Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
194A.025(3),
205.593,
304.14-135,
304.17A-700-304.17A-730,
42 C.F.R.
431.52, Part 438,
447.45,
447.46,
42 U.S.C.
1396a(a)(37),
1396n,
1396u-2(b)(2)(A)(i)
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 establish requirements relating to managed care. This administrative
regulation establishes the managed care organization requirements and policies
relating to providers.
Section 1.
Provider Network.
(1) An MCO shall:
(a) Enroll providers of sufficient types,
numbers, and specialties in its network to satisfy the access and capacity
requirements established in Section 2 of this administrative regulation;
and
(b) Exclude, terminate, or
suspend from the MCO's network a provider or subcontractor who engages in an
activity that results in suspension, termination, or exclusion from a Medicare
or Medicaid program.
(2)
If an MCO or the department determines that the MCO's provider network is
inadequate to comply with the access standards established in Section 2 of this
administrative regulation for ninety-five (95) percent of the MCO's enrollees,
the MCO shall:
(a) Notify the department;
and
(b) Submit a corrective action
plan to the department.
Section 2. Provider Access Requirements.
(1) The access standards requirements
established in 42 C.F.R. Part 438 shall apply to an MCO.
(2) An MCO shall make available and
accessible to an enrollee:
(a) Facilities,
service locations, and personnel sufficient to provide covered services
consistent with the requirements specified in this section;
(b) Specialists available for the
subpopulations designated in
907
KAR 17:010, Section 12; and
(c) Sufficient pediatric specialists to meet
the needs of enrollees who are less than twenty-one (21) years of
age.
(3) Emergency
medical and behavioral health services shall be available and accessible
twenty-four (24) hours a day, seven (7) days a week.
(4) Urgent care medical and behavioral health
services shall be available and accessible within forty-eight (48) hours of
request.
(5) Time and Distance
Standards.
(a) An MCO's primary care provider
delivery site shall be within:
1. Thirty (30)
miles or thirty (30) minutes from an enrollee's residence in an urban area;
or
2. Forty-five (45) miles or
forty-five (45) minutes from an enrollee's residence in a non-urban
area.
(b) A hospital
shall be within:
1. Thirty (30) miles or
thirty (30) minutes from an enrollee's residence in an urban area; or
2. Sixty (60) miles or sixty (60) minutes of
an enrollee's residence in a non-urban area.
(c) A behavioral or physical rehabilitation
service, a dental service, a general vision service, a laboratory service, a
radiological service, or a pharmacy service shall be within sixty (60) miles or
sixty (60) minutes of an enrollee's residence.
(d)
1. A
pharmacy delivery site, except for a mail order pharmacy, shall not be further
than fifty (50) miles from an enrollee's residence.
2. Transport time or distance threshold shall
not apply to a mail-order pharmacy except that the mail-order pharmacy shall:
a. Be physically located within the United
States of America; and
b. Provide
delivery to the enrollee's residence.
(6) An MCO's primary care provider
shall not have an enrollee to primary care provider ratio greater than
1,500:1.
(7) Appointment Wait
Times.
(a) Except as provided by subsection
(3) or (4) of this section or paragraph (b) of this subsection, an appointment
wait time for a primary care provider, behavioral health provider, specialist,
or dental, general vision, laboratory, or radiological service shall not exceed
thirty (30) calendar days from the date of an enrollee's request for a routine
or preventive service.
(b) A
behavioral health service appointment following a discharge from an acute
psychiatric hospital shall occur within seven (7) calendar days of
discharge.
Section
3. MCO Provider Enrollment.
(1) A
provider enrolled with an MCO shall:
(a) Be
credentialed by the MCO in accordance with 42 C.F.R. Part 438; and
(b) Be enrolled with the Kentucky Medicaid
Program in accordance with
907
KAR 1:672.
(2) An MCO shall:
(a) Have and maintain documentation regarding
a provider's qualifications; and
(b) Make the documentation referenced in
paragraph (a) of this subsection available for review by the
department.
(3) A
provider shall not be required to participate in Kentucky Medicaid
fee-for-service to enroll with an MCO.
Section 4. Prompt Payment of Claims.
(1) In accordance with
42 U.S.C.
1396a(a)(37), an MCO shall
have prepayment and postpayment claims review procedures that ensure the proper
and efficient payment of claims and management of the program.
(2) An MCO shall:
(a) Comply with the prompt payment provisions
established in:
1.
42 C.F.R.
447.45 and
447.46;
and
2.
KRS
205.593,
KRS
304.14-135, and
KRS
304.17A-700 to
304.17A-730;
and
(b) Notify a
requesting provider of a decision to:
1. Deny
a claim; or
2. Authorize a service
in an amount, duration, or scope that is less than requested.
(3) The payment
provisions in this section shall apply to a payment to:
(a) A provider within the MCO network;
and
(b) An out-of-network
provider.
Section
5. Primary Care Provider Responsibilities.
(1) A PCP shall:
(a) Maintain:
1. Continuity of an enrollee's health
care;
2. A current medical record
for an enrollee; and
3. Formalized
relationships with other PCPs to refer enrollees for after-hours care, during
certain days, for certain services, or other reasons to extend the hours of
service of the PCP's practice;
(b) Refer an enrollee for specialty care or
other medically necessary services:
1. Within
the MCO's network; or
2. If the
services are not available within the MCO's network, outside the MCO's
network;
(c) Discuss
advance medical directives with an enrollee;
(d) Provide primary and preventive care,
including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
services;
(e) Refer an enrollee for
a behavioral health service if clinically indicated; and
(f) Have an after-hours phone arrangement
that ensures that a PCP or a designated medical practitioner returns the call
within thirty (30) minutes.
(2) An MCO shall monitor a PCP to ensure
compliance with the requirements established in this section.
Section 6. Release for Ethical
Reasons. An MCO shall:
(1) Not require a
provider to perform a treatment or procedure that is contrary to the provider's
conscience, religious beliefs, or ethical principles in accordance with
42 C.F.R.
438.102;
(2) Not prohibit or restrict a provider from
advising an enrollee about health status, medical care, or a treatment:
(a) Whether or not coverage is provided by
the MCO; and
(b) If the provider is
acting within the lawful scope of practice; and
(3) Have a referral process in place if a
provider declines to perform a service because of an ethical reason.
Section 7. Centers for Medicare
and Medicaid Services Approval and Federal Financial Participation. A policy
established in this administrative regulation shall be null and void if the
Centers for Medicare and Medicaid Services:
(1) Denies or does not provide federal
financial participation for the policy; or
(2) Disapproves the policy. 907 KAR
17:015.
39 Ky.R. 1831;
2350; eff. 6-27-2013; 43 Ky.R. 1316; 1974; eff. 6-2-2017; -- Amd 44 Ky.R. 1441,
2075; eff. 5-4-2018.
STATUTORY AUTHORITY:
KRS
194A.010(1),
194A.025(3),
194A.030(2),
194A.050(1),
205.520(3),
205.560,
42 C.F.R. Part 438,
42 U.S.C.
1396n(b)
