Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.520,
605.115,
42
C.F.R. 440.40(b),
441.50-441.62,
447.201-447.205,
42 U.S.C.
1396a, b, d
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 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 for the provision of
Medicaid to Kentucky's indigent citizenry. This administrative regulation
establishes the method for determining amounts payable by the Department for
Medicaid Services for early and periodic screening, diagnosis, and treatment
services and early and periodic screening, diagnosis, and treatment special
services.
Section 1. Definitions.
(1) "Department" means the Department for
Medicaid Services or its designated agent.
(2) "EPSDT" means early and periodic
screening, diagnosis, and treatment in accordance with
42
C.F.R. 440.40(b),
441.56(b)-(c),
441.57,
and
441.58.
(3) "EPSDT special services" means a service
that is:
(a) Allowable under
42 C.F.R.
441.50 through
441.62
and 42 U.S.C.
1396d(r);
(b) Not otherwise covered under the Kentucky
Medicaid Program; and
(c) Medically
necessary in accordance with
907
KAR 3:130 to correct or ameliorate a defect, physical
or mental illness, or condition of a recipient.
(4) "Medicaid physician fee schedule" means a
list of current reimbursement rates for physician services established in
accordance with
907 KAR
3:010, Section 3(1).
(5) Recipient" means a Medicaid eligible
individual under the age of twenty-one (21), which includes the month in which
the child becomes twenty-one (21).
(6) "Usual and customary charge" means the
uniform amount a physician charges to the general public for a specific medical
procedure or service.
Section
2. Reimbursement.
(1) A provider
shall be reimbursed for a screening service in accordance with the payment
provisions established through the appropriate Medicaid provider
program.
(2) Payment for a
screening service provided by an EPSDT enrolled screening clinic shall be the
amount specified in the Medicaid physician fee schedule for the procedure
code.
(3) Payment for a screening
service shall not exceed the usual and customary charge of the provider for the
service.
Section 3.
Reimbursement of EPSDT Diagnosis and Treatment Providers. The department shall
reimburse an EPSDT diagnosis or treatment provider participating in compliance
with 907 KAR 1:034, Section 8(1) as specified in 907 KAR Chapters 1 and 3 for
reimbursement for the particular diagnosis or treatment service
rendered.
Section 4. Reimbursement
of EPSDT Special Services Providers.
(1)
Except as specified in Section 5 of this administrative regulation, the
department shall reimburse for an EPSDT special service which is similar to a
service covered in another Medicaid Program based on the payment methodology
established for that provider program.
(2) Reimbursement for a special service that
does not have a reimbursement rate established under subsection (1) of this
section shall be based on a fee negotiated by the department adequate to obtain
the service.
(3) The negotiated fee
shall not exceed 100 percent of the usual and customary charges.
(4) If the item is covered under Medicare,
the payment amount shall not exceed the amount that would be paid using the
Medicare payment methodology and upper limits.
(5) If an EPSDT special service is provided
before prior authorization is received, the provider shall assume the financial
risk that the prior authorization may not be subsequently approved.
Section 5. Reimbursement of
School-based Health Services Providers.
(1)
The department shall reimburse a school-based health service provider for a
service included in an individualized education program which is provided to a
Medicaid eligible recipient based on a fee-for-service system designed to
approximate cost for all participating providers in the aggregate without
settlement to exact cost.
(2)
Payment rates for a service shall be established using the following
methodology:
(a) Interim payment rates for a
service shall be based on annual cost data submitted in accordance with
paragraph (b) of this subsection for the previous state fiscal year and shall
be adjusted up or down as appropriate when final payment rates are
established.
(b) Final payment
rates shall be set based on the following:
1.
Except as specified in subparagraphs 4 and 5 of this paragraph, a payment rate
for a particular service shall be based on the lower of the mean or median of
the participating providers' cost of providing the service;
a. The statewide mean and median cost for a
service shall be based on the contracted hourly service cost and the cost
associated with publicly employed professionals; and
b. The mean and median hourly cost shall be
calculated, for each class of qualified professionals, from an array of hourly
cost data falling within one (1) standard deviation of the mean;
2. Cost for publicly employed
professionals shall be computed in the following manner:
a. Salary, fringe benefits, and indirect
overhead shall be included;
b.
Annual professional salaries (including full time equivalent employees) shall
be converted to hourly wages using 185 work days per year and six (6) work
hours per day;
c. The applicable
fringe benefit cost based on the actual percentage rate for classified and
certified employees shall be added to the hourly salary wage; and
d. An indirect overhead cost consisting of
seven (7) percent of the hourly wage shall be added to the hourly salary
wage;
3. Payments for a
professional service shall be based on units of service which are fifteen (15)
minute increments;
4. Payments for
medical transportation provided in accordance with
907 KAR
1:715, Section 3, shall be based on the average cost
per mile of pupil transportation as calculated by the Department of
Education;
5. Payments for
assistive technology and medical equipment provided in accordance with
907 KAR
1:715, Section 3, shall be based on actual invoiced
cost including cost, of shipping and handling, for the authorized equipment
included in an individualized education program;
6. For each school year ending June 30, final
payment rates shall be set using corresponding cost data available as of
September 1 for that school year; and
7. Final payment rates shall be the lower of
the billed charge or the Medicaid rate on file for the date the service is
provided;
(c)
1. A school based health services provider
shall submit annual cost data to the department no later than August 31 of each
year; and
2. If the cost data is
not submitted within the specified period, the school-based health services
provider shall be terminated from the program; and
(d) A school-based health services provider
shall certify quarterly expenditures of state or local funds used to provide
covered school-based health services to Medicaid-eligible children as specified
in
702 KAR
3:285.
2 Ky.R. 109; eff.
9-10-1975; 5 Ky.R. 64; eff. 9-6-1978; 7 Ky.R. 410; eff. 12-3-1980; Recodified
from 904 KAR 1:035, 5-2-1986; Ky.R. 1623; eff. 1-10-1992; 23 Ky.R. 1799; eff.
12-18-1996; 25 Ky.R. 933; 1382; eff. 12-16-1998; 30 Ky.R. 1859; 2035; eff.
3-18-2004; Re-codified from 907 KAR 1:035; eff. 5-3-2011; Crt eff.
12-6-2019.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
EO 2004-726
