907 KAR 1:084. Payment for medical assistance services furnished out of state.

 

      RELATES TO: KRS 205.520

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 42 C.F.R. 447 Subpart B, 42 U.S.C. 1396a, b, d, EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services has responsibility to administer the program of Medical Assistance. KRS 205.520(3) empowers 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 sets forth the conditions under which the Medicaid Program shall pay for covered medical services furnished eligible recipients who are out of state.

 

      Section 1. General. Medicaid services provided to an eligible Medicaid recipient who is a resident of Kentucky while that resident is in another state shall be reimbursed in accordance with Section 2 of this administrative regulation.

 

      Section 2. Criteria for Coverage while Out of State. (1) Payment shall be made if covered medical services are needed because of a medical emergency.

      (2) Payment shall be made if medical services are needed because the recipient's health would be endangered if he were required to travel to Kentucky for the medical service. With regard to long-term care patients, it shall be the policy of the cabinet to pay for the medical services only until the time when the patient's medical condition has stabilized so the patient return to Kentucky; it is expected that the period of coverage shall be sixty (60) days or less; continuation of payment shall be contingent upon presentation of medical evidence acceptable to the cabinet which justifies an additional stay in a facility outside the state.

      (3) Payment shall be made when the state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other state; provided, however, that this provision shall not be construed or interpreted in a manner which circumvents or negates the provisions and intent of this administrative regulation.

      (4) Payment shall be made when it is general practice for recipients in a particular locality to use medical resources in another state.

 

      Section 3. Exception. For individuals in long-term care out of state prior to the effective date of this administrative regulation, and for whom the cabinet is at that time paying for the cost of care, the cabinet may continue to pay for the cost of care if the cabinet deems the payments to be appropriate. Children in subsidized adoption or foster care status shall be exempt from the restrictions shown in this administrative regulation.

 

      Section 4. Cooperation with other States. The cabinet shall facilitate the furnishing of medical services to individuals who are present in Kentucky and are eligible for Medicaid under another state's Medicaid plan. (Recodified from 904 KAR 1:084, 5-6-86; Am. Ky.R. 1632; eff. 1-10-92.)