Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
42 U.S.C.
1396a(a)(10)(B),
42 U.S.C.
1396a(a)(23)
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 reimbursement
provisions and requirements regarding Medicaid Program outpatient behavioral
health services provided by Level I or Level II psychiatric residential
treatment facilities to Medicaid recipients who are not enrolled with a managed
care organization.
Section 1.
Definitions.
(1) "Advanced practice
registered nurse" or "APRN" is defined by
KRS
314.011(7).
(2) "Behavioral health practitioner under
supervision" means an individual who is:
(a)
1. A licensed professional counselor
associate;
2. A certified social
worker;
3. A marriage and family
therapy associate;
4. A licensed
professional art therapist associate;
5. A licensed assistant behavior
analyst;
6. A physician
assistant;
7. A certified alcohol
and drug counselor; or
8. A
licensed clinical alcohol and drug counselor associate in accordance with
Section 5 of this administrative regulation; and
(b) Employed by or under contract with the
same billing provider as the billing supervisor.
(3) "Billing provider" means the individual
who, group of individual providers that, or organization that:
(a) Is authorized to bill the department or a
managed care organization for a service; and
(b) Is eligible to be reimbursed by the
department or a managed care organization for a service.
(4) "Billing supervisor" means an individual
who is:
(a)
1. A physician;
2. A psychiatrist;
3. An advanced practice registered
nurse;
4. A licensed
psychologist;
5. A licensed
clinical social worker;
6. A
licensed professional clinical counselor;
7. A licensed psychological
practitioner;
8. A certified
psychologist with autonomous functioning;
9. A licensed marriage and family
therapist;
10. A licensed
professional art therapist; or
11.
A licensed behavior analyst; and
(b) Employed by or under contract with the
same billing provider as the behavioral health practitioner under supervision
who renders services under the supervision of the billing supervisor.
(5) "Certified alcohol and drug
counselor" means an individual who meets the requirements established in
KRS
309.083.
(6) "Certified psychologist" means an
individual who is a certified psychologist pursuant to
KRS
319.056.
(7) "Certified psychologist with autonomous
functioning" means an individual who is a certified psychologist with
autonomous functioning pursuant to
KRS
319.056.
(8) "Certified social worker" means an
individual who meets the requirements established in
KRS
335.080.
(9) "Department" means the Department for
Medicaid Services or its designee.
(10) "Federal financial participation" is
defined by
42 C.F.R.
400.203.
(11) "Healthcare common procedure coding
system" or "HCPCS" means a collection of codes acknowledged by the Centers for
Medicare and Medicaid Services (CMS) that represents procedures or
items.
(12) "Level I PRTF" means a
psychiatric residential treatment facility that meets the criteria established
in
KRS
216B.450(5)(a).
(13) "Level II PRTF" means a psychiatric
residential treatment facility that meets the criteria established in
KRS
216B.450(5)(b).
(14) "Licensed assistant behavior analyst" is
defined by
KRS
319C.010(7).
(15) "Licensed behavior analyst" is defined
by
KRS
319C.010(6).
(16) "Licensed clinical alcohol and drug
counselor" is defined by
KRS
309.080(4).
(17) "Licensed clinical alcohol and drug
counselor associate" is defined by
KRS
309.080(5).
(18) "Licensed clinical social worker" means
an individual who meets the licensed clinical social worker requirements
established in
KRS
335.100.
(19) "Licensed marriage and family therapist"
is defined by
KRS
335.300(2).
(20) "Licensed professional art therapist" is
defined by
KRS
309.130(2).
(21) "Licensed professional art therapist
associate" is defined by
KRS
309.130(3).
(22) "Licensed professional clinical
counselor" is defined by
KRS
335.500(3).
(23) "Licensed professional counselor
associate" is defined by
KRS
335.500(4).
(24) "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.
(25) "Licensed psychological practitioner"
means an individual who meets the requirements established in
KRS
319.053.
(26) "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.
(27) "Managed care organization" means an
entity for which the Department for Medicaid Services has contracted to serve
as a managed care organization as defined in
42
C.F.R. 438.2.
(28) "Marriage and family therapy associate"
is defined by
KRS
335.300(3).
(29) "Physician" is defined by
KRS
205.510(11).
(30) "Physician assistant" is defined by
KRS
311.840(3).
(31) "Provider" is defined by
KRS
205.8451(7).
Section 2. General Requirements.
For the department to reimburse for a service covered under this administrative
regulation, the service shall:
(1) Meet the
requirements established in
907
KAR 9:015; and
(2) Be covered in accordance with
907
KAR 9:015.
Section 3. Reimbursement.
(1)
(a) A
unit of service for a service listed on the Level I and Level II PRTF
Non-Medicare Services Fee Schedule shall be as established on the Level I and
Level II PRTF Non-Medicare Services Fee Schedule.
(b) A unit of service for a service not
listed on the Level I and Level II PRTF Non-Medicare Services Fee Schedule
shall be:
1. Fifteen (15) minutes in length
unless a different amount is established for the service in the corresponding:
a. Current procedural terminology code;
or
b. Healthcare common procedure
coding system code; or
2. The unit amount established in the
corresponding:
a. Current procedural
terminology code; or
b. Healthcare
common procedure coding system code.
(2) The rate per unit for a screening or for
crisis intervention shall be:
(a) Seventy-five
(75) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Physician; or
2.
Psychiatrist;
(b) 63.75
percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule
for the service if provided by:
1. An advanced
practice registered nurse; or
2. A
licensed psychologist;
(c) Sixty (60) percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by a:
1. Licensed professional clinical
counselor;
2. Licensed clinical
social worker;
3. Licensed
psychological practitioner;
4.
Certified psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist; or
7. Licensed
clinical alcohol and drug counselor in accordance with Section 5 of this
administrative regulation; or
(d) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a:
1. Marriage and
family therapy associate working under the supervision of a billing
supervisor;
2. Licensed
professional counselor associate working under the supervision of a billing
supervisor;
3. Licensed
psychological associate working under the supervision of a board-approved
licensed psychologist;
4. Certified
psychologist working under the supervision of a board-approved licensed
psychologist;
5. Certified social
worker working under the supervision of a billing supervisor;
6. Physician assistant working under the
supervision of a billing supervisor;
7. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
8. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
9. Licensed clinical alcohol and drug
counselor associate:
a. In accordance with
Section 5 of this administrative regulation; and
b. Working under the supervision of a billing
supervisor.
(3) The rate per unit for an assessment shall
be:
(a) Seventy-five (75) percent of the rate
on the Kentucky-specific Medicare Physician Fee Schedule for the service if
provided by a:
1. Physician; or
2. Psychiatrist;
(b) 63.75 percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by:
1. An advanced practice registered nurse;
or
2. A licensed
psychologist;
(c) Sixty
(60) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Licensed professional clinical counselor;
2. Licensed clinical social worker;
3. Licensed psychological
practitioner;
4. Certified
psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist;
7. Licensed behavior
analyst; or
8. Licensed clinical
alcohol and drug counselor in accordance with Section 5 of this administrative
regulation; or
(d)
Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific
Medicare Physician Fee Schedule for the service if provided by a:
1. Marriage and family therapy associate
working under the supervision of a billing supervisor;
2. Licensed professional counselor associate
working under the supervision of a billing supervisor;
3. Licensed psychological associate working
under the supervision of a board-approved licensed psychologist;
4. Certified psychologist working under the
supervision of a board-approved licensed psychologist;
5. Certified social worker working under the
supervision of a billing supervisor;
6. Physician assistant working under the
supervision of a billing supervisor;
7. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
8. Licensed assistant behavior analyst
working under the supervision of a billing supervisor;
9. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
10. Licensed clinical alcohol and drug
counselor associate:
a. In accordance with
Section 5 of this administrative regulation; and
b. Working under the supervision of a billing
supervisor.
(4) The rate per unit for psychological
testing shall be:
(a) 63.75 percent of the
rate on the Kentucky-specific Medicare Physician Fee Schedule for the service
if provided by a licensed psychologist;
(b) Sixty (60) percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by a:
1. Licensed psychological practitioner;
or
2. Certified psychologist with
autonomous functioning;
(c) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a:
1. Licensed
psychological associate working under the supervision of a board-approved
licensed psychologist; or
2.
Certified psychologist working under the supervision of a board-approved
licensed psychologist.
(5) The rate per unit for individual
outpatient therapy, group outpatient therapy, or collateral outpatient therapy
shall be:
(a) Seventy-five (75) percent of the
rate on the Kentucky-specific Medicare Physician Fee Schedule for the service
if provided by a:
1. Physician; or
2. Psychiatrist;
(b) 63.75 percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by:
1. An advanced practice registered nurse;
or
2. A licensed
psychologist;
(c) Sixty
(60) percent of the rate on the Kentucky-specific Medicare Physician Fee
Schedule for the service if provided by a:
1.
Licensed professional clinical counselor;
2. Licensed clinical social worker;
3. Licensed psychological
practitioner;
4. Certified
psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist;
7. Licensed behavior
analyst; or
8. Licensed clinical
alcohol and drug counselor in accordance with Section 5 of this administrative
regulation; or
(d)
Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific
Medicare Physician Fee Schedule for the service if provided by a:
1. Marriage and family therapy associate
working under the supervision of a billing supervisor;
2. Licensed professional counselor associate
working under the supervision of a billing supervisor;
3. Licensed psychological associate working
under the supervision of a board-approved licensed psychologist;
4. Certified psychologist working under the
supervision of a board-approved licensed psychologist;
5. Certified social worker working under the
supervision of a billing supervisor;
6. Physician assistant working under the
supervision of a billing supervisor;
7. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
8. Licensed assistant behavior analyst
working under the supervision of a billing supervisor;
9. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
10. Licensed clinical alcohol and drug
counselor associate:
a. In accordance with
Section 5 of this administrative regulation; and
b. Working under the supervision of a billing
supervisor.
(6) The rate per unit for family outpatient
therapy shall be:
(a) Seventy-five (75)
percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule
for the service if provided by a:
1.
Physician; or
2.
Psychiatrist;
(b) 63.75
percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule
for the service if provided by:
1. An advanced
practice registered nurse; or
2. A
licensed psychologist;
(c) Sixty (60) percent of the rate on the
Kentucky-specific Medicare Physician Fee Schedule for the service if provided
by a:
1. Licensed professional clinical
counselor;
2. Licensed clinical
social worker;
3. Licensed
psychological practitioner;
4.
Certified psychologist with autonomous functioning;
5. Licensed marriage and family
therapist;
6. Licensed professional
art therapist; or
7. Licensed
clinical alcohol and drug counselor in accordance with Section 5 of this
administrative regulation; or
(d) Fifty-two and five-tenths (52.5) percent
of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the
service if provided by a:
1. Marriage and
family therapy associate working under the supervision of a billing
supervisor;
2. Licensed
professional counselor associate working under the supervision of a billing
supervisor;
3. Licensed
psychological associate working under the supervision of a board-approved
licensed psychologist;
4. Certified
psychologist working under the supervision of a board-approved licensed
psychologist;
5. Certified social
worker working under the supervision of a billing supervisor;
6. Physician assistant working under the
supervision of a billing supervisor;
7. Licensed professional art therapist
associate working under the supervision of a billing supervisor;
8. Certified alcohol and drug counselor
working under the supervision of a billing supervisor; or
9. Licensed clinical alcohol and drug
counselor associate in accordance with Section 5 of this administrative
regulation.
(7) Reimbursement for the following services
shall be as established on the Level I and II PRTF Non-Medicare Services Fee
Schedule:
(a) Mobile crisis
services;
(b) Day
treatment;
(c) Peer support
services;
(d) Parent or family peer
support services;
(e) Intensive
outpatient program services;
(f)
Service planning;
(g) Screening,
brief intervention, and referral to treatment;
(h) Assertive community treatment;
(i) Comprehensive community support services;
or
(j) Therapeutic rehabilitation
services.
(8)
(a) The department shall use the current
version of the Kentucky-specific Medicare Physician Fee Schedule for
reimbursement purposes.
(b) For
example, if the Kentucky-specific Medicare Physician Fee Schedule currently
published and used by the Centers for Medicare and Medicaid Services for the
Medicare Program is:
1. An interim version,
the department shall use the interim version until the final version has been
published; or
2. A final version,
the department shall use the final version.
(9) The department shall not reimburse for a
service billed by or on behalf of an entity or individual that is not a billing
provider.
Section 4. 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)
907
KAR 9:015; and
(2) This administrative regulation.
Section 5. Federal Approval and
Federal Financial Participation.
(1) The
department's reimbursement for services pursuant to this administrative
regulation shall be contingent upon:
(a)
Receipt of federal financial participation for the reimbursement; and
(b) Centers for Medicare and Medicaid
Services' approval for the reimbursement.
(2) The reimbursement of services provided by
a licensed clinical alcohol and drug counselor or licensed clinical alcohol and
drug counselor associate shall be contingent and effective upon approval by the
Centers for Medicare and Medicaid Services.
Section 6. Incorporation by Reference.
(1) "Level I and Level II PRTF Non-Medicare
Services Fee Schedule", January 2015, is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky, Monday through Friday, 8:00 a.m. to
4:30 p.m.; or
(b) Online at the
department's Web site at
http://www.chfs.ky.gov/dms/incorporated.htm.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)