907 KAR 1:595. Model Waiver II services and payments.

907 KAR 1:595. Model Waiver II services and payments.

RELATES TO: KRS 314.011, 42 C.F.R. 440.70, 440.185, 42 U.S.C. 1396

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 U.S.C. 1315, 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 coverage provisions relating to Model Waiver II services provided to a Medicaid-eligible recipient. These services are provided pursuant to a 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) "Department" means the Department for Medicaid Services and its designated agent or representative.

(2) "Home health agency" means a facility licensed by the Office of the Inspector General to provide home health services.

(3) "Model Waiver II services" means community-based waiver 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 (NF) level of care in a hospital based NF which will accept a recipient who is dependent on a ventilator.

(4) "Registered nurse" (RN) is defined in KRS 314.011.

(5) "Licensed practical nurse" (LPN) is defined in KRS 314.011.

(6) "Respiratory therapist" (RT) is defined by KRS 314A.010(3)(a).

(7) "Ventilator dependent" means the condition or state of an individual who requires the aid of a ventilator (respiration stimulating mechanism) for respiratory function and meets the high intensity nursing facility patient status criteria established in 907 KAR 1:022, Section 4.

Section 2. General Coverage Provisions. (1) A service shall be provided to a Medicaid eligible recipient:

(a) Who meets the NF level-of-care determination for

ventilator dependency; and

(b) For whom the cost of Model Waiver II services does not exceed the cost of traditional institutional ventilator care.

(2) The department shall make the level-of-care determination.

(3) A Medicaid eligible recipient may choose Model Waiver II services as an alternative to traditional institutional services.

(4) A Medicaid eligible recipient requesting to receive Model Waiver II services shall choose a qualified home health agency which has obtained a valid provider number for provision of services pursuant to 907 KAR 1:672.

Section 3. Provider Participation. A home health agency participating in the Model Waiver II Program shall meet the applicable certification requirements for providing home- and community-based waiver services in accordance with 907 KAR 1:671, 907 KAR 1:672, 907 KAR 1:675 and 907 KAR 1:030.

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

(a) Skilled nursing provided by:

1. A registered nurse (RN); or

2. A licensed practical nurse (LPN); or

(b) Respiratory therapy (RT).

(2) Model Waiver II services shall be provided by a qualified individual employed by or under contract through the home health agency as a:

(a) Registered nurse (RN);

(b) Licensed practical nurse (LPN); or

Section 5. Prior Authorization for a Service. (1) Prior to authorizing a Model Waiver II service, the department shall ensure that:

(a) Client ventilator-dependent status is met;

(b) Service is available to meet the need of a recipient; and

(2) A physician shall:

(a) Evaluate the need for continuation of service; and

(b) Submit a completed MAP-9, Prior Authorization for Health Services, and a signed plan of treatment at least once every sixty (60) days.

Section 6. Payment for Services. The department shall reimburse a participating home health agency for the provision of covered Model Waiver II services as follows:

(1) Reimbursement shall be based on a fixed fee for a unit of service provided for each covered service defined 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 (RN) shall be thirty-one (31) dollars and ninety-eight (98) cents for each unit of service.

(b) A licensed practical nurse (LPN) shall be twenty-nine (20) dollars and ten (10) 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 home- and community-based service furnished under this administrative regulation would exceed the cost of the service if provided in a hospital-based NF.

Section 7. 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 8. Incorporation by Reference. (1) "MAP-9, Prior Authorization for Health Services", December 1995 edition, is incorporated by reference.

(2) It may be inspected, copied, or obtained 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.)