Current through Register Vol. 50, No. 9, March 1, 2024
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 Medicaid program
coverage policies regarding Level I and Level II psychiatric residential
treatment facility services that are not provided on an outpatient
basis.
Section 1. Definitions.
(1) "Active treatment" means a covered Level
I or II psychiatric residential treatment facility service provided:
(a) In accordance with an individual plan of
care as specified in
42 C.F.R.
441.154; and
(b) By an individual employed or contracted
by a Level I or II PRTF including a:
1.
Qualified mental health personnel;
2. Qualified mental health
professional;
3. Mental health
associate; or
4. Direct care staff
person.
(2)
"Acute care hospital" is defined by
KRS
205.639(1).
(3) "Advanced practice registered nurse" is
defined by
KRS
314.011(7).
(4) "Behavioral health professional" means:
(a) A psychiatrist;
(b) A physician licensed in Kentucky to
practice medicine or osteopathy, or a medical officer of the government of the
United States while engaged in the practice of official duties;
(c) A licensed psychologist;
(d) A licensed psychological
practitioner;
(e) A licensed
clinical social worker;
(f) An
advanced practice registered nurse;
(g) A licensed marriage and family
therapist;
(h) A licensed
professional clinical counselor;
(i) A licensed professional art
therapist;
(j) A licensed clinical
alcohol and drug counselor in accordance with Section 13 of this administrative
regulation;
(k) A certified
psychologist with autonomous functioning; or
(l) A certified alcohol and drug
counselor.
(5)
"Behavioral health professional under clinical supervision" means:
(a) A certified psychologist;
(b) A licensed psychological
associate;
(c) A marriage and
family therapy associate;
(d) A
certified social worker;
(e) A
licensed professional counselor associate;
(f) A licensed professional art therapist
associate;
(g) A physician
assistant; or
(h) A licensed
clinical alcohol and drug counselor associate in accordance with Section 13 of
this administrative regulation.
(6) "Certified alcohol and drug counselor"
means an individual who meets the requirements established in
KRS
309.083.
(7) "Certified psychologist" means an
individual who is a certified psychologist pursuant to
KRS
319.056.
(8) "Certified psychologist with autonomous
functioning" means an individual who is a certified psychologist with
autonomous functioning pursuant to
KRS
319.056.
(9) "Certified social worker" means an
individual who meets the requirements established in
KRS
335.080.
(10) "Child with a severe emotional
disability" is defined by
KRS
200.503(2).
(11) "Department" means the Department for
Medicaid Services or its designee.
(12) "Diagnostic and assessment services"
means at least one (1) face-to-face specialty evaluation or specialty
evaluation performed via telemedicine of a recipient's medical, social, and
psychiatric status provided by a physician or qualified mental health
professional that shall:
(a) Include:
1. Interviewing and evaluating; or
2. Testing;
(b) Be documented and record all contact with
the recipient and other interviewed individuals; and
(c) Result in a:
1. Medical data code in accordance with
45 C.F.R.
162.1000; and
2. Specific treatment
recommendation.
(13) "Enrollee" means a recipient who is
enrolled with a managed care organization.
(14) "Federal financial participation" is
defined by
42 C.F.R.
400.203.
(15) "Intensive treatment services" means a
program:
(a) For a child:
1. With a severe emotional disability; and
a. An intellectual disability;
b. A severe and persistent aggressive
behavior;
c. Sexually acting out
behavior; or
d. A developmental
disability;
2. Who
requires a treatment-oriented residential environment; and
3. Between the ages of four (4) to twenty-one
(21) years; and
(b) That
provides psychiatric and behavioral health services two (2) or more times per
week to a child referenced in paragraph (a) of this subsection:
1. As indicated by the child's psychiatric
and behavioral health needs; and
2.
In accordance with the child's therapeutic plan of care.
(16) "Interdisciplinary team"
means:
(a) For a recipient who is under the
age of eighteen (18) years:
1. A parent, legal
guardian, or caregiver of the recipient;
2. The recipient;
3. A qualified mental health professional;
and
4. A staff person, if
available, who worked with the recipient during the recipient's most recent
placement if the recipient has previously been in a Level I or II PRTF;
or
(b) For a recipient
who is eighteen (18) years of age or older:
1.
The recipient;
2. A qualified
mental health professional;
3. A
staff person, if available, who worked with the recipient during the
recipient's most recent placement if the recipient has previously been in a
Level I or II PRTF; and
4. If
requested by the recipient, a parent, legal guardian, or caregiver of the
recipient.
(17) "Level I PRTF" means a psychiatric
residential treatment facility that meets the criteria established in
KRS
216B.450(5)(a).
(18) "Level II PRTF" means a psychiatric
residential treatment facility that meets the criteria established in
KRS
216B.450(5)(b).
(19) "Licensed clinical alcohol and drug
counselor" is defined by
KRS
309.080(4).
(20) "Licensed clinical alcohol and drug
counselor associate" is defined by
KRS
309.080(5).
(21) "Licensed clinical social worker" means
an individual who meets the licensed clinical social worker requirements
established in
KRS
335.100.
(22) "Licensed marriage and family therapist"
is defined by
KRS
335.300(2).
(23) "Licensed professional art therapist" is
defined by
KRS
309.130(2).
(24) "Licensed professional art therapist
associate" is defined by
KRS
309.130(3).
(25) "Licensed professional clinical
counselor" is defined by
KRS
335.500(3).
(26) "Licensed professional counselor
associate" is defined by
KRS
335.500(4).
(27) "Licensed psychological associate" means
an individual who:
(a) Currently possesses a
licensed psychological associate license in accordance with
KRS
319.010(6); and
(b) Meets the licensed psychological
associate requirements established in 201 KAR Chapter 26.
(28) "Licensed psychological practitioner"
means an individual who meets the requirements established in
KRS
319.053.
(29) "Licensed psychologist" means an
individual who:
(a) Currently possesses a
licensed psychologist license in accordance with
KRS
319.010(6); and
(b) Meets the licensed psychologist
requirements established in 201 KAR Chapter 26.
(30) "Marriage and family therapy associate"
is defined by
KRS
335.300(3).
(31) "Medicaid payment status" means a
circumstance in which:
(a) The person:
1. Is eligible for and receiving Medicaid
benefits; and
2. Meets patient
status criteria for Level I or II psychiatric residential treatment facility
services; and
(b) The
facility is billing the Medicaid program for services provided to the
person.
(32) "Medically
necessary" or "medical necessity" means that a covered benefit is determined to
be needed in accordance with
907
KAR 3:130.
(33) "Mental health associate" means:
(a)
1. An
individual with a minimum of a bachelor's degree in a mental health related
field;
2. A registered nurse;
or
3. A licensed practical nurse
with at least one (1) year of experience in a psychiatric inpatient or
residential treatment setting for children; or
(b) An individual with:
1. A high school diploma or an equivalence
certificate; and
2. At least two
(2) years of work experience in a psychiatric inpatient or residential
treatment setting for children.
(34) "Physician" is defined by
KRS
205.510(11).
(35) "Physician assistant" is defined by
KRS
311.840(3).
(36) "Private psychiatric hospital" is
defined by
KRS
205.639(2).
(37) "Provider" is defined by
KRS
205.8451(7).
(38) "Provider abuse" is defined by
KRS
205.8451(8).
(39) "Psychiatric residential treatment
facility" or "PRTF" is defined by
KRS
216B.450(5).
(40) "Psychiatric services" means:
(a) An initial psychiatric evaluation of a
recipient which shall include:
1. A review of
the recipient's:
a. Personal
history;
b. Family
history;
c. Physical
health;
d. Prior treatment;
and
e. Current treatment;
2. A mental status examination
appropriate to the age of the recipient;
3. A meeting with the family or any
designated significant person in the recipient's life; and
4. Ordering and reviewing:
a. Laboratory data;
b. Psychological testing results;
or
c. Any other ancillary health or
mental health examinations;
(b) Development of an initial plan of
treatment which shall include:
1. Prescribing
and monitoring of psychotropic medications; or
2. Providing and directing therapy to the
recipient;
(c)
Implementing, assessing, monitoring, or revising the treatment as appropriate
to the recipient's psychiatric status;
(d) Providing a subsequent psychiatric
evaluation as appropriate to the recipient's psychiatric status;
(e) Consulting, if determined to be necessary
by the psychiatrist responsible for providing or overseeing the recipient's
psychiatric services, with another physician, an attorney, or the police
regarding the recipient's care and treatment; or
(f) Ensuring that the psychiatrist
responsible for providing or overseeing the recipient's psychiatric services
has access to the information resulting from or related to any consultation
referenced in paragraph (e) of this subsection.
(41) "Qualified mental health personnel" is
defined by
KRS
216B.450(6).
(42) "Qualified mental health professional"
is defined by
KRS
216B.450(7).
(43) "Recipient" is defined by
KRS
205.8451(9).
(44) "Recipient abuse" is defined by
KRS
205.8451(10).
(45) "Review agency" means, for a review,
evaluation, or authorization decision regarding an individual who is:
(a) Not enrolled with a managed care
organization:
1. The department; or
2. An entity under contract with the
department; or
(b)
Enrolled with a managed care organization:
1.
The managed care organization with which the enrollee is enrolled; or
2. An entity under contract with the managed
care organization with which the enrollee is enrolled.
(46) "State mental hospital" is
defined by
KRS
205.639(3).
(47) "Telemedicine" means two-way, real time
interactive communication between a patient and a physician or practitioner
located at a distant site for the purpose of improving a patient's health
through the use of interactive telecommunications equipment that includes, at a
minimum, audio and video equipment.
(48) "Treatment plan" means a plan created
for the care and treatment of a recipient that:
(a) Is developed in a face-to-face meeting by
the recipient's interdisciplinary team;
(b) Describes a comprehensive, coordinated
plan of medically necessary behavioral health services that specifies a
modality, frequency, intensity, and duration of services sufficient to maintain
the recipient in a PRTF setting; and
(c) Identifies:
1. A program of therapies, activities,
interventions, or experiences designed to accomplish the plan;
2. A qualified mental health professional, a
mental health associate, or qualified mental health personnel who shall manage
the continuity of care;
3.
Interventions by caregivers in the PRTF and school setting that support the
recipient's ability to be maintained in a PRTF setting;
4. Behavioral, social, and physical problems
with interventions and objective, measurable goals;
5. Discharge criteria that specifies the:
a. Recipient-specific behavioral indicators
for discharge from the service;
b.
Expected service level that would be required upon discharge; and
c. Identification of the intended provider to
deliver services upon discharge;
6. A crisis action plan that progresses
through a continuum of care that is designed to reduce or eliminate the
necessity of inpatient services;
7.
A plan for:
a. Transition to a lower intensity
of services; and
b. Discharge from
PRTF services;
8. An
individual behavior management plan;
9. A plan for the involvement and visitation
of the recipient with the birth family, guardian, or other significant person,
unless prohibited by a court, including therapeutic off-site visits pursuant to
the treatment plan; and
10.
Services and planning, beginning at admission, to facilitate the discharge of
the recipient to an identified plan for home-based services or a lower level of
care.
Section
2. Provider Participation.
(1)
(a) In order to participate, or continue to
participate, in the Kentucky Medicaid Program, a Level I PRTF shall:
1. Have a utilization review plan for each
recipient consisting of, at a minimum, a pre-admission certification review
submitted via telephone or electronically to the review agency prior to
admission of the recipient;
2.
Perform and place in each recipient's record:
a. A medical evaluation;
b. A social evaluation; and
c. A psychiatric evaluation;
3. Establish a plan of care for
each recipient which shall be placed in the recipient's record;
4. Appoint a utilization review committee
which shall:
a. Oversee and implement the
utilization review plan; and
b.
Evaluate each Medicaid admission and continued stay prior to the expiration of
the Medicaid certification period to determine if the admission or stay is or
remains medically necessary;
5. Comply with staffing requirements
established in
902
KAR 20:320;
6. Be located in the Commonwealth of
Kentucky;
7. Maintain accreditation
by the Joint Commission on Accreditation of Health Care Organizations or the
Council on Accreditation of Services for Families and Children or any other
accrediting body with comparable standards that is recognized by the state;
and
8. Comply with all conditions
of Medicaid provider participation established in
907
KAR 1:671 and
907
KAR 1:672.
(b) In order to participate, or continue to
participate, in the Kentucky Medicaid Program, a Level II PRTF shall:
1. Have a utilization review plan for each
recipient;
2. Establish a
utilization review process which shall evaluate each Medicaid admission and
continued stay prior to the expiration of the Medicaid certification period to
determine if the admission or stay is or remains medically necessary;
3. Comply with staffing requirements
established in
902
KAR 20:320;
4. Be located in the Commonwealth of
Kentucky;
5. Maintain accreditation
by the Joint Commission on Accreditation of Health Care Organizations or the
Council on Accreditation of Services for Families and Children or any other
accrediting body with comparable standards that is recognized by the
state;
6. Comply with all
conditions of Medicaid provider participation established in
907
KAR 1:671 and
907
KAR 1:672;
7. Perform and place in each recipient's
record a:
a. Medical evaluation;
b. Social evaluation; and
c. Psychiatric evaluation; and
8. Establish a plan of care for
each recipient which shall:
a. Address in
detail the intensive treatment services to be provided to the recipient;
and
b. Be placed in the recipient's
record.
(2)
(a) A
pre-admission certification review for a Level I PRTF shall:
1. Contain:
a. The recipient's valid Medicaid
identification number;
b. For a
recipient who is not enrolled with a managed care organization, a valid
MAP-569, Certification of Need by Independent Team Psychiatric Preadmission
Review of Elective Admissions for Kentucky Medicaid Recipients Under Age
Twenty-One (21), which satisfies the requirements of 42 C.F.R. 44.152 and
42 C.F.R.
441.153 for patients age twenty-one (21) and
under;
c. A DSM-IV-R diagnosis on
all five (5) axes, except that failure to record an axis IV or V diagnosis
shall be used as the basis for a denial only if those diagnoses are critical to
establish the need for Level I PRTF treatment;
d. A description of the initial treatment
plan relating to the admitting symptoms;
e. Current symptoms requiring inpatient
treatment;
f. Information to
support the medical necessity and clinical appropriateness of the services or
benefits of the admission to a Level I PRTF in accordance with
907
KAR 3:130;
g. Medication history;
h. Prior hospitalization;
i. Prior alternative treatment;
j. Appropriate medical, social, and family
histories; and
k. Proposed
aftercare placement;
2.
Remain in effect for the days certified by the review agency; and
3. Be completed within thirty (30)
days.
(b) A
pre-admission certification review for a Level II PRTF for a non-emergent
admission shall:
1. Contain:
a. The recipient's valid Medicaid
identification number;
b. For a
recipient who is not enrolled with a managed care organization, a valid
MAP-569, Certification of Need by Independent Team Psychiatric Preadmission
Review of Elective Admissions for Kentucky Medicaid Recipients Under Age
Twenty-One (21), which satisfies the requirements of 42 C.F.R. 44.152 and
42 C.F.R.
441.153 for patients age twenty-one (21) and
under;
c. A DSM-IV-R diagnosis on
all five (5) axes, except that failure to record an axis IV or V diagnosis
shall be used as the basis for a denial only if those diagnoses are critical to
establish the need for Level II PRTF treatment;
d. A description of the initial treatment
plan relating to the admitting symptoms;
e. Current symptoms requiring inpatient
treatment;
f. Information to
support the medical necessity and clinical appropriateness of the services or
benefits of the admission to a Level II PRTF in accordance with
907
KAR 3:130;
g. Medication history;
h. Prior hospitalization;
i. Prior alternative treatment;
j. Appropriate medical, social, and family
histories; and
k. Proposed
aftercare placement;
2.
Remain in effect for the days certified by the review agency; and
3. Be completed within thirty (30)
days.
(3)
Failure to admit a recipient within the recipient's certification period shall
require a new pre-admission certification review request.
(4) A utilization review plan for an
emergency admission to a Level II PRTF shall contain:
(a) For a recipient who is not enrolled with
a managed care organization, a completed MAP-570, Medicaid Certification of
Need for Inpatient Psychiatric Services for Individuals Under Age Twenty-One
(21):
1. Completed by the facility's
interdisciplinary team; and
2.
Placed in the recipient's medical record;
(b) Documentation, provided by telephone or
electronically to the review agency within two (2) days of the recipient's
emergency admission, justifying:
1. The
recipient's emergency admission;
2.
That ambulatory care resources in the recipient's community and placement in a
Level I PRTF do not meet the recipient's needs;
3. That proper treatment of the recipient's
psychiatric condition requires services provided by a Level II PRTF under the
direction of a physician; and
4.
That the services can reasonably be expected to improve the recipient's
condition or prevent further regression so that the services are no longer
needed;
(c) The
recipient's valid Medicaid identification number;
(d) For a recipient who is not enrolled with
a managed care organization, a valid MAP-569, Certification of Need by
Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21), which satisfies the
requirements of
42 C.F.R.
441.152 and
42 C.F.R.
441.153 for recipients age twenty-one (21)
and under;
(e) A DSM-IV-R diagnosis
on all five (5) axes, except that failure to record an axis IV or V diagnosis
shall be used as the basis for a denial only if those diagnoses are critical to
establish the need for Level II PRTF treatment;
(f)
1. A
description of the initial treatment plan relating to the admitting symptom;
and
2. As part of the initial
treatment plan, a full description of the intensive treatment services to be
provided to the recipient;
(g) Current symptoms requiring residential
treatment;
(h) Medication
history;
(i) Prior
hospitalization;
(j) Prior
alternative treatment;
(k)
Appropriate medical, social, and family histories; and
(l) Proposed aftercare placement.
(5) For an individual who becomes
Medicaid eligible after admission and who is not enrolled with a managed care
organization, a Level I or II PRTF's interdisciplinary team shall complete a
MAP-570, Medicaid Certification of Need for Inpatient Psychiatric Services for
Individuals Under Age Twenty-One (21), and the form shall be placed in the
recipient's medical record.
(6) For
a recipient, a Level I or II PRTF shall maintain medical records that shall:
(a) Be:
1.
Current;
2. Readily
retrievable;
3.
Organized;
4. Complete;
and
5. Legible;
(b) Reflect sound medical
recordkeeping practice in accordance with:
1.
902
KAR 20:320;
2.
KRS
194A.060;
3.
KRS 434.840 through
860;
4.
KRS
422.317; and
5.42 C.F.R. 431 Subpart F;
(c) Document the need for
admission and appropriate utilization of services;
(d) Be maintained, including information
regarding payments claimed, for a minimum of six (6) years or until an audit
dispute or issue is resolved, whichever is longer; and
(e) Be made available for inspection or
copying or provided to the following upon request:
1. A representative of the United States
Department for Health and Human Services or its designee;
2. The United States Office of the Attorney
General or its designee;
3. The
Commonwealth of Kentucky, Office of the Attorney General or its
designee;
4. The Commonwealth of
Kentucky, Office of the Auditor of Public Accounts or its designee;
5. The Commonwealth of Kentucky, Cabinet for
Health and Family Services, Office of the Inspector General or its
designee;
6. The department;
or
7. A managed care organization
with whom the department has contracted if the recipient is enrolled with the
managed care organization.
(7)
(a) If a
Level I or Level II psychiatric residential treatment facility receives any
duplicate payment or overpayment from the department or managed care
organization, regardless of reason, the Level I or Level II psychiatric
residential treatment facility shall return the payment to the department or
managed care organization that issued the duplicate payment or overpayment in
accordance with
907
KAR 1:671.
(b) Failure to return a payment to the
department or managed care organization 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.
(8)
(a) When the department or managed care
organization makes payment for a covered service and the Level I or Level II
psychiatric residential treatment facility accepts the payment:
1. The payment shall be considered payment in
full;
2. A bill for the same
service shall not be given to the recipient; and
3. Payment from the recipient for the same
service shall not be accepted by the Level I or Level II psychiatric
residential treatment facility.
(b)
1. A
Level I or Level II psychiatric residential treatment facility may bill a
recipient for a service that is not covered by the Kentucky Medicaid Program if
the:
a. Recipient requests the service;
and
b. Level I or Level II
psychiatric residential treatment facility makes the recipient aware in advance
of providing the service that the:
(i)
Recipient is liable for the payment; and
(ii) Department or managed care organization,
if the recipient is enrolled with a managed care organization, is not covering
the service.
2. If a recipient makes payment for a service
in accordance with subparagraph 1 of this paragraph, the:
a. Level I or Level II psychiatric
residential treatment facility shall not bill the department or managed care
organization, if applicable, for the service; and
b. Department or managed care organization,
if applicable, shall not:
(i) Be liable for
any part of the payment associated with the service; and
(ii) Make any payment to the Level I or Level
II psychiatric residential treatment facility regarding the service.
(c) Except
as established in paragraph (b) of this subsection or except for a cost sharing
obligation owed by a recipient, a provider shall not bill a recipient for any
part of a service provided to the recipient.
(9)
(a) A
Level I or Level II psychiatric residential treatment facility shall attest by
the Level I or Level II psychiatric residential treatment facility's staff's or
representative's signature that any claim associated with a service is valid
and submitted in good faith.
(b)
Any claim and substantiating record associated with a service shall be subject
to audit by the:
1. Department or its
designee;
2. Cabinet for Health and
Family Services, Office of Inspector General, or its designee;
3. Kentucky Office of Attorney General or its
designee;
4. Kentucky Office of the
Auditor for Public Accounts or its designee;
5. United States General Accounting Office or
its designee; or
6. For an
enrollee, managed care organization in which the enrollee is
enrolled.
(c)
1. If a Level I or Level II psychiatric
residential treatment facility receives a request from the:
a. Department to provide a claim, related
information, related documentation, or record for auditing purposes, the Level
I or Level II psychiatric residential treatment facility shall provide the
requested information to the department within the timeframe requested by the
department; or
b. Managed care
organization in which an enrollee is enrolled to provide a claim, related
information, related documentation, or record for auditing purposes, the Level
I or Level II psychiatric residential treatment facility shall provide the
requested information to the managed care organization within the timeframe
requested by the managed care organization.
2.
a. The
timeframe requested by the department or managed care organization for a Level
I or Level II psychiatric residential treatment facility to provide requested
information shall be:
(i) A reasonable amount
of time given the nature of the request and the circumstances surrounding the
request; and
(ii) A minimum of one
(1) business day.
b. A
Level I or Level II psychiatric residential treatment facility may request a
longer timeframe to provide information to the department or a managed care
organization if the Level I or Level II psychiatric residential treatment
facility justifies the need for a longer timeframe.
(d)
1. All services provided shall be subject to
review for recipient or provider abuse.
2. Willful abuse by a Level I or Level II
psychiatric residential treatment facility shall result in the suspension or
termination of the Level I or Level II psychiatric residential treatment
facility from Medicaid Program participation in accordance with
907
KAR 1:671.
Section 4. PRTF Covered Services.
(1)
(a)
There shall be a treatment plan developed for each recipient.
(b) A treatment plan shall specify:
1. The amount and frequency of services
needed; and
2. The number of
therapeutic pass days for a recipient, if the treatment plan includes any
therapeutic pass days.
(2) To be covered by the department:
(a) The following services shall be available
to a recipient covered under Section 3 of this administrative regulation and
shall meet the requirements established in paragraph (b) of this subsection:
1. Diagnostic and assessment
services;
2. Treatment plan
development, review, or revision;
3. Psychiatric services;
4. Nursing services which shall be provided
in compliance with
902
KAR 20:320;
5. Medication which shall be provided in
compliance with
907 KAR
23:010;
6.
Evidence-based treatment interventions;
7. Individual therapy which shall comply with
902
KAR 20:320;
8. Family therapy or attempted contact with
family which shall comply with
902
KAR 20:320;
9. Group therapy which shall comply with
902
KAR 20:320;
10. Individual and group interventions that
shall focus on additional and harmful use or abuse issues and relapse
prevention if indicated;
11.
Substance abuse education;
12.
Activities that:
a. Support the development of
an age-appropriate daily living skill including positive behavior management or
support; or
b. Support and
encourage the parent's ability to re-integrate the child into the
home;
13. Crisis
intervention which shall comply with:
a.
42 C.F.R. 483.350
through 376; and
b.
902
KAR 20:320;
14. Consultation with other professionals
including case managers, primary care professionals, community support workers,
school staff, or others;
15.
Educational activities; or
16.
Non-medical transportation services as needed to accomplish
objectives;
(b) A Level
I PRTF service listed in paragraph (a) of this subsection shall be:
1. Provided under the direction of a
physician;
2. If included in the
recipient's treatment plan, described in the recipient's current treatment
plan;
3. Medically necessary;
and
4. Clinically appropriate
pursuant to the criteria established in
907
KAR 3:130;
(c) A Level I PRTF service listed in
paragraph (a)7, 8, 9, 11, or 13 shall be provided by a qualified mental health
professional, behavioral health professional, or behavioral health professional
under clinical supervision; or
(d)
A Level II PRTF service listed in paragraph (a) of this subsection shall be:
1. Provided under the direction of a
physician;
2. If included in the
recipient's treatment plan, described in the recipient's current treatment
plan;
3. Provided at least once a
week:
a. Unless the service is necessary twice
a week, in which case the service shall be provided at least twice a week;
or
b. Except for diagnostic and
assessment services which shall have no weekly minimum requirement;
4. Medically necessary;
and
5. Clinically appropriate
pursuant to the criteria established in
907
KAR 3:130.
(3) A Level II PRTF service listed in
paragraph (a)7, 8, 9, 11, or 13 shall be provided by a qualified mental health
professional, behavioral health professional, or behavioral health professional
under clinical supervision.
Section 6. Durational Limit, Re-evaluation,
and Continued Stay.
(1) A recipient's stay,
including the duration of the stay, in a Level I or II PRTF shall be subject to
the department's approval.
(2)
(a) A recipient in a Level I PRTF shall be
re-evaluated at least once every thirty (30) days to determine if the recipient
continues to meet Level I PRTF patient status criteria established in Section
5(2) of this administrative regulation.
(b) A Level I PRTF shall complete a review of
each recipient's treatment plan at least once every thirty (30) days.
(c) The review referenced in paragraph (b) of
this subsection shall include:
1. Dated
signatures of:
a. Appropriate staff;
and
b. If present for the treatment
plan meeting, a parent, guardian, legal custodian, or conservator;
2. An assessment of progress
toward each treatment plan goal and objective with revisions indicated;
and
3. A statement of justification
for the level of services needed including:
a.
Suitability for treatment in a less-restrictive environment; and
b. Continued services.
(d) If a recipient no longer meets
Level I PRTF patient status criteria, the department shall only reimburse
through the last day of the individual's current approved stay.
(e) The re-evaluation referenced in paragraph
(a) of this subsection shall be performed by a review
agency.
(3) A Level II
PRTF shall complete by no later than the third (3rd) business day following an
admission, an initial review of services and treatment provided to a recipient
which shall include:
(a) Dated signatures of
appropriate staff, parent, guardian, legal custodian, or conservator;
(b) An assessment of progress toward each
treatment plan goal and objective with revisions indicated; and
(c) A statement of justification for the
level of services needed including:
1.
Suitability for treatment in a less-restrictive environment; and
2. Continued services.
(4)
(a) For a recipient aged four (4) to five (5)
years, a Level II PRTF shall complete a review of the recipient's treatment
plan of care at least once every fourteen (14) days after the initial review
referenced in subsection (3) of this section.
(b) The review referenced in paragraph (a) of
this subsection shall include:
1. Dated
signatures of appropriate staff, parent, guardian, legal custodian, or
conservator;
2. An assessment of
progress toward each treatment plan goal and objective with revisions
indicated; and
3. A statement of
justification for the level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
(5)
(a) For a recipient aged six (6) to
twenty-two (22) years, a Level II PRTF shall complete a review of the
recipient's treatment plan of care at least once every thirty (30) days after
the initial review referenced in subsection (3) of this section.
(b) The review referenced in paragraph (a) of
this subsection shall include:
1. Dated
signatures of appropriate staff, parent, guardian, legal custodian, or
conservator;
2. An assessment of
progress toward each treatment plan goal and objective with revisions
indicated; and
3. A statement of
justification for the level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
Section 7.
Exclusions and Limitations in Coverage.
(1)
The following shall not be covered as Level I or II PRTF services under this
administrative regulation:
(a) Outpatient
services, which shall be covered in accordance with
907
KAR 9:015;
(b) Pharmacy services, which shall be covered
in accordance with
907 KAR
23:010;
(c) Durable medical equipment, which shall be
covered in accordance with
907
KAR 1:479;
(d) Hospital emergency room services, which
shall be covered in accordance with
907
KAR 10:014;
(e) Acute care hospital inpatient services,
which shall be covered in accordance with
907 KAR
10:012;
(f) Laboratory and radiology services, which
shall be covered in accordance with
907
KAR 10:014 or
907
KAR 1:028;
(g) Dental services, which shall be covered
in accordance with
907
KAR 1:026;
(h) Hearing and vision services, which shall
be covered in accordance with
907
KAR 1:038; or
(i) Ambulance services, which shall be
covered in accordance with
907 KAR
1:060.
(2) A Level I or II PRTF shall not charge a
recipient or responsible party representing a recipient any difference between
private and semiprivate room charges.
(3) The department shall not reimburse for
Level I or II PRTF services for a recipient if appropriate alternative services
are available for the recipient in the community.
(4) The following shall not qualify as
reimbursable in a PRTF setting:
(a) An
admission that is not medically necessary; or
(b) Services for an individual:
1. With a major medical problem or minor
symptoms;
2. Who might only require
a psychiatric consultation rather than an admission to a PRTF; or
3. Who might need only adequate living
accommodations, economic aid, or social support services.
Section 8. Reserved Bed
and Therapeutic Pass Days.
(1)
(a) The department shall cover a bed reserve
day for an acute hospital admission, a state mental hospital admission, a
private psychiatric hospital admission, or an admission to a psychiatric bed in
an acute care hospital for a recipient's absence from a Level I or II PRTF if
the recipient:
1. Is in Medicaid payment
status in a Level I or II PRTF;
2.
Has been in the Level I or II PRTF overnight for at least one (1)
night;
3. Is reasonably expected to
return requiring Level I or II PRTF care; and
4.
a. Has
not exceeded the bed reserve day limit established in paragraph (b) of this
subsection; or
b. Received an
exception to the limit in accordance with paragraph (c) of this
subsection.
(b) The annual bed reserve day limit per
recipient shall be five (5) days per calendar year in aggregate for any
combination of bed reserve days associated with an acute care hospital
admission, a state mental hospital admission, a private psychiatric hospital
admission, or an admission to a psychiatric bed in an acute care
hospital.
(c) The department shall
allow a recipient to exceed the limit established in paragraph (b) of this
subsection, if the department determines that an additional bed reserve day is
in the best interest of the recipient.
(2)
(a) The
department shall cover a therapeutic pass day for a recipient's absence from a
Level I or II PRTF if the recipient:
1. Is in
Medicaid payment status in a Level I or II PRTF;
2. Has been in the Level I or II PRTF
overnight for at least one (1) night;
3. Is reasonably expected to return requiring
Level I or II PRTF care; and
4.
a. Has not exceeded the therapeutic pass day
limit established in paragraph (b) of this subsection; or
b. Received an exception to the limit in
accordance with paragraph (c) of this subsection.
(b) The annual therapeutic pass
day limit per recipient shall be fourteen (14) days per calendar
year.
(c) The department shall
allow a recipient to exceed the limit established in paragraph (b) of this
subsection, if the department determines that an additional therapeutic pass
day is in the best interest of the recipient.
(3) The bed reserve day and therapeutic pass
day count for each recipient shall begin at zero on January 1 of each calendar
year.
(4) An authorization decision
regarding a bed reserve day or therapeutic pass day in excess of the limits
established in this section shall be performed by a review agency.
(5)
(a) An
acute care hospital bed reserve day shall be a day when a recipient is
temporarily absent from a Level I or II PRTF due to an admission to an acute
care hospital.
(b) A state mental
hospital bed reserve day, private psychiatric hospital bed reserve day, or
psychiatric bed in an acute care hospital bed reserve day, respectively, shall
be a day when a recipient is temporarily absent from a Level I or II PRTF due
to receiving psychiatric treatment in a state mental hospital, private
psychiatric hospital, or psychiatric bed in an acute care hospital
respectively.
(c) A therapeutic
pass day shall be a day when a recipient is temporarily absent from a Level I
or II PRTF for a therapeutic purpose that is:
1. Stated in the recipient's treatment plan;
and
2. Approved by the recipient's
treatment team.
(6)
(a) A
Level I or II PRTF's occupancy percent shall be based on a midnight
census.
(b) An absence from a Level
I or II PRTF that is due to a bed reserve day for an acute hospital admission,
a state mental hospital admission, a private psychiatric hospital admission, or
an admission to a psychiatric bed in an acute care hospital shall count as an
absence for census purposes.
(c) An
absence from a Level I or II PRTF that is due to a therapeutic pass day shall
not count as an absence for census purposes.
Section 14. Appeal Rights.
(1)
(a) 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.
(b) 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.
(2) An appeal of a negative action regarding
Medicaid eligibility of an individual shall be in accordance with
907
KAR 1:560.
(3) An appeal of a negative action regarding
a Medicaid provider shall be in accordance with
907
KAR 1:671.
Section 15. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "MAP-569, Certification of Need
by Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21)", revised 5/90;
and
(b) "MAP-570, Medicaid
Certification of Need for Inpatient Psychiatric Services for Individuals Under
Age Twenty-one (21)", revised 5/90.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, Cabinet for Health and Family Services, 275 East Main
Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30
p.m.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
42
C.F.R. 440.160,
42 U.S.C.
1396a
-d