Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.510-205.647,
205.6481-205.6497,
304.5-040,
304.17A-005(8),
(14),
42 C.F.R.
432,
433,
435,
436,
440.230,
457,
42 U.S.C.
1396,
1396a,
1397aa -jj, 9902
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
194A.030(2) requires the
Cabinet for Health and Family Services, Department for Medicaid Services, to
administer Title XIX of the Federal Social Security Act,
42 U.S.C.
1396 through
1396v.
KRS
194A.050(1) requires the
secretary of the cabinet to promulgate administrative regulations necessary to
protect, develop, and maintain the health, personal dignity, integrity, and
sufficiency of the individual citizens of the commonwealth; to operate the
programs and fulfill the responsibilities vested in the cabinet; and to
implement programs mandated by federal law or to qualify for the receipt of
federal funds. KRS
205.6485 requires the cabinet to establish
the Kentucky Children's Health Insurance Program (KCHIP) to provide health care
coverage and other coordinated health care services to children of the
commonwealth who are uninsured and otherwise not eligible for health insurance
coverage. This administrative regulation establishes the KCHIP eligibility
criteria, covered services, application requirements, grievance and appeal
rights for recipients, and the requirements for providers who wish to
participate with the commonwealth to provide health care coverage to KCHIP
members through an expansion of the Title XIX Medicaid Program.
Section 1. Definitions.
(1) "Cabinet" means the Kentucky Cabinet for
Health and Family Services or its designee.
(2) "Child" means an individual under the age
of nineteen (19) years.
(3)
"Creditable coverage" is defined by
KRS
304.17A-005(8)(a) 1 through
3 and 5 through 10.
(4)
"Department" means the Department for Medicaid Services or its
designee.
(5) "Excepted benefits"
is defined by KRS
304.17A-005(14).
(6) "Health insurance" is defined by
KRS
304.5-040.
(7) "KCHIP" means the Kentucky Children's
Health Insurance Program administered in accordance with
42 U.S.C.
1397aa through jj.
Section 2. Eligibility Criteria.
(1) A child shall be eligible for KCHIP if
the child:
(a) Is a resident of Kentucky
meeting the conditions for determining state residency under
42 C.F.R.
435.403;
(b) Is a noncitizen who meets the requirement
established in
907 KAR 20:005;
(c) Meets the technical requirements of
907 KAR 20:005;
(d) Provides to the department the
information required in Section 4 of this administrative regulation;
(e) Meets the continuing eligibility
requirements established in
907 KAR 20:010, Section
2;
(f) Meets the relative
responsibility requirements established in
907 KAR 20:040;
(g) Is not eligible for Medicaid pursuant to
907 KAR 20:005 or
907 KAR 20:100; and
(h) Is an optional targeted low-income child
as defined by 42 U.S.C.
1397jj(b) who:
1. Has family income that does not exceed 213
percent of the federal poverty guidelines updated annually in the Federal
Register by the United States Department of Health and Human Services under
authority of 42 U.S.C.
9902(2);
2. Does not have creditable coverage and may
be covered by excepted benefits; and
3.
a. If an
eligibility determination indicates that an individual's income exceeds 213
percent of the federal poverty level established annually by the United States
Department of Health and Human Services pursuant to
42 U.S.C.
9902(2), the department
shall apply an additional cushion of five (5) percent of the federal poverty
level toward the eligibility determination for the individual as established
pursuant to 42 U.S.C.
1396a(e)(14)(I)(i).
b. If after the five (5) percent adjustment,
the individual's income is under the adjusted income threshold, the individual
shall meet the modified adjusted gross income standard.
(2) Eligibility for
KCHIP shall be determined by the department. Upon receipt of eligibility
information established in subsection (1) of this section, the department shall
determine if a child is eligible for benefits pursuant to
42 U.S.C.
1396 or
1397aa through
jj.
Section 3. Covered
Services.
(1) Health services shall be
considered medically necessary in accordance with:
(a)
907 KAR 3:130; and
(b)
42 C.F.R.
440.230.
(2) Amount and duration of benefits covered
by KCHIP shall be as established in Title 907 KAR.
(3) A medical service shall be covered
through KCHIP Phase II if an individual is determined eligible for KCHIP
benefits in accordance with Section 2 of this administrative
regulation.
(4) Preventive and
remedial public health services shall be provided to KCHIP Phase II members in
accordance with
907 KAR 1:360.
(5) KCHIP Phase II shall be the payor of last
resort.
Section 4. KCHIP
Application Requirements. The following information shall be required from a
child or responsible party for KCHIP enrollment:
(1) A child's demographics that shall
include:
(a) Name;
(b) Address;
(c) Sex;
(d) Date of birth;
(e) Race; and
(f) Social Security number;
(2) Monthly gross earned income,
if any, of a parent and a recipient for whom information is being
submitted;
(3) An employer type and
address, if any;
(4) Frequency of
income;
(5) Name and address of a
health insurance provider who currently provides creditable coverage;
(6) Creditable coverage policy number, policy
holder's name, Social Security number, and individuals covered by the
plan;
(7) Unearned income, if any,
received weekly, biweekly, bimonthly, quarterly, or annually;
(8) Name and age of a child or disabled adult
for whom care is purchased in order for a parent or responsible person to work;
and
(9) Signature, date, and
telephone number of a person submitting the information for a child.
Section 5. Provider Participation
Requirements. A provider's enrollment, disclosure, and documentation for
participation in KCHIP shall meet the requirements of:
(1)
907 KAR 1:671; and
(2)
907 KAR
1:672.
Section 6. Grievance, Hearing, and Appeal
Rights.
(1) If dissatisfied with an action
taken by the department as to the application of Sections 1 through 5 of this
administrative regulation, a child, the child's parent, or the child's guardian
shall be entitled to a grievance, hearing, or appeal with the department, to be
conducted in accordance with:
(a)
907 KAR 1:560, if pertaining to
initial eligibility; or
(b)
907 KAR 1:563, if pertaining to a
covered service.
(2) If a
service is provided by a managed care organization, a dispute resolution
between a provider and a child, the child's parent, or the child's guardian
shall be in accordance with
907 KAR 17:010.
(3) A KCHIP Phase II eligible child or a
responsible party shall be informed in writing of the right to and procedures
for due process by the cabinet:
(a) At the
time information to obtain KCHIP Phase II approval is submitted;
(b) If there is a change in eligibility
status; or
(c) As required by
federal and state laws.
Section 7. Quality Assurance and Utilization
Review. The department shall evaluate the following on a continuing basis:
(1) Access to services;
(2) Continuity of care;
(3) Health outcomes; and
(4) Services arranged or provided as
established in 907 KAR Chapter 17.
26 Ky.R. 1055;
1425; eff. 1-12-2000; 29 Ky.R. 1143; 1658; eff. 12-18-2002; 43 Ky.R. 1077,
1774; eff. 5-5-2017; Crt eff. 12-6-2019;
49
Ky.R. 642, 1273; eff. 1/12/2023.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.6485,
42 U.S.C.
1397aa
-jj
