††††† 907 KAR 1:054. Primary care center and federally-qualified health center services.

 

††††† RELATES TO: KRS 205.520, 310.005, 314.011, 335.100, 42 C.F.R. 400.203, 405.2401, 2412-2416, 2446, 2448, 2450, 2452, 441 Subpart E and F, 447.53, 42 U.S.C. 1395x(aa), 42 U.S.C. 1396d

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

††††† 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 for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the provisions relating to primary care center and federally-qualified health center services for which payment shall be made by the Medicaid Program on behalf of both the categorically needy and medically needy.

 

††††† Section 1. (1) "Advanced registered nurse practitioner" is defined by KRS 314.011(7).

††††† (2) "Clinical pharmacist" means a licensed pharmacist whose scope of service includes taking medication histories, monitoring drug use, contributing to drug therapy, drug selection, patient counseling, administering drug programs, or surveillance for adverse reactions and drug interactions.

††††† (3) "Clinical psychologist" means a doctorate level psychologist who is licensed in accordance with KRS 319.050.

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

††††† (5) "Emergency condition" means a condition or situation requiring an emergency service pursuant to 42 C.F.R. 447.53.

††††† (6) "Federally-qualified health center" or "FQHC" is defined by 42 U.S.C. 1396d(l)(2)(B).

††††† (7) "Licensed clinical social worker" means an individual who meets the licensed clinical social worker requirements established in KRS 335.100.

††††† (8) "Nurse-midwife" is defined by 42 C.F.R. 405.2401(b).

††††† (9) "Nutritionist" is defined by KRS 310.005(4).

††††† (10) "Physician" is defined by KRS 205.510(11) and 42 C.F.R. 405.2401(b).

††††† (11) "Physician assistant" is defined by KRS 311.840(3) and 42 C.F.R. 405.2401(b).

††††† (12) "Primary care center" or "PCC" means an entity meeting the primary care center requirements established in 902 KAR 20:058.

††††† (13) "State plan" is defined by 42 C.F.R. 400.203.

 

††††† Section 2. Primary Care Center Covered Services. (1) The department shall cover, and a primary care center shall provide, the following services:

††††† (a) Medical diagnostic or treatment services provided by a physician, advanced registered nurse practitioner, or a physician assistant if licensed under state authority;

††††† (b) Treatment of injuries or minor trauma;

††††† (c) Prenatal or postnatal care;

††††† (d) Preventive health services including well-baby care, well-child care, immunization, or other preventive care;

††††† (e) Referral services designed to ensure the referral to and acceptance by an appropriate medical resource if services necessary to the health of the patient are not provided directly by the center; and

††††† (f) Health education, including distribution of written material, provided by appropriate personnel to local school systems, civic organizations, or other concerned local groups.

††††† (2) The department shall cover the following services and a primary care center shall provide at least two (2) of the following services:

††††† (a) Dental services;

††††† (b) Optometric services;

††††† (c) Family planning services listed and as limited in 907 KAR 1:048;

††††† (d) Home health services listed and as limited in 907 KAR 1:030;

††††† (e) Social services counseling;

††††† (f) Pharmacy services which shall meet the coverage criteria established in 907 KAR 1:019;

††††† (g) Nutritional services provided by a nutritionist, including individual counseling relating to nutritional problems or nutritional education or group nutritional services; or

††††† (h) Nurse midwifery services which shall be provided:

††††† 1. As a program including prenatal services to expectant mothers, delivery or postnatal services; and

††††† 2. By a nurse midwife.

††††† (3) The department shall cover, and a primary care center may provide the following services:

††††† (a) Excluding institutional care, other state plan services;

††††† (b) Holding or observation accommodations;

††††† (c) Outreach services provided as a package structured to identify health care needs in the service area;

††††† (d) Clinical pharmacist services;

††††† (e) Behavioral health services provided by a clinical psychologist, licensed clinical social worker, or advanced registered nurse practitioner within the providerís legally authorized scope of service;

††††† (f) Services or supplies furnished as an incident to services provided by a physician, physician assistant, advanced registered nurse practitioner, or nurse midwife if the service or supply meets the criteria established in 42 C.F.R. 405.2413 or 42 C.F.R. 405.2415; or

††††† (g) Services or supplies incidental to a clinical psychologist's or licensed clinical social worker's behavioral health services if the service or supply meets the criteria established in 42 C.F.R.

 

††††† Section 3. Federally-qualified Health Center Covered Services. A federally-qualified health center shall provide:

††††† (1) Federally-qualified health center services pursuant to 42 U.S.C. 1395x(aa)(3);

††††† (2) Federally-qualified health center services pursuant to 42 U.S.C. 1396d(l)(2)(A);

††††† (3) Other Medicaid-covered ambulatory outpatient services established in the state plan; or

††††† (4) Any combination of the services described in subsections (1), (2), and (3) of this section.

 

††††† Section 4. Drugs for Specified Immunizations. The Cabinet for Health and Family Services shall provide free, upon request, drugs necessary for the following immunizations:

††††† (1) Diptheria and tetanus toxoids and pertussis vaccine (DPT);

††††† (2) Measles, mumps, and rubella virus vaccine live (MMR);

††††† (3) Poliovirus vaccine, live, oral, any type (OPV); or

††††† (4) Hemophilus B conjugate vaccine (HBCV).

 

††††† Section 5. Coverage Limits. (1)(a) Except as established in subsection (2) of this section, pharmacy service coverage shall be limited to drugs covered pursuant to 907 KAR 1:019.

††††† (b) A drug or biological not covered through the departmentís pharmacy program shall be covered if necessary for treatment of an emergency condition.

††††† (2) Laboratory service coverage shall be limited to:

††††† (a) Services provided directly by a PCC or FQHC; or

††††† (b) If purchased, other laboratory services covered pursuant to 907 KAR 1:028.

††††† (3) Dental service coverage shall be limited to dental service coverage pursuant to 907 KAR 1:026.

††††† (4) Vision service coverage shall be limited to vision service coverage pursuant to 907 KAR 1:038.

††††† (5) Audiology service coverage shall be limited to hearing service coverage pursuant to 907 KAR 1:038.

††††† (6) An abortion or sterilization service shall be:

††††† (a) Allowed in accordance with:

††††† 1. 42 C.F.R.441, Subpart E or Subpart F; and

††††† 2. KRS 205.010(3), 205.510(5), and 212.275(3); and

††††† (b) Covered within the scope and limitations of federal law, federal regulations, and state law.

††††† (7) Durable medical good and prosthetic coverage shall be limited to durable medical good or prosthetic coverage pursuant to 907 KAR 1:479 or 907 KAR 1:030.

††††† (8) A holding or observation accommodation shall be covered:

††††† (a) For no more than twenty-four (24) hours; and

††††† (b) If:

††††† 1. The recipientís medical record:

††††† a. Documents the appropriateness of the holding or observation accommodation; and

††††† b. Contains a statement of conditions observed and treatment rendered during the holding time;

††††† 2. A physician:

††††† a. Determines that the holding or observation accommodation is necessary; and

††††† b. Is on call at all times when a recipient is held beyond the regularly scheduled hours of the center; and

††††† 3. A licensed nurse is on duty during the time the recipient patient remains beyond regularly-scheduled hours.

††††† (9) A radiology procedure shall be covered if provided by a licensed practitioner of the healing arts or by an individual holding a valid certificate to operate sources of radiation.

 

††††† Section 6. Noncovered Services. The following services shall not be covered as PCC or FQHC services:

††††† (1) Services provided in a hospital as defined in 42 U.S.C. 1395x(e);

††††† (2) Institutional services;

††††† (3) Housekeeping, babysitting, or other similar homemaker services; or

††††† (4) Services which are not provided in accordance with restrictions imposed by law or administrative regulation. (Recodified from 904 KAR 1:054, 5-2-86; Am. 15 Ky.R. 1324; eff. 12-13-88; 16 Ky.R. 85; 369; eff. 8-16-89; 2599; eff. 6-27-90; 34 Ky.R. 1827; 2113; eff. 4-4-08.)