907 KAR 1:595. Model Waiver II service coverage and reimbursement policies and requirements.

 

††††† RELATES TO: KRS 314.011, 42 C.F.R. 440.70, 440.185, 42 U.S.C. 1396, 42 U.S.C. 1396n(c)

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 U.S.C. 1315

††††† 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, to qualify for federal Medicaid funds. This administrative regulation establishes the service coverage and reimbursement policies and requirements relating to Model Waiver II services provided to a Medicaid-eligible recipient. These services are provided pursuant to a 1915(c) home and community based waiver granted by the U. S. Department for Health and Human Services in accordance with 42 U.S.C. 1396n(c).

 

††††† Section 1. Definitions. (1) "1915(c) home and community based waiver program" means a Kentucky Medicaid program established pursuant to and in accordance with 42 U.S.C. 1396n(c).

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

††††† (3) "Federal financial participation" is defined in 42 C.F.R. 400.203.

††††† (4) "Home health agency" means an agency that is:

††††† (a) Licensed in accordance with 902 KAR 20:081;

††††† (b) Medicare certified; and

††††† (c) Medicaid certified.

††††† (5) "Licensed practical nurse" is defined by KRS 314.011(9).

††††† (6) "Model Waiver II services" means 1915(c) home and community based waiver program in-home ventilator services provided to a Medicaid-eligible recipient who:

††††† (a) Is dependent on a ventilator; and

††††† (b) Would otherwise require a nursing facility level of care in a hospital based nursing facility which will accept a recipient who is dependent on a ventilator.

††††† (7) "Private duty nursing agency" means a facility licensed to provide private duty nursing services:

††††† (a) By the Cabinet for Health and Family Services, Office of Inspector General; and

††††† (b) Pursuant to 902 KAR 20:370.

††††† (8) "Recipient" is defined by KRS 205.8451(9).

††††† (9) "Registered nurse" is defined by KRS 314.011(5).

††††† (10) "Registered respiratory therapist" is defined by KRS 314A.010(3)(a).

††††† (11) "Ventilator" means a respiration stimulating mechanism.

††††† (12) "Ventilator dependent" means the condition or state of an individual who:

††††† (a) Requires the aid of a ventilator for respiratory function; and

††††† (b) Meets the high intensity nursing facility patient status criteria established in 907 KAR 1:022.

 

††††† Section 2. Model Waiver II Recipient Eligibility and Related Policies. (1) To be eligible to receive Model Waiver II services, an individual shall:

††††† (a) Be eligible for Medicaid pursuant to 907 KAR 20:010;

††††† (b) Require ventilator support for at least twelve (12) hours per day;

††††† (c) Meet ventilator dependent patient status requirements established in 907 KAR 1:022;

††††† (d) Submit to the department an application packet which shall contain:

††††† 1. A MAP 350, Long Term Care Facilities and Home and Community Based Program Certification Form;

††††† 2. A MAP-351A, Medicaid Waiver Assessment Form; and

††††† 3. A MAP109 -MWII, Plan of Care/Prior Authorization for Model Waiver II Services, which shall be signed and dated by a physician; and

††††† (e) Receive notification of an admission packet approval from the department.

††††† (2) To remain eligible for Model Waiver II services, the requirements established in this subsection shall be met.

††††† (a) An individual shall:

††††† 1. Maintain Medicaid eligibility requirements established in 907 KAR 20:010; and

††††† 2. Remain ventilator dependent pursuant to 907 KAR 1:022.

††††† (b) A Model Waiver II level of care determination confirming that the individual qualifies shall be performed and submitted to the department every six (6) months.

††††† (c) A MAP 109, Plan of Care/Prior Authorization for Model Waiver II Services shall be:

††††† 1. Signed and dated by a physician every sixty (60) days on behalf of the individual; and

††††† 2. Submitted to the department, after being signed and dated in accordance with subparagraph 1 of this paragraph, every sixty (60) days.

††††† (3) A Model Waiver II service shall not be provided to a recipient who is:

††††† (a) Receiving a service in another 1915(c) home and community based waiver program; or

††††† (b) An inpatient of:

††††† 1. A nursing facility;

††††† 2. An intermediate care facility for individuals with an intellectual disability; or

††††† 3. Another facility.

††††† (4) The department shall not authorize a Model Waiver II service unless it has ensured that:

††††† (a) Ventilator dependent status has been met;

††††† (b) The service:

††††† 1. Is available to the recipient;

††††† 2. Will meet the need of the recipient; and

††††† 3. Does not exceed the cost of traditional institutional ventilator care.

 

††††† Section 3. Provider Participation Requirements. To participate in the Model Waiver II program, a:

††††† (1) Home health agency shall:

††††† (a) Be a currently participating Medicaid provider in accordance with 907 KAR 1:671;

††††† (b) Be currently enrolled as a Medicaid provider in accordance with 907 KAR 1:672; and

††††† (c) Meet the home and community based waiver service provider requirements established in 907 KAR 1:160; or

††††† (2) Private duty nursing agency shall:

††††† (a) Be a currently participating Medicaid provider in accordance with 907 KAR 1:671;

††††† (b) Be currently enrolled as a Medicaid provider in accordance with 907 KAR 1:672; and

††††† (c) Be a licensed private duty nursing agency in accordance with 902 KAR 20:370.

 

††††† Section 4. Covered Services. (1) The following shall be covered Model Waiver II services:

††††† (a) Skilled nursing provided by:

††††† 1. A registered nurse; or

††††† 2. A licensed practical nurse; or

††††† (b) Respiratory therapy.

††††† (2) Model Waiver II services shall be provided by an individual employed by or under contract through a private duty nursing agency or home health agency as a:

††††† (a) Registered nurse;

††††† (b) Licensed practical nurse; or

††††† (c) Registered respiratory therapist.

 

††††† Section 5. Payment for Services. The department shall reimburse a participating home health agency or private duty nursing agency for the provision of covered Model Waiver II services as established in this section.

††††† (1) Reimbursement shall be based on a fixed fee for a unit of service provided for each covered service referenced in Section 4 of this administrative regulation with one (1) hour equal to one (1) unit of service.

††††† (2) The fixed fee for skilled nursing services provided by:

††††† (a) A registered nurse shall be thirty-one (31) dollars and ninety-eight (98) cents for each unit of service;

††††† (b) A licensed practical nurse shall be twenty-nine (29) dollars and ten (10) cents for each unit of service; and

††††† (c) A registered respiratory therapist shall be twenty-seven (27) dollars and forty-two (42) cents for each unit of service.

††††† (3) Reimbursement shall not exceed sixteen (16) units of service per day.

††††† (4) Payment shall not be made for a service to an individual for whom it can reasonably be expected that the cost of the 1915(c) home and community based waiver program service furnished under this administrative regulation would exceed the cost of the service if provided in a hospital-based nursing facility.

 

††††† Section 6. Maintenance of Records. (1) A Model Waiver II service provider shall maintain:

††††† (a) A clinical record for each HCB recipient which shall contain the following:

††††† 1. Pertinent medical, nursing, and social history;

††††† 2. A comprehensive assessment entered on a MAP-351A, Medicaid Waiver Assessment Form, and signed by the:

††††† a. Assessment team; and

††††† b. Department;

††††† 3. A completed MAP109 -MWII, Plan of Care/Prior Authorization for Model Waiver II Services;

††††† 4. A copy of the MAP 350, Long Term Care Facilities and Home and Community Based Program Certification Form signed by the recipient or the recipientís legal representative at the time of application or reapplication and each recertification thereafter;

††††† 5. Documentation of all level of care determinations;

††††† 6. All documentation related to prior authorizations including requests, approvals, and denials;

††††† 7. Documentation that the recipient or legal representative was informed of the procedure for reporting complaints; and

††††† 8. Documentation of each service provided that shall include:

††††† a. The date the service was provided;

††††† b. The duration of the service;

††††† c. The arrival and departure time of the provider, excluding travel time, if the service was provided at the recipientís home;

††††† d. Progress notes which shall include documentation of changes, responses, and treatments utilized to evaluate the recipientís needs; and

††††† e. The signature of the service provider; and

††††† (b) Incident reports as required by Section 7 of this administrative regulation if an incident with the recipient occurs.

††††† (2)(a) Except as provided in paragraph (b) of this subsection, a clinical record or incident report shall be retained for at least six (6) years from the date that a covered service is provided.

††††† (b) If the recipient is a minor, a clinical record or incident report shall be retained for three (3) years after the recipient reaches the age of majority under state law, if that is a longer time period than the time period required by paragraph (a) of this subsection.

††††† (3) Upon request, a provider shall make information regarding service and financial records available to the:

††††† (a) Department;

††††† (b) Cabinet for Health and Family Services, Office of Inspector General or its designee;

††††† (c) United States Department for Health and Human Services or its designee;

††††† (d) General Accounting Office or its designee;

††††† (e) Office of the Auditor of Public Accounts or its designee; or

††††† (f) Office of the Attorney General or its designee.

 

††††† Section 7. Incident Reporting. A Model Waiver II service provider shall:

††††† (1) Implement a procedure or procedures to ensure that the following is reported:

††††† (a) Abuse, neglect, or exploitation of a Model Waiver II recipient in accordance with KRS Chapters 209 or 620;

††††† (b) A slip or fall;

††††† (c) A transportation incident;

††††† (d) Improper administration of medication;

††††† (e) A medical complication; or

††††† (f) An incident caused by the recipient, including:

††††† 1. Verbal or physical abuse of staff or other recipients;

††††† 2. Destruction or damage of property; or

††††† 3. Recipient self-abuse;

††††† (2) Ensure that a copy of each incident reported in this subsection is maintained in a central file subject to review by the department; and

††††† (3) Implement a process for communicating the incident, the outcome, and the prevention plan to:

††††† (a) The Model Waiver II service recipient involved, his or her family member, or his or her responsible party; and

††††† (b) The attending physician, physician assistant, or advanced practice registered nurse.

 

††††† Section 8. Use of Electronic Signatures. (1) The creation, transmission, storage, and other use of electronic signatures and documents shall comply with the requirements established in KRS 369.101 to 369.120.

††††† (2) A Model Waiver II service provider that chooses to use electronic signatures shall:

††††† (a) Develop and implement a written security policy that shall:

††††† 1. Be adhered to by each of the provider's employees, officers, agents, and contractors;

††††† 2. Identify each electronic signature for which an individual has access; and

††††† 3. Ensure that each electronic signature is created, transmitted, and stored in a secure fashion;

††††† (b) Develop a consent form that shall:

††††† 1. Be completed and executed by each individual using an electronic signature;

††††† 2. Attest to the signature's authenticity; and

††††† 3. Include a statement indicating that the individual has been notified of his or her responsibility in allowing the use of the electronic signature; and

††††† (c) Provide the department with:

††††† 1. A copy of the provider's electronic signature policy;

††††† 2. The signed consent form; and

††††† 3. The original filed signature immediately upon request.

 

††††† Section 9. Federal Financial Participation. A policy established in this administrative regulation shall be null and void if the Centers for Medicare and Medicaid Services:

††††† (1) Denies federal financial participation for the policy; or

††††† (2) Disapproves the policy.

 

††††† Section 10. Appeal Rights. (1) An appeal of a negative action regarding a Medicaid recipient shall be appealed in accordance with 907 KAR 1:563.

††††† (2) An appeal of a negative action regarding a Medicaid beneficiary's eligibility shall be appealed in accordance with 907 KAR 1:560.

††††† (3) An appeal of a negative action regarding a Medicaid provider shall be appealed in accordance with 907 KAR 1:671.

 

††††† Section 11. Incorporation by Reference. (1) The following material is incorporated by reference:

††††† (a) "MAP109 -MWII, Plan of Care/Prior Authorization for Model Waiver II Services", April 2004 edition;

††††† (b) "MAP 350, Long Term Care Facilities and Home and Community Based Program Certification Form", January 2000 edition; and

††††† (c) "MAP-351A, Medicaid Waiver Assessment Form", June 15, 2002 edition.

††††† (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. to 4:30 p.m. (24 Ky.R. 2788; Am. 25 Ky.R. 585; 863; eff. 9-16-98; 38 Ky.R.697; 968; eff. 12-2-11; 39 Ky.R. 243

8; eff. 9-6-2013; TAm 9-30-2013.)