Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
205.560
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 any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the policies and
requirements regarding Medicaid program supplemental payments for certain
primary care services and vaccines in accordance with Title V, Subtitle F,
Section 5501 of the Affordable Care Act (42 U.S.C.
1395l and
42
U.S.C. 1395w-4(c)(2)(B)) ,
42 C.F.R.
447.405,
42 C.F.R.
447.410, and
42 C.F.R.
447.415.
Section
1. Definitions.
(1) "Advanced
practice registered nurse" is defined by
KRS
314.011(7).
(2) "CPT code" means a code used for
reporting procedures and services performed by medical practitioners and
published annually by the American Medical Association in Current Procedural
Terminology.
(3) "Department" means
the Department for Medicaid Services or its designee.
(4) "Eligible evaluation and management
service" means a service:
(a) Which qualifies
for supplemental reimbursement in accordance with Section 3(1)(a), (b), and
(c)1. of this administrative regulation; and
(b) For which there is a corresponding paid
claim.
(5) "Eligible
provider" means a provider who qualifies for supplemental reimbursement in
accordance with Section 2 of this administrative regulation.
(6) "Eligible vaccine" means a vaccine:
(a) Which qualifies for supplemental
reimbursement in accordance with Section 3(1)(a), (b) and (c)2. of this
administrative regulation; and
(b)
For which there is a corresponding paid claim.
(7) "Federal financial participation" is
defined by
42 C.F.R.
400.203.
(8) "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.
(9) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(10) "Medicaid program" means Kentucky's
program of services and benefits covered by the Department for Medicaid
Services or managed care organizations.
(11) "Personal supervision" means being
professionally responsible for the services rendered by an advanced practice
registered nurse or a physician assistant.
(12) "Physician" is defined by
KRS
311.550(12).
(13) "Physician assistant" is defined by
KRS
311.840(3).
(14) "Provider" is defined by
KRS
205.8451(7).
(15) "Recipient" is defined in
KRS
205.8451(9).
Section 2. Conditions to Qualify for
Supplemental Reimbursement for Primary Care Services and Vaccines.
(1) To qualify for a supplemental payment, a
provider shall:
(a) Be currently enrolled
with the Medicaid program in accordance with
907
KAR 1:672;
(b)
1. Be
currently participating in the Medicaid program in accordance with
907
KAR 1:671; and
2. Comply with
907
KAR 1:671;
(c) Be a primary care physician practicing in
one (1) of the following areas:
1. Family
medicine;
2. General internal
medicine; or
3. Pediatric medicine;
and
(d) Attest to being
a primary care physician and to one (1) of the following:
1. Currently having board certification as a
primary care physician by the:
a. American
Board of Medical Specialties;
b.
American Board of Physician Specialties; or
c. American Osteopathic
Association;
2. Unless a
newly eligible physician or physician without a prior billing history, having
provided the following evaluation and management services or vaccines in an
amount that equals at least sixty (60) percent of Medicaid codes billed to the
Medicaid program during the most recently completed calendar year:
a. Evaluation and management CPT codes:
(i) Within the range of 99201 through 99499;
and
(ii) That are covered by the
department in accordance with
907 KAR
3:010; or
b. Vaccine codes which are covered by the
department in accordance with
907 KAR
1:680 (regardless of the age of the recipient) or
907 KAR
3:010;
3. If a newly eligible physician, having
provided the services or vaccines referenced in subparagraph 2a or 2b of this
paragraph in an amount that equals at least sixty (60) percent of Medicaid
codes billed to the Medicaid program during the prior month; or
4. Being an eligible primary care physician:
a. Without a billing history; and
b. For whom sixty (60) percent of total
Medicaid billings shall be of codes referenced in subparagraph 2a or 2b of this
paragraph.
(2) Services or vaccines which meet the
qualifying criteria in Section 3 of this administrative regulation and which
are provided by a physician assistant or advanced practice registered nurse
working under the personal supervision of a qualifying primary care physician
shall qualify for the supplemental reimbursement.
Section 3. Supplemental Reimbursement for
Primary Care Services and Vaccines.
(1)
Supplemental reimbursement shall be made, as established in subsections (2) and
(3) of this section, for providing a service or vaccine:
(a) On a day on or after January 1, 2013
until midnight December 31, 2014:
1. To a
recipient; and
2. By a:
a. Provider who qualifies for the
supplemental reimbursement pursuant to Section 2 of this administrative
regulation; or
b. An APRN or a
physician assistant working under the personal supervision of a primary care
physician who qualifies for the supplemental reimbursement pursuant to Section
2 of this administrative regulation;
(b) That is medically necessary for the given
recipient; and
(c) That is:
1. An evaluation and management service
which:
a. Corresponds to a CPT code within the
range of 99201 through 99499; and
b. Is currently covered by the department in
accordance with
907 KAR
3:010; or
2. Billed using a vaccine code which is
covered by the department in accordance with
907 KAR
1:680 (regardless of the age of the recipient) or
907 KAR
3:010.
(2)
(a) For
a given quarter of paid claims associated with eligible evaluation and
management services provided by an eligible provider to recipients who were not
enrolled in a managed care organization and for which:
1. DMS had an established rate as of July 1,
2009, the department shall make a lump sum payment that represents the
difference between:
a. The DMS established
rates as of July 1, 2009 for the claims in aggregate for the quarter; and
b. What the provider would have
received for the same paid claims in aggregate for the same quarter if the
provider's reimbursement for the claims had been the amount established in
42 C.F.R.
447.405(a);
or
2. DMS did not have an
established rate as of July 1, 2009, but established a rate prior to January 1,
2013, the department shall make a lump sum payment that represents the
difference between:
a. The DMS established
rates as of December 31, 2012 for the claims in aggregate for the quarter;
and
b. What the provider would have
received for the same paid claims in aggregate for the same quarter if the
provider's reimbursement for the claims had been the amount established in
42 C.F.R.
447.405(a).
(b) For a given quarter of paid claims
associated with eligible vaccines provided by an eligible provider to
recipients who were not enrolled in a managed care organization and for which:
1. DMS had an established rate as of July 1,
2009, the department shall make a lump sum payment that represents the
difference between:
a. The DMS established
rates as of July 1, 2009 for the claims in aggregate for the quarter; and
b. What the provider would have
received for the same paid claims in aggregate for the same quarter if the
provider's reimbursement for the claims had been the amount established in
42 C.F.R.
447.405(b);
or
2. DMS did not have an
established rate as of July 1, 2009, but established a rate prior to January 1,
2013, the department shall make a lump sum payment that represents the
difference between:
a. The DMS established
rates as of December 31, 2012 for the claims in aggregate for the quarter;
and
b. What the provider would have
received for the same paid claims in aggregate for the same quarter if the
provider's reimbursement for the claims had been the amount established in
42 C.F.R.
447.405(b).
(3)
(a) For
a given quarter of paid claims associated with eligible evaluation and
management services provided by all eligible providers to recipients who were
enrolled in a given managed care organization, the:
1. Department shall send funds to the managed
care organization representing the aggregate supplemental reimbursement amount
for the paid claims; and
2. Managed
care organization shall:
a. Within fifteen
(15) business days of receiving the funds referenced in subparagraph 1. of this
paragraph, supplement reimbursement to each eligible provider in an amount
determined using the methodology described in subsection (2)(a) of this
section; and
b. Submit documentation
to the department demonstrating that the supplemental reimbursement referenced
in subparagraph 1 of this paragraph was made to all eligible providers for the
corresponding quarter.
(b) For a given quarter of paid claims
associated with eligible vaccines provided by all eligible providers to
recipients who were enrolled in a given managed care organization, the:
1. Department shall send funds to the managed
care organization representing the aggregate supplemental reimbursement amount
for the paid claims; and
2. Managed
care organization shall:
a. Within fifteen
(15) business days of receiving the funds referenced in subparagraph 1 of this
paragraph, supplement reimbursement to each eligible provider in an amount
determined using the methodology described in subsection (2)(b) of this
section; and
b. Submit
documentation to the department demonstrating that the supplemental
reimbursement referenced in subparagraph 1 of this paragraph was made to all
eligible providers for the corresponding quarter.
Section 4.
Applicability.
(1) The policies and
requirements established in this administrative regulation shall govern
supplemental payments for certain primary care services and vaccines in
accordance with Title V, Subtitle F, Section 5501 of the Affordable Care Act
(42 U.S.C.
1395l and
42
U.S.C. 1395w-4(c)(2)(B)) ,
42
C.F.R. 447.400,
42 C.F.R.
447.405,
42 C.F.R.
447.410, and
42 C.F.R.
447.415.
(2) Any policy or requirement regarding
payments for physician or primary care services or vaccines established in any
other administrative regulation within Title 907 of the Kentucky Administrative
Regulations shall not apply to the supplemental payments referenced in
subsection (1) of this section.
Section 5. Auditing.
(1) A provider shall be subject to
departmental review or audit.
(2)
The department shall be authorized to take action regarding fraud or abuse in
accordance with:
(a)
907
KAR 1:671; or
(b)
KRS
205.8453.
Section 6. 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.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.560(1),
42 U.S.C.
1395l,
42
U.S.C. 1395w-4(c)(2)(B),
42
C.F.R. 447.400,
42 C.F.R.
447.405,
42 C.F.R.
447.410,
42 C.F.R.
447.415