Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.520(3),
205.560(1),
42 C.F.R. Part 413,
42
C.F.R. 447.204,
42
C.F.R. 447.321
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 reimbursement
policies and requirements for covered specialty intermediate care clinic
services provided to a Medicaid recipient who is not enrolled with a managed
care organization and optional policies for covered specialty IC clinic
services provided to a Medicaid recipient who is enrolled with a managed care
organization.
Section 1. Definitions.
(1) "Bad debt" means accounts receivable
which will likely remain uncollected.
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "Federal financial participation" is
defined in
42 C.F.R.
400.203.
(4) "Government Auditing Standards" means the
standards:
(a) For audits of government
organizations, programs, activities, functions, and of government assistance
received by contractors, nonprofit organizations, and other nongovernment
organizations;
(b) Often referred
to as generally accepted government auditing standards or GAGAS; and
(c) Accessible at the Web site of
http://www.gao.gov/govaud/ybk01.htm.
(5) "Medically necessary" means
determined by the department to be needed in accordance with
907
KAR 3:130.
(6) "Recipient" is defined by
KRS
205.8451(9).
(7) "Specialty intermediate care clinic" or
"specialty IC clinic" means a clinic located on the grounds of a state-owned
facility licensed pursuant to
902
KAR 20:086 as an intermediate care facility for
individuals with an intellectual disability.
Section 2. Interim Reimbursement.
(1)
(a)
Except for a specialty IC clinic's first fiscal year of operation, the
department shall reimburse on an interim basis:
1. For specialty intermediate care clinic
services via an interim rate and utilizing a clinic-specific cost-to-charge
ratio:
a. For each service;
b. Based on the clinic's most recently filed
cost report, unless no cost report exists; and
c. Expressed as a percent of the clinic's charges;
and
2. During the course
of a state fiscal year until the most recent full fiscal year cost report from
the clinic has been finalized by the department.
(b) The department shall use projected costs
to establish interim rates for the first fiscal year of a specialty IC clinic's
operation.
(2) The
department shall determine a:
(a)
Clinic-specific cost-to-charge ratio for each service; and
(b) Specialty IC clinic's interim rate for a
service by:
1. Multiplying the total charges
for the service by the service-specific cost-to-charge ratio; and
2. Dividing the number established pursuant
to subparagraph 1. of this paragraph by the applicable number of service units.
For example, $500,000 in total charges multiplied by a cost-to-charge ratio of
0.95 divided by 10,000 units equals an interim rate of forty-seven (47) dollars
and fifty (50) cents.
(3) An interim rate for a fiscal year shall
be effective on July 1 of a calendar year and remain in effect until close of
business June 30 of the subsequent calendar year.
(4)
(a) The
department shall adjust an interim rate if:
1. The department miscalculated a specialty
IC clinic's interim rate;
2. A
specialty IC clinic submits an amended cost report which applies to the interim
rate period; or
3. A further desk
or on-site audit of a cost report used to establish the interim rate discloses
a change in allowable costs.
(b) The department shall not adjust an
interim rate for a reason not described in paragraph (a)1, 2, or 3 of this
subsection.
(5) The
department shall use the most recently received ICF-IID and Specialty
Intermediate Care Clinic Cost Report as of March 15 to establish interim rates
for a specialty IC clinic to be effective on July 1 of a given
year.
Section 3. Final
Reimbursement.
(1) After the most recent full
fiscal year cost report for a specialty IC clinic has been finalized by the
department, the department shall cost settle with the clinic to establish final
reimbursement to the clinic for the corresponding fiscal year.
(2) A cost settlement between the department
and a specialty IC clinic shall:
(a) Be
limited to an amount, if any, by which the specialty IC clinic's allowable
costs exceeds the amount of:
1. Any third
party recovery during the fiscal year; and
2. Interim payments made to the specialty IC
clinic; and
(b) Not
exceed the federal upper payment limit in accordance with
42
C.F.R. 447.321.
(3)
(a)
The department's reimbursement to a specialty IC clinic shall be payment in
full to the specialty IC clinic for services provided to recipients.
(b) A specialty IC clinic shall not bill a
recipient for a service provided to a recipient.
(c) A bad debt shall not be:
1. An allowable cost; or
2. Reimbursable by the department.
Section 4.
Cost Reporting Requirements.
(1)
(a) A specialty IC clinic shall annually
submit to the department a fully completed ICF-IID and Specialty Intermediate
Care Clinic Cost Report within four (4) calendar months of the end of the prior
state fiscal year.
(b) For example,
an ICF-IID and Specialty Intermediate Care Clinic Cost Report covering the
fiscal year ending June 30, 2013 shall be submitted to the department by close
of business October 31, 2013.
(2) A specialty IC clinic shall complete an
ICF-IID and Specialty Intermediate Care Clinic Cost Report in accordance with
the ICF-IID and Specialty Intermediate Care Clinic Cost Report
Instructions.
(3) Interim
reimbursement for a specialty IC clinic which does not submit a legible and
complete ICF-IID and Specialty Intermediate Care Clinic Cost Report to the
department within the time period referenced in subsection (1) of this section
shall be placed in escrow by the department until the department receives a
legible and completed ICF-IID and Specialty Intermediate Care Clinic Cost
Report.
(4) After finalizing the
first full fiscal year cost report submitted by a facility, the department
shall establish an interim rate based on the first full year cost
report.
(5) An ICF-IID and
Specialty Intermediate Care Clinic Cost Report shall include the following
statement immediately before the dated signature of the specialty IC clinic's
administrator or chief financial officer: "I certify that I am familiar with
the laws and regulations regarding the provision of health care services under
the Kentucky Medicaid program, including the statutes and administrative
regulations relating to claims for Medicaid reimbursements and payments, and
that the services identified in this cost report were reported in compliance
with those statutes and administrative regulations. This cost report includes
total computable cost incurred to provide Medicaid services."
(6) If a cost report indicates a payment is
due by a specialty IC clinic to the department, the specialty IC clinic shall
submit the amount due or submit a payment plan request with the cost
report.
(7) If a cost report
indicates a payment is due by a specialty IC clinic to the department and the
specialty IC clinic fails to remit the amount due or request a payment plan,
the department shall suspend future payment to the specialty IC clinic until
the specialty IC clinics remits the payment or submits a request for a payment
plan.
(8)
(a) If it is determined that an additional
payment is due by a specialty IC clinic after a final determination of cost has
been made by the department, the additional payment shall be due by the
specialty IC clinic to the department within sixty (60) days after
notification.
(b) If a specialty IC
clinic does not submit the additional payment within sixty (60) days, the
department shall withhold future payment to the specialty IC clinic until the
department has collected in full the amount owed by the specialty IC clinic to
the department.
(9)
(a) A specialty IC clinic shall report all of
its costs, allowable costs, and unallowable costs on a cost report.
(b) The department shall not reimburse for or
cost settle unallowable costs.
Section 5. Allowable and Unallowable Costs.
(1) An allowable cost shall:
(a) Be allowable in accordance with 42 C.F.R.
Part 413 ;
(b) Be a cost allowed
after an audit by the department; and
(c) Include:
1. A cost incurred by a specialty IC clinic
in meeting and maintaining health standards pursuant to
42 C.F.R.
431.610(c); and
2. Costs resulting from meeting Kentucky
specialty clinic licensure requirements pursuant to
902 KAR
20:410.
(2) Reimbursable services shall be the
specialty IC clinic services established in
907
KAR 3:225.
(3) Costs relating to unallowable clinic
activities shall:
(a) Be excluded from any
cost settlement;
(b) Not be
reimbursable; and
(c) Be reported
separately on a cost report.
Section 6. Audits.
(1) An ICF-IID and Specialty Intermediate
Care Clinic Cost Report and all related documents submitted to the department
by a specialty IC clinic shall be subject to audit, review, and reconciliation
by the department.
(2) An audit, if
performed, shall be performed in accordance with the most current Government
Auditing Standards.
Section
7. Pharmacy, Medication, Immunization, and Other Costs Not
Reimbursed at Cost.
(1) The department shall
reimburse for:
(a) Prescription drug costs
experienced by a specialty IC clinic through the department's pharmacy program
in accordance with
907
KAR 23:020; or
(b) Immunization costs experienced by a
specialty IC clinic through the department's physician program in accordance
with
907 KAR
3:010.
(2) Medication:
(a) Consultation costs shall be allowable;
and
(b) Management costs shall be
allowable.
Section
8. Not Applicable to Managed Care Organizations.
(1) A managed care organization may elect to
reimburse for specialty IC clinic services in accordance with this
administrative regulation.
(2) The
reimbursement policies established in this administrative regulation shall not
apply to a managed care organization.
Section 9. 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 federal financial participation
for the policy; or
(2) Disapproves
the policy.
Section 10.
Appeals.
(1) An interim rate adjustment or
denial of an interim rate adjustment may be appealed in accordance with
907
KAR 1:671.
(2) A Medicaid program sanction or appeal
shall be in accordance with
907
KAR 1:671.
Section 11. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "ICF-IID and Specialty IC
Clinic Cost Report", March 2013 edition; and
(b) "ICF-IID and Specialty IC Clinic Cost
Report Instructions", March 2013 edition.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40601, Monday
through Friday, 8 a.m. to 4:30 p.m.
39 Ky.R. 2449; 40
Ky.R. 848; eff. 11-1-2013; TAm eff. 10-6-2017; Crt eff.
7-23-2018.
STATUTORY AUTHORITY:
KRS
194A.010(1),
194A.030(2),
194A.050(1),
205.520(3),
and
205.560(2)