Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
42 U.S.C.
1396a(a)(10)(B),
42 U.S.C.
1396a(a)(23)
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 reimbursement
provisions and requirements regarding Medicaid Program outpatient behavioral
health services provided by psychiatric hospitals to Medicaid recipients who
are not enrolled with a managed care organization.
Section 1.
(1) "Advanced practice registered nurse" or
"APRN" is defined by KRS
314.011(7).
(2) "Approved behavioral health services
provider" means:
(a) A physician;
(b) A psychiatrist;
(c) An advanced practice registered
nurse;
(d) A physician
assistant;
(e) A licensed
psychologist;
(f) A licensed
psychological practitioner;
(g) A
certified psychologist with autonomous functioning;
(h) A licensed clinical social
worker;
(i) A licensed professional
clinical counselor;
(j) A licensed
marriage and family therapist;
(k)
A licensed psychological associate;
(l) A certified psychologist;
(m) A marriage and family therapy
associate;
(n) A certified social
worker;
(o) A licensed professional
counselor associate;
(p) A licensed
professional art therapist;
(q) A
licensed professional art therapist associate;
(r) A licensed clinical alcohol and drug
counselor in accordance with Section 7 of this administrative
regulation;
(s) A licensed clinical
alcohol and drug counselor associate in accordance with Section 7 of this
administrative regulation; or
(t) A
certified alcohol and drug counselor.
(3) "Behavioral health practitioner under
supervision" means an individual who is:
(a)
1. A licensed professional counselor
associate;
2. A certified social
worker;
3. A marriage and family
therapy associate;
4. A licensed
professional art therapist associate;
5. A licensed assistant behavior
analyst;
6. A physician
assistant;
7. A certified alcohol
and drug counselor; or
8. A
licensed clinical alcohol and drug counselor associate in accordance with
Section 7 of this administrative regulation; and
(b) Employed by or under contract with the
same billing provider as the billing supervisor.
(4) "Billing provider" means the individual
who, group of individual providers that, or organization that:
(a) Is authorized to bill the department or a
managed care organization for a service; and
(b) Is eligible to be reimbursed by the
department or a managed care organization for a service.
(5) "Billing supervisor" means an individual
who is:
(a)
1. A physician;
2. A psychiatrist;
3. An advanced practice registered
nurse;
4. A licensed
psychologist;
5. A licensed
clinical social worker;
6. A
licensed professional clinical counselor;
7. A licensed psychological
practitioner;
8. A certified
psychologist with autonomous functioning;
9. A licensed marriage and family
therapist;
10. A licensed
professional art therapist;
11. A
licensed behavior analyst; or
12. A
licensed clinical alcohol and drug counselor in accordance with Section 7 of
this administrative regulation; and
(b) Employed by or under contract with the
same billing provider as the behavioral health practitioner under supervision
who renders services under the supervision of the billing supervisor.
(6) "Certified alcohol and drug
counselor" is defined by
KRS
309.080(2).
(7) "Certified psychologist" means an
individual who is a certified psychologist pursuant to
KRS
319.056.
(8) "Certified psychologist with autonomous
functioning" means an individual who is a certified psychologist with
autonomous functioning pursuant to
KRS
319.056.
(9) "Certified social worker" means an
individual who meets the requirements established in
KRS
335.080.
(10) "Department" means the Department for
Medicaid Services or its designee.
(11) "Federal financial participation" is
defined by 42 C.F.R.
400.203.
(12) "Licensed assistant behavior analyst" is
defined by KRS
319C.010(7).
(13) "Licensed behavior analyst" is defined
by KRS
319C.010(6).
(14) "Licensed clinical alcohol and drug
counselor" is defined by
KRS
309.080(4).
(15) "Licensed clinical alcohol and drug
counselor associate" is defined by
KRS
309.080(5).
(16) "Licensed clinical social worker" means
an individual who meets the licensed clinical social worker requirements
established in KRS
335.100.
(17) "Licensed marriage and family therapist"
is defined by KRS
335.300(2).
(18) "Licensed professional art therapist" is
defined by KRS
309.130(2).
(19) "Licensed professional art therapist
associate" is defined by
KRS
309.130(3).
(20) "Licensed professional clinical
counselor" is defined by
KRS
335.500(3).
(21) "Licensed professional counselor
associate" is defined by
KRS
335.500(4).
(22) "Licensed psychological associate" means
an individual who:
(a) Currently possesses a
licensed psychological associate license in accordance with
KRS
319.010(6); and
(b) Meets the licensed psychological
associate requirements established in 201 KAR Chapter 26.
(23) "Licensed psychological practitioner"
means an individual who meets the requirements established in
KRS
319.053.
(24) "Licensed psychologist" means an
individual who:
(a) Currently possesses a
licensed psychologist license in accordance with
KRS
319.010(6); and
(b) Meets the licensed psychologist
requirements established in 201 KAR Chapter 26.
(25) "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.
(26) "Marriage and family therapy associate"
is defined by KRS
335.300(3).
(27) "Physician" is defined by
KRS
205.510(11).
(28) "Physician assistant" is defined by
KRS
311.840(3).
(29) "Provider" is defined by
KRS
205.8451(7).
Section 2. General Requirements.
For the department to reimburse for a service covered under this administrative
regulation, the service shall:
(1) Meet the
requirements established in
907 KAR 10:020; and
(2) Be covered in accordance with
907 KAR 10:020.
Section 3. Reimbursement.
(1) One (1) unit of service shall be:
(a) Fifteen (15) minutes in length;
or
(b) The unit amount identified
in the corresponding:
1. Current procedural
terminology code;
2. Healthcare
common procedure coding system code; or
3. Revenue code.
(2) The rate per unit for a
screening or for crisis intervention shall be:
(a) Seventy-five (75) percent of the rate on
the Kentucky-specific Medicare Physician Fee Schedule for the service if
provided by a:
1. Physician; or
2. Psychiatrist;
(b) 63.75 percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by:
1. An advanced practice registered nurse;
or
2. A licensed
psychologist;
(c) Sixty
(60) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Licensed professional clinical counselor;
2. Licensed clinical social worker;
3. Licensed psychological
practitioner;
4. Certified
psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist; or
7. Licensed
clinical alcohol and drug counselor; or
(d) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a:
1. Marriage and
family therapy associate working under the supervision of a billing
supervisor;
2. Licensed
professional counselor associate working under the supervision of a billing
supervisor;
3. Licensed
psychological associate working under the supervision of a billing
supervisor;
4. Certified social
worker working under the supervision of a billing supervisor;
5. Physician assistant working under the
supervision of a billing supervisor;
6. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
7. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
8. Licensed clinical alcohol and drug
counselor associate working under the supervision of a billing
supervisor.
(3) The rate per unit for an assessment shall
be:
(a) Seventy-five (75) percent of the rate
on the Kentucky-specific Medicare Physician Fee Schedule for the service if
provided by a:
1. Physician; or
2. Psychiatrist;
(b) 63.75 percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by:
1. An advanced practice registered nurse;
or
2. A licensed
psychologist;
(c) Sixty
(60) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Licensed professional clinical counselor;
2. Licensed clinical social worker;
3. Licensed psychological
practitioner;
4. Certified
psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist;
7. Licensed behavior
analyst; or
8. Licensed clinical
alcohol and drug counselor; or
(d) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a:
1. Marriage and
family therapy associate working under the supervision of a billing
supervisor;
2. Licensed
professional counselor associate working under the supervision of a billing
supervisor;
3. Licensed
psychological associate working under the supervision of a billing
supervisor;
4. Certified social
worker working under the supervision of a billing supervisor;
5. Physician assistant working under the
supervision of a billing supervisor;
6. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
7. Licensed assistant behavior analyst
working under the supervision of a billing supervisor;
8. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
9. Licensed clinical alcohol and drug
counselor associate working under the supervision of a billing
supervisor.
(4) The rate per unit for psychological
testing shall be:
(a) 63.75 percent of the
rate on the Kentucky-specific Medicare Physician Fee Schedule for the service
if provided by a licensed psychologist;
(b) Sixty (60) percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by a:
1. Licensed psychological practitioner;
or
2. Certified psychologist with
autonomous functioning; or
(c) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a licensed psychological associate working under the
supervision of a licensed psychologist.
(5) The rate per unit for individual
outpatient therapy, group outpatient therapy, or collateral outpatient therapy
shall be:
(a) Seventy-five (75) percent of the
rate on the Kentucky-specific Medicare Physician Fee Schedule for the service
if provided by a:
1. Physician; or
2. Psychiatrist;
(b) 63.75 percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by:
1. An advanced practice registered nurse;
or
2. A licensed
psychologist;
(c) Sixty
(60) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Licensed professional clinical counselor;
2. Licensed clinical social worker;
3. Licensed psychological
practitioner;
4. Certified
psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist;
7. Licensed behavior
analyst; or
8. Licensed alcohol and
drug counselor; or
(d)
Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific
Medicare Physician Fee Schedule for the service if provided by a:
1. Marriage and family therapy associate
working under the supervision of a billing supervisor;
2. Licensed professional counselor associate
working under the supervision of a billing supervisor;
3. Licensed psychological associate working
under the supervision of a billing supervisor;
4. Certified social worker working under the
supervision of a billing supervisor;
5. Physician assistant working under the
supervision of a billing supervisor;
6. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
7. Licensed assistant behavior analyst
working under the supervision of a billing supervisor;
8. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
9. Licensed alcohol and drug counselor
associate working under the supervision of a billing supervisor.
(6) The rate per unit
for family outpatient therapy shall be:
(a)
Seventy-five (75) percent of the rate on the Kentucky-specific Medicare
Physician Fee Schedule for the service if provided by a:
1. Physician; or
2. Psychiatrist;
(b) 63.75 percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by:
1. An advanced practice registered nurse;
or
2. A licensed
psychologist;
(c) Sixty
(60) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Licensed professional clinical counselor;
2. Licensed clinical social worker;
3. Licensed psychological
practitioner;
4. Certified
psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist; or
7. Licensed
clinical alcohol and drug counselor; or
(d) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a:
1. Marriage and
family therapy associate working under the supervision of a billing
supervisor;
2. Licensed
professional counselor associate working under the supervision of a billing
supervisor;
3. Licensed
psychological associate working under the supervision of a billing
supervisor;
4. Certified social
worker working under the supervision of a billing supervisor;
5. Physician assistant working under the
supervision of a billing supervisor;
6. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
7. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
8. Licensed clinical alcohol and drug
counselor associate working under the supervision of a billing
supervisor.
(7) Reimbursement for the following services
shall be as established on the DMS Psychiatric Hospital Outpatient Non-Medicare
Fee Schedule:
(a) Mobile crisis
services;
(b) Day
treatment;
(c) Peer support
services;
(d) Parent or family peer
support services;
(e) Intensive
outpatient program services;
(f)
Service planning;
(g) Residential
services for substance use disorders;
(h) Screening, brief intervention, and
referral to treatment for a substance use disorder (SBIRT);
(i) Assertive community treatment;
(j) Comprehensive community support
services;
(k) Therapeutic
rehabilitation services; or
(l)
Partial hospitalization.
(8)
(a) The
department shall use the current version of the Kentucky-specific Medicare
Physician Fee Schedule for reimbursement purposes.
(b) For example, if the Kentucky-specific
Medicare Physician Fee Schedule currently published and used by the Centers for
Medicare and Medicaid Services for the Medicare Program is:
1. An interim version, the department shall
use the interim version until the final version has been published;
or
2. A final version, the
department shall use the final version.
Section 4. Outpatient Psychiatric
Hospital Laboratory Services Reimbursement.
(1) The department shall reimburse for an
outpatient psychiatric hospital diagnostic laboratory service:
(a) At the Medicare-established technical
component rate for the service in accordance with
907 KAR 1:028 if a
Medicare-established component rate exists for the service; or
(b) By multiplying the statewide average
in-state outpatient hospital cost-to-charge ratio by the psychiatric hospital's
billed laboratory charges if no Medicare rate exists for the service.
(2) The department shall update
the statewide average outpatient hospital cost-to-charge ratio effective July 1
of each year.
Section 5.
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:
(1)
907 KAR 10:020; and
(2) This administrative regulation.
Section 6. Federal Approval and
Federal Financial Participation.
(1) The
department's reimbursement for services pursuant to this administrative
regulation shall be contingent upon:
(a)
Receipt of federal financial participation for the reimbursement; and
(b) Centers for Medicare and Medicaid
Services' approval for the reimbursement.
(2) The coverage of services provided by a
licensed clinical alcohol and drug counselor, licensed clinical alcohol and
drug counselor associate, registered alcohol and drug peer support specialist,
or certified prevention specialist shall be contingent and effective upon
approval by the Centers for Medicare and Medicaid Services.
Section 7. Appeals. A psychiatric
hospital may appeal a decision by the department regarding the application of
this administrative regulation in accordance with
907 KAR 1:671.
Section 8. Incorporation by Reference.
(1) The "Psychiatric Hospital Outpatient
Behavioral Health Fee Schedule", November 2015, is incorporated by
reference.
(2) This material may be
inspected, copied, or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m.
to 4:30 p.m.; or
(b) 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)