Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
205.622,
369.101-369.120,
42 C.F.R.
431.17,
440.130,
45 C.F.R. Part 164,
42 U.S.C.
1396a(a)(30)
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has a 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 Medicaid Program
coverage provisions and requirements regarding occupational therapy services,
physical therapy services, and speech-language pathology services provided by
adult day health care programs, rehabilitation agencies, special health
clinics, mobile health services, multi-therapy agencies, and comprehensive
outpatient rehabilitation facilities to Medicaid recipients.
Section 1. Provider Participation. To be
eligible to provide and be reimbursed for services covered under this
administrative regulation, a provider shall be:
(1) Currently enrolled in the Kentucky
Medicaid Program in accordance with
907
KAR 1:672;
(2) Currently participating in the Kentucky
Medicaid Program in accordance with
907
KAR 1:671; and
(3)
(a) An
adult day health care program;
(b)
A multi-therapy agency;
(c) A
comprehensive outpatient rehabilitation facility;
(d) A mobile health service;
(e) A special health clinic; or
(f) A rehabilitation agency.
Section 2. Coverage of
Services.
(1) The services covered under this
administrative regulation shall include:
(a)
Physical therapy;
(b) Occupational
therapy; or
(c) Speech-language
pathology services.
(2)
To be covered under this administrative regulation, a service shall be:
(a) Provided to a recipient;
(b) Provided by:
1. An occupational therapist who renders
services on behalf of a provider listed in Section 1(3) of this administrative
regulation;
2. A physical therapist
who renders services on behalf of a provider listed in Section 1(3) of this
administrative regulation;
3. A
speech-language pathologist who renders services on behalf of a provider listed
in Section 1(3) of this administrative regulation;
4. An occupational therapy assistant who
renders services:
a. Under supervision in
accordance with
201
KAR 28:130; and
b. On behalf of a provider listed in Section
1(3) of this administrative regulation; or
5. A physical therapist assistant who renders
services:
a. Under supervision in accordance
with
201
KAR 22:053; and
b. On behalf of a provider listed in Section
1(3) of this administrative regulation;
(c) Ordered by:
1. A physician currently participating in the
Medicaid Program in accordance with
907
KAR 1:671;
2. An advanced practice registered nurse
currently participating in the Medicaid Program in accordance with
907
KAR 1:671;
3. A physician assistant currently
participating in the Medicaid Program in accordance with
907
KAR 1:671; or
4. A psychiatrist currently participating in
the Medicaid Program in accordance with
907
KAR 1:671;
(d) Consistent with a plan of care that
shall:
1. Be developed:
a. By:
(i)
An occupational therapist currently participating in the Medicaid Program in
accordance with
907
KAR 1:671;
(ii) A physical therapist currently
participating in the Medicaid Program in accordance with
907
KAR 1:671; or
(iii) A speech-language pathologist currently
participating in the Medicaid Program in accordance with
907
KAR 1:671; and
b. In collaboration with:
(i) A physician currently participating in
the Medicaid Program in accordance with
907
KAR 1:671;
(ii) An advanced practice registered nurse
currently participating in the Medicaid Program in accordance with
907
KAR 1:671;
(iii) A physician assistant currently
participating in the Medicaid Program in accordance with
907
KAR 1:671; or
(iv) A psychiatrist currently participating
in the Medicaid Program in accordance with
907
KAR 1:671; and
2. Identify a specific amount and
duration;
(e) For the:
1. Maximum reduction of the effects of a
physical or intellectual disability; or
2. Restoration of a recipient to the
recipient's best possible functioning level; and
(f) Medically necessary.
(3)
(a)
There shall be an annual limit of twenty (20) rehabilitative visits and an
annual limit of twenty (20) habilitative visits for each of the following:
1. Occupational therapy service visits per
recipient per calendar year except as established in paragraph (c) of this
subsection;
2. Physical therapy
service visits per recipient per calendar year except as established in
paragraph (c) of this subsection; and
3. Speech-language pathology service visits
per recipient per calendar year except as established in paragraph (c) of this
subsection.
(b) For
example, a recipient may receive twenty (20) rehabilitative occupational
therapy visits, twenty (20) rehabilitative physical therapy visits, and twenty
(20) rehabilitative speech-language pathology service visits per calendar year
and in the same calendar year, a recipient may receive twenty (20) habilitative
occupational therapy visits, twenty (20) habilitative physical therapy visits,
and twenty (20) habilitative speech-language pathology service
visits.
(c) The limit established
in paragraph (a) of this subsection may be exceeded if services in excess of
the limits are determined to be medically necessary by the:
1. Department, if the recipient is not
enrolled with a managed care organization; or
2. Managed care organization in which the
enrollee is enrolled, if the recipient is an enrollee.
(d) Medical necessity shall be determined on
an individual basis per recipient based on the given recipient's
needs.
(e) Prior authorization by
the department shall be required for visits above the limit established in
paragraph (a) of this subsection for a recipient who is not enrolled with a
managed care organization.
Section 3. Documentation, Records
Maintenance, Protection, and Security.
(1) A
provider shall maintain a current health record for each recipient.
(2) A health record shall:
(a) Document the provider's initial
assessment of the recipient and any subsequent assessments;
(b) Document each service provided to the
recipient; and
(c) Include detailed
staff notes that state:
1. Progress made
toward outcomes identified according to the provider's assessment and in the
plan of care developed pursuant to Section 2(2)(d) of this administrative
regulation;
2. The date of each
service;
3. The beginning and
ending time of each service; and
4.
The signature and title of the individual providing each service.
(3) The individual who
provides a service shall date and sign the health record within forty-eight
(48) hours of the date that the individual provides the service.
(4)
(a)
Except as established in paragraph (b) of this subsection, a provider shall
maintain a health record regarding a recipient for at least six (6) years from
the date of the service or until any audit dispute or issue is resolved beyond
six (6) years.
(b) If the secretary
of the United States Department of Health and Human Services requires a longer
document retention period than the period referenced in paragraph (a) of this
subsection, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(5) A provider shall comply with 45 C.F.R.
Part 164 .
Section 4.
Medicaid Program Participation Compliance.
(1)
A provider shall comply with:
(a)
907
KAR 1:671;
(b)
907
KAR 1:672;
(c) KAR Title 895; and
(d) All applicable state and federal
laws.
(2)
(a) If a provider receives any duplicate
payment or overpayment from the department, regardless of reason, the provider
shall return the payment to the department in accordance with
907
KAR 1:671.
(b) Failure to return a payment to the
department in accordance with paragraph (a) of this subsection may be:
1. Interpreted to be fraud or abuse;
and
2. Prosecuted in accordance
with applicable federal or state law.
Section 5. No Duplication of
Service.
(1) The department shall not
reimburse for an occupational therapy service, physical therapy service, or
speech-language pathology service provided to a recipient by more than one (1)
provider of any Medicaid program in which the respective service is covered
during the same time period.
(2)
For example, if a recipient is receiving an occupational therapy service from a
multitherapy agency enrolled with the Medicaid Program, the department shall
not reimburse for the same occupational therapy service provided to the same
recipient during the same time period via the home health program.
Section 6. Third Party Liability.
A provider shall comply with
KRS
205.622.
Section 7. Out-of-State Providers. The
department shall cover a service under this administrative regulation that is
provided by an out-of-state provider if the:
(1) Service meets the coverage requirements
of this administrative regulation; and
(2) Provider:
(a) Complies with the requirements of this
administrative regulation; and
(b)
Is:
1.
a.
Licensed as an adult day health care program in the state in which it is
located;
b. A comprehensive
outpatient rehabilitation facility licensed in the state in which it is
located;
c. Licensed as a mobile
health service in the state in which it is located;
d. A special health clinic licensed in the
state in which it is located;
e. A
rehabilitation agency licensed in the state in which it is located;
f. An occupational therapist or occupational
therapist group;
g. A physical
therapist or physical therapist group;
h. A speech-language pathologist or
speech-language pathologist group; or
i. A multi-therapy
agency;
2. Currently
enrolled in the Kentucky Medicaid Program in accordance with
907
KAR 1:672; and
3. Currently participating in the Kentucky
Medicaid Program in accordance with
907
KAR 1:671.
Section 8. Use of Electronic Signatures.
(1) The creation, transmission, storage, and
other use of electronic signatures and documents shall comply with the
requirements established in
KRS
369.101 to
369.120.
(2) A provider that chooses to use electronic
signatures shall:
(a) Develop and implement a
written security policy that shall:
1. Be
adhered to by each of the provider's employees, officers, agents, or
contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the provider's
electronic signature policy;
2. The
signed consent form; and
3. The
original filed signature.
Section 9. Auditing Authority. The department
shall have the authority to audit any claim, medical record, or documentation
associated with any claim or medical record.
Section 10. Federal Approval and Federal
Financial Participation. The department's coverage of services pursuant to this
administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 11. Appeals.
(1) An appeal of an adverse action by the
department regarding a service and a recipient who is not enrolled with a
managed care organization shall be in accordance with
907
KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with
907
KAR 17:010.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
42 U.S.C.
1396a(a)(30)