907 KAR 1:092. Payments for personal care assistance waiver services.

      RELATES TO: 42 C.F.R. 441 Subpart G, 42 U.S.C. 1396a, b, d, n

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 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, 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 payment provisions relating to personal care assistance waiver services.

      Section 1. Definitions. (1) "Department" means the Department for Medicaid Services or its designee.

      (2) "Family member" means:

      (a) Husband or wife;

      (b) Natural or adoptive parent, child or sibling;

      (c) Stepparent, stepchild, stepbrother, stepsister;

      (d) Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law,

      (e) Sister-in-law;

      (f) Grandparent or grandchild;

      (g) Spouse of grandparent or grandchild;

      (h) Aunt or uncle; or

      (i) Spouse of aunt or uncle.

      (3) "Unit of service" means a fixed amount by which a whole service is measured and recorded for payment.

      Section 2. Reimbursement. (1) The department shall reimburse a participating provider for a service pursuant to 907 KAR 1:090 the lessor of the:

      (a) Provider’s usual and customary charge; or

      (b) Medicaid fixed upper payment rate per unit of service pursuant to Section 3 of this administrative regulation.

      (2) The department shall not reimburse a provider for a service:

      (a) That is not listed in the approved plan of care;

      (b) Provided prior to approval of the plan of care; or

      (c) Provided by a family member.

      Section 3. Payment Rate Limits Effective July 1, 2002. Effective July 1, 2002, the following shall be the payment rate limits for each unit of service pursuant to 907 KAR 1:090, Section 3.

Personal Care Assistance Waiver Service	Medicaid Fixed Upper Payment Rate Limit	Unit Of Service	Maximum Units of Service Per Week (Sunday- Saturday)	Minimum Units of Service Per Week
Personal Care Assistance	$6.52	1 hour	40	14
Case Management	$19.10	30 minutes	No limit	No limit
Program Coordination	$12.73	30 minutes	No limit	No limit

      Section 4. Auditing and Reporting. (1) A participating provider shall maintain fiscal and service records of services provided for a period of at least five (5) years from the date that a covered service is provided.

      (2) A participating provider shall upon request provide or make available information regarding service and financial records to:

      (a) The department;

      (b) The United States Department for Health and Human Service, or its designee;

      (c) The United States General Accounting Office, or its designee;

      (d) The Commonwealth of Kentucky, Office of the Auditor of Public Accounts, or its designee; or

      (e) The Commonwealth of Kentucky, Office of the Attorney General, or its designee.

      Section 5. Payment Rate for State Fiscal Year (SFY) 2002. Effective July 1, 2001, the payment rate that was in effect on June 30, 2001 for a personal care assistance waiver service shall remain in effect.

      Section 6. Appeal Rights. A provider may appeal a department decision as to the application of this administrative regulation in accordance with 907 KAR 1:671. (26 Ky.R. 1877; Am. 2248; eff. 6-12-2000; 28 Ky.R. 954; eff. 12-19-2001; 29 Ky.R. 1134; 1652; eff. 12-18-02.)