907 KAR 4:020. Kentucky Children’s Health Insurance Program Medicaid Expansion Title XXI of the Social Security Act.

 

      RELATES TO: KRS 205.510-205.645, 205.6481-205.6497, 42 C.F.R. 432, 433, 435, 436, 457, 42 U.S.C. 1397aa-jj

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3) 205.6485, 42 U.S.C. 1397aa-jj, 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. KRS 194A.030(2) requires the Cabinet for Health and Family Services, Department for Medicaid Services, to administer Title XIX of the Federal Social Security Act, 42 U.S.C. 1396 to 1396v. KRS 194A.050(1) requires the secretary of the cabinet to promulgate administrative regulations necessary to protect, develop, and maintain the health, personal dignity, integrity, and sufficiency of the individual citizens of the Commonwealth; to operate the programs and fulfill the responsibilities vested in the cabinet; and to implement programs mandated by federal law or to qualify for the receipt of federal funds. KRS 205.6485 authorizes the cabinet to establish the Kentucky Children’s Health Insurance Program (KCHIP) to provide health care coverage and other coordinated health care services to children of the Commonwealth who are uninsured and otherwise not eligible for health insurance coverage. This administrative regulation establishes the KCHIP eligibility criteria, covered services, application requirements, grievance and appeal rights for recipients, and the requirements for providers who wish to participate with the Commonwealth to provide health care coverage to KCHIP members through an expansion of the Title XIX Medicaid Program.

 

      Section 1. Definitions. (1) "Cabinet" means the Kentucky Cabinet for Health and Family Services or its designee.

      (2) "Child" means an individual under age nineteen (19).

      (3) "Creditable coverage" is defined in KRS 304.17A-005(7)(a)1-3 and 5-10.

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

      (5) "Excepted benefits" is defined in KRS 304.17A-005(11).

      (6) "Health insurance" is defined in KRS 304.5-040.

      (7) "KCHIP" means the Kentucky Children’s Health Insurance Program administered in accordance with 42 U.S.C. 1397aa to jj.

 

      Section 2. Eligibility Criteria. (1) A child shall be eligible for KCHIP if the child:

      (a) Meets the technical and income requirements of 907 KAR 1:011, Section 2(3)(h) and meets the following requirements:

      1. Provides to the department the information required in Section 4 of this administrative regulation;

      2. Meets the continuing eligibility requirement established in 907 KAR 1:605, Section 3;

      3. Meets the relative responsibility requirements of 907 KAR 1:660; and

      4. Is not eligible for Medicaid; or

      (b) Is an optional targeted low-income child as defined in 42 U.S.C. 1397jj(b) and meets the following requirements:

      1. Has family income which does not exceed 150 percent of the federal poverty guidelines, updated annually in the Federal Register by the United States Department of Health and Human Services under authority of 42 U.S.C. 9902(2); and

      2. Does not have creditable coverage but may be covered by excepted benefits.

      (2) Eligibility for KCHIP shall be determined by the department. Upon receipt of eligibility information defined in subsection (1) of this section, the department shall determine if a child is eligible for benefits pursuant to 42 U.S.C. 1396 or 1397aa to jj.

 

      Section 3. Covered Services. (1) Health services shall be considered medically necessary in accordance with 907 KAR 3:130 and 42 CFR 440.230.

      (2) Amount and duration of benefits covered by KCHIP shall be as established in 907 KAR Chapters 1 and 3.

      (3) A medical service shall be covered through KCHIP if an individual is determined eligible for KCHIP benefits in accordance with Section 2 of this administrative regulation.

      (4) Preventive and remedial public health services shall be provided to KCHIP members in accordance with 907 KAR 1:360.

      (5) KCHIP shall be the payor of last resort.

 

      Section 4. KCHIP Application Requirements. The following information shall be required from a child or responsible party for KCHIP enrollment:

      (1) A child’s demographics which shall include name, address, sex, date of birth, race, and Social Security number;

      (2) Monthly gross earned income, if any, of a parent and a child for whom information is being submitted, an employer type and address, if any, and frequency of income;

      (3) Name and address of a health insurance provider who:

      (a) Currently provides creditable coverage; or

      (b) Provided creditable coverage during the six (6) months prior to the date the information in this section is submitted to the department;

      (4) Creditable coverage policy number, policy holder’s name, Social Security number, and individuals covered by the plan;

      (5) Unearned income, if any, received weekly, biweekly, bimonthly, quarterly, or annually;

      (6) Name and age of a child or disabled adult for whom care is purchased in order for a parent or responsible person to work; and

      (7) Signature, date, and telephone number of a person submitting the information for a child.

 

      Section 5. Provider Participation Requirements. A provider’s enrollment, disclosure, and documentation for participation in KCHIP shall meet the requirements of 907 KAR 1:671, 907 KAR 1:672, and if a KenPAC provider, 907 KAR 1:320.

 

      Section 6. Grievance, Hearing, and Appeal Rights. (1) If dissatisfied with an action taken by the department as to the application of Sections 1 through 5 of this administrative regulation, a child, the child's parent, or the child's guardian shall be entitled to a grievance, hearing, or appeal with the department, to be conducted in accordance with 907 KAR 1:560, if pertaining to initial eligibility, or 907 KAR 1:563, if pertaining to a covered service.

      (2) If a service is provided by a managed care organization, a dispute resolution between a provider and a child, the child's parent, or the child's guardian shall be in accordance with KRS 211.461 through 211.466 and 907 KAR 1:563.

      (3) A KCHIP-eligible child or a responsible party shall be informed, in writing, of his rights to and procedures for due process by the cabinet:

      (a) When information to obtain KCHIP approval is submitted;

      (b) If there is a change in eligibility; or

      (c) As required by federal and state laws.

 

      Section 7. Quality Assurance and Utilization Review. The department shall evaluate, on a continuing basis, access, continuity of care, health outcomes, and services arranged or provided as established in 907 KAR 1:705. (26 Ky.R. 1055; Am. 1425; eff. 1-12-2000; 29 Ky.R. 1143; 1658; eff. 12-18-02.)