806 KAR 18:010. Minimum standards for treatment of alcoholism.

 

      RELATES TO: KRS 304.18-130, 304.18-140, 304.18-150, 304.18-160, 304.18-170, 304.32-158, 304.38-197

      STATUTORY AUTHORITY: KRS 304.2-110

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110 provides that the Executive Director of Insurance may make reasonable rules and administrative regulations necessary for and as an aid to the effectuation of any provision of the Kentucky Insurance Code. This administrative regulation clarifies the minimum standards for the treatment of alcoholism as set forth in KRS Chapter 304, Subtitles 18, 32 and 38.

 

      Section 1. The purpose of this administrative regulation is to assure all persons covered under group health insurance policies or contracts as defined in KRS 304.18-020 issued to the master policyholder, benefits for the treatment of alcoholism as hereinafter set forth when such benefits are selected by the master policyholder of the group health insurance policy or contract.

 

      Section 2. Definitions. (1) "Emergency detoxification treatment" as used in this administrative regulation means the systematic treatment undertaken when attempting to remove or counteract the acutely threatening physiological or hypersensitive reaction to alcohol.

      (2) "Residential treatment" as used in this administrative regulation means the process of assisting the alcoholic patient in an approved residential facility through the use of medically ordered services to attain an unimpaired or improved level of physiological, psychological, or social functioning.

      (3) "Outpatient treatment" as used in this administrative regulation means the necessary care under the direction of a licensed physician for the patient to properly function in the community.

      (4) All other definitions relating to alcoholism or the treatment of alcoholism which are applicable to KRS Chapter 304, Subtitles 18, 32 and 38 are contained in KRS 222.011 and the administrative regulations promulgated therefrom.

 

      Section 3. Applicability. (1) The provisions of this administrative regulation shall apply solely to:

      (a) Group health insurance policies or contracts providing major medical benefits or benefits for outpatient care. Outpatient care is deemed to include eligible services or treatment received in the outpatient department of a hospital or other licensed treatment facility.

      (b) The group policies or contracts as specified in subsection (1) of this section, which group health insurance carriers are required to offer to the master policyholder on behalf of its employees or members, only when the master policyholder elects to purchase in new policies or contracts the coverage specified in this administrative regulation.

      (2) Disability and accident income benefits and basic health insurance policies and contracts that do not provide major medical benefits or outpatient care are specifically excluded from complying with KRS Chapter 304, Subtitles 18, 32 and 38.

 

      Section 4. Administration of Treatment. (1) Before benefits shall be available for services for the treatment of alcoholism, a physician must examine the patient and assign a diagnosis of alcoholism as classified in categories 303.0-304.7 of the Eighth Revision "International Classification of Diseases," Adapted for Use in the United States, U.S. Department of Health, Education and Welfare.

      (2) The phases of treatment for alcoholism available to the patient shall be divided into the following levels:

      (a) Emergency detoxification treatment, as previously defined;

      (b) Resident treatment, as previously defined; and

      (c) Outpatient treatment, as previously defined.

      (3) Emergency detoxification treatment is designed to furnish care to patients who are both unable to function within the community and require constant supervision and treatment in the context of an inpatient setting in those approved treatment facilities. Residential treatment is designed to provide care to patients unable to adjust within the community environment and who require constant supervision and care but not on the acute care level generally associated with hospital inpatients. Outpatient treatment is designed to render care to patients, who are able to function within the community and do not require constant supervision and treatment.

 

      Section 5. Facility and Provider Eligibility. (1) Facilities in which the treatment of alcoholism may be provided, as hereinabove enumerated, shall be licensed by the Department for Human Resources pursuant to KRS 222.210 to 222.300 and the administrative regulations issued in accordance therewith, and accredited by the Joint Commission on the Accreditation of Hospitals for the treatment of alcoholism, except that hospitals licensed in accordance with the provisions of KRS 216.405 to 216.485 shall be approved as eligible facilities for the provision of alcoholism treatment.

      (2) All services rendered by an approved facility shall comply with the requirements for such services as contained in KRS 222.210 to 222.300 and the administrative regulations pursuant thereto.

      (3) Other than the requirement established in Section 4(1) of this administrative regulation, a patient admitted to any approved facility for the treatment of alcoholism or receiving such care on an outpatient basis shall at all times be under the guidance and supervision of a licensed physician or such professional personnel specifically designated by such physician who is a recognized staff member of a treatment facility licensed in accordance with subsection (1) of this section.

      (4) It shall be the responsibility of the approved treatment facility or the physician in charge of the care rendered to a patient, depending upon the setting of the treatment, to provide the necessary medical records and other medical information to the patient's group health insurance carrier for the purposes of claims processing and adjudication, and all such information shall be kept strictly confidential to the extent provided by law.

 

      Section 6. Benefits and Reimbursement. (1) The minimum benefits to be provided pursuant to KRS Chapter 304, Subtitles 18, 32 and 38 on a per patient basis over the course of a contract year however such term is defined in the patient's group policy or contract, shall be as follows:

      (a) Emergency detoxification treatment - three (3) to five (5) days of facility care at forty (40) dollars a day;

      (b) Residential treatment - ten (10) to thirty (30) days of total facility care at fifty (50) dollars per day; and

      (c) Outpatient treatment - one (1) to fifty (50) visits at ten (10) dollars a visit.

      (2) With respect to subsections (1)(a) and (b) of this section, the specified days of care are independent of and separate from any other eligible hospital days for which the patient has coverage under any appropriate group policy or contract. With respect to subsection (1)(c) of this section, a visit is considered only if therapy, counseling and/or psychological testing have been provided. The need for the continuation of treatment requiring repetitive visits must be certified by a physician every three (3) months.

      (3) For those group health insurance carriers whose benefit structures under the appropriate group policies or contracts for the provision of alcoholism treatment are incompatible with the minimum format established under subsection (1) of this section, the offering of minimum benefits pursuant to this administrative regulation shall be satisfied if an equivalent in terms of service benefits are provided for the treatment of alcoholism.

      (4) Existing inpatient coverage provided under a group health insurance carrier's basic group policies or contracts shall not be reduced by the provisions of KRS Chapter 304, Subtitles 18, 32 and 38.

      (5) No provision of this administrative regulation shall be construed as prohibiting appropriate group health insurance policies or contracts from providing benefits in excess of the minimum benefits established under KRS Chapter 304, Subtitles 18, 32 and 38, whether such benefits be in the form of cash allowances, service benefits, or otherwise.

      (6) All applicable policies and contracts shall stipulate that payment thereunder shall not be made by a group health insurance carrier except upon completion of a phase of treatment by the patient. Payment may be made under such group policy or contracts to the provider of service or the member covered under a group policy or contract held by the master policyholder, in accordance with the provisions of the group policy or contract, but in any event, if payment is made to the provider, the approved treatment facility or the physician in charge of the care rendered to the patient, depending upon the setting of the treatment, shall have the responsibility for coordinating the charges for services rendered and submitting such charges on approved forms to the patient's group health insurance carrier. If payment is to be made to the group health insurance carrier's member, then the provider of service, be it an approved treatment facility or the physician in charge of the care rendered to the patient, depending upon the setting of the treatment, shall have the responsibility for coordinating the charges for services rendered and submitting such charges on approved forms to the patient's group health insurance carrier. If payment is to be made to the group health insurance carrier's member, then the provider of service, be it an approved facility or the physician in charge of the care rendered to a patient, shall submit a bill or statement of services rendered to the patient with sufficient information contained thereon, including diagnosis and treatment, to permit the group health insurance carrier to proceed and adjudicate claims on behalf of the patient.

      (7) Treatment for alcoholism in licensed acute care hospitals shall be considered, in terms of reimbursement by all group health insurance carriers as any other disease, illness or condition covered by such policies or contracts. (5 Ky.R. 636; Am. 919; eff. 5-2-79; TAm eff. 8-9-2007.)