907 KAR 1:790. Medicaid service category expenditure information.

 

      RELATES TO: KRS Chapter 45A, 304.17A, 304.38, 42 C.F.R. 440.230, 41 Subpart B, 42 U.S.C. 1396d(r), 1396u-2

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 C.F.R. 440.230, 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 provisions relating to Medicaid service category expenditure information for which a managed care organization and the Region 3 Partnership shall report expenditures to the department.

 

      Section 1. Definitions. (1) "BBA" means the Balanced Budget Act of 1997 as amended and codified under 42 U.S.C. 1396u-2.

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

      (3) "MCO" means the risk-bearing managed care organization that provides physical or behavioral health services through provider networks on a prepaid capitated basis as either an HMO or a PSN.

      (4) "Partnership" means a legal entity that satisfies the requirements of 907 KAR 1:705, Section 5, and while under contract with the department, in accordance with KRS Chapter 45A, agrees to provide or arrange for the provision of health services to Medicaid eligible members on a prepaid capitation payment basis.

 

      Section 2. Medicaid Expenditure Data Requirements. (1) A Medicaid managed care contract shall comply for financial reporting purposes with the provisions of 2000 Ky. Acts ch. 549, Part IX, 22., g.

      (2) A category of Medicaid service reporting requirement shall pertain to a provider who has a managed care contract through one (1) of the following:

      (a) A Section 1115 Waiver of the Social Security Act;

      (b) The Region 3 Partnership; or

      (c) A BBA state plan amendment MCO.

      (3) The following categories of service shall be reported to the department:

      (a) Inpatient hospital;

      (b) Physicians;

      (c) Nursing facilities;

      (d) Outpatient hospital;

      (e) Home health;

      (f) Durable medical equipment (DME);

      (g) Family planning;

      (h) Early and periodic screening, diagnosis and treatment (EPSDT) screens;

      (i) Early and periodic screening, diagnosis and treatment (EPSDT) related;

      (j) Laboratories;

      (k) Dental;

      (l) Nonemergency transportation;

      (m) Ambulance;

      (n) Vision;

      (o) Hearing;

      (p) Primary care center or federally-qualified health clinic (FQHC);

      (q) Rural health clinic;

      (r) Qualified Medicare beneficiaries (QMB);

      (s) Nurse practitioner or midwife;

      (t) Intermediate care facility for individuals with an intellectual disability (ICF-IID);

      (u) Pharmacy;

      (v) Chiropractic services;

      (w) Community mental health centers;

      (x) Mental hospital;

      (y) Psychiatric residential treatment facilities (PRTF);

      (z) Renal dialysis;

      (aa) Podiatry;

      (bb) Supports for community living (SCL);

      (cc) Ambulatory surgical care center;

      (dd) Home and community based services;

      (ee) Adult day care;

      (ff) Model waivers;

      (gg) Hospice;

      (hh) Preventive;

      (ii) Children with special health care needs;

      (jj) Targeted case management - emotionally disturbed child;

      (kk) Targeted case management - mentally ill adults;

      (ll) Other lab or X-ray;

      (mm) Nurse anesthetist;

      (nn) Title V - disability determination services (DDS);

      (oo) School-based services;

      (pp) Early intervention - First Steps;

      (qq) Brain injury;

      (rr) Impact Plus;

      (ss) Health Access Nurturing Developmental Services (HANDS);

      (tt) Home care waiver;

      (uu) Personal care assistance waiver;

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

      (ww) Empower transportation; and

      (xx) Drug rebate.

      (3) Other categories shall be added as necessary in accordance with department expenditures in order to meet the reporting requirements of 2000 Ky. Acts ch. 549, Part IX, 22., g. (27 Ky.R. 1124; Am. 1494; eff. 12-21-2000; TAm 7-16-2013.)