907 KAR 1:320. Kentucky Patient Access and Care System (KenPAC).

907 KAR 1:320. Kentucky Patient Access and Care System (KenPAC).

RELATES TO: KRS 205.520, 42 U.S.C. 1396a, b, d, u-2, 42 C.F.R. 438.56

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 U.S.C. 1396a, b, d, u-2, 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 requirements for the Kentucky Patient Access and Care (KenPAC) System.

Section 1. Definitions. (1) "Advanced registered nurse practitioner" or "ARNP" is defined in KRS 314.011(7).

(2) "AFDC-related" means a recipient who meets the requirements in effect on July 16, 1996 for Aid to Families with Dependent Children (AFDC) related Medicaid, including a specified relative or second parent.

(3) "Complex and extensive medical care needs" means a recipient:

(a) Has either:

1. An acute catastrophic illness or injury; or

2. Severe chronic multiple physical or psychological illnesses; and

(b) Requires complex coordination of medical and mental health care needs by multiple providers on an ongoing basis to maintain physical and psychological stability as determined in accordance with Section 4(3) of this administrative regulation.

(4) "Department" means the Department for Medicaid Services or its designated agent.

(5) "Disenrollment" means the termination of a recipient and primary care provider relationship.

(6) "Emergency care" means:

(a) Covered inpatient and outpatient services furnished by a qualified provider that are needed to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard; or

(b) Emergency ambulance transport.

(7) "Emergency medical condition" means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(8) "EPSDT" means the early and periodic screening, diagnosis and treatment services provided to Medicaid-eligible children under Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq.

(9) "Family-related" means:

(a) A specified relative, second parent, or child under the age of eighteen (18) years; or

(b) A child age eighteen (18) years who:

1. Is in full-time attendance in high school or the equivalent level of vocational or technical school;

2. Will complete that course of study before the 19th birthday; and

3. Except for income or resources, would be eligible under the guidelines in place for the AFDC-related Medicaid Program in effect on July 16, 1996.

(10) "Inadequate access to a primary care provider" means a KenPAC recipient does not have a choice of at least two (2) KenPAC primary care providers who practice in the recipient’s county of residence or an adjacent county.

(11) "Kentucky Children’s Health Insurance Program" or "KCHIP" means the children’s insurance program administered in accordance with 907 KAR 4:020 and 907 KAR 4:030.

(12) "Medical service area" means the recipient’s county of residence and the counties that adjoin the recipient’s county of residence.

(13) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

(14) "Newborn care service" means a routine health care service that is provided by a physician, an advanced registered nurse practitioner, or a physician assistant to a newborn as a continuation of care following the delivery while the mother and newborn are hospitalized in the same hospital and that includes:

(a) Standby for newborn care;

(b) Initial normal newborn care;

(d) Hospital discharge; and

(e) Circumcision.

(15) "Physician assistant" is defined in KRS 311.840(3).

(16) "Physician group practice" means one (1) or more licensed physicians who have enrolled both individually and as a group and share the same Medicaid group provider number.

(17) "Poverty-related women and children" means a group of eligibles that includes a pregnant woman or a child up to the age of nineteen (19) years whose eligibility is determined using the federal poverty levels as an income standard.

(18) "Primary care case management" or "PCCM" means a system of managed care used by state Medicaid agencies in which a primary care provider is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries.

(19) "Primary care center" means a health facility operating in accordance with 907 KAR 1:054.

(20) "Primary care provider" or "PCP" means a health care provider who meets the requirements of Section 6 of this administrative regulation.

(21) "Prudent layperson standard" means the criterion used to determine the existence of an emergency medical condition whereby a prudent layperson determines that a medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) so that the person could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(22) "Recertification" means the review and approval of a recipient’s eligibility for Medicaid Program benefits.

(23) "Rural health clinic" means a health facility operating in accordance with 907 KAR 1:082.

(24) "Spend-down" means time-limited medical assistance to individuals with eligibility determined by using medical expenses to meet excess income amounts in accordance with 907 KAR 1:640, Section 9.

(25) "SSI-related" means an individual age sixty-five (65) or older, blind or disabled who does not qualify for an SSI payment under 42 U.S.C. 1382(e).

(26) "Supplemental security income" or "SSI" is defined in 42 U.S.C. 1382(e).

(27) "Urgent care" means a covered service that:

(a) Is not required on an emergency basis;

(b) Is required to prevent substantial deterioration of a KenPAC recipient’s health status and for which the failure to provide a service would reasonably be anticipated to cause substantial harm to a recipient; and

(c) Is required promptly, which shall be the same day or within forty-eight (48) hours based on a medical provider’s assessment of urgency of need.

Section 2. General Requirements. (1) The Kentucky Patient Access and Care (KenPAC) System shall be available statewide except in geographic areas where:

(a) Medicaid services are provided under the authority of a Section 1115 waiver in accordance with 907 KAR 1:705; or

(b) The department has determined that there is not an adequate number of primary care providers participating in KenPAC.

(2) If a partnership formed in accordance with 907 KAR 1:705 is dissolved, terminated, or fails to renew its contract with the department, Medicaid recipients shall be provided primary care case management in accordance with this administrative regulation.

Section 3. Recipient Participation. A recipient included in one of the following categories shall be required to receive Medicaid services through KenPAC unless excluded in accordance with Section 4 of this administrative regulation:

(1) AFDC-related;

(2) Family-related;

(3) Poverty-related women and children;

(4) Kentucky Children’s Health Insurance Program (KCHIP);

(5) Supplemental security income (SSI) recipients age nineteen (19) and above;

(6) SSI-related; or

(7) Receiving state supplementation.

Section 4. Recipient Exclusions from KenPAC. (1) The following shall not be enrolled in the KenPAC program:

(a) An individual receiving Medicare benefits;

(b) An American Indian who is a registered member of a federally-recognized tribe;

1. Eligible for supplemental security income under 42 U.S.C. 1382(e);

2. Described in 42 U.S.C. 1396a(e)(3);

3. In foster care or subsidized adoption;

4. Receiving comprehensive case management services through a family-centered, community-based, coordinated care system receiving grant funds under 42 U.S.C. 701(a)(1)(D); or

5. In the custody of the Department of Juvenile Justice and is placed outside the home;

(d) A recipient who participates in the Kentucky Health Insurance Premium Payment Program (KHIPP);

(e) A recipient who is:

1. A resident of a nursing facility;

2. A resident of an intermediate care facility for the mentally retarded; or

3. Receiving services through a home and community based waiver program in accordance with 907 KAR 1:070, 907 KAR 1:090, 907 KAR 1:145, 907 KAR 1:160, 907 KAR 1:595, or 907 KAR 3:090;

(f) A recipient who resides in a county in which Medicaid services are provided through a managed care partnership operating under the authority of a Section 1115 waiver in accordance with 907 KAR 1:705;

(g) A recipient who is an alien with time-limited Medicaid eligibility;

(h) A recipient who has a Medicaid eligibility period that is only retroactive;

(i) A recipient who is Medicaid eligible through spend-down status;

(j) A recipient who is deceased on the date of eligibility approval;

(k) A resident of a psychiatric hospital or psychiatric residential treatment facility;

(l) A recipient who is receiving hospice services;

(m) A recipient whose care is coordinated through the Hemophilia Treatment Program of the Kentucky Commission for Children with Special Health Care Needs;

(n) A recipient for whom the primary payer is a third-party payer other than Medicaid and whose health care is coordinated by a primary care provider; or

(o) A recipient eligible in accordance with 907 KAR 1:800, Breast and cervical cancer eligibility for Medicaid.

(2) An individual who would be eligible for and required to participate in KenPAC but who resides in a county where the department has determined there is an inadequate number of PCPs participating in KenPAC shall be exempt from mandatory KenPAC enrollment until an adequate number of PCPs are available in the recipient’s county of residence.

(3) The department shall have the right to exempt a recipient from participation in KenPAC if the recipient has complex and extensive medical care needs that would not be appropriately met through the primary care case management system.

(a) A request for exemption from participation in KenPAC shall be determined by clinical review of medical and psychosocial information on a case-by-case basis by the department.

(b) The determination of whether a recipient is to be exempt from KenPAC shall be based on:

1. Whether the health care needs can be treated by a KenPAC PCP in the recipient's medical service area, with referral, as appropriate, considering the nature and extent of the treatment regimen; and

2. The complexity of the medical diagnoses.

Section 5. Burden of Proof. Pursuant to KRS 13B.090(7), the recipient shall have the burden of proof to show that he or she meets the criteria for exemption or exclusion from KenPAC.

Section 6. Provider Participation. A KenPAC primary care provider shall:

(1) Be limited to the following:

(a) A licensed primary care physician who is a doctor of medicine or osteopathy and who is a general practitioner, family practitioner, pediatrician, internist, obstetrician, or gynecologist;

(b) A licensed, certified advanced registered nurse practitioner who:

1. Has a "Collaborative Practice Agreement for Prescriptive Authority" in accordance with KRS 314.042; and

2. Has a signed written agreement with a primary care physician for backup twenty-four (24) hours per day seven (7) days a week for needed prescriptions and other primary care services outside the scope of practice of the advanced registered nurse practitioner;

(d) A licensed primary care center operating under physician supervision which has at least one (1) full-time equivalent primary care physician who is a general practitioner, family practitioner, doctor of osteopathy, pediatrician, internist, obstetrician, or gynecologist;

(e) A licensed rural health clinic operating under physician supervision by a primary care physician who is a general practitioner, family practitioner, doctor of osteopathy, pediatrician, internist, obstetrician, or gynecologist; or

(f) A licensed physician specialist who is a doctor of medicine or osteopathy if the specialist agrees to serve as a primary care provider and agrees to perform all the duties and responsibilities established in the Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC);

(2) Be responsible for supervising, coordinating, and providing initial and primary care to KenPAC recipients;

(3) Be responsible for initiating referrals for specialty care;

(4) Be responsible for maintaining the continuity of patient care twenty-four (24) hours per day, seven (7) days a week; and

(5) Have hospital admitting privileges or a formal referral agreement with a primary care provider who has hospital admitting privileges.

Section 7. KenPAC Provider Agreements. A participating primary care provider shall be required to:

(1) Sign an Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC) in compliance with 42 U.S.C. 1396d(t); and

(2) Comply with the provider enrollment, disclosure, and documentation requirements for Medicaid participation established in 907 KAR 1:672.

Section 8. Quotas. (1) Each PCP shall be required to specify in the Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC) the number of recipients the PCP is willing to serve.

(2) The upper limit shall be 1,500 recipients per full-time equivalent individually enrolled primary care provider unless the department has made a determination that it is in the best interest of Medicaid recipients to exceed the limit.

(3) The upper limit for a group practice shall be 1,500 recipients per participating full-time equivalent physician or ARNP who signs the Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC) with the department.

(4) The upper limit for a rural health clinic or primary care center shall be 1,500 recipients per participating full-time equivalent physician, ARNP or physician assistant employed by or under contract with a licensed primary care center or licensed rural health clinic.

Section 9. Primary Care Provider Fees. (1) The department shall pay a primary care case management fee of four (4) dollars per month per KenPAC recipient assigned.

(2) If a physician, ARNP, or physician assistant is employed by or under contract with a licensed primary care center or a licensed rural health clinic, the KenPAC case management fee shall be paid to the primary care center or rural health clinic.

(3) If a physician or ARNP participates in a group practice that is enrolled with the KenPAC program under a Medicaid group practice number, the KenPAC case management fee shall be paid to the group practice.

(4) If a physician or ARNP is enrolled with the KenPAC program under an individual Medicaid provider number, the KenPAC case management fee shall be paid to the individual PCP.

Section 10. Prior Authorization and Management of Services. (1) Except for services identified in subsection (3)(a) through (q) of this section or provided pursuant to an approved referral to a physician specialist, the PCP shall be responsible for managing the following:

(a) Primary care provider and physician specialty services;

(b) Hospital inpatient and outpatient services;

(d) Home health services;

(e) Primary care center services and rural health clinic services;

(f) Advanced registered nurse practitioner services if it is a nonexcluded service provided by an ARNP who is not the primary care case manager;

(g) Durable medical equipment and medical supplies;

(h) Laboratory and radiological services;

(i) Pharmacy services prescribed by the PCP; and

(j) Physical therapy, occupational therapy, and speech therapy.

(2) Access to emergency care or services for treatment of an emergency medical condition shall be made available in accordance with the prudent layperson standard.

(3) A covered Medicaid service in the following categories shall not require prior authorization from the KenPAC PCP:

(a) A service provided by a dentist or oral surgeon in accordance with 907 KAR 1:026;

(b) A mental health service provided by:

1. A psychiatrist;

2. A psychiatric hospital; or

3. A mental health provider in accordance with:

a. 907 KAR 1:044; or

b. 907 KAR 1:505;

(d) A maternity care service including prenatal care, delivery, and postpartum care;

(e) A service provided by a podiatrist in accordance with 907 KAR 1:270;

(f) A general medical transportation service or an emergency or nonemergency ambulance service provided in accordance with 907 KAR 1:060 and 907 KAR 3:066;

(g) An EPSDT service provided in accordance with 907 KAR 1:034;

(h) A service provided by the Kentucky Early Intervention Services Program in accordance with 907 KAR 1:720;

(i) A service provided by an audiologist or hearing aid dealer and hearing aids in accordance with 907 KAR 1:038;

(j) A family planning service;

(k) A service provided through the Medicaid preventive services program by a local public health department in accordance with 907 KAR 1:360;

(l) A chiropractic service provided in accordance with 907 KAR 3:125;

(m) A newborn care service;

(n) A specialized children’s services clinic service provided in accordance with 907 KAR 3:160;

(o) A service provided by a Health Access Nurturing Development Service (HANDS) provider in accordance with 907 KAR 3:140;

(p) A school-based service provided in accordance with 907 KAR 1:715; or

(q) A service for which the department has made a determination on an individual basis that it would be in the best interest of the Medicaid recipient to exempt the service from KenPAC prior authorization.

(4) Prior authorization shall not be required prior to delivery of emergency care.

(5) A recipient may receive urgent care from a provider other than the recipient’s PCP if:

(a) The urgent care is:

1. Medically necessary; and

2. Needed the same day; and

(b) A service provider is unable to contact the PCP for prior authorization.

Section 11. Primary Care Provider Requirements. The primary care provider shall:

(1) Accept a KenPAC recipient pursuant to the terms and conditions of the Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC);

(2) Supervise, coordinate, and provide initial and primary care to KenPAC recipients;

(3) Initiate referrals for specialty care to a Medicaid participating provider;

(4) Except for an emergency room service or a service specified in Section 10(3) of this administrative regulation, authorize medically necessary services or specialist referrals;

(5) Maintain continuity of patient care twenty-four (24) hours per day, seven (7) days a week;

(6) Assure that a recipient under age twenty-one (21) receives appropriate preventive care in accordance with the EPSDT periodicity schedule specified in 907 KAR 1:034; and

(7) Serve as a resource, as needed, to providers of nonemergency ambulance transportation and nonemergency transportation services to facilitate recipient access to medically-necessary transportation services.

Section 12. Recipient Assignment. (1) Except as permitted in accordance with subsection (8) of this section, a recipient shall select a KenPAC primary care provider from the participating KenPAC providers in the recipient’s county of residence or an adjacent county.

(2) A recipient shall have a choice of at least two (2) KenPAC PCPs who:

(a) Are accepting new patients; and

(b) Practice in the recipient’s county of residence or an adjacent county.

(3) If a recipient does not make a selection, the recipient shall be assigned on an equitable basis by the department to a KenPAC PCP in accordance with 42 U.S.C. 1396u-2(a)(4)(D).

(4) If a recipient was disenrolled due to a temporary loss of Medicaid eligibility and recertified for Medicaid eligibility within six (6) months, the recipient shall be assigned to the KenPAC PCP he had prior to disenrollment.

(5) A recipient may request disenrollment from a KenPAC PCP without cause:

(a) Within ninety (90) days of:

1. The date of the recipient’s initial enrollment; or

2. The date the department sends the recipient notice of initial enrollment with a provider;

(b) At least once every twelve (12) months after initial enrollment;

(c) Upon recertification, if a temporary loss of Medicaid eligibility for six (6) months or less has caused a recipient to miss an annual disenrollment opportunity;

(d) If the department imposes an intermediate sanction on the PCP as specified in 42 C.F.R. 438.702(a)(3); or

(e) If the recipient and his PCP are no longer located in the same medical service area.

(6) A recipient may request disenrollment from a PCP at any time with cause and select another KenPAC PCP. The following shall be cause for disenrollment:

(a) The recipient was homeless or a migrant worker at the time of enrollment and was enrolled with a PCP by default;

(b) The recipient was denied access to a needed medical service;

(d) The recipient does not have access to providers qualified to treat the recipient’s health care needs.

(7) The department shall provide notice to a recipient sixty (60) days prior to an annual opportunity to select another PCP.

(8) If it is determined by the department that a recipient’s medical care needs are so complex and extensive that a primary care provider with specialized disease management expertise is required and is unavailable in the recipient’s county of residence or an adjacent county, the department shall have the right to approve a recipient’s request for assignment to a primary care provider located in another geographic area.

(9) A recipient shall have the burden of proof to show cause, if required, for disenrollment from a PCP.

Section 13. Recipient Disenrollment Procedures. (1) A recipient shall submit an oral or written request for disenrollment to the department.

(2) A request for disenrollment for a reason identified in Section 12(6)(b), (c) or (d) of this administrative regulation shall be submitted in writing using, as appropriate, either:

(a) A MAP 357A KenPAC SSI Primary Care Provider (PCP) Change Form; or

(b) A MAP 357B KenPAC Primary Care Provider (PCP) Change Form.

(3) The department shall approve or disapprove a disenrollment request for cause based on:

(a) Whether a reason cited in the request is a reason specified in Section 12(6) of this administrative regulation;

(b) Information obtained from the recipient; and

(4) The effective date of an approved disenrollment request shall not be later than the first day of the second month following the month in which the department receives the request.

(5) If the department fails to make a disenrollment determination within the time frame specified in subsection (4) of this section, the disenrollment request shall be considered approved.

Section 14. Provider Disenrollment of a Recipient. (1) A primary care provider may request the department to disenroll a KenPAC recipient in accordance with the following:

(a) Due to incompatibility of the PCP-patient relationship;

(b) Due to inability to adequately meet the medical needs of the recipient; or

(c) For a reason for which the department has made a determination on an individual basis that it would be in the best interest of the Medicaid recipient to change the PCP.

(2) A PCP shall not request disenrollment because of:

(a) A change in a recipient’s health status except as specified in subsection (1)(b) of this section;

(b) A recipient’s utilization of medical services;

(d) A recipient’s uncooperative or disruptive behavior resulting from his or her special needs unless the behavior impairs the ability of the PCP to furnish services to the recipient or others.

(3) The effective date of an approved disenrollment shall not be later than the first day of the second month following the month in which the department receives a request for disenrollment from the provider.

(4) Upon disenrollment, the PCP shall continue to provide or arrange for the provision of primary care and other medically-necessary services and make referrals until the recipient is no longer assigned to that PCP.

(5) To request the disenrollment of a KenPAC recipient, a PCP shall write a letter to the recipient and mail or fax a copy to the department indicating the reason for the request for disenrollment.

Section 15. Utilization Control. (1) A primary care provider identified by the department as having an inappropriate utilization or performance pattern as defined in the Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC) shall be subject to probation as specified in the agreement.

(2) The PCP shall be:

(a) Notified in writing of the probationary period, which shall not exceed six (6) months; and

(b) Provided with the opportunity for corrective action.

(3) A pattern of persistent and significant inappropriate utilization or performance as defined in the Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC) shall be grounds for termination as a KenPAC PCP.

(4) A KenPAC provider placed on probation or terminated may request an appeal of the decision in accordance with Section 16(3) of this administrative regulation.

Section 16. Appeal Rights. (1) An appeal of a negative action regarding a Medicaid recipient shall be conducted in accordance with 907 KAR 1:563.

(2) An appeal regarding the Medicaid eligibility of an individual shall be conducted in accordance with 907 KAR 1:560.

(3) An appeal of an action involving utilization control of a Medicaid provider under Section 15 of this administrative regulation shall be conducted in accordance with 907 KAR 1:671.

(4) If a recipient is dissatisfied with the department’s decision regarding a disenrollment request, the recipient shall request the department to reconsider its decision prior to pursuing an administrative hearing. The request for reconsideration shall be made in writing within ten (10) days of the date the recipient receives the department’s notification letter.

(5) A recipient whose disenrollment from a PCP is denied by the department shall be provided notice of the right to file a request for an administrative hearing and information about how to file an appeal.

Section 17. Incorporation by Reference. (1) The following material is incorporated by reference:

(a) "Agreement for Participation as a Primary Care Provider or Clinic in the Kentucky Patient Access and Care System (KenPAC)", "May 2002 edition";

(b) "MAP357A KenPAC SSI Primary Care Provider (PCP) Change Form", "October 2002 Edition"; and

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. through 4:30 p.m. (Recodified from 904 KAR 1:320, 5-2-86; Am. 18 Ky.R. 1650; eff. 1-10-92; 22 Ky.R. 2076; eff. 7-5-96; 28 Ky.R. 2736; 29 Ky.R. 460; eff. 8-12-2002; 2165; 2474; eff. 4-11-03.)