Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
199.680,
205.634
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.
KRS
199.680(3) and
205.634(4)
require the department to promulgate an administrative regulation establishing
the requirements for a determination of the availability of providers of
residential care within Kentucky.
KRS
199.680(1) and
205.634(2)
prohibit the reimbursement of an out-of-state provider of residential care for
children whose care is paid by state general funds or state administered
federal funds unless a determination has been made that a provider in Kentucky
is not capable or willing to provide comparable services to the child. This
administrative regulation establishes uniform conditions and requirements for
certification for out-of-state residential services for Medicaid-eligible
children under age twenty-one (21), and for determining the availability of
providers of residential care within the Commonwealth.
Section 1. Definitions.
(1) "Comparable cost per child" means total
payments made by the department per child to an out-of-state facility are
comparable to total payments made by the department per child to an in-state
facility for comparable residential care.
(2) "Comparable services" mean services
provided by an in-state residential provider equal to or surpassing services
provided by an out-of-state residential provider.
(3) "Department" means the Department for
Medicaid Services or its designated agent.
(4) "Participating provider" means a provider
who receives reimbursement from the Department for Medicaid Services for
services provided to a Medicaid-eligible child under age twenty-one
(21).
(5) "Residential care" means
behavioral health services provided twenty-four (24) hours a day by a
participating provider in a structured setting with an organized program of
care.
Section 2.
Exceptions and Exclusions.
(1) The department
shall not preauthorize or reimburse an out-of-state provider for a
Medicaid-eligible child except as provided by
KRS
199.680 and
205.634.
(2) An incidental acute physical health care
or routine preventive care payment made by the department during the
residential episode of care shall be excluded from the calculation of
comparable cost per child.
(3) A
participating in-state or out-of-state provider shall meet the provider
qualification criteria established in
907
KAR 11:034 or
907
KAR 3:030.
Section 3. Procedures for Placement.
(1) The following actions shall occur before
an out-of-state placement:
(a) The department
or its designated agent shall document that there is no in-state provider with
comparable services and costs capable of and willing to serve a specific
child.
(b) The department or its
designated agent shall obtain all necessary information, both demographic and
medical, about each child who presents for review and services.
(c) The information shall include, at a
minimum:
1. Child's demographics;
2. Child's parent or legal guardian's name
and address;
3. Child's clinical
history, placements and diagnoses;
4. Child's proposed treatment plan, including
the estimated date of discharge and a proposed transition plan to the home and
community; and
5. Other pertinent
information regarding the child's case, including special medical
needs.
(d) A
participating in-state provider shall fax, call, or otherwise transmit to the
department, a weekly report of the availability of residential care, which
shall be reviewed by the department prior to approval of an out-of-state
placement.
(e) The department shall
create a database of participating in-state and out-of-state providers
containing each participating provider's identifying information, clinical
program descriptions, staff credentials, staffing models, quality improvement
plan, utilization management, protocols and opportunity for family interaction,
discharge and outcome management, services, costs, licensure status, and
negotiated payment rates by the department. The department shall utilize this
database to determine comparable costs and services among providers and shall
update the database not less than annually.
(2) For a child approved for out-of-state
residential care, the department shall maintain records documenting diagnoses,
specific treatment needs, demographics, and the specific reason for an
exception, meeting the criteria established in
KRS
199.680(1) and
205.634(2).
The department shall transmit this data to a participating provider who
requests it.
25 Ky.R. 2732; 26
Ky.R. 407; 619; eff. 9-15-1999; TAm eff. 4-28-2011; Crt eff.
12-6-2019.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
199.680,
205.520(3),
205.634,
EO 2004-726
