provide documentation supporting the
applicant's position; and
(d) State
the name, address, and telephone number of an individual expected to attend the
resolution meeting on the applicant's behalf.
(3) The department shall, within thirty (30)
calendar days of receipt of a request for resolution meeting, send written
notice to the applicant of the date, time and place of the meeting.
(4) The resolution meeting shall be conducted
by the department in an informal manner. The applicant or the department may
present relevant evidence or testimony at the meeting in support of their
respective positions.
(5) In lieu
of requesting a resolution meeting, an applicant may submit additional
information it wishes the department to consider.
(a) The additional information shall be
received by the department within thirty (30) days of notice of the
department's decision; and
(b) The
submission of additional documentation shall not:
1. Constitute a request for a resolution
meeting; and
2. Extend the thirty
(30) day time period for requesting a resolution meeting.
(6) The department may rescind,
modify or take no action with regard to its initial adverse decision.
(a) The department shall provide written
notice to the provider of the department's decision within thirty (30) calendar
days from:
1. The date of the resolution
meeting; or
2. The date additional
information was received for consideration.
(b) The notice shall state the decision and
the facts on which it is based, including references to applicable statutes and
administrative regulations.
(7) The department may extend a time frame
specified in this section, upon written notice to the applicant, if an
extension:
(a) Is determined to be necessary
for the efficient administration of the resolution meeting process;
or
(b) Is needed to prevent a
miscarriage of justice with regard to the provider.
Section 5. Administrative Hearing
Process. An applicant may appeal an adverse decision rendered by the
department. An appeal shall be in accordance with the provisions established in
907
KAR 1:671, Section 9(1) and (3) through
(14).
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
216B.075,
EO 2004-726