907 KAR 1:810. Presumptive eligibility for pregnant women.
RELATES TO: KRS 205.520, 205.592, 42 U.S.C. 1396a(a)(47), r-1
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 any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. KRS 205.592 establishes Medicaid eligibility requirements for pregnant women and children up to age one (1). This administrative regulation establishes requirements for the determination of presumptive eligibility and the provision of services to pregnant women deemed presumptively eligible for Medicaid-covered services.
Section 1. Definitions. (1) "Ambulatory prenatal care" means health-related care furnished to a presumed eligible pregnant woman provided in an outpatient setting.
(2) "Cabinet" means the Cabinet for Health and Family Services.
(3) "DCBS" means the Department for Community Based Services. (4) "Department" means the Department for Medicaid Services or its designated agent.
(5) "Presumptive eligibility" means eligibility granted for Medicaid-covered services as specified in Section 6 of this administrative regulation to a qualified pregnant woman based on an income screening performed by a qualified provider.
(6) "Qualified provider" means a provider who:
(a) Is currently enrolled with the department;
(b) Has been trained and certified by the department to grant presumptive eligibility to pregnant women; and
(c) Provides services of the type described in 42 USC 1396d(a)(2)(A) or (B) or (9).
Section 2. Providers Eligible to Grant Presumptive Eligibility. A determination of presumptive eligibility shall be made by a qualified provider who is:
(1) A family or general practitioner;
(2) A pediatrician;
(3) An internist;
(4) An obstetrician or gynecologist;
(5) A physician assistant;
(6) A certified nurse midwife;
(7) An advanced registered nurse practitioner;
(8) A federally-qualified health care center;
(9) A primary care center;
(10) A rural health clinic; or
(11) A local health department.
Section 3. Provider Responsibilities. (1) A qualified provider who determines that a pregnant woman is presumptively eligible for Medicaid based on criteria established in Section 4 of this administrative regulation shall:
(a) Notify the department and obtain an authorization number;
(b) Inform the woman at the time the determination is made that she is required to make an application for Medicaid benefits through her local DCBS office;
(c) Issue presumptive eligibility identification to the presumed eligible woman; and
(d) Maintain a record of the presumptive eligibility screening for each applicant.
(2) If a woman is determined not to be presumptively eligible, the qualified provider shall inform the woman of the following in writing:
(a) The reason for the determination;
(b) That she may file an application for Medicaid if she wishes to have a formal determination made; and
(c) The location of her local DCBS office.
Section 4. Eligibility Criteria. Presumptive eligibility may be granted to a woman if she:
(1) Is pregnant;
(2) Is a Kentucky resident;
(3) Meets income guidelines established in 907 KAR 1:640, Section 2(2)(a);
(4) Does not currently have a pending Medicaid application on file with the DCBS;
(5) Is not currently enrolled in Medicaid;
(6) Has not been previously granted presumptive eligibility for the current pregnancy; and
(7) Is not an inmate of a public institution.
Section 5. Presumptive Eligibility Period. (1) Presumptive eligibility shall begin on the date on which a qualified provider:
(a) Determines that a woman is presumptively eligible based on the criteria specified in Section 4 of this administrative regulation if the qualified provider obtains an authorization number from the department on:
1. That day; or
2. If the department is closed, the next business day the department is open; or
(b) Obtains an authorization number from the department if it is not the day specified in paragraph (a) of this subsection.
(2) The presumptive eligibility period shall end on:
(a) The day preceding the date the presumptively-eligible woman is granted full eligibility in the Medicaid Program by the DCBS; or
(b) The last day of the second month following the month in which a qualified provider made the presumptive eligibility determination if a presumed eligible woman:
1. Does not apply for the full Medicaid benefit package; or
2. Applies for and is found ineligible for the full Medicaid benefit package.
(3) Only one (1) presumptive eligibility period shall be granted for each episode of pregnancy.
Section 6. Covered Services. (1) Payment for a covered service provided to a presumptively-eligible pregnant woman shall be in accordance with current Medicaid policy for reimbursement.
(2) Covered services for a presumptively-eligible woman shall be limited to ambulatory prenatal care services delivered in an outpatient setting and shall include:
(a) Services furnished by a primary care provider, including:
1. A family or general practitioner;
2. A pediatrician;
3. An internist;
4. An obstetrician or gynecologist;
5. A physician assistant;
6. A certified nurse midwife; or
7. An advanced registered nurse practitioner;
(b) Laboratory services provided in accordance with 907 KAR 10:014 and 907 KAR 1:028;
(c) X-ray services provided in accordance with 907 KAR 10:014 and 907 KAR 1:028;
(d) Dental services provided in accordance with 907 KAR 1:026, Section 2(1) and (2);
(e) Emergency room services provided in accordance with 907 KAR 10:014, Section 1(1)(c);
(f) Emergency and nonemergency transportation provided in accordance with 907 KAR 1:060;
(g) Pharmacy services provided in accordance with 907 KAR 1:019E;
(h) Services delivered by rural health clinics provided in accordance with 907 KAR 1:082;
(i) Services delivered by primary care centers and federally-qualified health care centers provided in accordance with 907 KAR 1:054; or
(j) Primary care services delivered by local health departments provided in accordance with 907 KAR 1:360.
Section 7. Appeal Rights. (1) The appeal rights of the Medicaid Program shall not apply if a woman is:
(a) Determined not to be presumptively eligible; or
(b) Determined to be presumptively eligible but fails to file an application for Medicaid with the DCBS before her presumptive eligibility ends and therefore is determined to be ineligible for Medicaid benefits.
(2) The appeal rights of the Medicaid Program shall apply if a woman is:
(a) Determined to be presumptively eligible; and
(b) Files an application with the DCBS but is determined ineligible for Medicaid benefits.
(3) Except as specified in subsection (1) of this section, an appeal of a negative action taken by the department regarding a Medicaid recipient shall be in accordance with 907 KAR 1:563.
(4) Except as specified in subsection (1) of this section, an appeal of a negative action taken by the department regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.
(5) An appeal of a negative action regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.
Section 8. Quality Assurance and Utilization Review. The cabinet shall evaluate, on a continuing basis, access, continuity of care, health outcomes, and services arranged or provided by a Medicaid provider to a presumed eligible woman in accordance with accepted standards of practice for medical service. (28 Ky.R. 2133; Am. 2355; eff. 4-30-2002; T. Am.; eff. 5-3-11.)