907 Ky. Admin. Regs. 3:017

Current through Register Vol. 51, No. 5, November 1, 2024

Section 907 KAR 3:017 - Enhanced reimbursement for preventive and wellness services

RELATES TO: KRS 205.520, 205.560

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) 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 policies and requirements regarding the Department for Medicaid Services' enhanced reimbursement for certain preventive services and wellness services provided 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) "Currently enrolled with the Medicaid Program" means:

(a) Currently enrolled with the Medicaid Program pursuant to 907 KAR 1:672; and

(b) Currently participating with the Medicaid Program pursuant to 907 KAR 1:671.

(3) "Department" means the Department for Medicaid Services or its designee.

(4) "Federal financial participation" is defined by 42 C.F.R. 400.203.

(5) "Managed care organization" or "MCO" 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.

(6) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

(7) "Physician" is defined by KRS 311.550(12).

(8) "Physician assistant" is defined by KRS 311.840(3).

(9) "Provider group" means a group of at least:

(a) Two (2) individually licensed physicians who:

1. Are currently enrolled with the Medicaid Program individually and as a group; and

2. Share the same Medicaid group provider number;

(b) Two (2) individually licensed APRNs who:

1. Are currently enrolled with the Medicaid Program individually and as a group; and

2. Share the same Medicaid group provider number; or

(c) At least one (1) APRN and at least one (1) physician who:

1. Are currently enrolled with the Medicaid Program individually and as a group; and

2. Share the same Medicaid group provider number.

(10) "Recipient" is defined in KRS 205.8451(9).

Section 2. Qualifying Requirements. To qualify as a service to be reimbursed at the amount established on the Medicaid Preventive and Wellness Enhanced Fee Schedule, the service shall:

(1) Be medically necessary;

(2) Meet the criteria established for the service on the Medicaid Preventive and Wellness Enhanced Fee Schedule; and

(3) Be provided:

(a) To a recipient who is not enrolled with a managed care organization; and

(b) By:

1. A physician who is:

a. Currently enrolled with the Medicaid Program; or

b. Participating with a provider group that is currently enrolled with the Medicaid Program;

2. An APRN who is:

a. Currently enrolled with the Medicaid Program; or

b. Participating with a provider group that is currently enrolled with the Medicaid Program; or

3. A physician assistant who is employed by or under contract with:

a. A physician who is currently enrolled with the Medicaid Program;

b. An APRN who is currently enrolled with the Medicaid Program; or

c. A provider group that is currently enrolled with the Medicaid Program.

Section 3. Enhanced Reimbursement for Preventive and Wellness Services.

(1) The department shall reimburse for a preventive or wellness service listed on the Medicaid Preventive and Wellness Enhanced Fee Schedule:

(a) If the service meets the qualifying requirements established in Section 2 of this administrative regulation;

(b) In accordance with the requirements and limits established on the Medicaid Preventive and Wellness Enhanced Fee Schedule; and

(c) The amount corresponding to the service as listed on the Medicaid Preventive and Wellness Enhanced Fee Schedule.

(2) The department's reimbursement referenced in subsection (1)(c) of this section shall:

(a) Apply to services rendered from January 1, 2015 through June 30, 2016; and

(b) Not apply to services rendered July 1, 2016 going forward.

Section 4. Auditing Authority. The department shall have the authority to audit any:

(1) Claim;

(2) Medical record; or

(3) Documentation associated with any claim or medical record.

Section 5. Not Applicable to Managed Care Organizations. A managed care organization shall not be required to implement the reimbursement established in this administrative regulation.

Section 6. Federal Approval and 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 7. Supersede. If any reimbursement provision stated in 907 KAR 3:010 or 907 KAR 1:104 contradicts a provision stated in this administrative regulation or in the Medicaid Preventive and Wellness Enhanced Fee Schedule, the provision stated in this administrative regulation or in the Medicaid Preventive and Wellness Enhanced Fee Schedule shall supersede the provision stated in 907 KAR 3:010 or 907 KAR 1:104.

Section 8. Incorporation by Reference.

(1) The "Medicaid Preventive and Wellness Enhanced Fee Schedule", April 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.

907 KAR 3:017

41 Ky.R. 1943; 2224; eff. 6-5-2015.

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.560(1), 42 U.S.C. 1396a(a)(30)