907 KAR 1:280. Payments for Podiatry Program services.


      RELATES TO: KRS 205.520

      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 a 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 method for determining payments for podiatry services.


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

      (2) "Resource-based relative value scale (RBRVS) unit" means a value based on the service which takes into consideration the practitioner's work, practice expenses, liability insurance, and a geographic factor based on the price of staffing and other resources required to provide the service in an area relative to national average prices.


      Section 2. Payments for Podiatry Services. (1) The cabinet shall reimburse a licensed, participating podiatrist for a covered podiatry service within the podiatrist's scope of licensure as established in 907 KAR 1:270, except a laboratory service, provided to an eligible Medicaid recipient at the usual and customary actual billed charge up to the fixed upper limit per procedure established by the department using the Kentucky Medicaid fee schedule developed from a resource-based relative value scale (RBRVS) on parity with medical doctors as described in subsection (2) of this section. If an RBRVS based fee is not established, the department shall set a reasonable fixed upper limit for the procedure consistent with general Medicaid rate setting methodology.

      (2) The RBRVS unit shall be multiplied by a dollar conversion factor to arrive at the fixed upper limit. The department shall use the Kentucky conversion factor for "All Other Services" as established in 907 KAR 3:010, Section 2(2)(b).

      (3) Reimbursement for a covered clinical laboratory service shall be based on the Medicare allowable payment rate. For a laboratory service with no established allowable payment rate, the payment shall be sixty-five (65) percent of the usual and customary actual billed charge. (11 Ky.R. 1013; eff. 1-7-1985; Recodified from 904 KAR 1:280, 5-2-1986; 17 Ky.R. 579; eff. 10-14-1990; 23 Ky.R. 4243; 24 Ky.R. 384; eff. 7-16-1997.)