907 KAR 4:030. Kentucky Children’s Health Insurance Program Phase III Title XXI of the Social Security Act.


      RELATES TO: KRS Chapter 45A, 205.510-205.645, 42 U.S.C. 1397aa

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.6481-205.6497, 42 U.S.C. 1397aa, 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 Services, Department for Medicaid Services, has responsibility to administer the Kentucky Children’s Health Insurance Program. KRS 205.6485 authorizes the cabinet, by administrative regulations, 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, quality assurance and utilization review, covered services, the approval process, grievance and appeal rights and the requirements for delivery of health services for providers who wish to participate with the Commonwealth to provide health care coverage for KCHIP members through the provision of a separate health insurance program under Title XXI.


      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(6)(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.

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

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


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

      (a) Is a resident of Kentucky meeting the conditions for determining state residency under 42 C.F.R. 435.403;

      (b) Is an alien who meets the requirements established in 907 KAR 1:011(5)(12)(a).

      (c) Is not an inmate of a public institution or a patient in an institution for mental disorders;

      (d) Is not eligible for Medicaid pursuant to 907 KAR 1:011; and

      (e) Is a targeted low-income child as defined in 42 U.S.C. 1397jj(b) who:

      1. Has family income which does not exceed 200 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);

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

      3. Did not have creditable coverage within six (6) months prior to applying for KCHIP, unless the coverage was terminated for other than voluntary reasons or the coverage was Medicaid;

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

      5. Meets the continuing eligibility requirements established in 907 KAR 1:605, Section 3; and

      6. Meets the relative responsibility requirements of 907 KAR 1:660.

      (2) Eligibility for KCHIP shall be determined by the department. Upon receipt of the 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 1397bb.


      Section 3. Covered Services. (1) Health services shall be considered as medically necessary if services are:

      (a) Reasonable and necessary to diagnose and provide preventive, palliative, curative, or restorative treatment for physical or mental conditions;

      (b) In accordance with professionally recognized standards of health care generally accepted at the time services are provided; and

      (c) In accordance with 42 C.F.R. 440.230.

      (2) Covered services shall exclude:

      (a) EPSDT special services as defined in 907 KAR 1:034, Section 7;

      (b) Human service transportation delivery as defined in 603 KAR 7:080; and

      (c) Locally authorized medical transportation as defined in 907 KAR 1:060, Section 4.

      (3) The amount and duration of benefits covered by KCHIP shall be as established in 907 KAR Chapters 1 and 3 excluding the services identified in subsection (2) of this section.

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

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

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


      Section 4. KCHIP Approval Process. 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) The name and address of a health insurance provider who currently provides creditable coverage; or who provided creditable coverage during the six (6) months prior to the date the information in this section is submitted to the department;

      (4) The 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) The 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) The signature, date, and telephone number of the 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 907 KAR 1:320.


      Section 6. Complaint, Grievance and Appeal Rights. (1) If dissatisfied with an action taken by the cabinet, the child, his parent or guardian shall be entitled to a complaint, grievance, or appeal with the cabinet, to be conducted in accordance with 907 KAR 1:560 or 907 KAR 1:563.

      (2) If a service is provided by a managed care organization, a dispute resolution between a provider and a child, his parent or 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) At the time information to obtain KCHIP approval is submitted;

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

      (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. 1879; eff. 6-12-2000.)