Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO: KRS Chapter 13B, 194A.025(3), 199.555(2), Chapter
202A, 205.8451-205.8483, 311.550(12), 314.011(7), 387.510(15), 620.020(5),
42
U.S.C. 1382c,
1395tt,
1396-1396w-5, 20 C.F.R. 416.2101,
42 C.F.R.
400.203,
405.2401(b),
412.62,
Part 438,
440.40(b),
447.280,
482.58
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 a requirement that may be
imposed or opportunity presented by federal law to qualify for federal Medicaid
funds.
42 U.S.C.
1396n(b) and 42 C.F.R. Part
438 require specific standards relating to managed care. This administrative
regulation establishes the definitions for 907 KAR Chapter 17.
Section 1. Definitions.
(1) "1915(c) home and community based waiver
program" means a Kentucky Medicaid program established pursuant to, and in
accordance with,
42 U.S.C.
1396n(c).
(2) "Advanced practice registered nurse" is
defined by
KRS
314.011(7).
(3) "Adverse action" means the:
(a) Denial or limited authorization of a
requested service, including the type or level of service;
(b) Reduction, suspension, or termination of
a previously authorized service;
(c) Denial, in whole or in part, of payment
for a service;
(d) Failure to
provide services in a timely manner; or
(e) Failure of a managed care organization to
act within the timeframes provided in
42 C.F.R.
438.408(b).
(4) "Appeal" means a request for
review of an adverse action or a decision by an MCO related to a covered
service.
(5) "Authorized
representative" means:
(a) For an enrollee who
is authorized by Kentucky law to provide written consent, an individual or
entity acting on behalf of, and with written consent from, the enrollee;
or
(b) A legal guardian.
(6) "Behavioral health service"
means a clinical, rehabilitative, or support service in an inpatient or
outpatient setting to treat a mental illness, emotional disability, or
substance use disorder.
(7) "Blind"
is defined by
42
U.S.C.
1382c(a)(2).
(8) "Capitation payment" means the total per
enrollee, per month payment amount the department pays an MCO.
(9) "Care coordination" means the integration
of all processes in response to an enrollee's needs and strengths to ensure
the:
(a) Achievement of desired outcomes;
and
(b) Effectiveness of
services.
(10) "Case
management" means a collaborative process that:
(a) Assesses, plans, implements, coordinates,
monitors, and evaluates the options and services required to meet an enrollee's
health and human service needs;
(b)
Is characterized by advocacy, communication, and resource management;
(c) Promotes quality and cost-effective
interventions and outcomes; and
(d)
Is in addition to and not in lieu of targeted case management for individuals
pursuant to 907 KAR Chapter 15.
(11) "CHFS OIG" means the Cabinet for Health
and Family Services, Office of Inspector General.
(12) "Child" means a person who:
(a)
1. Is
under the age of eighteen (18) years;
2.
a. Is a
full-time student in a secondary school or the equivalent level of vocational
or technical training; and
b. Is
expected to complete the program before the age of nineteen (19)
years;
3. Is not self
supporting;
4. Is not a participant
in any of the United States Armed Forces; and
5. If previously emancipated by marriage, has
returned to the home of his or her parents or to the home of another
relative;
(b) Has not
attained the age of nineteen (19) years in accordance with
42 U.S.C.
1396a(l)(1)(D);
(c) Is under the age of nineteen (19) years
if the person is a KCHIP recipient; or
(d) Is under the age of twenty-one (21) years
for EPSDT.
(13) "Complex
or chronic condition" means a physical, behavioral, or developmental condition
that:
(a) Seems to have no known
cure;
(b) Is progressive;
or
(c) Can be debilitating or fatal
if left untreated or under-treated.
(14) "Court-ordered commitment" means an
involuntary commitment by an order of a court to a psychiatric facility for
treatment pursuant to KRS Chapter 202A.
(15) "DAIL" means the Department for Aging
and Independent Living.
(16) "DCBS"
means the Department for Community Based Services.
(17) "Department" means the Department for
Medicaid Services or its designee.
(18) "Disabled" is defined by
42
U.S.C.
1382c(a)(3).
(19) "DSM-IV" means the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Editions, published by the
American Psychiatric Association that covers all mental health disorders for
both children and adults.
(20)
"Dual eligible" means an individual eligible for Medicare and Medicaid
benefits.
(21) "Early and periodic
screening, diagnosis, and treatment" or "EPSDT" is defined by
42
C.F.R. 440.40(b).
(22) "Emergency service" means "emergency
services" as defined by
42 U.S.C.
1396u-2(b)(2)(B).
(23) "Enrollee" means a recipient who is
enrolled with a managed care organization for the purpose of receiving Medicaid
or KCHIP covered services.
(24)
"Family planning service" means a counseling service, a medical service, or a
pharmaceutical supply or device to prevent or delay pregnancy.
(25) "Federally qualified health center" or
"FQHC" is defined by
42 C.F.R.
405.2401(b).
(26) "Federally qualified health center
look-alike" or "FQHC look-alike" means an entity that is currently approved by
the United States Department of Health and Human Services, Health Resources and
Services Administration, and the Centers for Medicare and Medicaid Services to
be a federally qualified health center look-alike.
(27) "Fee-for-service" means a reimbursement
model in which a health insurer reimburses a provider for each service provided
to a recipient.
(28) "Foster care"
is defined by
KRS
620.020(5).
(29) "Fraud" means any act that constitutes
fraud under applicable federal law or
KRS
205.8451 through
KRS
205.8483.
(30) "Grievance" is defined by
42 C.F.R.
438.400(b).
(31) "Homeless individual" means an
individual who:
(a) Lacks a fixed, regular, or
nighttime residence;
(b) Is at risk
of becoming homeless in a rural or urban area because the residence is not
safe, decent, sanitary, or secure;
(c) Has a primary nighttime residence at a:
1. Publicly or privately operated shelter
designed to provide temporary living accommodations; or
2. Public or private place not designed as
regular sleeping accommodations; or
(d) Lacks access to routine accommodations
due to violence or the threat of violence from a cohabitant.
(32) "Individual with a special
health care need" or "ISHCN" means an individual who:
(a) Has, or is at a high risk of having, a
chronic physical, developmental, behavioral, neurological, or emotional
condition; and
(b) Might require a
broad range of primary, specialized, medical, behavioral health, or related
services.
(33) "KCHIP"
means the Kentucky Children's Health Insurance Program administered in
accordance with
42 U.S.C.
1397aa to jj.
(34) "Managed care organization" or "MCO"
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.
(35) "Maternity care" means prenatal,
delivery, and postpartum care and includes care related to complications from
delivery.
(36) "Medical record"
means a single, complete record that documents all of the treatment plans
developed for, and medical services received by, an individual.
(37) "Medicare qualified individual group 1
(QI-1)" means an eligibility category that includes, pursuant to
42 U.S.C.
1396a(a)(10)(E)(iv), an
individual who would be a Qualified Medicaid beneficiary but for the fact that
the individual's income:
(a) Exceeds the
income level established in accordance with
42
U.S.C. 1396d(p)(2);
and
(b) Is at least 120 percent,
but less than 135 percent, of the federal poverty level for a family of the
size involved and who is not otherwise eligible for Medicaid under the state
plan.
(38) "Nonqualified
alien" means a resident of the United States of America who does not meet the
qualified alien requirements established in
907
KAR 20:005, Section 2(2)(a)2. or 3.
(39) "Nursing facility" means:
(a) A facility:
1. To which the state survey agency has
granted a nursing facility license;
2. For which the state survey agency has
recommended to the department certification as a Medicaid provider;
and
3. To which the department has
granted certification for Medicaid participation; or
(b) A hospital swing bed that provides
services in accordance with
42 U.S.C.
1395tt and
1396l,
if the swing bed is certified to the department as meeting requirements for the
provision of swing bed services in accordance with
42 U.S.C.
1396r(b), (c), and (d) and
42 C.F.R. 447.280 and 482.58.
(40) "Olmstead decision" means the court
decision of Olmstead v. L.C. and E.W., U.S. Supreme Court, No. 98-536, June 26,
1999, in which the U.S. Supreme Court ruled, "For the reasons stated, we
conclude that, under Title II of the ADA, States are required to provide
community-based treatment for persons with mental disabilities when the State's
treatment professionals determine that such placement is appropriate, the
affected persons do not oppose such treatment, and the placement can be
reasonably accommodated, taking into account the resources available to the
State and the needs of others with mental disabilities."
(41) "Open enrollment" means an annual period
during which an enrollee can choose a different MCO.
(42) "Out-of-network provider" means a person
or entity that has not entered into a participating provider agreement with an
MCO or any of the MCO's subcontractors.
(43) "Physician" is defined by
KRS
311.550(12).
(44) "Post-stabilization services" means
covered services related to an emergency medical condition that are provided to
an enrollee:
(a) After an enrollee is
stabilized in order to maintain the stabilized condition; or
(b) Under the circumstances described in
42 C.F.R.
438.114(e) to improve or
resolve the enrollee's condition.
(45) "Primary care provider" or "PCP" means a
licensed or certified health care practitioner who meets the description as
established in
907
KAR 17:010, Section 6(6).
(46) "Prior authorization" means the advance
approval by an MCO of a service or item provided to an enrollee.
(47) "Provider" means any person or entity
under contract with an MCO or its contractual agent that provides covered
services to enrollees.
(48)
"Provider network" means the group of physicians, hospitals, and other medical
care professionals that a managed care organization has contracted with to
deliver medical services to its enrollees.
(49) "QAPI" means the Quality Assessment and
Performance Improvement Program established in accordance with 42 C.F.R. 438
Subpart D, 438.206 to 438.242.
(50)
"Qualified alien" means an alien who, at the time of applying for or receiving
Medicaid benefits, meets the requirements established in
907
KAR 20:005, Section 2(2)(a)2. or 3.
(51) "Qualified disabled and working
individual" is defined by
42
U.S.C. 1396d(s).
(52) "Qualified Medicare beneficiary" or
"QMB" is defined by
42
U.S.C.
1396d(p)(1).
(53) "Recipient" is defined by
KRS
205.8451(9).
(54) "Rural area" means an area not in an
urban area.
(55) "Rural health
clinic" is defined by
42 C.F.R.
405.2401(b).
(56) "Specialist" means a provider who
provides specialty care.
(57)
"Specialty care" means care or a service that is provided by a provider who is
not:
(a) A primary care provider; or
(b) Acting in the capacity of a primary care
provider while providing the service.
(58) "Specified low-income Medicare
beneficiary" means an individual who meets the requirements established in
42 U.S.C.
1396a(a)(10)(E)(iii).
(59) "State fair hearing" means an
administrative hearing provided by the Cabinet for Health and Family Services
pursuant to KRS Chapter 13B.
(60)
"State plan" is defined by
42 C.F.R.
400.203.
(61) "State survey agency" means the Cabinet
for Health and Family Services, Office of Inspector General, Division of Health
Care Facilities and Services.
(62)
"State-funded adoption assistance" is defined by
KRS
199.555(2).
(63) "Supplemental security income benefits"
or "SSI benefits" is defined by
20
C.F.R.
416.2101(c).
(64) "Third party liability resource" means a
resource available to an enrollee for the payment of expenses:
(a) Associated with the provision of covered
services; and
(b) That does not
include amounts exempt under Title XIX of the Social Security Act,
42 U.S.C.
1396 to
1396w-5.
(65) "Transport time" means travel
time:
(a) Under normal driving conditions;
and
(b) With no extenuating
circumstances.
(66)
"Urban area" is defined by
42
C.F.R.
412.62(f)(1)(ii).
(67) "Urgent care" means care for a condition
not likely to cause death or lasting harm but for which treatment should not
wait for a normally scheduled appointment.
(68) "Ward" is defined by
KRS
387.510(15).
38 Ky.R. 1249;
1588; 1738; eff. 5-4-2012; 39 Ky.R. 1792; 2322; eff. 9-19-2013; TAm eff.
9-30-2013; 44 Ky.R. 1428, 2216; eff. 5-4-2018; 48 Ky.R. 1939, 2446; eff.
3-10-2022.
STATUTORY AUTHORITY:
KRS
194A.010(1),
194A.025(3),
194A.030(2),
194A.050(1),
205.520(3),
205.560,
42 U.S.C.
1396n(b), 42 C.F.R. Part
438