Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
200.460,
200.470,
200.654(13),
Chapters 311, 319, 334A,
42
U.S.C. 9902(2),
42 C.F.R.
435.603
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
194A.030(5) authorizes the
Office for Children with Special Health Care Needs to promulgate administrative
regulations to implement and administer its responsibilities. This
administrative regulation establishes application forms used for clinical
programs, procedures for application and reapplication, eligibility criteria,
assignment of pay category, and processes used to determine initial and
continuing eligibility for services, as well as a process for reconsideration
of an adverse decision.
Section 1.
Definitions.
(1) "Affordable Care Act" is
defined by
42
U.S.C. 9902(2).
(2) "Applicant" means a person in need of
services offered by the Office for Children with Special Health Care Needs
clinical program.
(3) "Clinical
program" means an established clinical service by which OCSHCN delivers care to
treat conditions listed on the OCSHCN-10g, Medical Eligibility List for
Clinical and Case Management Services, through a provider:
(a) Contracted in accordance with
911 KAR 1:060;
or
(b) Employed by OCSHCN as an
audiologist.
(4)
"Eligibility Committee" means an OCSHCN committee that is charged with:
(a) Clarifying financial eligibility
questions that arise during:
1. The
application review process; and
2.
Ongoing eligibility reviews;
(b) Evaluating appeal requests for
reconsideration pursuant to Section 13 of this administrative
regulation;
(c) Clarifying medical
eligibility questions that arise during the application review process;
and
(d) Determining if a diagnosis
qualifies for inclusion in the clinical program.
(5) "Income" means money received from:
(a) Statutory benefits (for example, Social
Security, Veterans Administration pension, black lung benefits, or railroad
retirement benefits);
(b) Military
housing;
(c) Clerical
housing;
(d) Farm or business
operations;
(e) Pensions;
(f) Wages for labor or services;
(g) Royalties;
(h) Alimony, maintenance, or child
support;
(i) Miscellaneous income
as defined by the Internal Revenue Service at
www.irs.gov/form1099misc.;
(j) Retirement Survivors Disability
Insurance;
(k) Disability
benefits;
(l) Unemployment
benefits;
(m) Supplemental Security
Income;
(n) Workers'
compensation;
(o) Annuities;
or
(p) Interest and
dividends.
(6) "OCSHCN"
means Office for Children with Special Health Care Needs.
(7) "Responsible adult" means a person who
is:
(a) Responsible for making decisions about
an OCSHCN clinical program applicant or recipient of services; or
(b) Required to provide financial support for
an OCSHCN clinical program applicant or recipient of services.
Section 2. Criteria for
Application to an OCSHCN Clinical Program.
(1)
In order to be eligible to apply to an OCSHCN clinical program, an applicant
shall:
(a) Be under twenty-one (21) years of
age;
(b) Live in
Kentucky;
(c) Provide a Kentucky
physical mailing address at which the applicant receives mail; and
(d) Declare Kentucky as permanent domicile
and residency.
(2) An
applicant to the OCSHCN Autism Spectrum Disorder Diagnostic Service shall be
referred by:
(a) A physician, licensed in
accordance with KRS Chapter 311;
(b) An advanced practice registered nurse,
licensed in accordance with KRS Chapter 314;
(c) A licensed behavioral analyst, licensed
in accordance with KRS Chapter 319;
(d) A therapist, licensed in accordance with
KRS Chapter 334A;
(e) A qualified
service provider with the Kentucky Early Intervention System, as defined by
KRS
200.654(13); or
(f) School personnel, based on testing
results.
(3) An
applicant to the OCSHCN Autism Spectrum Disorder Medical Service shall be:
(a) Referred by a:
1. Physician, licensed in accordance with KRS
Chapter 311;
2. Psychologist,
licensed in accordance with KRS Chapter 319; or
3. Speech-language pathologist, licensed in
accordance with KRS Chapter 334A, if an Autism Diagnostic Observation Schedule
assessment tool was used; and
(b) Diagnosed with an autism spectrum
disorder.
(4) An
applicant to the OCSHCN Hearing Aid Only Service shall be:
(a) Diagnosed to have a permanent childhood
hearing loss; and
(b) Under the
care of a licensed otorhinolaryngologist.
(5) An applicant to clinical services not
established in subsections (2), (3), or (4) of this section may be referred by
any person or provider.
(6) An
individual shall be ineligible for application to clinical programs if a
write-off balance for services is owed to OCSHCN for clinical services
delivered to the individual.
(7)
Any balances owed pursuant to subsection (6) of this section shall be paid in
accordance with the:
(a) Individual's pay
category status; and
(b) Provisions
of
911 KAR
1:020.
(8) OCSHCN shall allow up to three (3)
reapplications for an applicant if the applicant has been discharged for
failure to:
(a) Complete financial update in
accordance with Section 12 of this administrative regulation;
(b) Cooperate with medical care;
(c) Make payments on a past due account
balance;
(d) Pay OCSHCN for
services received; or
(e) Reimburse
OCSHCN if an insurance payment has been received by the applicant.
(9) Exceptions to subsections (7)
and (8) this section shall be determined by the OCSHCN request for
reconsideration process in accordance with Section 13 of this administrative
regulation.
Section 3.
Initial Application.
(1) If an individual who
meets the criteria established in Section 2 of this administrative regulation
expresses interest in submitting an application to OCSHCN's clinical program,
designated staff shall provide the application packet indicated for the
individual's situation, in accordance with Section 4 of this administrative
regulation:
(a) At a scheduled intake
appointment with the individual;
(b) By postal mail; or
(c) Electronically.
(2) An application shall be made by:
(a) The parent or other legally appointed
guardian, if the individual is:
1. A minor who
is not legally emancipated; or
2.
An adult who is in custodial care; or
(b) The individual, if the individual is:
1. An adult; and
2. Not in the custodial care of another
person or entity.
(3) OCSHCN may require the signature of both
the applicant and responsible adult if:
(a)
The applicant is over the age of eighteen (18); and
(b) There is a question of the applicant's
competence to make decisions regarding self-care.
Section 4. Application Forms.
(1) An applicant to an OCSHCN clinical
program shall provide to the agency within thirty (30) days:
(a) A copy of the applicant's insurance card,
or documentation thereof, if the applicant is not receiving Medicaid or
K-CHIP;
(b) OCSHCN-10b, Consent for
Care Agreement;
(c) OCSHCN-10c,
Guaranty of Payment Agreement;
(d)
OCSHCN-10d, Coordination of Benefits Agreement;
(e) OCSHCN-10a, Application for Service Legal
Guardian, if the application is made by a legal guardian on behalf of a child
or adult who is:
1. Under the age of
twenty-one (21); and
2. Not legally
emancipated;
(f)
OCSHCN-10e, Application for Service Young Adult, if the application is made by
an individual who is:
1. Not legally
emancipated; or
2.
a. Between the ages of eighteen (18) and
twenty-one (21); and
b. A full-time
student; and
(g) OCSHCN-10f, Application for Service Head
of Household, if the application is made by an individual who is:
1. Under the age of eighteen (18) and legally
emancipated; or
2. Between the ages
of eighteen (18) and twenty-one (21) and financially emancipated.
(2) OCSHCN may request
that the applicant submit additional information or documentation concerning
medical history within thirty (30) days, based on:
(a) Medical staff request; and
(b) Specific medical need.
Section 5. Limited
English Proficiency.
(1) OCSHCN shall ensure
the availability of foreign language interpretation services in order to assure
that families, staff, and providers have an opportunity to communicate
effectively.
(2) OCSHCN shall
arrange sign language interpreter services for persons who are deaf or hard of
hearing, pursuant to
920 KAR
1:070.
Section 6. Proof of Custody for Applicants.
(1) OCSHCN shall require a signed and dated
legal court filing establishing custody rights of a minor if:
(a) The parents of a minor are
divorced;
(b) The minor is adopted
or in the legal custody of the commonwealth; or
(c) The legal guardianship of the minor is in
question.
(2) OCSHCN
shall require a signed and dated legal court filing establishing custody rights
of an adult if the adult is said to be in custodial care of another
individual.
(3) OCSHCN may require
that the application be signed by the responsible adult if:
(a) The applicant is his or her own legal
guardian; and
(b) There is a
legitimate concern as to the applicant's ability to make decisions regarding
self-care.
Section
7. Application Review Process.
(1) Upon receipt of an application for the
OCSHCN clinical program, designated staff shall review the packet to ensure all
materials have been completed in accordance with Sections 3 and 4 of this
administrative regulation.
(2)
Designated staff shall notify the applicant of:
(a) Missing information or clarification
needed; and
(b) The timeframe for
submitting requested information.
(3) Complete applications shall be processed
in accordance with Sections 8, 9, and 10 of this administrative
regulation.
(4) Failure to submit
requested information to OCSHCN within the specified timeframe shall result in
the application process being closed.
Section 8. Medical Eligibility Determination.
(1) In order to be eligible for an OCSHCN
clinical program, the applicant shall have a documented condition that is
treated by OCSHCN.
(2) An
application shall be eligible for expedited review if designated OCSHCN staff
determine that recent medical records exist documenting that a contracted
provider staffing an OC-SHCN clinical program has:
(a) Diagnosed the applicant with a condition
on the OCSHCN-10g, Medical Eligibility List for Clinical and Case Management
Services; and
(b) Agreed to a
treatment plan for the child's condition that is supported by the OCSHCN
services offered.
(3) If
records established in subsection (2) of this section are not available for
OCSHCN review, designated OCSHCN staff shall schedule an onsite clinical
evaluation:
(a) By:
1. A contracted provider staffing an OCSHCN
clinical program; or
2. An OCSHCN
clinic employee; and
(b)
To obtain documentation needed to confirm medical eligibility.
(4) Upon receipt of documentation
pursuant to this section, designated staff shall determine an applicant's
medical eligibility for the OCSHCN clinical program.
Section 9. Financial Eligibility
Determination and Pay Category Assignment.
(1)
Each applicant shall undergo a financial review process upon:
(a) Application;
(b) Confirmation of medical
eligibility;
(c) Change in income
or household size prior to annual financial review; and
(d) Annual financial review.
(2) The OCSHCN process to
determine pay category assignment shall:
(a)
Be based on the household income of the responsible adult requesting services;
and
(b) Include income of:
1. The applicant, if the applicant is:
a. An adult; or
b. Not in the custodial care of another
person or entity;
2.
Parents, step-parents, or legal guardians, if the applicant is:
a. A minor who is not legally emancipated; or
b. An adult who is in custodial
care; and
3. Spouse of
the applicant, if the applicant is married.
(3) Designated OCSHCN staff shall establish a
household size based on family composition, including:
(a) The applicant;
(b) If the applicant is a minor:
1. Parents;
2. Step-parents;
3. Siblings, including:
a. Half siblings; and
b. Step-siblings; and
4. Any other dependent child claimed by the
applicant on a federal tax return; and
(c) If the applicant is an emancipated minor
or adult:
1. Spouse;
2. Children, including:
a. Half children; and
b. Step-children; and
3. Any other dependent child claimed by the
applicant on a federal tax return.
(4) The documents required for income
verification shall be the most recent:
(a)
Federal tax return of the applicant or the responsible adult; and
(b) Paycheck statement with year-to-date
gross earnings for each currently held job.
(5) An applicant or responsible adult without
a paycheck containing the criteria established in subsection (4)(b) of this
section shall provide two (2) consecutive and the most recent pay stubs or a
written statement from the employer that shows:
(a) Gross amount earned; and
(b) Frequency of pay.
(6) An applicant who is covered by Kentucky
Medicaid shall be:
(a) Exempt from income
verification;
(b) Considered
financially eligible; and
(c)
Placed in the zero percent pay category.
(7) If household income suggests that an
applicant is possibly Medicaid- eligible, a Medicaid application shall be
completed within thirty (30) days.
(8) If a Medicaid application completed
pursuant to subsection (7) of this section is denied for a reason other than
being over income, the applicant shall:
(a) Be
considered financially eligible;
(b) Meet medical eligibility criteria
pursuant to Section 8 of this administrative regulation; and
(c) Be assigned a pay category in accordance
with Section 10 of this administrative regulation.
(9) If a Medicaid application completed
pursuant to subsection (7) of this section is denied for being over income, the
applicant shall be:
(a) Considered financially
eligible; and
(b) Assigned a pay
category in accordance with Section 10 of this administrative
regulation.
(10) If an
application for Medicaid is not completed as requested within the specified
timeframe, the application process shall be closed.
Section 10. Family Participation Scale.
(1) An eligible applicant shall be assigned a
pay category, which is determined based on:
(a) Annual gross income; and
(b) Household size.
(2) OCSHCN shall:
(a) Calculate minimum and maximum annual
gross income limits annually, utilizing:
1.
The federal poverty level established annually by the United States Department
of Health and Human Services pursuant to
42
U.S.C. 9902(2);
and
2. Modified adjusted gross
income-based methods established in
42 C.F.R.
435.603; and
(b) Post the current Family Participation
Scale at
https://chfs.ky.gov/agencies/ccshcn.
(3) Except as established in
subsection (5) of this section, pay categories shall:
(a) Represent eligibility requirements at
income levels for the Kentucky Children's Health Insurance Program established
in
907
KAR 4:030; and
(b) Be established at:
1. Zero percent;
2. Twenty (20) percent;
3. Forty (40) percent;
4. Sixty (60) percent;
5. Eighty (80) percent; and
6. 100 percent.
(4) In accordance with
KRS
200.470(1), an applicant who
is placed in the 100 percent pay category shall be eligible for acceptance only
if access to adequate care and treatment is limited as evidenced by:
(a) Service needed is not otherwise available
within a fifty (50) mile radius of where the patient resides;
(b) Treatment requires a multi-disciplinary
team, which may include a physician, RN care coordinator, social worker,
nutritionist, and therapist;
(c)
Service is needed for the purchase of hearing aids;
(d) The patient is:
1. Uninsured; and
2. A member of a religious sect that is
exempt from the requirement to maintain minimum essential coverage as required
by the Affordable Care Act;
(e) The patient is:
1. Uninsured;
2. Not eligible for Medicaid or the Kentucky
Children's Health Insurance Program (KCHIP); and
3. Is exempt from the requirement to maintain
minimum essential coverage as required by the Affordable Care Act; or
(f) The medical care or service
ordered by an OCSHCN-contracted specialist as treatment for a qualifying
condition:
1. Is a non-covered benefit or
excluded under the patient's insurance policy; and
2. The patient would benefit from the OCSHCN
negotiated rate.
(5) An exception to subsection (3) of this
section shall be determined by the OCSHCN request for reconsideration process
in accordance with Section 13 of this administrative regulation.
Section 11. Notice of Eligibility
Determination.
(1) If an applicant is
determined to be eligible in accordance with Sections 8 and 9 of this
administrative regulation, designated staff shall notify the applicant in
writing of the:
(a) Acceptance into the OCSHCN
clinical program;
(b) Effective
date of eligibility;
(c) Pay
category assigned and a description of family participation fees and
responsibilities;
(d) Annual review
date;
(e) Name of the OCSHCN
contact person assigned to:
1. Manage medical
care;
2. Schedule appointments;
and
3. Discuss services available;
and
(f) Right to request
reconsideration of pay category assignment, in accordance with Section 13 of
this administrative regulation.
(2) If an applicant is determined to be
ineligible for acceptance into the OCSHCN clinical program, designated staff
shall notify the following individuals, in writing, of the reason for denial:
(a) The applicant, enumerating a right to
request reconsideration of the adverse decision; and
(b) The applicant's primary care or referring
physician, if applicable.
Section 12. Continuing Eligibility and
Reapplication.
(1) A responsible adult shall
advise OCSHCN if there is a change in:
(a)
Employment;
(b) Contact
information;
(c) Insurance
coverage; or
(d) Family
composition.
(2) A
financial recertification shall be completed annually.
(3) During the financial recertification,
designated OCSHCN staff shall:
(a) Verify
continued Medicaid enrollment; or
(b) If the recipient of services is not
enrolled in Kentucky Medicaid, send the responsible adult written notice
pursuant to Section 4 of this administrative regulation, requesting completion
of:
1. The financial portion of the
application form; and
2. The
OCSHCN-10c, Guaranty of Payment Agreement form.
(4) If the forms requested pursuant to
subsection (3)(b) of this section are not returned in accordance with the
requested timeframe, designated staff shall follow up in writing.
(5) If the requested forms are not returned
subsequent to a written follow up pursuant to subsection (4) of this section,
designated staff shall:
(a) Initiate discharge
of the recipient from the OCSHCN clinical program; and
(b) Notify the responsible adult or person
receiving services, providing the:
1. Date of
discharge;
2. Referral to primary
care physician;
3. Option to
reapply for OCSHCN services, and contact phone number; and
4. Courtesy copies of notifications of
discharge sent to:
a. Primary care
physician;
b. Dental provider, if
applicable; and
c. Pharmacy
provider, if applicable.
(6) Financial recertification shall occur if
there is:
(a) A loss of Medicaid;
(b) Change in circumstances, such as income
or household size; or
(c) Change in
guardianship.
(7) Upon
receipt of documentation related to this section's continuing eligibility and
reapplication, designated staff shall notify the responsible adult in writing
of the:
(a) Acceptance into the OCSHCN
clinical program;
(b) Effective
date of eligibility;
(c) Pay
category assigned and a description of family participation fees and
responsibilities;
(d) Annual review
date;
(e) Name of OCSHCN contact
person assigned to:
1. Manage medical
care;
2. Schedule appointments;
and
3. Discuss services available;
and
(f) Right to request
reconsideration of pay category assignment, pursuant to Section 13 of this
administrative regulation.
Section 13. Request for Reconsideration.
(1) An individual who is aggrieved by an
adverse decision regarding initial eligibility, termination of services, or pay
category assignment in accordance with the procedures established in Section 10
of this administrative regulation may request a reconsideration. A request for
reconsideration shall be filed within thirty (30) days of receipt of the
adverse decision.
(2) A request for
reconsideration of pay category assignment shall be directed to the Eligibility
Committee for resolution.
(3) Once
a request for reconsideration of the pay category assigned is received, the
applicant shall be provided with an OCSHCN-10h, Medical Expense Worksheet,
which shall be completed and returned to OCSHCN within thirty (30)
days.
(4) An applicant shall submit
with the OCSHCN-10h, Medical Expense Worksheet, and written proof of out of
pocket payment for allowable medical expenses as established in subsection (5)
of this section and paid for:
(a) By the
applicant or a member of the applicant's household; and
(b) Within the last twelve (12) months from
the date of the letter of pay category assignment.
(5) Allowable medical expenses shall include:
(a) Insurance premiums;
(b) Medical office or clinic
visits;
(c) Medical
supplies;
(d) Nutritional
supplies;
(e) Prescription
medications;
(f) Over the counter
medications;
(g) Durable medical
equipment;
(h) Hearing
aids;
(i) Dental or
orthodontia;
(j) Vision or
Eye;
(k)
Hospitalizations;
(l) Additional
expenses for consideration; and
(m)
OCSHCN payments in accordance with
911 KAR
1:020.
(6) Upon receipt of the OCSHCN-10h, Medical
Expense Worksheet, and documentation established in subsection (4) of this
section, OCSHCN staff shall:
(a) Verify
expenses;
(b) Present to the OCSHCN
Eligibility Committee for review; and
(c) Notify the applicant in writing of the
determination.
Section
14. Request for Hearing. An individual who has received a notice
of adverse action following a reconsideration may request an administrative
hearing. A request for an administrative hearing shall be:
(1) In accordance with KRS Chapter 13B;
and
(2) Received by OCSHCN within
thirty (30) days of the notice of adverse action.
Section 15. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) OCSHCN-10a, "Application for
Service Legal Guardian," 01/2019;
(b) OCSHCN-10b, "Consent for Care Agreement,"
01/2019;
(c) OCSHCN-10c, "Guaranty
of Payment Agreement," 01/2019;
(d)
OCSHCN-10d, "Coordination of Benefits Agreement," 01/2019;
(e) OCSHCN-10e, "Application for Service
Young Adult," 01/2019;
(f)
OCSHCN-10f, "Application for Service Head of Household," 01/2019;
(g) OCSHCN-10g, "Medical Eligibility List for
Clinical and Case Management Services," 08/2019;
(h) OCSHCN-10h, "Medical Expense Worksheet,"
01/2019; and
(i) "Family
Participation Scale," 04/01/2019.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Office for Children
with Special Health Care Needs, 310 Whittington Parkway, Suite 200, Louisville,
Kentucky 40222, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the
agency's Web site at
https://chfs.ky.gov/agencies/ccshcn.
STATUTORY AUTHORITY:
KRS
194A.030(5)