Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
194A.025(3), Chapters 202A,
645,
42 U.S.C.
1396n(c),
42
C.F.R. 422.113(c),
431.51(a)(4),
431.52,
Part 438, 447.500-447.522,
42 U.S.C.
1396b(m)(2)(A) (xiii),
1396d(r), 1396u-2(b)(2)(A)(i), (ii)
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 Medicaid managed care organization service and
service coverage requirements and policies.
Section
1. Covered Services.
(1) Except
as established in subsection (2) of this section, an MCO shall be responsible
for the provision of a covered health service:
(a) That is established in Title 907 of the
Kentucky Administrative Regulations;
(b) That shall be in the amount, duration,
and scope that the services are covered for recipients pursuant to the
department's administrative regulations located in Title 907 of the Kentucky
Administrative Regulations; and
(c)
Beginning on the date of enrollment of a recipient into the MCO.
(2) Other than a nursing facility
cost referenced in subsection (3)(i) of this section, an MCO shall be
responsible for the cost of a non-nursing facility covered service provided to
an enrol-lee during the first thirty (30) days of a nursing facility admission
in accordance with this administrative regulation.
(3) An MCO shall not be responsible for the
provision or costs of the following:
(a) A
service provided to a recipient in an intermediate care facility for
individuals with an intellectual disability;
(b) A service provided to a recipient in a
1915(c) home and community based waiver program;
(c) A hospice service provided to a recipient
in an institution;
(d) A
nonemergency medical transportation service provided in accordance with
907
KAR 3:066;
(e) Except as established in Section 5 of
this administration regulation, a school-based health service;
(f) A service not covered by the Kentucky
Medicaid Program;
(g) A health
access nurturing development service pursuant to
907
KAR 3:140;
(h) An early intervention program service
pursuant to
907
KAR 1:720; or
(i) A nursing facility service for an
enrollee during the first thirty (30) days of a nursing facility
admission.
(4) The
following covered services provided by an MCO shall be accessible to an
enrollee without a referral from the enrollee's primary care provider:
(a) A primary care vision service;
(b) A primary dental or oral surgery
service;
(c) An evaluation by an
orthodontist or a prosthodontist;
(d) A service provided by a women's health
specialist;
(e) A family planning
service;
(f) An emergency
service;
(g) Maternity care for an
enrollee under age eighteen (18);
(h) An immunization for an enrollee under
twenty-one (21);
(i) A screening,
evaluation, or treatment service for a sexually transmitted disease or
tuberculosis;
(j) Testing for HIV,
HIV-related condition, or other communicable disease;
(k) A chiropractic service;
(l) A behavioral health service; and
(m) A substance use disorder
service.
(5) An MCO
shall:
(a) Not require the use of a network
provider for a family planning service;
(b) In accordance with
42 C.F.R.
431.51(a)(4), reimburse for
a family planning service provided within or outside of the MCO's provider
network;
(c) Cover an emergency
service:
1. In accordance with
42 U.S.C.
1396u-2(b)(2)(A)(i);
2. Provided within or outside of the MCO's
provider network; and
3. If
provided out-of-state, in accordance with
42 C.F.R.
431.52;
(d) Comply with
42 U.S.C.
1396u-2(b)(2)(A)(ii);
and
(e) Be responsible for the
provision and reimbursement of a covered service as described in this section
beginning on or after the beginning date of enrollment of a recipient with an
MCO as established in
907
KAR 17:010.
(6)
(a) If
an enrollee is receiving a medically necessary covered service the day before
enrollment with an MCO, the MCO shall be responsible for the reimbursement of
continuation of the medically necessary covered service without prior approval
and without regard to whether services are provided within or outside the MCO's
network until the MCO can reasonably transfer the enrollee to a network
provider.
(b) An MCO shall comply
with paragraph (a) of this subsection without impeding service delivery or
jeopardizing the enrollee's health.
(7) To determine if a service is medically
necessary and clinically appropriate, the MCO shall:
(a) Comply with
907
KAR 3:130; and
(b) Make utilization decisions as follows:
1. Until the commissioner of the Department
of Insurance issues a final order pursuant to KRS 304.240(1)(b)2., in
accordance with nationally recognized criteria as approved by the department;
and
2. Once the commissioner of the
Department of Insurance issues a final order pursuant to KRS 304.240(1)(b)2.,
by complying with
KRS
205.536.
Section 2. Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) Services.
(1) An MCO shall provide an enrollee under
the age of twenty-one (21) years with EPSDT services in compliance with:
(a)
907
KAR 11:034; and
(b)
42
U.S.C. 1396d(r).
(2) A provider of an EPSDT service
shall meet the requirements established in
907
KAR 11:034.
Section 3. Emergency Care, Urgent Care, and
Post-stabilization Care.
(1) An MCO shall
provide to an enrollee:
(a) Emergency care
twenty-four (24) hours a day, seven (7) days a week; and
(b) Urgent care within forty-eight (48)
hours.
(2)
Post-stabilization services shall be provided and reimbursed in accordance with
42
C.F.R. 422.113(c) and
438.114(e).
(3)
(a)
Prior authorization shall not be required for a physical emergency service or a
behavioral health emergency service.
(b) In order to be covered, an emergency
service shall be:
1. Medically necessary;
and
2. Covered in accordance with
Section 1(5)(c) of this administrative regulation.
Section 4. Maternity
Care. An MCO shall:
(1) Have procedures to
assure:
(a) Prompt initiation of prenatal
care; or
(b) Continuation of
prenatal care without interruption for a woman who is pregnant at the time of
enrollment;
(2) Provide
maternity care that includes:
(a)
Prenatal;
(b) Delivery;
(c) Postpartum care; and
(d) Care for a condition that complicates a
pregnancy; and
(3)
Perform all the newborn screenings referenced in
902 KAR
4:030.
Section 5. Pediatric Interface.
(1) An MCO shall:
(a) Have procedures to coordinate care for a
child receiving a school-based health service or an early intervention service;
and
(b) Monitor the continuity and
coordination of care for the child receiving a service referenced in paragraph
(a) of this subsection as part of its quality assessment and performance
improvement (QAPI) program.
(2) Except when a child's course of treatment
is interrupted by a school break, after-school hours, or summer break, an MCO
shall not be responsible for a service referenced in subsection (1)(a) of this
section.
(3) A school-based health
service provided by a school district shall not be covered by an MCO.
(4) A school-based health service provided by
a local health department shall be covered by an MCO.
Section 6. Lock-in Program.
(1) An MCO shall have a program to control
utilization of:
(a) Drugs and other pharmacy
benefits; and
(b) Non-emergency
care provided in an emergency setting.
(2)
(a) The
program referenced in subsection (1) of this section shall be approved by the
department.
(b) An MCO shall not be
required to use the criteria established in
907 KAR
1:677 for placing an enrollee in the MCO's lock-in
program if:
1. The MCO provides notice to the
enrollee, in accordance with the adverse action notice requirements established
in
907
KAR 17:010, of being placed in the MCO's lock-in
program; and
2. The enrollee is
granted the opportunity to appeal being placed in a lock-in program in
accordance with the:
a. MCO internal appeal
process requirements established in
907
KAR 17:010; and
b. The department's state fair hearing
requirements established in
907
KAR 17:010.
Section 7. Pharmacy Benefit
Program.
(1) The pharmacy benefit program
shall be in compliance with the applicable federal and state law, including
42 U.S.C.
1396b(m)(2)(A) (xiii) and
42 C.F.R.
447.500 through
447.522.
(2) If a prescription for an enrollee is for
a non-preferred drug and the pharmacist cannot reach the enrollee's primary
care provider or the MCO for approval and the pharmacist determines it
necessary to provide the prescribed drug, the pharmacist shall:
(a) Provide a seventy-two (72) hour supply of
the prescribed drug; or
(b) Provide
less than a seventy-two (72) hour supply of the prescribed drug, if the request
is for less than a seventy-two (72) hour supply.
(3) Cost sharing imposed by an MCO shall not
exceed the cost sharing limits established in
907 KAR
1:604.
Section 8. Behavioral Health Services.
(1) An MCO shall:
(a) Provide a medically necessary behavioral
health service to an enrollee in accordance with the access standards
established in
907
KAR 17:015, Section 2;
(b) Use the DSM-IV multi-axial classification
system to assess an enrollee for a behavioral service;
(c) Have an emergency or crisis behavioral
health toll-free hotline staffed by trained personnel twenty-four (24) hours a
day, seven (7) days a week;
(d) Not
operate one (1) hotline to handle both an emergency or crisis call and a
routine en-rollee call; and
(e) Not
impose a maximum call duration limit.
(2) Staff of a hotline referenced in
subsection (1)(c) of this section shall:
(a)
Communicate in a culturally competent and linguistically accessible manner to
an enrollee; and
(b) Include or
have access to a qualified behavioral health professional to assess and triage
a behavioral health emergency.
(3) A face-to-face emergency service shall be
available:
(a) Twenty-four (24) hours a day;
and
(b) Seven (7) days a
week.
Section
9. Court-Ordered Psychiatric Services.
(1) An MCO shall:
(a) Provide an inpatient psychiatric service
to an enrollee under the age of twenty-one (21) or over the age of sixty-five
(65) who has been ordered to receive the service by a court of competent
jurisdiction under the provisions of KRS Chapters 202A or 645;
(b) Not deny, reduce, or negate the medical
necessity of an inpatient psychiatric service provided pursuant to a
court-ordered commitment for an enrollee under the age of twenty-one (21) or
over the age of sixty-five (65);
(c) Coordinate with a provider of a
behavioral health service the treatment objectives and projected length of stay
for an enrollee committed by a court of law to a state psychiatric hospital;
and
(d) Enter into a collaborative
agreement with the state-operated or state-contracted psychiatric hospital
assigned to the enrollee's district in accordance with
908 KAR
2:040 and in accordance with the Olmstead
decision.
(2) An MCO
shall present a modification or termination of a service referenced in
subsection (1)(b) of this section to the court with jurisdiction over the
matter for determination.
(3)
(a) An MCO behavioral health service provider
shall:
1. Participate in a quarterly
continuity of care meeting with a state-operated or state- contracted
psychiatric hospital;
2. Assign a
case manager prior to or on the date of discharge of an enrollee from a
state-operated or state-contracted psychiatric hospital; and
3. Provide case management services to an
enrollee with a severe mental illness and co-occurring developmental disability
who is discharged from a:
a. State-operated
or state-contracted psychiatric hospital; or
b. State-operated nursing facility for
individuals with severe mental illness.
(b) A case manager and a behavioral health
service provider shall participate in discharge planning to ensure compliance
with the Olmstead decision.
Section 10. 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.
39 Ky.R. 1836;
2353; eff. 6-27-2013; TAm eff. 7-16-2013; 44 Ky.R. 1406, 2081, 2329; eff.
6-1-2018; TAm eff. 6-5-2018; TAm eff.
1-25-2021.
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