2014 Kentucky Revised Statutes CHAPTER 205 - PUBLIC ASSISTANCE AND MEDICAL ASSISTANCE 205.560 Scope of care to be designated by administrative regulations -- Reimbursements mandated or prohibited -- Assessment of health care provider credentials -- Guidelines for dentists' participation.
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205.560 Scope of care to be designated by administrative regulations -Reimbursements mandated or prohibited -- Assessment of health care
provider credentials -- Guidelines for dentists' participation.
(1)
The scope of medical care for which the Cabinet for Health and Family
Services undertakes to pay shall be designated and limited by regulations
promulgated by the cabinet, pursuant to the provisions in this section. Within
the limitations of any appropriation therefor, the provision of complete upper
and lower dentures to recipients of Medical Assistance Program benefits who
have their teeth removed by a dentist resulting in the total absence of teeth
shall be a mandatory class in the scope of medical care. Payment to a dentist
of any Medical Assistance Program benefits for complete upper and lower
dentures shall only be provided on the condition of a preauthorized agreement
between an authorized representative of the Medical Assistance Program and
the dentist prior to the removal of the teeth. The selection of another class or
other classes of medical care shall be recommended by the council to the
secretary for health and family services after taking into consideration, among
other things, the amount of federal and state funds available, the most
essential needs of recipients, and the meeting of such need on a basis insuring
the greatest amount of medical care as defined in KRS 205.510 consonant with
the funds available, including but not limited to the following categories, except
where the aid is for the purpose of obtaining an abortion:
(a) Hospital care, including drugs, and medical supplies and services during
any period of actual hospitalization;
(b) Nursing-home care, including medical supplies and services, and drugs
during confinement therein on prescription of a physician, dentist, or
podiatrist;
(c) Drugs, nursing care, medical supplies, and services during the time when
a recipient is not in a hospital but is under treatment and on the
prescription of a physician, dentist, or podiatrist. For purposes of this
paragraph, drugs shall include products for the treatment of inborn errors
of metabolism or genetic conditions, consisting of therapeutic food,
formulas, supplements, or low-protein modified food products that are
medically indicated for therapeutic treatment and are administered under
the direction of a physician, and include but are not limited to the following
conditions:
1.
Phenylketonuria;
2.
Hyperphenylalaninemia;
3.
Tyrosinemia (types I, II, and III);
4.
Maple syrup urine disease;
5.
A-ketoacid dehydrogenase deficiency;
6.
Isovaleryl-CoA dehydrogenase deficiency;
7.
3-methylcrotonyl-CoA carboxylase deficiency;
8.
3-methylglutaconyl-CoA hydratase deficiency;
9.
3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMG-CoA lyase
deficiency);
(2)
10. B-ketothiolase deficiency;
11. Homocystinuria;
12. Glutaric aciduria (types I and II);
13. Lysinuric protein intolerance;
14. Non-ketotic hyperglycinemia;
15. Propionic acidemia;
16. Gyrate atrophy;
17. Hyperornithinemia/hyperammonemia/homocitrullinuria syndrome;
18. Carbamoyl phosphate synthetase deficiency;
19. Ornithine carbamoyl transferase deficiency;
20. Citrullinemia;
21. Arginosuccinic aciduria;
22. Methylmalonic acidemia; and
23. Argininemia;
(d) Physician, podiatric, and dental services;
(e) Optometric services for all age groups shall be limited to prescription
services, services to frames and lenses, and diagnostic services provided
by an optometrist, to the extent the optometrist is licensed to perform the
services and to the extent the services are covered in the ophthalmologist
portion of the physician's program. Eyeglasses shall be provided only to
children under age twenty-one (21);
(f) Drugs on the prescription of a physician used to prevent the rejection of
transplanted organs if the patient is indigent;
(g) Nonprofit neighborhood health organizations or clinics where some or all
of the medical services are provided by licensed registered nurses or by
advanced medical students presently enrolled in a medical school
accredited by the Association of American Medical Colleges and where
the students or licensed registered nurses are under the direct
supervision of a licensed physician who rotates his services in this
supervisory capacity between two (2) or more of the nonprofit
neighborhood health organizations or clinics specified in this paragraph;
(h) Services provided by health-care delivery networks as defined in KRS
216.900;
(i) Services provided by midlevel health-care practitioners as defined in KRS
216.900; and
(j) Smoking cessation treatment interventions or programs prescribed by a
physician, advanced practice registered nurse, physician assistant, or
dentist, including but not limited to counseling, telephone counseling
through a quitline, recommendations to the recipient that smoking should
be discontinued, and prescription and over-the-counter medications and
nicotine replacement therapy approved by the United States Food and
Drug Administration for smoking cessation.
Payments for hospital care, nursing-home care, and drugs or other medical,
ophthalmic, podiatric, and dental supplies shall be on bases which relate the
amount of the payment to the cost of providing the services or supplies. It shall
be one (1) of the functions of the council to make recommendations to the
Cabinet for Health and Family Services with respect to the bases for payment.
In determining the rates of reimbursement for long-term-care facilities
participating in the Medical Assistance Program, the Cabinet for Health and
Family Services shall, to the extent permitted by federal law, not allow the
following items to be considered as a cost to the facility for purposes of
reimbursement:
(a) Motor vehicles that are not owned by the facility, including motor vehicles
that are registered or owned by the facility but used primarily by the owner
or family members thereof;
(b) The cost of motor vehicles, including vans or trucks, used for facility
business shall be allowed up to fifteen thousand dollars ($15,000) per
facility, adjusted annually for inflation according to the increase in the
consumer price index-u for the most recent twelve (12) month period, as
determined by the United States Department of Labor. Medically
equipped motor vehicles, vans, or trucks shall be exempt from the fifteen
thousand dollar ($15,000) limitation. Costs exceeding this limit shall not
be reimbursable and shall be borne by the facility. Costs for additional
motor vehicles, not to exceed a total of three (3) per facility, may be
approved by the Cabinet for Health and Family Services if the facility
demonstrates that each additional vehicle is necessary for the operation
of the facility as required by regulations of the cabinet;
(c) Salaries paid to immediate family members of the owner or administrator,
or both, of a facility, to the extent that services are not actually performed
and are not a necessary function as required by regulation of the cabinet
for the operation of the facility. The facility shall keep a record of all work
actually performed by family members;
(d) The cost of contracts, loans, or other payments made by the facility to
owners, administrators, or both, unless the payments are for services
which would otherwise be necessary to the operation of the facility and
the services are required by regulations of the Cabinet for Health and
Family Services. Any other payments shall be deemed part of the owner's
compensation in accordance with maximum limits established by
regulations of the Cabinet for Health and Family Services. Interest paid to
the facility for loans made to a third party may be used to offset allowable
interest claimed by the facility;
(e) Private club memberships for owners or administrators, travel expenses
for trips outside the state for owners or administrators, and other indirect
payments made to the owner, unless the payments are deemed part of
the owner's compensation in accordance with maximum limits established
by regulations of the Cabinet for Health and Family Services; and
(f) Payments made to related organizations supplying the facility with goods
or services shall be limited to the actual cost of the goods or services to
the related organization, unless it can be demonstrated that no
relationship between the facility and the supplier exists. A relationship
shall be considered to exist when an individual, including brothers, sisters,
(3)
(4)
(5)
(6)
(7)
(8)
(9)
father, mother, aunts, uncles, and in-laws, possesses a total of five
percent (5%) or more of ownership equity in the facility and the supplying
business. An exception to the relationship shall exist if fifty-one percent
(51%) or more of the supplier's business activity of the type carried on
with the facility is transacted with persons and organizations other than
the facility and its related organizations.
No vendor payment shall be made unless the class and type of medical care
rendered and the cost basis therefor has first been designated by regulation.
The rules and regulations of the Cabinet for Health and Family Services shall
require that a written statement, including the required opinion of a physician,
shall accompany any claim for reimbursement for induced premature births.
This statement shall indicate the procedures used in providing the medical
services.
The range of medical care benefit standards provided and the quality and
quantity standards and the methods for determining cost formulae for vendor
payments within each category of public assistance and other recipients shall
be uniform for the entire state, and shall be designated by regulation
promulgated within the limitations established by the Social Security Act and
federal regulations. It shall not be necessary that the amount of payments for
units of services be uniform for the entire state but amounts may vary from
county to county and from city to city, as well as among hospitals, based on the
prevailing cost of medical care in each locale and other local economic and
geographic conditions, except that insofar as allowed by applicable federal law
and regulation, the maximum amounts reimbursable for similar services
rendered by physicians within the same specialty of medical practice shall not
vary according to the physician's place of residence or place of practice, as
long as the place of practice is within the boundaries of the state.
Nothing in this section shall be deemed to deprive a woman of all appropriate
medical care necessary to prevent her physical death.
To the extent permitted by federal law, no medical assistance recipient shall be
recertified as qualifying for a level of long-term care below the recipient's
current level, unless the recertification includes a physical examination
conducted by a physician licensed pursuant to KRS Chapter 311 or by an
advanced practice registered nurse licensed pursuant to KRS Chapter 314 and
acting under the physician's supervision.
If payments made to community mental health centers, established pursuant to
KRS Chapter 210, for services provided to the intellectually disabled exceed
the actual cost of providing the service, the balance of the payments shall be
used solely for the provision of other services to the intellectually disabled
through community mental health centers.
No long-term-care facility, as defined in KRS 216.510, providing inpatient care
to recipients of medical assistance under Title XIX of the Social Security Act on
July 15, 1986, shall deny admission of a person to a bed certified for
reimbursement under the provisions of the Medical Assistance Program solely
on the basis of the person's paying status as a Medicaid recipient. No person
shall be removed or discharged from any facility solely because they became
eligible for participation in the Medical Assistance Program, unless the facility
(10)
(11)
(12)
(13)
can demonstrate the resident or the resident's responsible party was fully
notified in writing that the resident was being admitted to a bed not certified for
Medicaid reimbursement. No facility may decertify a bed occupied by a
Medicaid recipient or may decertify a bed that is occupied by a resident who
has made application for medical assistance.
Family-practice physicians practicing in geographic areas with no more than
one (1) primary-care physician per five thousand (5,000) population, as
reported by the United States Department of Health and Human Services, shall
be reimbursed one hundred twenty-five percent (125%) of the standard
reimbursement rate for physician services.
The Cabinet for Health and Family Services shall make payments under the
Medical Assistance program for services which are within the lawful scope of
practice of a chiropractor licensed pursuant to KRS Chapter 312, to the extent
the Medical Assistance Program pays for the same services provided by a
physician.
The Medical Assistance Program shall use the form and guidelines established
pursuant to KRS 304.17A-545(5) for assessing the credentials of those
applying for participation in the Medical Assistance Program, including those
licensed and regulated under KRS Chapters 311, 312, 314, 315, and 320, any
facility required to be licensed pursuant to KRS Chapter 216B, and any other
health care practitioner or facility as determined by the Department for
Medicaid Services through an administrative regulation promulgated under
KRS Chapter 13A. For any provider who is credentialed by a Medicaid
managed care organization the cabinet shall complete the enrollment and
credentialing process and deny, or approve and issue a Medical Assistance
Identification Number (MAID) within fifteen (15) business days from the time all
necessary completed credentialing forms have been submitted and all
outstanding accounts receivable have been satisfied.
Dentists licensed under KRS Chapter 313 shall be excluded from the
requirements of subsection (12) of this section. The Department for Medicaid
Services shall develop a specific form and establish guidelines for assessing
the credentials of dentists applying for participation in the Medical Assistance
Program.
Effective:April 4, 2013
History: Amended 2013 Ky. Acts ch. 118, sec. 8, effective April 4, 2013. -Amended 2010 Ky. Acts ch. 85, sec. 34, effective July 15, 2010; and ch. 141,
sec. 12, effective July 15, 2010. -- Amended 2008 Ky. Acts ch. 119, sec. 1,
effective July 15, 2008. -- Amended 2007 Ky. Acts ch. 34, sec. 1, effective June
26, 2007; and ch. 90, sec. 1, effective June 26, 2007. -- Amended 2005 Ky. Acts
ch. 99, sec. 234, effective June 20, 2005; ch. 144, sec. 4, effective June 20,
2005. -- Amended 2000 Ky. Acts ch. 290, sec. 1, effective July 14, 2000; and
ch. 457, sec. 1, effective July 14, 2000. -- Amended 1998 Ky. Acts ch. 426,
sec. 199, effective July 15, 1998. -- Amended 1996 Ky. Acts ch. 304, sec. 1,
effective July 15, 1996. -- Amended 1990 Ky. Acts ch. 482, sec. 8, effective July
13, 1990. -- Amended 1986 Ky. Acts ch. 154, sec. 1, effective July 15, 1986;
ch. 306, sec. 1, effective July 15, 1986; ch. 310, sec. 1, effective July 15, 1986;
and 466, sec. 1, effective July 15, 1986. -- Amended 1982 Ky. Acts ch. 133,
sec. 1, effective July 15, 1982; and ch. 248, sec. 4, effective July 15, 1982. -Amended 1980 Ky. Acts ch. 29, sec. 1, effective July 15, 1980; and ch. 315,
sec. 3, effective July 15, 1980. -- Amended 1978 Ky. Acts ch. 99, sec. 1,
effective June 17, 1978; and ch. 140, sec. 3, effective July 17, 1978. -Amended 1976 Ky. Acts ch. 141, sec. 1. -- Amended 1974 Ky. Acts ch. 74, Art.
VI, secs. 50 and 107(1), (14), (15) and (19); and ch. 225, sec. 3. -- Amended
1972 Ky. Acts ch. 256, sec. 16. -- Amended 1970 Ky. Acts ch. 78, sec. 3. -Amended 1960 (1st Extra. Sess.) Ky. Acts ch. 2, sec. 3. -- Created 1960 ch. 68,
Art. VII, sec. 7.
Legislative Research Commission Note (6/20/2005). 2005 Ky. Acts chs. 11, 85,
95, 97, 98, 99, 123, and 181 instruct the Reviser of Statutes to correct statutory
references to agencies and officers whose names have been changed in 2005
legislation confirming the reorganization of the executive branch. Such a
correction has been made in this section.
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