907 Ky. Admin. Regs. 13:015

Current through Register Vol. 51, No. 7, January 1, 2025

Section 907 KAR 13:015 - Private duty nursing service or supply reimbursement provisions and requirements

RELATES TO: KRS 205.520

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 Department for Medicaid Services' reimbursement provisions and requirements regarding private duty nursing services and supplies.

Section 1. General Requirements. For the department to reimburse for a private duty nursing service or supply under this administrative regulation, the:

(1) Provider shall meet the provider requirements established in 907 KAR 13:010; and

(2) The service or supply shall meet the coverage and related requirements established in 907 KAR 13:010.

Section 2. Reimbursement. The department shall:

(1) Reimburse for private duty nursing services at a specific rate that is established pursuant to the current fee schedule utilized by the department and authorized by state and federal law. As appropriate, billing and reimbursement information shall be included in the Medicaid Physician Fee Schedule established in 907 KAR 3:010, available at https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx, per fifteen (15) minutes, which shall constitute one (1) unit;

(2) Not reimburse for more than:

(a) Ninety-six (96) units per recipient per twenty-four (24) hour period; or

(b) 35,040 units per twelve (12) consecutive month period per recipient; and

(3) Reimburse for supplies as established on the Private Duty Nursing Supplies Fee Schedule posted at https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.

Section 3. Not Applicable to Managed Care Organizations. A managed care organization shall not be required to reimburse the same amount as established in this administrative regulation for a service or supply covered pursuant to 907 KAR 13:010 and this administrative regulation.

Section 4. Federal Approval and Federal Financial Participation. The department's reimbursement for services or supplies 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 5. Appeal Rights.

(1) An appeal of a negative action regarding a Medicaid recipient shall be in accordance with 907 KAR 1:563.

(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..

907 KAR 13:015

40 Ky.R. 2062; 2777; eff. 7-7-2014; Crt eff. 12-6-2019; 50 Ky.R. 1795; eff. 6/18/2024.

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)