Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
216B.450,
216B.455,
42 U.S.C.
1395u
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) empowers 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
reimbursement policies for non-outpatient Level I and Level II psychiatric
residential treatment facility services provided to a Medicaid recipient who is
not enrolled in a managed care organization.
Section 1. Definition
(1) "Department" means the Department for
Medicaid Services or its designee.
(2) "Federal financial participation" is
defined by 42 C.F.R.
400.203.
(3) "Level I PRTF" means a psychiatric
residential treatment facility that meets the criteria established in
KRS
216B.450(5)(a).
(4) "Level II PRTF" means a psychiatric
residential treatment facility that meets the criteria established in
KRS
216B.450(5)(b).
(5) "Managed care organization" means an
entity for which the department has contracted to serve as a managed care
organization as defined in 42 C.F.R. 438.2.
(6) "Medicare Economic Index" or "MEI" means
the economic index referred to in
42 U.S.C.
1395u(b)(3)(L).
(7) "Percentage increase in the MEI" is
defined in 42 U.S.C.
1395u(i)(3).
(8) "Per diem rate" means a Level I or II
PRTF's total daily reimbursement as calculated by the department.
(9) "Recipient" is defined by
KRS
205.8451(9).
Section 2. Reimbursement for Level
I PRTF Services and Costs.
(1) To be
reimbursable under the Medicaid Program, Level I PRTF services and associated
costs, respectively, shall be provided to or associated with a recipient
receiving Level I PRTF services in accordance with
907 KAR 9:005.
(2) The department shall reimburse for Level
I PRTF services and costs referenced in subsection (4) of this section for a
recipient not enrolled in a managed care organization:
(a) At the lesser of:
1. A per diem rate of $500; or
2. The usual and customary charge;
and
(b) An amount not to
exceed the prevailing charges, in the locality where the Level I PRTF is
located, for comparable services provided under comparable
circumstances.
(3) The
per diem rate referenced in subsection (2) of this section shall be increased
annually by the percentage increase in the MEI.
(4) The reimbursement referenced in
subsection (2) of this section shall represent the total Medicaid reimbursement
for Level I PRTF services and costs:
(a)
Including all care and treatment costs;
(b) Including costs for all ancillary
services;
(c) Including capital
costs;
(d) Including room and board
costs; and
(e) Excluding the costs
of drugs as drugs shall be:
1. Covered in
accordance with
907 KAR 23:010; and
2. Reimbursed via the department's pharmacy
program in accordance with
907 KAR 23:020.
Section 3.
Reimbursement for Level II PRTF Services and Costs.
(1) To be reimbursable under the Medicaid
program, Level II PRTF services and associated costs, respectively, shall be
provided to or associated with a recipient receiving Level II PRTF services in
accordance with
907 KAR 9:005.
(2) The department shall reimburse at the
lesser of the usual and customary charge or a per diem rate of $600 for Level
II PRTF services and costs for a recipient not enrolled in a managed care
organization.
(3) The per diem rate
referenced in subsection (2) of this section, or the usual and customary charge
if less than the per diem rate, shall represent the total Medicaid
reimbursement for Level II PRTF services and costs:
(a) Including all care and treatment
costs;
(b) Including costs for all
ancillary services;
(c) Including
capital costs;
(d) Including room
and board costs; and
(e) Excluding
the costs of drugs as drugs shall be:
1.
Covered in accordance with
907 KAR 23:010; and
2. Reimbursed via the department's pharmacy
program in accordance with
907 KAR 23:020.
(4) The per diem rate
referenced in subsection (2) of this section shall be increased annually by the
percentage increase in the MEI.
Section 4. Cost Reports and Audits.
(1)
(a) A
Level I or II PRTF shall annually submit to the department, within ninety (90)
days of the closing date of the facility's fiscal year end, a legible and
completed Form CMS 2552-96.
(b) The
department shall grant a thirty (30) day extension for submitting a legible and
completed Form CMS 2552-96 to the department if an extension is requested by a
Level I or II PRTF.
(2)
(a) A Form CMS 2552-96 shall be subject to
review and audit by the department.
(b) The review and audit referenced in
paragraph (a) of this subsection shall be to determine if the information
provided is accurate.
Section 5. Access to Level I and II PRTF
Fiscal and Services Records. A Level I or II PRTF shall provide, upon request,
all fiscal and service records relating to services provided to a Kentucky
recipient, to the:
(1) Department;
(2) Cabinet for Health and Family Services,
Office of Inspector General;
(3)
Commonwealth of Kentucky, Office of the Attorney General;
(4) Commonwealth of Kentucky, Auditor of
Public Accounts;
(5) Secretary of
the United States Department of Health and Human Services; or
(6) United States Office of the Attorney
General.
Section 6. Bed
Reserve and Therapeutic Pass Reimbursement.
(1) The department's reimbursement for a bed
reserve day which qualifies as a bed reserve day pursuant to
907 KAR 9:005 for a recipient not
enrolled in a managed care organization shall be:
(a) Seventy-five (75) percent of the rate
established in Section 2 or 3 of this administrative regulation if the Level I
or II PRTF's occupancy percent is at least eighty-five (85) percent;
or
(b) Fifty (50) percent of the
rate established in Section 2 or 3 of this administrative regulation if the
Level I or II PRTF's occupancy percent is less than eighty-five (85)
percent.
(2) The
department's reimbursement for a therapeutic pass day which qualifies as a
therapeutic pass day pursuant to
907 KAR 9:005 for a recipient not
enrolled in a managed care organization shall be:
(a) 100 percent of the rate established in
Section 2 or 3 of this administrative regulation if the Level I or II PRTF's
occupancy percent is at least fifty (50) percent; or
(b) Fifty (50) percent of the rate
established in Section 2 or 3 of this administrative regulation if the Level I
or II PRTF's occupancy percent is below fifty (50) percent.
(3)
(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 7. Outpatient Services Reimbursement
Established in
907 KAR 9:020. The department's
reimbursement provisions and requirements regarding outpatient behavioral
health services provided by a Level I or II PRTF shall be as established in
907 KAR 9:020.
Section 8. Federal Financial Participation.
The department's reimbursement for services pursuant to this administrative
regulation shall be contingent upon:
(1)
Receipt of federal financial participation for the reimbursement; and
(2) Centers for Medicare and Medicaid
Services' approval for the reimbursement.
Section 9. Appeals. A provider may appeal a
decision by the department regarding the application of this administrative
regulation in accordance with
907 KAR 1:671.
Section 10. Not Applicable to Managed Care
Organizations. A managed care organization shall not be required to reimburse
in accordance with this administrative regulation for a service covered
pursuant to:
(1) This administrative
regulation; or
(2)
907 KAR 9:005.
Section 11. Incorporation by
Reference.
(1) "Form CMS 2552-96", August 2010
edition, is incorporated by reference.
(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 40621, Monday
through Friday, 8:00 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