CABINET FOR HEALTH AND FAMILY SERVICES
Department for Medicaid Services
Commissioner’s Office
(Amendment)
907 KAR 17:005.
Definitions for 907 KAR Chapter 17[Managed care organization requirements
and policies].
RELATES TO: 194A.025(3), 42 U.S.C. 1396n(c), 42 C.F.R. 438
STATUTORY AUTHORITY: KRS 194A.010(1), 194A.025(3), 194A.030(2), 194A.050(1), 205.520(3), 205.560, 42 U.S.C. 1396n(b), 42 C.F.R. Part 438
NECESSITY, FUNCTION, AND CONFORMITY: 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 a requirement that may be imposed or opportunity presented by federal law to qualify for federal Medicaid funds. 42 U.S.C. 1396n(b) and 42 C.F.R. Part 438 establish requirements relating to managed care. This administrative regulation establishes the definitions for 907 KAR Chapter 17, which apply to the policies and procedures relating to the provision of Medicaid services through contracted managed care organizations pursuant to, and in accordance with, 42 U.S.C. 1396n(b) and 42 C.F.R. Part 438.
Section 1. Definitions. (1) "1915(c) home and community based waiver program" means a Kentucky Medicaid program established pursuant to, and in accordance with, 42 U.S.C. 1396n(c).
(2) "Advanced practice registered nurse" is defined by KRS 314.011(7).
(3) "Adverse action" means:
(a) The denial or limited authorization of a requested service, including the type or level of service;
(b) The reduction, suspension, or termination of a previously authorized service;
(c) The denial, in whole or in part, of payment for a service;
(d) The failure to provide services in a timely manner; or
(e) The failure of a managed care organization to act within the timeframes provided in 42 C.F.R. 438.408(b).
(4) "Aged" means at least sixty-five (65) years of age.
(5) "Appeal" means a request for review of an adverse action or a decision by an MCO related to a covered service.
(6) "Authorized representative" means an individual or entity acting on behalf of, and with written consent from, an enrollee.
(7) "Behavioral health service" means a clinical, rehabilitative, or support service in an inpatient or outpatient setting to treat a mental illness, emotional disability, or substance abuse disorder.
(8)[(7)] "Blind"
is defined by 42 U.S.C. 1382c(a)(2).
(9)[(8)] "Capitation
payment" means the total per enrollee, per month payment amount the
department pays an MCO.
(10)[(9)] "Capitation
rate" means the negotiated amount to be paid on a monthly basis by the
department to an MCO:
(a) Per enrollee; and
(b) Based on the enrollee’s aid category, age, and gender.
(11)[(10)] "Care
coordination" means the integration of all processes in response to an
enrollee’s needs and strengths to ensure the:
(a) Achievement of desired outcomes; and
(b) Effectiveness of services.
(12)[(11)] "Case
management" means a collaborative process that:
(a) Assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an enrollee’s health and human service needs;
(b) Is characterized by advocacy, communication, and resource management;
(c) Promotes quality and cost-effective interventions and outcomes; and
(d) Is in addition to and not in lieu of targeted case management for:
1. Adults with a chronic mental illness pursuant to 907 KAR 1:515; or
2. Children with a severe emotional disability pursuant to 907 KAR 1:525.
(13)[(12)] "CHFS OIG"
means the Cabinet for Health and Family Services, Office of Inspector General.
(14)[(13)] "Child"
means a person who:
(a)1. Is under the age of eighteen (18) years;
2.a. Is a full-time student in a secondary school or the equivalent level of vocational or technical training; and
b. Is expected to complete the program before the age of nineteen (19) years;
3. Is not self supporting;
4. Is not a participant in any of the United States Armed Forces; and
5. If previously emancipated by marriage, has returned to the home of his or her parents or to the home of another relative;
(b) Has not attained the age of nineteen (19) years in accordance with 42 U.S.C. 1396a(l)(1)(D); or
(c) Is under the age of nineteen (19) years if the person is a KCHIP recipient.
(15)[(14)] "Chronic Illness and Disability Payment System" means a
diagnostic classification system that Medicaid programs use to make
health-based, capitated payments for TANF and Medicaid beneficiaries with a disability.
(16)[(15)] "Commission
for Children with Special Health Care Needs" or "CCSHCN" means
the Title V agency which provides specialty medical services for children with
specific diagnoses and health care needs that make them eligible to participate
in programs sponsored by the CCSHCN, including the provision of medical care.
(17)[(16)] "Community
mental health center" means a facility which meets the community mental
health center requirements established in 902 KAR 20:091.
(18)[(17)] "Complex
or chronic condition" means a physical, behavioral, or developmental
condition which:
(a) May have no known cure;
(b) Is progressive; or
(c) Can be debilitating or fatal if left untreated or under-treated.
(19)[(18)] "Consumer
Assessment of Healthcare Providers and Systems" or "CAHPS" means
a program that develops standardized surveys that ask consumers and patients to
report on and evaluate their experiences with health care.
(20)[(19)] "Court-ordered
commitment" means an involuntary commitment by an order of a court to a
psychiatric facility for treatment pursuant to KRS Chapter 202A.
(21)[(20)] "DAIL"
means the Department for Aging and Independent Living.
(22)[(21)] "DCBS"
means the Department for Community Based Services.
(23)[(22)] "Department"
means the Department for Medicaid Services or its designee.
(24)[(23)] "Disabled"
is defined by 42 U.S.C. 1382c(a)(3).
(25)[(24)] "DSM-IV"
means a manual published by the American Psychiatric Association that covers
all mental health disorders for both children and adults.
(26)[(25)] "Dual
eligible" means an individual eligible for Medicare and Medicaid benefits.
(27)[(26)] "Early
and periodic screening, diagnosis and treatment" or "EPSDT" is defined
by 42 C.F.R. 440.40(b).
(28)[(27)] "Emergency
service" means "emergency services" as defined by 42 U.S.C. 1396u-2(b)(2)(B).
(29)[(28)] "Encounter"
means a health care visit of any type by an enrollee to a provider of care,
drugs, items, or services.
(30)[(29)] "Enrollee"
means a recipient who is enrolled with a managed care organization for the
purpose of receiving Medicaid or KCHIP covered services.
(31)[(30)] "External
quality review organization" or "EQRO":
(a) Is defined by 42 C.F.R. 438.320; and
(b) Includes any affiliate or designee of the EQRO.
(32)[(31)] "Family
planning service" means a counseling service, medical service, or
a pharmaceutical supply or device to prevent or delay pregnancy.
(33)[(32)] "Federally
qualified health center" or "FQHC" is defined by 42 C.F.R.
405.2401(b).
(34)[(33)] "Fee-for-service"
means a reimbursement model in which a health insurer reimburses a provider for
each service provided to a recipient.
(35)[(34)] "Foster
care" is defined by KRS 620.020(5).
(36)[(35)] "Fraud"
means any act that constitutes fraud under applicable federal law or KRS
205.8451 to KRS 205.8483.
(37)[(36)] "Grievance"
is defined by 42 C.F.R. 438.400.
(38)[(37)] "Grievance
system" means a system that includes a grievance process, an appeal
process, and access to the Commonwealth of Kentucky’s fair hearing system.
(39)[(38)] "Health
maintenance organization" is defined by KRS 304.38-030(5).
(40)[(39)] "Health
risk assessment" or "HRA" means a health questionnaire used to
provide individuals with an evaluation of their health risks and quality of
life.
(41)[(40)] "Healthcare
Effectiveness Data and Information Set" or "HEDIS" means a tool
used to measure performance regarding important dimensions of health care or
services.
(42)[(41)] "Homeless
individual" means an individual who:
(a) Lacks a fixed, regular, or nighttime residence;
(b) Is at risk of becoming homeless in a rural or urban area because the residence is not safe, decent, sanitary, or secure;
(c) Has a primary nighttime residence at a:
1. Publicly or privately operated shelter designed to provide temporary living accommodations; or
2. Public or private place not designed as regular sleeping accommodations; or
(d) Lacks access to normal accommodations due to violence or the threat of violence from a cohabitant.
(43)[(42)] "Individual
with a special health care need" or "ISHCN" means an individual
who:
(a) Has, or is at a high risk of having, a chronic physical, developmental, behavioral, neurological, or emotional condition; and
(b) May require a broad range of primary, specialized, medical, behavioral health, or related services.
(44)[(43)] "Initial
implementation" means the process of transitioning a current Medicaid or
KCHIP recipient from fee-for-service into managed care.
(45)[(44)] "KCHIP"
means the Kentucky Children’s Health Insurance Program administered in
accordance with 42 U.S.C. 1397aa to jj.
(46)[(45)] "Kentucky
Health Information Exchange" or "KHIE" means the name given to
the system that will support the statewide exchange of health information among
healthcare providers and organizations according to nationally-recognized
standards.
(47)[(46)] "Managed
care organization" or "MCO" means an entity for which the Department
for Medicaid Services has contracted to serve as a managed care organization as
defined in 42 C.F.R. 438.2.
(48)[(47)] "Marketing"
means any activity conducted by or on behalf of an MCO in which information
regarding the services offered by the MCO is disseminated in order to educate
enrollees or potential enrollees about the MCO’s services.
(49)[(48)] "Maternity
care" means prenatal, delivery, and postpartum care and includes care
related to complications from delivery.
(50)[(49)] "Medicaid
works individual" means an individual who:
(a) But for earning in excess of the income limit established under 42 U.S.C. 1396d(q)(2)(B), would be considered to be receiving SSI benefits;
(b) Is at least sixteen (16), but less than sixty-five (65), years of age;
(c) Is engaged in active employment verifiable with:
1. Paycheck stubs;
2. Tax returns;
3. 1099 forms; or
4. Proof of quarterly estimated tax;
(d) Meets the income standards established in 907 KAR 1:640; and
(e) Meets the resource standards established in 907 KAR 1:645.
(51)[(50)] "Medical
record" means a single, complete record that documents all of the
treatment plans developed for, and medical services received by, an individual.
(52)[(51)] "Medically
necessary" means that a covered benefit is determined to be needed in
accordance with 907 KAR 3:130.
(53)[(52)] "Medicare
qualified individual group 1 (QI-1)" means an eligibility category, in which
pursuant to 42 U.S.C. 1396a(a)(10)(E)(iv), an individual who would be a
Qualified Medicaid beneficiary but for the fact that the individual’s income:
(a) Exceeds the income level established in accordance with 42 U.S.C. 1396d(p)(2); and
(b) Is at least 120 percent, but less than 135 percent, of the federal poverty level for a family of the size involved and who are not otherwise eligible for Medicaid under the state plan.
(54)[(53)] "National
Practitioner Data Bank" means an electronic repository that collects:
(a) Information on adverse licensure activities, certain actions restricting clinical privileges, and professional society membership actions taken against physicians, dentists, and other practitioners; and
(b) Data on payments made on behalf of physicians in connection with liability settlements and judgments.
(55)[(54)] "Nonqualified
alien" means a resident of the United States of America who does not meet
the qualified alien requirements established in 907 KAR 1:011, Section 5(12).
(56)[(55)] "Nursing
facility" means:
(a) A facility:
1. To which the state survey agency has granted a nursing facility license;
2. For which the state survey agency has recommended to the department certification as a Medicaid provider; and
3. To which the department has granted certification for Medicaid participation; or
(b) A hospital swing bed that provides services in accordance with 42 U.S.C. 1395tt and 1396l, if the swing bed is certified to the department as meeting requirements for the provision of swing bed services in accordance with 42 U.S.C. 1396r(b), (c), and (d) and 42 C.F.R. 447.280 and 482.66.
(57)[(56)] "Olmstead
decision" means the court decision of Olmstead v. L.C. and E.W., U.S.
Supreme Court, No. 98–536, June 26, 1999 in which the U.S. Supreme Court ruled,
"For the reasons stated, we conclude that, under Title II of the ADA,
States are required to provide community-based treatment for persons with mental
disabilities when the State's treatment professionals determine that such
placement is appropriate, the affected persons do not oppose such treatment,
and the placement can be reasonably accommodated, taking into account the
resources available to the State and the needs of others with mental
disabilities."
(58)[(57)] "Open
enrollment" means an annual period during which an enrollee can choose a
different MCO.
(59)[(58)] "Out-of-network
provider" means a person or entity that has not entered into a
participating provider agreement with an MCO or any of the MCO’s subcontractors.
(60)[(59)] "Physician"
is defined by KRS 311.550(12).
(61)[(60)] "Post-stabilization
services" means covered services related to an emergency medical condition
that are provided to an enrollee:
(a) After an enrollee is stabilized in order to maintain the stabilized condition; or
(b) Under the circumstances described in 42 C.F.R. 438.114(e) to improve or resolve the enrollee’s condition.
(62)[(61)] "Primary
care center" means an entity that meets the primary care center
requirements established in 902 KAR 20:058.
(63)[(62)] "Primary
care provider" or "PCP" means a licensed or certified health
care practitioner who meets the description as established in 907 KAR
17:010, Section 7(6)[of this administrative regulation].
(64)[(63)] "Prior
authorization" means the advance approval by an MCO of a service or item
provided to an enrollee.
(65)[(64)] "Provider"
means any person or entity under contract with an MCO or its contractual agent
that provides covered services to enrollees.
(66)[(65)] "Provider
network" means the group
of physicians, hospitals, and other medical care professionals that a managed
care organization has contracted with to deliver medical services to its enrollees.
(67)[(66)]
"QAPI" means the Quality Assessment and Performance Improvement
Program established in accordance with 907 KAR 17:025, Section 5[Section
48 of this administrative regulation].
(68)[(67)] "Qualified
alien" means an alien who, at the time of
applying for or receiving Medicaid benefits, meets the requirements established
in 907 KAR 1:011, Section 5(12).
(69)[(68)] "Qualified
disabled and working individual" is defined by 42 U.S.C. 1396d(s).
(70)[(69)] "Qualified
Medicare beneficiary" or "QMB" is defined by 42 U.S.C.
1396d(p)(1).
(71)[(70)] "Quality
improvement" or "QI" means the process of assuring that covered
services provided to enrollees are appropriate, timely, accessible, available,
and medically necessary and the level of performance of key processes and
outcomes of the healthcare delivery system is improved through the MCO’s
policies and procedures.
(72)[(71)] "Recipient"
is defined in KRS 205.8451(9).
(73) "Region eight (8)" means the region containing Bell, Breathitt, Clay, Floyd, Harlan, Johnson, Knott, Knox, Laurel, Lee, Leslie, Letcher, Magoffin, Martin, Owsley, Perry, Pike, Whitley, and Wolfe Counties.
(74) "Region five (5)" means the region containing Anderson, Bourbon, Boyle, Clark, Estill, Fayette, Franklin, Garrard, Harrison, Jackson, Jessamine, Lincoln, Madison, Mercer, Montgomery, Nicholas, Owen, Powell, Rockcastle, Scott, and Woodford Counties.
(75) "Region four (4)" means the region containing Adair, Allen, Barren, Butler, Casey, Clinton, Cumberland, Edmonson, Green, Hart, Logan, McCreary, Metcalfe, Monroe, Pulaski, Russell, Simpson, Taylor, Warren, and Wayne Counties.
(76) "Region one (1)" means the region containing Ballard, Caldwell, Calloway, Carlisle, Crittenden, Fulton, Graves, Hickman, Livingston, Lyon, Marshall, and McCracken Counties.
(77) "Region seven (7)" means the region containing Bath, Boyd, Bracken, Carter, Elliott, Fleming, Greenup, Lawrence, Lewis, Mason, Menifee, Morgan, Robertson, and Rowan Counties.
(78) "Region six (6)" means the region containing Boone, Campbell, Gallatin, Grant, Kenton, and Pendleton Counties.
(79) "Region three (3)" means the region containing Breckenridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble, and Washington Counties.
(80) "Region two (2)" means the region containing Christian, Daviess, Hancock, Henderson, Hopkins, McLean, Muhlenberg, Ohio, Todd, Trigg, Union, and Webster Counties.
(81)[(72)] "Risk
adjustment" means a corrective tool to reduce both the negative financial
consequences for a managed care organization that enrolls high-risk users and
the positive financial consequences for a managed care organization that
enrolls low-risk users.
(82)[(73)] "Rural
area" means an area not in an urban area.
(83)[(74)] "Rural
health clinic" is defined by 42 C.F.R. 405.2401(b).
(84)[(75)] "Specialist"
means a provider who provides specialty care.
(85)[(76)] "Specialty
care" means care or a service that is provided by a provider who is not:
(a) A primary care provider; or
(b) Acting in the capacity of a primary care provider while providing the service.
(86)[(77)] "Specified
low-income Medicare beneficiary" means an individual who meets the
requirements established in 42 U.S.C. 1396a(a)(10)(E)(iii).
(87)[(78)] "State
fair hearing" means an administrative hearing provided by the Cabinet for
Health and Family Services pursuant to KRS Chapter 13B and 907 KAR 1:563.
(88)[(79)] "State
plan" is defined by 42 C.F.R. 400.203.
(89)[(80)] "State
survey agency" means the Cabinet for Health and Family Services, Office of
Inspector General, Division of Health Care Facilities and Services.
(90)[(81)] "State-funded
adoption assistance" is defined by KRS 199.555(2).
(91)[(82)] "Subcontract"
means an agreement entered into, directly or indirectly, by an MCO to arrange
for the provision of covered services, or any administrative, support or other
health service, but does not include an agreement with a provider.
(92)[(83)] "Supplemental
security income benefits" or "SSI benefits" is defined by 20 C.F.R.
416.2101.
(93)[(84)] "Teaching
hospital" means a hospital which has a teaching program approved as
specified in 42 U.S.C. 1395x(b)(6).
(94)[(85)] "Temporary
Assistance for Needy Families" or "TANF" means a block grant program
which is designed to:
(a) Assist needy families so that children can be cared for in their own homes;
(b) Reduce the dependency of needy parents by promoting job preparation, work, and marriage;
(c) Prevent out-of-wedlock pregnancies; and
(d) Encourage the formation and maintenance of two-parent families.
(95)[(86)] "Third
party liability resource" means a resource available to an enrollee for
the payment of expenses:
(a) Associated with the provision of covered services; and
(b) That does not include amounts exempt under Title XIX of the Social Security Act, 42 U.S.C. 1396 to 1396v.
(96)[(87)] "Transport
time" means travel time:
(a) Under normal driving conditions; and
(b) With no extenuating circumstances.
(97)[(88)] "Urban
area" is defined by 42 C.F.R. 412.62(f)(1)(ii).
(98)[(89)] "Urgent
care" means care for a condition not likely to cause death or lasting harm
but for which treatment should not wait for a normally scheduled appointment.
(99)[(90)] "Ward"
is defined in KRS 387.510(15).
(100)[(91)] "Women,
Infants and Children program" means a federally-funded health and
nutrition program for women, infants, and children.[Section 2. Enrollment of
Medicaid or KCHIP Recipients into Managed Care. (1) Except as provided in
subsection (3) of this section, enrollment into a managed care organization
shall be mandatory for a Medicaid or KCHIP recipient.
(2) The provisions in this
administrative regulation shall be applicable to a:
(a) Medicaid recipient; or
(b) KCHIP recipient.
(3) The following recipients shall
not be required to enroll, and shall not enroll, into a managed care
organization:
(a) A recipient who resides in:
1. A nursing facility for more than
thirty (30) days; or
2. An intermediate care facility for
individuals with mental retardation or a developmental disability; or
(b) A recipient who is:
1. Determined to be eligible for
Medicaid benefits due to a nursing facility admission;
2. Enrolled in another managed care
program in accordance with 907 KAR 1:705;
3. Receiving:
a. Services through the breast and
cervical cancer program pursuant to 907 KAR 1:805;
b. Medicaid benefits in accordance
with the spend-down policies established in 907 KAR 1:640;
c. Services through a 1915(c) home
and community based services waiver program;
d. Hospice services in a nursing
facility or intermediate care facility for individuals with mental retardation
or a developmental disability; or
e. Medicaid benefits as a Medicaid
Works individual;
4. A Qualified Medicare beneficiary
who is not otherwise eligible for Medicaid benefits;
5. A specified low-income Medicare
beneficiary who is not otherwise eligible for Medicaid benefits;
6. A Medicare qualified individual
group 1 (QI-1) individual;
7. A qualified disabled and working
individual;
8. A qualified alien eligible for
Medicaid benefits for a limited period of time; or
9. A nonqualified alien eligible for
Medicaid benefits for a limited period of time.
(4)(a) Except for a child in foster
care, a recipient who is eligible for enrollment into managed care shall be
enrolled with an MCO that provides services to an enrollee whose primary
residence is within the MCO’s service area.
(b) A child in foster care shall be
enrolled with an MCO in the county where the child’s DCBS case is located.
(5)(a) During the department’s
initial implementation of managed care in accordance with this administrative
regulation, the department shall assign a recipient to an MCO based upon an algorithm
that considers:
1. Continuity of care;
2. Enrollee preference of MCO or of
an MCO provider; and
3. Cost.
(b) An assignment shall focus on a
need of a child or an individual with a special health care need.
(6)(a) A newly eligible recipient or
a recipient who has had a break in eligibility of greater than two (2) months
shall have an opportunity to choose an MCO during the eligibility application
process.
(b) If a recipient does not choose
an MCO during the eligibility application process, the department shall assign
the recipient to an MCO.
(7) Each member of a household shall
be assigned to the same MCO.
(8) The effective date of enrollment
for a recipient described in subsection (6)of this section shall be:
(a) The date of Medicaid
eligibility; and
(b) No earlier than November 1,
2011.
(9) A recipient shall be given a
choice of MCOs.
(10) A recipient enrolled with an
MCO who loses Medicaid eligibility for less than two (2) months shall be
automatically reenrolled with the same MCO upon redetermination of Medicaid
eligibility unless the recipient moves to a county in region three (3) as established
in Section 28 of this administrative regulation.
(11) A newborn who has been deemed
eligible for Medicaid shall be automatically enrolled with the newborn’s
mother’s MCO as an individual enrollee for up to sixty (60) days.
(12)(a) An enrollee may change an
MCO for any reason, regardless of whether the MCO was selected by the enrollee
or assigned by the department:
1. Within ninety (90) days of the
effective date of enrollment;
2.a. Annually during an open
enrollment period that shall be at the time of an enrollee’s recertification
for Medicaid eligibility; or
b. Annually during the month of
birth for an enrollee who receives SSI benefits;
3. Upon automatic enrollment under
subsection (10)of this section, if a temporary loss of Medicaid eligibility
caused the recipient to miss the annual opportunity in subparagraph 2. of this
paragraph; or
4. When the Commonwealth of Kentucky
imposes an intermediate sanction specified in 42 C.F.R. 438.702(a)(3).
(b) An MCO shall accept an enrollee
who changes MCOs under this section.
(13) Only the department shall have
the authority to enroll a Medicaid recipient with an MCO in accordance with
this section.
(14) Upon enrollment with an MCO, an
enrollee shall receive two (2) identification cards.
(a) A card shall be issued from the
department that shall verify Medicaid eligibility.
(b) A card shall be issued by the
MCO that shall verify enrollment with the MCO.
(15)(a) Within five (5) business
days after receipt of notification of a new enrollee, an MCO shall send, by a
method that shall not take more than three (3) days to reach the enrollee, a confirmation
letter to an enrollee.
(b) The confirmation letter shall
include at least the following information:
1. The effective date of enrollment;
2. The name, location and contact
information of the PCP;
3. How to obtain a referral;
4. Care coordination;
5. The benefits of preventive health
care;
6. The enrollee identification card;
7. A member handbook; and
8. A list of covered services.
(16) Enrollment with an MCO shall be
without restriction.
(17) An MCO shall:
(a) Have continuous open enrollment
for new enrollees; and
(b) Accept enrollees regardless of
overall enrollment.
(18)(a) Except as provided in
paragraph (b) of this subsection, a recipient eligible to enroll with an MCO
shall be enrolled beginning with the first day of the month that the enrollee applied
for Medicaid.
(b)1. A newborn shall be enrolled
beginning with the newborn’s date of birth.
2. An unemployed parent shall be
enrolled beginning with the date the unemployed parent met the definition of
unemployment in accordance with 45 C.F.R. 233.100.
3. If an enrollee is retro-actively
determined eligible for Medicaid, the retro-active eligibility shall be for a
period up to three (3) months prior to the month that the enrollee applied for
Medicaid.
a. The department shall be
responsible for reimbursing for services provided to an individual determined
to be retroactively eligible for any portion of the retroactive eligibility
period which occurred prior to November 1, 2011, if the individual has a
retroactive eligibility period prior to November 1, 2011.
b. A retroactive eligible
individual’s MCO shall be responsible for reimbursing for services provided to
an individual determined to be retroactively eligible for any portion of the
retroactive eligibility period which occurred beginning on or after November 1,
2011.
(19) For an enrollee whose
eligibility resulted from a successful appeal of a denial of eligibility, the
enrollment period shall begin:
(a)1. On the first day of the month
of the original application for eligibility; or
2. On the first day of the month of
retroactive eligibility as referenced in subsection (18)(b)3. of this section,
if applicable; and
(b) No earlier than November 1,
2011.
(20) A provider shall be responsible
for verifying an individual’s eligibility for Medicaid and enrollment in a
managed care organization when providing a service.
Section 3. Disenrollment. (1) The
policies established in 42 C.F.R. 438.56 shall apply to an MCO.
(2) Only the department shall have
the authority to disenroll a recipient from an MCO.
(3) A disenrollment of a recipient
from an MCO shall:
(a) Become effective on the first
day of the month following disenrollment; and
(b) Occur:
1. If the enrollee:
a. No longer resides in an area
served by the MCO;
b. Becomes incarcerated or deceased;
or
c. Is exempt from managed care enrollment
in accordance with Section 2(3) of this administrative regulation; or
2. In accordance with 42 C.F.R.
438.56.
(4) An MCO may recommend to the department
that an enrollee be disenrolled if the enrollee:
(a) Is found guilty of fraud in a
court of law or administratively determined to have committed fraud related to
the Medicaid Program;
(b) Is abusive or threatening but
not for uncooperative or disruptive behavior resulting from his or her special
needs (except if his or her continued enrollment in the MCO seriously impairs
the entity’s ability to furnish services to either this particular enrollee or
other enrollees) pursuant to 42 C.F.R. 438.56(b)(2);
(c) Becomes deceased; or
(d) No longer resides in an area
served by the MCO.
(5) An enrollee shall not be
disenrolled by the department, nor shall the managed care organization
recommend disenrollment of an enrollee, due to an adverse change in the enrollee’s
health.
(6)(a) An approved disenrollment
shall be effective no later than the first day of the second month following
the month the enrollee or the MCO files a request in accordance with 42 C.F.R.
438.56(e)(1).
(b) If the department fails to make
a determination within the timeframe specified in paragraph (a) of this subsection,
the disenrollment shall be considered approved in accordance with 42 C.F.R.
438.56(e)(2).
(7) If an enrollee is disenrolled
from an MCO, the:
(a) Enrollee shall be enrolled with
a new MCO if the enrollee is:
1. Eligible for Medicaid; and
2. Not excluded from managed care
participation; and
(b) MCO shall:
1. Assist in the selection of a new
primary care provider, if requested;
2. Cooperate with the new primary
care provider in transitioning the enrollee’s care; and
3. Make the enrollee’s medical
record available to the new primary care provider, in accordance with state and
federal law.
(8) An MCO shall notify the
department or Social Security Administration in an enrollee’s county of
residence within five (5) working days of receiving notice of the death of an
enrollee.
Section 4. Enrollee Rights and
Responsibilities. (1) An MCO shall have written policies and procedures:
(a) To protect the rights of an
enrollee that includes the:
1. Protection against liability for
payment in accordance with 42 U.S.C. 1396u-2(b)(6);
2. Rights specified in 42 C.F.R.
438.100;
3. Right to prepare an advance
medical directive pursuant to KRS 311.621 through KRS 311.643;
4. Right to choose and change a
primary care provider;
5. Right to file a grievance or
appeal;
6. Right to receive assistance in
filing a grievance or appeal;
7. Right to a state fair hearing;
8. Right to a timely referral and
access to medically indicated specialty care; and
9. Right to access the enrollee’s
medical records in accordance with federal and state law; and
(b) Regarding the responsibilities
of enrollees that include the responsibility to:
1. Become informed about:
a. Enrollee rights specified in
paragraph (a) of this subsection; and
b. Service and treatment options;
2. Abide by the MCO’s and
department’s policies and procedures;
3. Actively participate in personal
health and care decisions;
4. Report suspected fraud or abuse;
and
5. Keep appointments or call to
cancel if unavailable to keep an appointment.
(2) The information specified in
subsection (1) of this section shall meet the information requirements
established in 42 C.F.R. 438.10.
Section 5. Enrollee Grievance System.
(1) An MCO shall have an
internal grievance system in place that allows an enrollee or a provider on
behalf of an enrollee to challenge a denial of coverage of, or payment for, a
service in accordance with 42 C.F.R. 438.400 through 438.424 and 42 U.S.C. 1396u-2(b)(4).
(2) An enrollee shall have a right
to a state fair hearing in accordance with KRS Chapter 13B without exhausting
an MCO’s internal appeal process.
(3) An MCO shall have written
policies and procedures describing how an enrollee shall submit a request for
a:
(a) Grievance or an appeal with the
MCO; or
(b) State fair hearing in accordance
with KRS Chapter 13B.
(4) A legal guardian of an enrollee
who is a minor or an incapacitated adult, a representative of an enrollee as
designated in writing to an MCO, or a provider acting on behalf of an enrollee
and with the enrollee’s written consent shall have the right to file a
grievance on behalf of the enrollee.
(5) An enrollee shall have thirty
(30) calendar days from the date of an event causing dissatisfaction to file a
grievance orally or in writing with the MCO.
(6) Within five (5)
working days of receipt of a grievance, an MCO shall provide the enrollee with
written notice that the grievance has been received and the expected date of
its resolution.
(7) An investigation and final
resolution of a grievance shall:
(a) Be completed within thirty (30)
calendar days of the date the grievance is received by the MCO; and
(b) Include a resolution letter to
the enrollee that shall include:
1. All information considered in
investigating the grievance;
2. Findings and conclusions based on
the investigation; and
3. The disposition of the grievance.
(8) An enrollee shall have thirty
(30) calendar days from the date of receiving a notice of adverse action from
an MCO to file an appeal either orally or in writing with the MCO.
(9) A legal guardian of an enrollee
who is a minor or an incapacitated adult, a representative of the enrollee as
designated in writing to an MCO, or a provider acting on behalf of an enrollee
with the enrollee’s written consent shall have the right to file an appeal of
an adverse action on behalf of the enrollee.
(11) An MCO shall have a process in
place that ensures that an oral or written inquiry from an enrollee seeking to
appeal an adverse action is treated as an appeal to establish the earliest
possible filing date for the appeal.
(12) An oral appeal shall be
followed by a written appeal that is signed by the enrollee within ten (10)
calendar days.
(13) Within five (5) working days of
receipt of an appeal, an MCO shall provide the enrollee with written notice
that the appeal has been received and the expected date of its resolution,
unless an expedited resolution has been requested.
(14) An MCO shall extend the thirty
(30) day timeframe for resolution of an appeal established in subsection (10)
of this section by fourteen (14) calendar days if:
(a) The enrollee requests the
extension; or
(b)1. The MCO demonstrates to the
department that there is need for additional information; and
2. The extension is in the
enrollee’s interest.
(15) For an extension requested by
an MCO, the MCO shall give the enrollee written notice of the extension and the
reason for the extension within two (2) working days of the decision to extend.
(16) For an appeal, an MCO shall
provide written notice of its decision within thirty (30) calendar days to an enrollee
or a provider, if the provider filed the appeal. The provider shall:
(a) Give a copy of the notice to the
enrollee; or
(b) Inform the enrollee of the
provisions of the notice.
(17) An MCO shall:
(a) Continue to provide benefits to
an enrollee, if the enrollee requested a continuation of benefits, until one of
the following occurs:
1. The enrollee withdraws the
appeal;
2. Fourteen (14) days have passed
since the date of the resolution letter, if the resolution of the appeal was
against the enrollee and the enrollee has not requested a state fair hearing or
taken any further action; or
3. A state fair hearing decision
adverse to the enrollee has been issued;
(b) Have an expedited review process
for appeals if the MCO determines that allowing the time for a standard
resolution could seriously jeopardize an enrollee’s life or health or ability
to attain, maintain, or regain maximum function;
(c) Resolve an expedited appeal
within three (3) working days of receipt of the request; and
(d) Extend the timeframe for an
expedited appeal established in paragraph (c) of this subsection by up to
fourteen (14) calendar days if:
1. The enrollee requests the
extension; or
2.a. The MCO demonstrates to the
department that there is need for additional information; and
b. The extension is in the
enrollee’s interest.
(18) For an extension requested by
an MCO, the MCO shall give the enrollee written notice of the reason for the
extension.
(19) If an MCO denies a request for
an expedited resolution of an appeal, it shall:
(a) Transfer the appeal to the
thirty (30) day timeframe for a standard resolution, in which the thirty (30)
day period shall begin on the date the MCO received the original request for appeal;
(b) Give prompt oral notice of the
denial; and
(c) Follow up with a written notice
within two (2) calendar days of the denial.
(20) An MCO shall document in
writing an oral request for an expedited resolution and shall maintain the
documentation in the enrollee case file.
(21) The department shall provide an
enrollee with a hearing process that shall adhere to 907 KAR 1:563, 42 C.F.R.
438 Subpart F and 42 C.F.R. 431 Subpart E.
(22) An enrollee shall be
able to request a state fair hearing if dissatisfied with an adverse action
that has been taken by an MCO:
(a) Within thirty (30) days of
receiving notice of an adverse action; or
(b) Within thirty (30) days of the
final decision of an MCO to an appeal filed by the enrollee.
(23) A document supporting an MCO’s
adverse action shall be:
(a) Received by the department no
later than five (5) days from the date the MCO
receives a notice from the department that a
request for a state fair hearing has been filed by an enrollee; and
(b) Made available to an enrollee
upon request by either the enrollee or the enrollee’s legal counsel.
(24) An automatic ruling shall be
made by the department in favor of an enrollee if an MCO fails to:
(a) Comply with the state fair
hearing requirements established by the state and federal Medicaid law; or
(b) Appear in person and present
evidence at the state fair hearing.
(25) An MCO shall:
(a) Provide information specified in
42 C.F.R. 438.10(g)(1) about the grievance system to a service provider and a
subcontractor at the time they enter into a contract;
(b) Maintain a grievance or an
appeal file in a secure and designated area;
(c) Make a grievance or an appeal
file accessible to the department or its designee upon request;
(d) Retain a grievance or an appeal
file for ten (10) years following a final decision by the MCO, the department,
an administrative law judge, judicial appeal, or closure of a file, whichever
occurs later;
(e) Have procedures for assuring
that a grievance or an appeal file contains:
1. Information to identify the
grievance or appeal;
2. The date a grievance or appeal
was received;
3. The nature of the grievance or
appeal;
4. A notice to the enrollee of
receipt of the grievance or appeal;
5. Correspondence between the MCO
and the enrollee;
6. The date the grievance or appeal is resolved;
7. The decision made by the MCO of
the grievance or appeal;
8. The notice of a final decision to
the enrollee; and
9. Information pertaining to the
grievance or appeal; and
(f) Make available to an enrollee documentation
regarding a grievance or an appeal.
(26) An MCO shall designate
an individual to:
(a) Execute the policies and
procedures for resolution of a grievance or appeal;
(b) Review patterns or trends in
grievances or appeals; and
(c) Initiate a corrective action, if
needed.
Section 6. Member Services. (1) An MCO shall
have a member services function that includes a member call center and a behavioral
health call center that shall:
(a) Be staffed Monday through Friday
from 7:00 a.m. to 7:00 p.m. Eastern Time; and
(b) Meet the call center standards,
which shall:
1. Be approved by the American
Accreditation Health Care Commission or Utilization Review Accreditation
Committee (URAC); and
2. Include provisions addressing the
call center abandonment rate, blockage rate and average speed of answer.
(2)(a) An MCO shall provide access
to medical advice to an enrollee through a toll-free call-in system, available
twenty-four (24) hours a day, seven (7) days a week.
(b) The call-in system shall be
staffed by medical professionals to include:
1. Physicians;
2. Physician assistants;
3. Licensed practical nurses; or
4. Registered nurses.
(3) An MCO shall:
(a) Provide foreign language
interpreter services, free of charge, for an enrollee;
(b) Respond to the special
communication needs of the disabled, blind, deaf, or aged;
(c) Facilitate direct access to a
specialty physician for an enrollee:
1. With a chronic or complex health
condition;
2. Who is aged, blind, deaf, or
disabled; or
3. Identified as having a special
healthcare need and requiring a course of treatment or regular healthcare
monitoring;
(d) Arrange for and assist with
scheduling an EPSDT service in conformance with federal law governing EPSDT;
(e) Provide an enrollee with
information or refer the enrollee to a support service;
(f) Facilitate direct access to a
covered service in accordance with Section 29(4) of this administrative
regulation.
(g) Facilitate access to a:
1. Behavioral health service;
2. Pharmaceutical service; or
3. Service provided by a public
health department, community mental health center, rural health clinic,
federally qualified health center, the Commission for Children with Special
Health Care Needs, or a charitable care provider;
(h) Assist an enrollee in:
1. Scheduling an appointment with a
provider;
2. Obtaining transportation for an
emergency or non-emergency service;
3. Completing a health risk
assessment; or
4. Accessing an MCO health education
program;
(i) Process, record, and track an
enrollee grievance and appeal; or
(j) Refer an enrollee to case
management or disease management.
Section 7. Enrollee Selection of
Primary Care Provider. (1) Except for an enrollee described in subsection (2)
of this section, an MCO shall have a process for enrollee selection and
assignment of a primary care provider.
(2) The following shall not be
required to have a primary care provider:
(a) A dual eligible;
(b) A child in foster care;
(c) A child under the age of
eighteen (18) years who is disabled; or
(d) A pregnant woman who is
presumptively eligible pursuant to 907 KAR 1:810.
(3)(a) For an enrollee who is not
receiving supplemental security income benefits:
1. An MCO shall notify the enrollee
within ten (10) days of notification of enrollment by the department of the
procedure for choosing a primary care provider; and
2. If the enrollee does not choose a
primary care provider, an MCO shall assign to the enrollee a primary care
provider who:
a. Has historically provided
services to the enrollee; and
b. Meets the requirements of
subsection (6) of this section.
(b) If no primary care provider
meets the requirements of paragraph (a)2 of this subsection, an MCO shall
assign the enrollee to a primary care provider who is within:
1. Thirty (30) miles or thirty (30)
minutes from the enrollee’s residence or place of employment if the enrollee is
in an urban area; or
2. Forty-five (45) miles or
forty-five (45) minutes from the enrollee’s residence or place of employment if
the enrollee is in a rural area.
(4)(a) For an enrollee who is
receiving supplemental security income benefits and
is not a dual eligible, an MCO shall notify
the enrollee of the procedure for choosing a primary care provider.
(b) If an enrollee has not chosen a
primary care provider within thirty (30) days, an MCO shall send a second
notice to the enrollee.
(c) If an enrollee has not chosen a
primary care provider within thirty (30) days of the second notice, the MCO
shall send a third notice to the enrollee.
(d) If an enrollee has not chosen a
primary care provider after the third notice, the MCO shall assign a primary
care provider.
(e) Except for an enrollee who was
previously enrolled with the MCO, an MCO shall not automatically assign a
primary care provider within ninety (90) days of the enrollee’s initial enrollment.
(5)(a) An enrollee shall be allowed
to select from at least two (2) primary care providers within an MCO’s provider
network.
(b) At least one (1) of the two (2) primary
care providers referenced in paragraph (a) of this subsection shall be a
physician.
(6) A primary care provider shall:
(a) Be a licensed or certified
health care practitioner who functions within the provider’s scope of licensure
or certification, including:
1. A physician;
2. An advanced practice registered
nurse;
3. A physician assistant; or
4. A clinic, including a primary
care center, federally qualified health center, or rural health clinic;
(b) Have admitting privileges at a
hospital or a formal referral agreement with a provider possessing admitting
privileges;
(c) Agree to provide twenty-four
(24) hours a day, seven (7) days a week primary health care services to
enrollees; and
(d) For an enrollee who has a
gynecological or obstetrical health care need, a disability, or chronic
illness, be a specialist who agrees to provide or arrange for primary and
preventive care directly or through linkage with a primary care provider.
(7) Upon enrollment in an MCO, an
enrollee shall have the right to change primary care providers:
(a) Within the first ninety (90)
days of assignment;
(b) Once a year regardless of
reason;
(c) At any time for a reason
approved by the MCO;
(d) If during a temporary loss of
eligibility, an enrollee loses the opportunity provided by paragraph (b) of
this subsection;
(e) If Medicare or Medicaid imposes
a sanction on the PCP;
(f) If the PCP is no longer in the
MCO provider network; or
(g) At any time with cause which
shall include the enrollee:
1. Receiving poor quality of care;
2. Lacking access to providers
qualified to treat the enrollee’s medical condition; or
3. Being denied access to needed
medical services.
(8) A PCP shall not be able to
request the reassignment of an enrollee to a different PCP for the following
reasons:
(a) A change in the enrollee’s
health status or treatment needs;
(b) An enrollee’s utilization of
health services;
(c) An enrollee’s diminished mental
capacity; or
(d) Disruptive behavior of an
enrollee due to the enrollee’s special health care needs unless the behavior
impairs the PCP’s ability to provide services to the enrollee or others.
(9) A PCP change request shall not
be based on race, color, national origin, disability, age, or gender.
(10) An MCO shall have the authority
to approve or deny a primary care provider change.
(11) An enrollee shall be able to
obtain the following services outside of an MCO’s provider network:
(a) A family planning service in
accordance with 42 C.F.R. 431.51;
(b) An emergency service in
accordance with 42 C.F.R. 438.114;
(c) A poststabilization service in
accordance with 42 C.F.R. 438.114 and 42 C.F.R. 422.113(c); or
(d) An out-of-network service that
an MCO is unable to provide within its network to meet the medical need of the
enrollee in accordance with 42 C.F.R. 438.206(b)(4).
(12) An MCO shall:
(a) Notify an enrollee within:
1. Thirty (30) days of the effective
date of a voluntary termination of the enrollee’s primary care provider; or
2. Fifteen (15) days of an
involuntary termination of the enrollee’s primary care provider; and
(b) Assist the enrollee in selecting
a new primary care provider.
Section 8. Primary Care Provider
Responsibilities. (1) A PCP shall:
(a) Maintain:
1. Continuity of an enrollee’s
health care;
2. A current medical record for an
enrollee in accordance with Section 24 of this administrative regulation; and
3. Formalized relationships with
other PCPs to refer enrollees for after hours care, during certain days, for
certain services, or other reasons to extend their practice;
(c)
Discuss advance medical directives with an enrollee;
(d) Provide primary and preventive
care, including EPSDT services;
(e)
Refer an enrollee for a behavioral health service if clinically indicated; and
(f) Have an after-hours phone
arrangement that ensures that a PCP or a designated
medical practitioner returns the call within thirty (30) minutes.
(2) An MCO shall monitor a PCP to
ensure compliance with the requirements established in this section.
Section 9. Member Handbook. (1) An
MCO shall:
(a) Send a member handbook to an
enrollee, by a method that shall not take more than three (3) days to reach the
enrollee, within five (5) business days of enrollment;
(b) Review the member handbook at
least annually;
(c) Communicate a change to the
member handbook to an enrollee in writing; and
(d) Add a revision date to the
member handbook after revising the member handbook.
(2) A member handbook shall:
(a) Be available:
1. In hardcopy in English, Spanish,
and any other language spoken by at least five (5) percent of the potential
enrollee or enrollee population; and
2. On the MCO’s Web site;
(b) Be written at no higher than a
sixth grade reading comprehension level; and
(c) Include at a minimum the
following information:
1. The MCO’s network of primary care
providers, including the names, telephone numbers, and service site addresses
of available primary care providers, and, if desired by the MCO, the names and contact
information for other providers included in the MCO’s network;
2. The procedures for:
a. Selecting a PCP and scheduling an
initial health appointment;
b. Obtaining:
(i) Emergency or non-emergency care
after hours;
(ii) Transportation for emergency or
non-emergency care;
(iii) An EPSDT service;
(iv) A covered service from an
out-of-network provider; or
(v) A long term care service;
c. Notifying DCBS of a change in
family size or address, a birth, or a death of an enrollee;
d.(i) Selecting or requesting to
change a PCP;
(ii) A reason a request for a change
may be denied by the MCO;
(iii) A reason a provider may
request to transfer an enrollee to a different PCP; and
e. Filing a grievance or appeal,
including the title, address and telephone number of the person responsible for
processing and resolving a grievance or appeal;
3. The name of the MCO, address, and
telephone number from which it conducts its business;
4. The MCO’s:
a. Business hours; and
b. Member service and toll-free
medical call-in telephone numbers;
5. Covered services, an explanation
of any service limitation or exclusion from coverage, and a notice stating that
the MCO shall be liable only for those services authorized by the MCO, except
for the services excluded in Section 7(11) of this administrative regulation;
6. Member rights and
responsibilities;
7. For a life-threatening situation,
instructions to use the emergency medical services available or to activate
emergency medical services by dialing 911;
8. Information on:
a. The availability of maternity and
family planning services, and for the prevention and treatment of sexually
transmitted diseases;
b. Accessing the services referenced
in clause a. of this paragraph;
c. Accessing care before a primary
care provider is assigned or chosen;
d. The Cabinet for Health and Family
Services’ independent ombudsman program; and
e. The availability of, and
procedures for, obtaining:
(i) A behavioral health or substance
abuse service;
(ii) A health education service; and
(iii) Care coordination, case
management, and disease management services;
9. Direct access services that may
be accessed without a referral; and
10. An enrollee’s right to obtain a
second opinion and information on obtaining a second opinion; and
(c) Meet the information
requirements established in Section 12 of this administrative regulation.
(3) Changes to the member handbook
shall be approved by the department prior to the publication of the handbook.
Section 10. Member Education and Outreach.
(1) An MCO shall:
(a) Have an enrollee and community
education and outreach program throughout the MCO’s service area;
(b) Submit an annual outreach plan
to the department for approval;
(c) Assess the homeless
population within its service area by implementing and maintaining an outreach
plan for homeless individuals, including victims of domestic violence; and
(d) Not differentiate between a
service provided to an enrollee who is homeless and an enrollee who is not
homeless.
(2) An MCO’s outreach plan shall
include:
(a) Utilizing existing community
resources including shelters and clinics; and
(b) Face-to-face encounters.
Section 11. Enrollee Non-Liability
for Payment. (1) Except as specified in Section 58 of this administrative
regulation, an enrollee shall not be required to pay for a medically necessary
covered service provided by the enrollee’s MCO.
(2) An MCO shall not impose cost
sharing on an enrollee greater than the limits established by the department in
907 KAR 1:604.
(3) If an enrollee agrees, in
advance and in writing, to pay for a non-Medicaid covered service, the provider
of the service shall be authorized to bill the enrollee for the service.
Section 12. Provision of Information
Requirements. (1) An MCO shall:
(a) Comply with the requirements
established in 42 U.S.C. 1396u-2(a)(5) and 42 C.F.R. 438.10; and
(b) Provide translation services to
an enrollee on site or via telephone.
(2) Written material provided by an
MCO to an enrollee or potential enrollee shall:
(a) Be written at a sixth grade
reading comprehension level;
(b) Be published in at least a
twelve (12) point font;
(c) Comply with the requirements
established in 42 U.S.C. Chapter 126, the Americans with Disabilities Act;
(d) Be updated as necessary to
maintain accuracy;
(e) Be available in Braille or in an
audio format for an individual who is partially blind or blind; and
(f) Be provided and printed in each
language spoken by five (5) percent or more of the enrollees in each county.
(3) All written material intended
for an enrollee, unless unique to an individual enrollee or exempted by the
department, shall be submitted to the department for review and approval prior
to publication or distribution to the enrollee.
Section 13. Provider Services. (1)
An MCO shall have a provider services function responsible for:
(a) Enrolling, credentialing,
recredentialing, and evaluating a provider;
(b) Assisting a provider with an
inquiry regarding enrollee status, prior authorization, referral, claim
submission, or payment;
(c) Informing a provider of the
provider’s rights and responsibilities;
(d) Handling, recording, and
tracking a provider grievance and appeal;
(e) Developing, distributing, and
maintaining a provider manual;
(f) Provider orientation and
training, including:
1. Medicaid covered services;
2. EPSDT coverage;
3. Medicaid policies and procedures;
4. MCO policies and procedures; and
5. Fraud, waste, and abuse;
(g) Assisting in coordinating care
for a child or adult with a complex or chronic condition;
(h) Assisting a provider with
enrolling in the Vaccines for Children Program in accordance with 907 KAR
1:680; and
(i) Providing technical support to a
provider regarding the provision of a service.
(2) An MCO’s provider services staff
shall:
(a) Be available at a minimum Monday
through Friday from 8:00 a.m. to 6:00 p.m. Eastern Time; and
(b) Operate a provider call center.
Section 14. Provider Network. (1) An
MCO shall:
(a) Enroll providers of sufficient
types, numbers, and specialties in its network to satisfy the:
1. Access and capacity requirements
established in Section 15 of this administrative regulation; and
2. Quality requirements established
in Section 48 of this administrative regulation;
(b) Attempt to enroll the following
providers in its network:
1. A teaching hospital;
2. A rural health clinic;
3. The Kentucky Commission for
Children with Special Health Care Needs;
4. A local health department; and
5. A community mental health center;
(c) Demonstrate to the department
the extent to which it has enrolled providers in its network who have
traditionally provided services to Medicaid recipients;
(d) Have at least one
(1) FQHC in a region where the MCO operates in accordance with Section 28 of
this administrative regulation, if there is an FQHC that is licensed to provide
services in the region; and
(e) Exclude, terminate, or suspend
from its network a provider or subcontractor who engages in an activity that
results in suspension, termination, or exclusion from the Medicare or a Medicaid
program.
(2) The length of an exclusion,
termination, or suspension referenced in subsection (1)(e) of this section
shall equal the length of the exclusion, termination, or suspension imposed by
the Medicare or a Medicaid program.
(3) If an MCO is unable to enroll a
provider specified in subsection (1)(b) or (c) of this section, the MCO shall
submit to the department for approval, documentation which supports the MCO’s
conclusion that adequate services and service sites as required in Section 15 of
this administrative regulation shall be provided without enrolling the specified
provider.
(4) If an MCO determines that its
provider network is inadequate to comply with the access standards established
in Section 15 of this administrative regulation, the MCO shall:
(a) Notify the department; and
(b) Submit a corrective action plan
to the department.
(5) A corrective action plan
referenced in subsection (4)(b) of this section shall:
(a) Describe the deficiency in
detail; and
(b) Identify a specific action to be
taken by the MCO to correct the deficiency, including a time frame.
Section 15. Provider
Access Requirements. (1) The access standards requirements established in 42 C.F.R.
438.206 through 438.210 shall apply to an MCO.
(2) An MCO shall make available and
accessible to an enrollee:
(a) Facilities, service locations,
and personnel sufficient to provide covered services consistent with the
requirements specified in this section;
(b) Emergency medical services
twenty-four (24) hours a day, seven (7) days a week; and
(c) Urgent care services within 48
hours of request.
(3)(a) An MCO’s primary care
provider delivery site shall be no more than:
1. Thirty (30) miles or thirty (30)
minutes from an enrollee’s residence or place of employment in an urban area;
or
2. Forty-five (45) miles or
forty-five (45) minutes from an enrollee’s residence or place of employment in
a non-urban area.
(b) An MCO’s primary care provider
shall not have an enrollee to primary care provider ratio greater than 1,500:1.
(c) An appointment wait time at an
MCO’s primary care delivery site shall not exceed:
1. Thirty (30) days from the date of
an enrollee’s request for a routine or preventive service; or
2. Forty-eight (48) hours from an
enrollee’s request for urgent care.
(4)(a) An appointment wait time for
a specialist, except for a specialist providing a behavioral health service as
provided in paragraph (b) of this subsection, shall not exceed:
1. Thirty (30) days from the
referral for routine care; or
2. Forty-eight (48) hours from the
referral for urgent care.
(b)1. A behavioral health service
requiring crisis stabilization shall be provided within twenty-four (24) hours
of the referral.
2. Behavioral health urgent care
shall be provided within forty-eight (48) hours of the referral.
3. A behavioral health service
appointment following a discharge from an acute psychiatric hospital shall
occur within fourteen (14) days of discharge.
4. A behavioral health service
appointment not included in subparagraph 1, 2, or 3 of this paragraph shall
occur within sixty (60) days of the referral.
(5) An MCO shall have:
1. Specialists available for the
subpopulations designated in Section 30 of this administrative regulation; and
2. Sufficient pediatric specialists
to meet the needs of enrollees who are less than twenty-one (21) years of age.
(6) An emergency service shall be
provided at a health care facility most suitable for the type of injury,
illness, or condition, whether or not the facility is in the MCO network.
(7)(a) Except as provided in
paragraph (b) of this subsection, an enrollee’s transport time to a hospital
shall not exceed thirty (30) minutes from an enrollee’s residence.
(b) Transport time to a hospital
shall not exceed sixty (60) minutes from an enrollee’s residence:
1. In a rural area; or
2. For a behavioral or physical
rehabilitation service.
(8)(a) Transport time for a dental
service shall not exceed one (1) hour from an enrollee’s residence.
(b) A dental appointment wait time
shall not exceed:
1. Three (3) weeks for a regular
appointment; or
2. Forty-eight (48) hours for urgent
care.
(9)(a) Transport time to a general
vision, laboratory, or radiological service shall not exceed one (1) hour from
an enrollee’s residence.
(b) A general vision, laboratory, or
radiological appointment wait time shall not exceed:
1. Three (3) weeks for a regular
appointment; or
2. Forty-eight (48) hours for urgent
care.
(10)(a) Transport time to a pharmacy
service shall not exceed one (1) hour from an enrollee’s residence.
(b) A pharmacy delivery site, except
for a mail-order pharmacy, shall not be further than fifty (50) miles from an
enrollee’s residence.
(c) Transport time or distance
threshold shall not apply to a mail-order pharmacy except that it shall:
1. Be physically located within the
United States of America; and
2. Provide delivery to the
enrollee’s residence.
(11)(a) Prior authorization shall
not be required for a physical emergency service or a behavioral health
emergency service.
(b) In order to be covered, an
emergency service shall be:
1. Medically necessary;
2. Authorized after being provided
if the service was not prior authorized; and
3. Covered in accordance with
Section 29(1) of this administrative regulation.
Section 16. Provider Manual. (1) An
MCO shall provide a provider manual to a provider within five (5) working days
of enrollment with the MCO.
(2) Prior to distributing a provider
manual or update to a provider manual, an MCO shall procure the department’s
approval of the provider manual or provider manual update.
(3) The provider manual shall be
available in hard copy and on the MCO’s website.
Section 17. Provider Orientation and
Education. An MCO shall:
(1) Conduct an initial orientation
for a provider within thirty (30) days of enrollment with the MCO to include:
(a) Medicaid coverage policies and
procedures;
(b) Reporting fraud and abuse;
(c) Medicaid eligibility groups;
(d) The standards for preventive
health services;
(e) The special needs of enrollees;
(f) Advance medical directives;
(g) EPSDT services;
(h) Claims submission;
(i) Care management or disease
management programs available to enrollees;
(j) Cultural sensitivity;
(k) The needs of enrollees with
mental, developmental, or physical disabilities;
(l) The reporting of communicable
diseases;
(m) The MCO’s QAPI program as
referenced in Section 48 of this administrative regulation;
(n) Medical records;
(o) The external quality review
organization; and
(p) The rights and responsibilities
of enrollees and providers; and
(2) Ensure that a provider:
(a) Is informed of an update on a
federal, state, or contractual requirement;
(b) Receives education on a finding
from its QAPI program if deemed necessary by the MCO or department; and
(c) Makes available to the
department training attendance rosters that shall be dated and signed by the
attendees.
Section 18. Provider Credentialing
and Recredentialing. (1) An MCO shall:
(a) Have policies and procedures
that comply with 907 KAR 1:672, KRS 205.560, and 42 C.F.R. 455 Subpart E,
455.400 to 455.470, regarding the credentialing and recredentialing of a provider;
(b) Have a process for verifying a
provider’s credentials and malpractice insurance that shall include:
1. Written policies and procedures
for credentialing and recredentialing of a provider;
2. A governing body, or a group or
individual to whom the governing body has formally delegated the credentialing
function; and
3. A review of the credentialing
policies and procedures by the governing body or its delegate;
(c) Have a credentialing committee
that makes recommendations regarding credentialing;
(d) If a provider requires a review
by the credentialing committee, based on the MCO’s quality criteria, notify the
department of the facts and outcomes of the review;
(e) Have written policies and
procedures for:
1. Excluding, terminating, or suspending
a provider; and
2. Reporting a quality deficiency
that results in an exclusion, suspension, or termination of a provider;
(f) Document its monitoring of a provider;
(g) Verify a provider’s
qualifications through a primary source that includes:
1. A current valid license or
certificate to practice in the Commonwealth of Kentucky;
2. A Drug Enforcement Administration
certificate and number, if applicable;
3. If a provider is not board
certified, proof of graduation from a medical school and completion of a
residency program;
4. Proof of completion of an
accredited nursing, dental, physician assistant, or vision program, if
applicable;
5. If a provider states on an
application that the provider is board certified in a specialty, a professional
board certification;
6. A previous five (5) year work
history;
7. A professional liability claims
history;
8. If a provider requires access to
a hospital to practice, proof that the provider has clinical privileges and is
in good standing at the hospital designated by the provider as the primary
admitting hospital;
9. Malpractice insurance;
10. Documentation, if applicable, of
a:
a. Revocation, suspension, or
probation of a state license or Drug Enforcement Agency certificate and number;
b. Curtailment or suspension of a
medical staff privilege;
c. Sanction or penalty imposed by
the United States Department of Health and Human Services or a state Medicaid
agency; or
d. Censure by a state or county
professional association; and
11. The most recent provider
information available from the National Practitioner Data Bank;
(h) Obtain access to the National
Practitioner Data Bank as part of its credentialing process;
(i) Have:
1. A process to recredential a
provider at least once every three (3) years that shall be in accordance with
subsection (3) of this section; and
2. Procedures for monitoring a
provider sanction, a complaint, or a quality issue between a recredentialing
cycle;
(j) Have or obtain National
Committee for Quality Assurance (NCQA) accreditation for its Medicaid product
line within four (4) years of implementation of this administrative regulation;
and
(k) Continuously maintain NCQA accreditation
for its Medicaid product line after obtaining the accreditation.
(2) If an MCO subcontracts a
credentialing or recredentialing function, the MCO and the subcontractor shall
have written policies and procedures for credentialing and recredentialing.
(3) A provider shall complete a
credentialing application, in accordance with 907 KAR 1:672, that includes a
statement by the provider regarding:
(a) The provider’s ability to
perform essential functions of a position, with or without accommodation;
(b) The provider’s lack of current
illegal drug use;
(c) The provider’s history of a:
1. Loss of license or a felony
conviction;
2. Loss or limitation of a
privilege; or
3. Disciplinary action;
(d) A sanction, suspension, or
termination by the United States Department of Health and Human Services or a
state Medicaid agency;
(e) Clinical privileges and standing
at a hospital designated as the primary admitting hospital of the provider;
(f) Malpractice insurance maintained
by the provider; and
(g) The correctness and completeness
of the application.
(4) The department shall be
responsible for credentialing and recredentialing a hospital-based provider.
Section 19. MCO Provider Enrollment.
(1) A provider enrolled with an MCO shall:
(a) Be credentialed by the MCO in
accordance with the standards established in Section 18 of this administrative
regulation; and
(b) Be eligible to enroll with the
Kentucky Medicaid Program in accordance with 907 KAR 1:672.
(2) An MCO shall:
(a) Not enroll a provider in its
network if:
1. The provider has an active
sanction imposed by the Centers for Medicare and Medicaid Services or a state
Medicaid agency;
2. A required provider license or a
certification is not current;
3. Based on information or records
available to the MCO:
a. The provider owes money to the
Kentucky Medicaid program; or
b. The Kentucky Office of the
Attorney General has an active fraud investigation of the provider; or
4. The provider is not credentialed;
(b) Have and maintain documentation
regarding a provider’s qualifications; and
(c) Make the documentation
referenced in paragraph (b) of this subsection available for review by the
department.
(3)(a) A provider shall not be
required to participate in Kentucky Medicaid fee-for-service to enroll with an
MCO.
(b) If a provider is not a
participant in Kentucky Medicaid fee-for-service, the provider shall obtain a
Medicaid provider number from the department in accordance with 907 KAR 1:672.
Section 20. Provider Discrimination.
An MCO shall:
(1) Comply with the
antidiscrimination requirements established in:
(a) 42 U.S.C. 1396u-2(b)(7);
(b) 42 C.F.R. 438.12; and
(c) KRS 304.17A-270; and
(2) Provide written notice to a
provider denied participation in the MCO’s network stating the reason for the
denial.
Section 21. Release for Ethical
Reasons. An MCO shall:
(1) Not require a provider to
perform a treatment or procedure that is contrary to the provider’s conscience,
religious beliefs, or ethical principles in accordance with 42 C.F.R. 438.102;
(2) Not prohibit or restrict a
provider from advising an enrollee about health status, medical care, or a
treatment:
(a) Whether or not coverage is
provided by the MCO; and
(b) If the provider is acting within
the lawful scope of practice; and
(3) Have a referral process in place
if a provider declines to perform a service because of an ethical reason.
Section 22. Provider Grievances and
Appeals. (1) An MCO shall have written policies and procedures for the filing
of a provider grievance or appeal.
(2) A provider shall have the right
to file:
(a) A grievance with an MCO; or
(b) An appeal with an MCO regarding:
1. A provider payment issue; or
2. A contractual issue.
(3)(a) A provider grievance or
appeal shall be resolved within thirty (30) calendar days.
(b) If a grievance or appeal is not
resolved within thirty (30) days, an MCO shall request a fourteen (14) day
extension from the provider. The provider shall approve the extension request
from the MCO.
(c) If a provider requests an
extension, the MCO shall approve the extension.
Section 23. Cost Reporting
Information. The department shall provide to the MCO the calculation of
Medicaid allowable costs as used in the Medicaid Program.
Section 24. Medical Records. (1) An
MCO shall:
(a) Require a provider to maintain
an enrollee medical record on paper or in an electronic format; and
(b) Have a process to systematically
review provider medical records to ensure compliance with the medical records
standards established in this section.
(2) An enrollee medical record
shall:
(a) Be legible, current, detailed,
organized, and signed by the service provider;
(b)1. Be kept for at least five (5)
years from the date of service unless a federal statute or regulation requires
a longer retention period; and
2. If a federal statute or
regulation requires a retention period longer than five (5) years, be kept for
at least as long as the federally-required retention period;
(c) Include the following minimal
detail for an individual clinical encounter:
1. The history and physical
examination for the presenting complaint;
2. A psychological or social factor
affecting the patient’s physical or behavioral health;
3. An unresolved problem, referral,
or result from a diagnostic test; and
4. The plan of treatment including:
a. Medication history, medications
prescribed, including the strength, amount, and directions for use and refills;
b. Therapy or other prescribed
regimen; and
c. Follow-up plans, including
consultation, referrals, and return appointment.
(3) A medical chart organization and
documentation shall, at a minimum, contain the following:
(a) Enrollee identification
information on each page;
(b) Enrollee date of birth, age,
gender, marital status, race or ethnicity, mailing address, home and work
addresses, and telephone numbers (if applicable), employer (if applicable),
school (if applicable), name and telephone number of an emergency contact,
consent form, language spoken and guardianship information (if applicable);
(c) Date of data entry and of the
encounter;
(d) Provider’s name;
(e) Any known allergies or adverse
reactions of the enrollee;
(f) Enrollee’s past medical history;
(g) Identification of any current
problem;
(h) If a consultation, laboratory,
or radiology report is filed in the medical record, the ordering provider’s
initials or other documentation indicating review;
(i) Documentation of immunizations;
(j) Identification and history of
nicotine, alcohol use, or substance abuse;
(k) Documentation of notification of
reportable diseases and conditions to the local health department serving the
jurisdiction in which the enrollee resides or to the Department for Public
Health pursuant to 902 KAR 2:020;
(l) Follow-up visits provided
secondary to reports of emergency room care;
(m) Hospital discharge summaries;
(n) Advance medical directives for
adults; and
(o) All written denials of service
and the reason for each denial.
Section 25. Confidentiality of
Medical Information. (1) An MCO shall:
(a) Maintain confidentiality of all
enrollee eligibility information and medical records;
(b) Prevent unauthorized disclosure
of the information referenced in this subsection in accordance with KRS
194A.060, KRS 214.185, KRS 434.840 to 434.860, and 42 C.F.R. 431 Subpart F,
431.300 to 431.307;
(c) Have written policies and
procedures for maintaining the confidentiality of enrollee records;
(d) Comply with 42 U.S.C. 1320d-2,
the Health Insurance Portability and Accountability Act, and 45 C.F.R. Parts
160 and 164;
(e) On behalf of its employees and
agents:
1. Sign a confidentiality agreement
attesting that it will comply with the confidentiality requirements established
in this section; and
2. Submit the confidentiality
agreement referenced in subparagraph 1. of this paragraph to the department;
(f) Limit access to medical
information to a person or agency which requires the information in order to
perform a duty related to the department’s administration of the Medicaid
program, including the department, the United States Department of Health and Human
Services, the United States Attorney General, the CHFS OIG, the Kentucky
Attorney General, or other agency required by the department; and
(g) Submit a request for disclosure
of information referenced in this subsection which has been received by the MCO
to the department within twenty-four (24) hours.
(2) Information referenced in
subsection (1)(g) of this section shall not be disclosed by an MCO pursuant to
the request without prior written authorization from the department.
Section 26. Americans with
Disabilities Act and Cabinet Ombudsman. (1) An MCO shall:
(a) Require by contract with its
network providers and subcontractors that a service location meets:
1. The requirements established in
42 U.S.C. Chapter 126, the Americans with Disabilities Act; and
2. All local requirements which
apply to health facilities pertaining to adequate space, supplies, sanitation,
and fire and safety procedures;
(b) Fully cooperate with the Cabinet
for Health and Family Services independent ombudsman; and
(c) Provide immediate access, to the
Cabinet for Health and Family Services independent ombudsman, to an enrollee’s
records if the enrollee has given consent.
(2) An MCO’s member handbook shall
contain information regarding the Cabinet for Health and Family Services
independent ombudsman program.
Section 27. Marketing. (1) An MCO
shall:
(a) Comply with the requirements
established in 42 C.F.R. 438.104 regarding marketing activities;
(b) Have a system of control over
the content, form, and method of dissemination of its marketing and information
materials;
(c) Submit a marketing plan and
marketing materials to the department for written approval prior to
implementation or distribution;
(d) If conducting mass media
marketing, direct the marketing activities to enrollees in the entire service
area pursuant to the marketing plan;
(e) Not conduct face-to-face
marketing;
(f) Not use fraudulent, misleading,
or misrepresentative information in its marketing materials;
(g) Not offer material or financial
gain to a:
1. Potential enrollee as an
inducement to select a particular provider or use a product; or
2. Person for the purpose of
soliciting, referring, or otherwise facilitating the enrollment of an enrollee;
(h) Not conduct:
1. Direct telephone marketing to
enrollees or potential enrollees who do not reside in the MCO service area; or
2. Direct or indirect door-to-door,
telephone, or other cold-call marketing activity; and
(i) Not include in its marketing
materials an assertion or statement that CMS, the federal government, the
Commonwealth, or another entity endorses the MCO.
(2) An MCO’s marketing material
shall meet the information requirements established in Section 12 of this
administrative regulation.
Section 28. MCO Service Areas. (1)(a)
An MCO’s service areas shall include regions one (1), two (2), four (4), five
(5), six (6), seven (7), and eight (8).
(b) An MCO’s service areas shall not
include region three (3).
(2) A recipient who is eligible for
enrollment with a managed care organization and who resides in region three (3)
shall receive services in accordance with 907 KAR 1:705.
(3) Region one (1) shall include the
following counties:
(a) Ballard;
(b) Caldwell;
(c) Calloway;
(d) Carlisle;
(e) Crittenden;
(f) Fulton;
(g) Graves;
(h) Hickman;
(i) Livingston;
(j) Lyon;
(k) Marshall; and
(l) McCracken.
(4) Region two (2) shall include the
following counties:
(a) Christian;
(b) Daviess;
(c) Hancock;
(d) Henderson;
(e) Hopkins;
(f) McLean;
(g) Muhlenberg;
(h) Ohio;
(i) Trigg;
(j) Todd;
(k) Union; and
(l) Webster.
(5) Region three (3) shall include
the following counties:
(a) Breckenridge;
(b) Bullitt;
(c) Carroll;
(d) Grayson;
(e) Hardin;
(f) Henry;
(g) Jefferson;
(h) Larue;
(i) Marion;
(j) Meade;
(k) Nelson;
(l) Oldham;
(m) Shelby;
(n) Spencer;
(o) Trimble; and
(p) Washington.
(6) Region four (4) shall include
the following counties:
(a) Adair;
(b) Allen;
(c) Barren;
(d) Butler;
(e) Casey;
(f) Clinton;
(g) Cumberland;
(h) Edmonson;
(i) Green;
(j) Hart;
(k) Logan;
(l) McCreary;
(m) Metcalfe;
(n) Monroe;
(o) Pulaski;
(p) Russell;
(q) Simpson;
(r) Taylor;
(s) Warren; and
(t) Wayne.
(7) Region five (5) shall include
the following counties:
(a) Anderson;
(b) Bourbon;
(c) Boyle;
(d) Clark;
(e) Estill;
(f) Fayette;
(g) Franklin;
(h) Garrard;
(i) Harrison;
(j) Jackson;
(k) Jessamine;
(l) Lincoln;
(m) Madison;
(n) Mercer;
(o) Montgomery;
(p) Nicholas;
(q) Owen;
(r) Powell;
(s) Rockcastle;
(t) Scott; and
(u) Woodford.
(8) Region six (6) shall include the
following counties:
(a) Boone;
(b) Campbell;
(c) Gallatin;
(d) Grant;
(e) Kenton; and
(f) Pendleton.
(9) Region seven (7) shall include
the following counties:
(a) Bath;
(b) Boyd;
(c) Bracken;
(d) Carter;
(e) Elliott;
(f) Fleming;
(g) Greenup;
(h) Lawrence;
(i) Lewis;
(j) Mason;
(k) Menifee;
(l) Morgan;
(m) Rowan; and
(n) Robertson.
(10) Region eight (8) shall include
the following counties:
(a) Bell;
(b) Breathitt;
(c) Clay;
(d) Floyd;
(e) Harlan;
(f) Johnson;
(g) Knott;
(h) Knox;
(i) Laurel;
(j) Lee;
(k) Leslie;
(l) Letcher;
(m) Magoffin;
(n) Martin;
(o) Owsley;
(p) Perry;
(q) Pike;
(r) Wolfe; and
(s) Whitley.
Section 29. Covered Services. (1) Except as established in
subsection (2) of this section, an MCO shall be responsible for the provision
and costs of a covered health service:
(a) Established in Title 907 of the
Kentucky Administrative Regulations;
(b) In the amount, duration, and
scope that the services are covered for recipients pursuant to the department’s
administrative regulations located in Title 907 of the Kentucky Administrative
Regulations; and
(c) Beginning on the date of
enrollment of a recipient into the MCO.
(2) Other than a nursing facility
cost referenced in subsection (3)(i) of this section, an MCO shall be
responsible for the cost of a non-nursing facility covered service provided to
an enrollee during the first thirty (30) days of a nursing facility admission
in accordance with this administrative regulation.
(3) An MCO shall not be responsible
for the provision or costs of the following:
(a) A service provided to a
recipient in an intermediate care facility for individuals with mental
retardation or a developmental disability;
(b) A service provided to a
recipient in a 1915(c) home and community based waiver program;
(c) A hospice service provided to a
recipient in an institution;
(d) A nonemergency transportation
service provided in accordance with 907 KAR 3:066;
(e) Except as established in Section
35 of this administration regulation, a school-based health service;
(f) A service not covered by the
Kentucky Medicaid program;
(g) A health access nurturing
developing service pursuant to 907 KAR 3:140;
(h) An early intervention program
service pursuant to 907 KAR 1:720; or
(i) A nursing facility service for
an enrollee during the first thirty (30) days of a nursing facility admission.
(4) The following covered services
provided by an MCO shall be accessible to an enrollee without a referral from
the enrollee’s primary care provider:
(a) A primary care vision service;
(b) A primary dental or oral surgery
service;
(c) An evaluation by an orthodontist
or a prosthodontist;
(d) A service provided by a women’s
health specialist;
(e) A family planning service;
(f) An emergency service;
(g) Maternity care for an enrollee
under age eighteen (18);
(h) An immunization for an enrollee
under twenty-one (21);
(i) A screening, evaluation, or
treatment service for a sexually transmitted disease or tuberculosis;
(j) Testing for HIV, HIV-related
condition, or other communicable disease; and
(k) A chiropractic service.
(5) An MCO shall:
(a) Not require the use of a network
provider for a family planning service;
(b) In accordance with 42 C.F.R. 431.51(b),
reimburse for a family planning service provided within or outside of the MCO’s
provider network;
(c) Cover an emergency service:
1. In accordance with 42 U.S.C.
1396u-2(b)(2)(A)(i);
2. Provided within or outside of the
MCO’s provider network; or
3. Out-of-state in accordance with
42 C.F.R. 431.52;
(d) Comply with 42 U.S.C.
1396u-2(b)(A)(ii); and
(e) Be responsible for the provision
and costs of a covered service as described in this section beginning on or
after the beginning date of enrollment of a recipient with an MCO as
established in Section 2 of this administrative regulation.
(6)(a) If an enrollee is receiving a
medically necessary covered service the day before enrollment with an MCO, the
MCO shall be responsible for the costs of continuation of the medically
necessary covered service without prior approval and without regard to whether
services are provided within or outside the MCO’s network until the MCO can
reasonably transfer the enrollee to a network provider.
(b) An MCO shall comply with
paragraph (a) of this subsection without impeding service delivery or
jeopardizing the enrollee’s health.
Section 30. Enrollees with Special
Health Care Needs. (1) In accordance with 42 C.F.R. 438.208:
(a) The following shall be
considered an individual with a special health care need:
1. A child in or receiving foster
care or adoption assistance;
2. A homeless individual;
3. An individual with a chronic
physical or behavioral illness;
4. A blind or disabled child;
5. An individual who is eligible for
SSI benefits; or
6. An adult who is a ward of the
Commonwealth in accordance with 910 KAR Chapter 2; and
(b) An MCO shall:
1. Have a process to target
enrollees for the purpose of screening and identifying those with special
health care needs;
2. Assess each enrollee identified
by the department as having a special health care need to determine if the
enrollee needs case management or regular care monitoring;
3. Include the use of appropriate
health care professionals to perform an assessment; and
4. Have a treatment plan for an
enrollee with a special health care need who has been determined, through an assessment,
to need a course of treatment or regular care monitoring.
(2) A treatment plan referenced in
subsection (1)(b)4 of this section shall be developed:
(a) With participation from the
enrollee or the enrollee’s legal guardian as referenced in Section 43 of this
administrative regulation; and
(b) By the enrollee’s primary care
provider, if the enrollee has a primary care provider.
(3) An MCO shall:
(a)1. Develop materials specific to
the needs of an enrollee with a special health care need; and
2. Provide the materials referenced
in subparagraph 1. of this paragraph to the enrollee, caregiver, parent, or
legal guardian;
(b) Have a mechanism to allow an
enrollee identified as having a special health care need to directly access a
specialist, as appropriate, for the enrollee’s condition and identified need;
and
(c) Be responsible for the ongoing
care coordination for an enrollee with a special health care need.
(4) The information referenced in
subsection (3)(a) of this section shall include health educational material to
assist the enrollee with a special health care need or the enrollee’s
caregiver, parent, or legal guardian in understanding the enrollee’s special
need.
(5)(a) An enrollee who is a child in
foster care or receiving adoption assistance shall be enrolled with an MCO
through a service plan that shall be completed for the enrollee by DCBS prior
to being enrolled with the MCO.
(b) The service plan referenced in
paragraph (a) of this subsection shall be used by DCBS and the MCO to determine
the enrollee’s medical needs and identify the need for case management.
(c) The MCO shall be available to
meet with DCBS at least once a month to discuss the health care needs of the
child as identified in the service plan.
(d) If a service plan identifies the
need for case management or DCBS requests case management for an enrollee, the
foster parent of the child or DCBS shall work with the MCO to develop a case
management plan of care.
(e) The MCO shall consult with DCBS
prior to developing or modifying a case management plan of care.
(6)(a) An enrollee who is a ward of
the Commonwealth shall be enrolled with an MCO through a service plan that
shall be completed for the enrollee by DAIL prior to being enrolled with the
MCO.
(b) If the service plan referenced
in paragraph (a) of this subsection identifies the need for case management,
the MCO shall work with DAIL or the enrollee to develop a case management plan
of care.
Section 31. Second Opinion. An
enrollee shall have the right to a second opinion within the MCO’s provider
network for a surgical procedure or diagnosis and treatment of a complex or
chronic condition.
Section 32. Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Services. (1) An MCO shall provide
an enrollee under the age of twenty-one (21) years with EPSDT services in
compliance with:
(a) 907 KAR 11:034;
(b) 42 U.S.C. 1396d(r); and
(c) The Early and Periodic
Screening, Diagnosis and Treatment Program Periodicity Schedule.
(2) A provider of an EPSDT service
shall meet the requirements established in 907 KAR 11:034.
Section 33. Emergency Care, Urgent
Care, and Poststabilization Care. (1) An MCO shall provide to an enrollee:
(a) Emergency care twenty-four (24)
hours a day, seven (7) days a week; and
(b) Urgent care within forty-eight
(48) hours.
(2) Poststabilization services shall
be provided and reimbursed in accordance with 42 C.F.R. 422.113(c) and
438.114(e).
Section 34. Maternity Care. An MCO
shall:
(1) Have procedures to assure:
(a) Prompt initiation of prenatal
care; or
(b) Continuation of prenatal care
without interruption for a woman who is pregnant at the time of enrollment;
(2) Provide maternity care that
includes:
(a) Prenatal;
(b) Delivery;
(c) Postpartum care; and
(d) Care for a condition that
complicates a pregnancy; and
(3) Perform all the newborn
screenings referenced in 902 KAR 4:030.
Section 35. Pediatric Interface. (1)
An MCO shall:
(a) Have procedures to coordinate
care for a child receiving a school-based health service or an early
intervention service; and
(b) Monitor the continuity and
coordination of care for the child receiving a service referenced in paragraph
(a) of this subsection as part of its quality assessment and performance
improvement (QAPI) program established in Section 48 of this administrative
regulation.
(2) Except when a child’s course of
treatment is interrupted by a school break, after-school hours, or summer
break, an MCO shall not be responsible for a service referenced in subsection
(1)(a) of this section.
(3) A school-based health
service provided by a school district shall not be covered by an MCO.
(4) A school-based health
service provided by a local health department shall be covered by an MCO.
Section 36. Pediatric Sexual Abuse Examination.
(1) An MCO shall enroll at least one (1) provider in its network who has the capacity
to perform a forensic pediatric sexual abuse examination.
(2) A forensic pediatric sexual
abuse examination shall be conducted for an enrollee at the request of the
DCBS.
Section 37. Lock-in Program. (1) An
MCO shall have a program to control utilization of:
(a) Drugs and other pharmacy
benefits; and
(b) Non-emergency care provided in
an emergency setting.
(2) The program referenced in
subsection (1) of this section shall be:
(a) Approved by the department; and
(b) In accordance with 907 KAR
1:677.
Section 38. Pharmacy Benefit
Program. (1)
An MCO shall:
(a) Have a pharmacy benefit program
that shall have:
1. A point-of-sale claims processing
service;
2. Prospective drug utilization
review;
3. An accounts receivable process;
4. Retrospective utilization review
services;
5. Formulary and non-formulary
drugs;
6. A prior authorization process for
drugs;
7. Pharmacy provider relations;
8. A toll-free call center that
shall respond to a pharmacy or a physician prescriber twenty-four (24) hours a
day, seven (7) days a week; and
9. A seamless interface with the
department’s management information system;
(b) Maintain a preferred drug list
(PDL);
(c) Provide the following to an
enrollee or a provider:
1. PDL information; and
2. Pharmacy cost sharing
information; and
(d) Have a Pharmacy and Therapeutics
Committee (P&T Committee), which shall:
1. Meet periodically throughout the
calendar year as necessary; and
2. Make recommendations to the MCO
for changes to the drug formulary.
(2)(a) The department shall comply
with the drug rebate collection requirement established in 42 U.S.C.
1396b(m)(2)(A)(xiii).
(b) An MCO shall:
1. Cooperate with the department in
complying with 42
U.S.C. 1396b(m)(2)(A)(xiii);
2. Assist the department in
resolving a drug rebate dispute with a manufacturer; and
3. Be responsible for drug rebate
administration in a non-pharmacy setting.
(3) An MCO’s P&T committee shall
meet and make recommendations to the MCO for changes to the drug formulary.
(4) If a prescription for an
enrollee is for a non-preferred drug and the pharmacist cannot reach the
enrollee’s primary care provider or the MCO for approval and the pharmacist
determines it necessary to provide the prescribed drug, the pharmacist shall:
(a) Provide a seventy-two (72) hour
supply of the prescribed drug; or
(b) Provide less than a seventy-two
(72) hour supply of the prescribed drug, if the request is for less than a
seventy-two (72) hour supply.
(5) Cost sharing imposed by an MCO
shall not exceed the cost sharing limits established in 907 KAR 1:604.
Section 39. MCO Interface with the
Department Regarding Behavioral Health. An MCO shall:
(1) Meet with the department monthly
to discuss:
(a) Serious mental illness and
serious emotional disturbance operating definitions;
(b) Priority populations;
(c) Targeted case management and
peer support provider certification training and processes;
(d) IMPACT Plus program operations;
(e) Satisfaction survey
requirements;
(f) Priority training topics;
(g) Behavioral health services
hotline; or
(h) Behavioral health crisis
services;
(2) Coordinate:
(a) An IMPACT Plus covered service
provided to an enrollee in accordance with 907 KAR 3:030;
(b) With the department:
1. An enrollee education process
for:
a. Individuals with a serious mental
illness; and
b. Children or youth with a serious
emotional disturbance; and
2. On establishing a collaborative
agreement with a:
a. State-operated or
stated-contracted psychiatric hospital; and
b. Facility that provides a service
to an individual with a co-occurring behavioral health and developmental and
intellectual disabilities; and
(c) With the department and
community mental health centers a process for integrating a behavioral health
service hotline; and
(3) Provide the department with
proposed materials and protocols for the enrollee education referenced in
subsection (2)(b) of this section.
Section 40. Behavioral Health Services. (1) An MCO shall:
(a) Provide a medically necessary
behavioral health service to an enrollee in accordance with the access
standards established in Section 15 of this administrative regulation;
(b) Use the DSM-IV multi-axial
classification system to assess an enrollee for a behavioral service;
(c) Have an emergency or crisis
behavioral health toll-free hotline staffed by trained personnel twenty-four
(24) hours a day, seven (7) days a week;
(d) Not operate one (1) hotline to
handle both an emergency or crisis call and a routine enrollee call; and
(e) Not impose a maximum call
duration limit.
(2) Staff of a hotline referenced in
subsection (1)(c) of this section shall:
(a) Communicate in a culturally
competent and linguistically accessible manner to an enrollee; and
(b) Include or have access to a
qualified behavioral health professional to assess and triage a behavioral
health emergency.
(3) A face-to-face emergency service
shall be available:
(a) Twenty-four (24) hours a day;
and
(b) Seven (7) days a week.
Section 41. Coordination Between a
Behavioral Health Provider and a Primary Care Provider. (1) An MCO shall:
(a) Require a PCP to have a
screening and evaluation procedure for the detection and treatment of, or
referral for, a known or suspected behavioral health problem or disorder;
(b) Provide training to a PCP in its
network on:
1. Screening and evaluating a
behavioral health disorder;
2. The MCO’s referral process for a
behavioral health service;
3. Coordination requirements for a
behavioral health service; and
4. Quality of care standards;
(c) Have policies and procedures
that shall be approved by the department regarding clinical coordination
between a behavioral health service provider and a PCP;
(d) Establish guidelines and
procedures to ensure accessibility, availability, referral, and triage to
physical and behavioral health care;
(e) Facilitate the exchange of information
among providers to reduce inappropriate or excessive use of
psychopharmacological medications and adverse drug reactions;
(f) Identify a method to evaluate
continuity and coordination of care; and
(g) Include the monitoring and
evaluation of the MCO’s compliance with the requirements established in
paragraphs (a) to (f) of this subsection in the MCO’s quality improvement plan.
(2) With consent from an
enrollee or the enrollee’s legal guardian, an MCO shall require a behavioral
health service provider to:
(a) Refer an enrollee with a known
or suspected and untreated physical health problem or disorder to their PCP for
examination and treatment; and
(b) Send an initial and quarterly
summary report of an enrollee’s behavioral health status to the enrollee’s PCP.
Section 42. Court-Ordered
Psychiatric Services. (1) An MCO shall:
(a) Provide an inpatient psychiatric
service to an enrollee under the age of twenty-one (21) and over the age of
sixty-five (65) who has been ordered to receive the service by a court of
competent jurisdiction under the provisions of KRS Chapters 202A and 645;
(b) Not deny, reduce, or negate the
medical necessity of an inpatient psychiatric service provided pursuant to a
court-ordered commitment for an enrollee under the age of twenty-one (21) or
over the age of sixty-five (65);
(c) Coordinate with a provider of a
behavioral health service the treatment objectives and projected length of stay
for an enrollee committed by a court of law to a state psychiatric hospital; and
(d) Enter into a collaborative
agreement with the state-operated or state-contracted psychiatric hospital
assigned to the enrollee’s region in accordance with 908 KAR 3:040 and in
accordance with the Olmstead decision.
(2) An MCO shall present a modification
or termination of a service referenced in subsection (1)(b) of this section to
the court with jurisdiction over the matter for determination.
(3)(a) An MCO behavioral health
service provider shall:
1. Participate in a quarterly
continuity of care meeting with a state-operated or state- contracted
psychiatric hospital;
2. Assign a case manager prior to or
on the date of discharge of an enrollee from a state-operated or
state-contracted psychiatric hospital; and
3. Provide case management services to
an enrollee with a severe mental illness and co-occurring developmental disability
who is discharged from a:
a. State-operated or
state-contracted psychiatric hospital; or
b. State-operated nursing facility
for individuals with severe mental illness.
(b) A case manager and a behavioral
health service provider shall participate in discharge planning to ensure
compliance with the Olmstead decision.
Section 43. Legal Guardians. (1) A
parent, custodial parent, person exercising custodial control or supervision,
or an agency with a legal responsibility for a child by virtue of a voluntary
commitment or of an emergency or temporary custody order shall be authorized to
act on behalf of an enrollee who is under the age of eighteen (18) years, a potential
enrollee, or a former enrollee for the purpose of:
(a) Selecting a primary care
provider;
(b) Filing a grievance or appeal; or
(c) Taking an action on behalf of
the child regarding an interaction with an MCO.
(2)(a) A legal guardian who has been
appointed pursuant to KRS 387.500 to 387.800 shall be allowed to act on behalf
of an enrollee who is a ward of the commonwealth.
(b) A person authorized to make a
health care decision pursuant to KRS 311.621 to 311.643 shall be allowed to act
on behalf of an enrollee, potential enrollee, or former enrollee.
(c) An enrollee shall have the right
to:
1. Represent the enrollee; or
2. Use legal counsel, a relative, a
friend, or other spokesperson.
Section 44. Utilization Management
or UM. (1) An MCO shall:
(a) Have a utilization management program
that shall:
1. Meet the requirements established
in 42 C.F.R. Parts 431, 438, and 456, and the private review agent requirements
of KRS 304.17A, as applicable;
2. Identify, define, and specify the
amount, duration, and scope of each service that the MCO is required to offer;
3. Review, monitor, and evaluate the
appropriateness and medical necessity of care and services;
4. Identify and describe the UM mechanisms
used to:
a. Detect the under or over
utilization of services; and
b. Act after identifying under
utilization or over utilization of services;
5. Have a written UM program
description in accordance with subsection (2) of this section; and
6. Be evaluated annually by the:
a MCO, including an evaluation of
clinical and service outcomes; and
b. Department;
(b) Adopt nationally-recognized
standards of care and written criteria that shall be:
1. Based upon sound clinical
evidence, if available, for making utilization decisions; and
2. Approved by the department;
(c) Include physicians and other
health care professionals in the MCO network in reviewing and adopting medical
necessity criteria;
(d) Have:
1. A process to review, evaluate,
and ensure the consistency with which physicians and other health care professionals
involved in UM apply review criteria for authorization decisions;
2. A medical director who:
a. Is licensed to practice medicine
or osteopathy in Kentucky;
b. Is responsible for treatment
policies, protocols, and decisions; and
c. Supervises the UM program; and
3. Written policies and procedures
that explain how prior authorization data will be incorporated into the MCO’s
Quality Improvement Plan;
(e) Submit a request for a change in
review criteria for authorization decisions to the department for approval
prior to implementation;
(f) Administer or use a CAHPS survey
to evaluate and report enrollee and provider satisfaction with the quality of,
and access to, care and services in accordance with Section 55 of this
administrative regulation;
(g) Provide written confirmation of
an approval of a request for a service within two (2) business days of
providing notification of a decision if:
1. The initial decision was not in
writing; and
2. Requested by an enrollee or
provider;
(h) If the MCO uses a subcontractor
to perform UM, require the subcontractor to have
written policies, procedures, and a process
to review, evaluate, and ensure consistency with which physicians and other
health care professionals involved in UM apply review criteria for
authorization decisions; and
(i) Not provide a financial or other
type of incentive to an individual or entity that conducts UM activities to
deny, limit, or discontinue a medically necessary service to an enrollee
pursuant to 42 C.F.R. 422.208, 42 C.F.R. 438.6(h), and 42 C.F.R. 438.210(e).
(2) A UM program description
referenced in subsection (1)(a)5. of this section shall:
(a) Outline the UM program’s
structure;
(b) Define the authority and
accountability for UM activities, including activities delegated to another
party; and
(c) Include the:
1. Scope of the program;
2. Processes and information sources
used to determine service coverage, clinical necessity, and appropriateness and
effectiveness;
3. Policies and procedures to
evaluate:
a. Care coordination;
b. Discharge criteria;
c. Site of services;
d. Levels of care;
e. Triage decisions; and
f. Cultural competence of care
delivery; and
4. Processes to review, approve, and
deny services as needed.
(3) Only a physician with clinical
expertise in treating an enrollee’s medical condition or disease shall be
authorized to make a decision to deny a service authorization request or authorize
a service in an amount, duration, or scope that is less than requested by the
enrollee or the enrollee’s treating physician.
(4) A medical necessity review
process shall be in accordance with Section 45 of this administrative
regulation.
Section 45. Service Authorization
and Notice. (1) For the processing of a request for initial or continuing
authorization of a service, an MCO shall identify what constitutes medical
necessity and establish a written policy and procedure, which includes a timeframe
for:
(a) Making an authorization
decision; and
(b) If the service is denied or
authorized in an amount, duration, or scope which is less than requested,
providing a notice to an enrollee and provider acting on behalf of and with the
consent of an enrollee.
(2) For an authorization of a
service, an MCO shall make a decision:
(a) As expeditiously as the enrollee’s
health condition requires; and
(b) Within two (2) business days
following receipt of a request for service.
(3) The timeframe for making an
authorization decision referenced in subsection (2) of this section may be
extended:
(a) By the:
1. Enrollee, or the provider acting
on behalf of and with consent of an enrollee, if the enrollee requests an extension;
or
2. MCO, if the MCO:
a. Justifies to the department, upon
request, a need for additional information and how the extension is in the
enrollee’s interest;
b. Gives the enrollee written notice
of the extension, including the reason for extending the authorization decision
timeframe and the right of the enrollee to file a grievance if the enrollee
disagrees with that decision; and
c. Makes and carries out the
authorization decision as expeditiously as the enrollee’s health condition
requires and no later than the date the extension expires; and
(b) Up to fourteen (14) additional
calendar days.
(4) If an MCO denies a service
authorization or authorizes a service in an amount, duration, or scope which is
less than requested, the MCO shall provide a notice:
(a) To the:
1. Enrollee, in writing, as
expeditiously as the enrollee’s condition requires and within two (2) business
days of receipt of the request for service; and
2. Requesting provider, if
applicable;
(b) Which shall:
1. Meet the language and formatting
requirements established in 42 C.F.R. 438.404;
2. Include the:
a. Action the MCO or its
subcontractor, if applicable, has taken or intends to take;
b. Reason for the action;
c. Right of the enrollee or provider
who is acting on behalf of the enrollee to file an MCO appeal;
d. Right of the enrollee to request
a state fair hearing;
e. Procedure for filing an appeal
and requesting a state fair hearing;
f. Circumstance under which an
expedited resolution is available and how to request it; and
g. Right to have benefits continue
pending resolution of the appeal, how to request that benefits be continued,
and the circumstance under which the enrollee may be required to pay the costs
of these services; and
3. Be provided:
a. At least ten (10) days before the
date of action if the action is a termination, suspension, or reduction of a
covered service authorized by the department, department designee, or
enrollee’s MCO, except the department may shorten the period of advance notice
to five (5) days before the date of action because of probable fraud by the
enrollee;
b. By the date of action for the
following:
(i) The death of a member;
(ii) A signed written enrollee
statement requesting service termination or giving information requiring
termination or reduction of services in which the enrollee understands this
will be the result of supplying the information;
(iii) The enrollee’s address is
unknown and mail directed to the enrollee has no forwarding address;
(iv) The enrollee has been accepted
for Medicaid services by another local jurisdiction;
(v) The enrollee’s admission to an
institution results in the enrollee’s ineligibility for more services;
(vi) The enrollee’s physician
prescribes a change in the level of medical care;
(vii) An adverse decision has been
made regarding the preadmission screening requirements for a nursing facility
admission, pursuant to 907 KAR 1:755 and 42 U.S.C. 1396r(b)(3)(F), on or after
January 1, 1989; or
(viii) The safety or health of
individuals in a facility would be endangered, if the enrollee’s health
improves sufficiently to allow a more immediate transfer or discharge, an
immediate transfer or discharge is required by the enrollee’s urgent medical
needs, or an enrollee has not resided in the nursing facility for thirty (30)
days;
c. On the date of action, if the
action is a denial of payment;
d. As expeditiously as the
enrollee’s health condition requires and within two (2) business days following
receipt of a request;
e. When the MCO carries out its
authorization decision, as expeditiously as the enrollee’s health condition
requires and no later than the date the extension as identified in subsection
(3) of this section expires;
f. If a provider indicates or the
MCO determines that following the standard timeframe could seriously jeopardize
the enrollee’s life or health, or ability to attain, maintain or regain maximum
function, as expeditiously as the enrollee’s health condition requires and no
later than two (2) business days after receipt of the request for service; and
g. For an authorization decision not
made within the timeframe identified in subsection (2) of this section, on the
date the timeframe expires as this shall constitute a denial.
Section 46. Health Risk Assessment.
An MCO shall:
(1) After the initial implementation
of the MCO program, conduct an initial health risk assessment of each enrollee
within ninety (90) days of enrolling the individual if the individual has not
been enrolled with the MCO in a prior twelve (12) month period;
(2) Use health care professionals in
the health risk assessment process;
(3) Screen an enrollee who it
believes to be pregnant within thirty (30) days of enrollment;
(4) If an enrollee is pregnant,
refer the enrollee for prenatal care;
(5) Use a health risk assessment to
determine an enrollee’s need for:
(a) Care management;
(b) Disease management;
(c) A behavioral health service;
(d) A physical health service or
procedure; or
(e) A community service.
Section 47. Care Coordination and Management.
An
MCO shall:
(1) Have a care coordinator and a
case manager who shall:
(a) Arrange, assure delivery of,
monitor, and evaluate care, treatment, and services for an enrollee; and
(b) Not duplicate or supplant
services provided by a targeted case manager to:
1. Adults with a chronic mental
illness pursuant to 907 KAR 1:515; or
2. Children with a severe emotional
disability pursuant to 907 KAR 1:525;
(2) Have guidelines for care
coordination that shall be approved by the department prior to implementation;
(3) Develop a plan of care for an
enrollee in accordance with 42 C.F.R. 438.208;
(4) Have policies and procedures to
ensure access to care coordination for a DCBS client or a DAIL client;
(5) Provide information on and
coordinate services with the Women, Infants and Children program; and
(6) Provide information to an
enrollee and a provider regarding:
(a) An available care management
service; and
(b) How to obtain a care management
service.
Section 48. Quality Assessment and
Performance Improvement (QAPI) Program. An MCO shall:
(1) Have a quality assessment and
performance improvement (QAPI) program that shall:
(a) Conform to the requirements of
42 C.F.R. 438 Subpart D, 438.200 to 438.242;
(b) Assess, monitor, evaluate, and
improve the quality of care provided to an enrollee;
(c) Provide for the evaluation of:
1. Access to care;
2. Continuity of care;
3. Health care outcomes; and
4. Services provided or arranged for
by the MCO;
(d) Demonstrate the linkage of
Quality Improvement (QI) activities to findings from a quality evaluation; and
(e) Be developed in collaboration
with input from enrollees;
(2) Submit annually to the department
a description of its QAPI program;
(3) Conduct and submit to the
department an annual review of the program;
(4) Maintain documentation of:
(a) Enrollee input;
(b) The MCO’s response to the
enrollee input;
(c) A performance improvement
activity; and
(d) MCO feedback to an enrollee;
(5) Have or obtain within four (4)
years of initial implementation National Committee for Quality Assurance (NCQA)
accreditation for its Medicaid product line;
(6) If the MCO has obtained NCQA accreditation:
(a) Submit to the department a copy
of its current certificate of accreditation with a copy of the complete
accreditation survey report; and
(b) Maintain the accreditation;
(7) Integrate behavioral health
service indicators into its QAPI program;
(8) Include a systematic, on-going
process for monitoring, evaluating, and improving the quality and
appropriateness of a behavioral health service provided to an enrollee;
(9) Collect data, monitor, and
evaluate for evidence of improvement to a physical
health outcome resulting from integration of
behavioral health into an enrollee’s care; and
(10) Annually review and evaluate
the effectiveness of the QAPI program.
Section 49. Quality Assessment and
Performance Improvement Plan. (1) An MCO shall:
(a) Have a written QAPI work plan
that:
1. Outlines the scope of activities;
2. Is submitted quarterly to the
department; and
3. Sets goals, objectives, and
timelines for the QAPI program;
(b) Set new goals and objectives:
1. At least annually; and
2. Based on a finding from:
a. A quality improvement activity or
study;
b. A survey result;
c. A grievance or appeal;
d. A performance measure; or
e. The External Quality Review
Organization;
(c) Be accountable to the department
for the quality of care provided to an enrollee;
(d) Obtain approval from the
department for its QAPI program and annual QAPI work plan;
(e) Have an accountable entity
within the MCO:
1. To provide direct oversight of
its QAPI program; and
2. To review reports from the
quality improvement committee referenced in paragraph (h) of this subsection;
(f) Review its QAPI program
annually;
(g) Modify its QAPI program to
accommodate a review finding or concern of the MCO if a review finding or
concern occurs;
(h) Have a quality improvement
committee that shall:
1. Be responsible for the QAPI
program;
2. Be interdisciplinary;
3. Include:
a. Providers and administrative
staff; and
b. Health professionals with
knowledge of and experience with individuals with special health care needs;
4. Meet on a regular basis;
5. Document activities of the
committee;
6. Make committee minutes and a
committee report available to the department upon request; and
7. Submit a report to the
accountable entity referenced in paragraph (e) of this subsection that shall
include:
a. A description of the QAPI
activities;
b. Progress on objectives; and
c. Improvements made;
(i) Require a provider to
participate in QAPI activities in the provider agreement or subcontract; and
(j) Provide feedback to a provider
or a subcontractor regarding integration of or operation of a corrective action
necessary in a QAPI activity if a corrective action is necessary.
(2) If a QAPI activity of a provider
or a subcontractor is separate from an MCO’s QAPI program, the activity shall be
integrated into the MCO’s QAPI program.
Section 50. QAPI Monitoring and
Evaluation. (1) Through its QAPI program, an MCO shall:
(a) Monitor and evaluate the quality
of health care provided to an enrollee;
(b) Study and prioritize health care
needs for performance measurement, performance improvement, and development of
practice guidelines;
(c) Use a standardized quality
indicator:
1. To assess improvement, assure
achievement of at least a minimum performance level, monitor adherence to a
guideline, and identify a pattern of over and under utilization of a service;
and
2. Which shall be:
a. Supported by a valid data
collection and analysis method; and
b. Used to improve clinical care and
services;
(d) Measure a provider performance
against a practice guideline and a standard adopted by the quality improvement
committee;
(e) Use a multidisciplinary team to
analyze and address data and systems issues; and
(f) Have practice guidelines that
shall:
1. Be:
a. Disseminated to a provider, or
upon request, to an enrollee;
b. Based on valid and reliable
medical evidence or consensus of health professionals;
c. Reviewed and updated; and
d. Used by the MCO in making a
decision regarding utilization management, a covered service, or enrollee
education;
2. Consider the needs of enrollees;
and
3. Include consultation with network
providers.
(2) If an area needing improvement
is identified by the QAPI program, the MCO shall take a corrective action and
monitor the corrective action for improvement.
Section 51. Quality and Member
Access Committee. (1) An MCO shall:
(a) Have a Quality and Member Access
Committee (QMAC) composed of:
1. Enrollees who shall be
representative of the enrollee population; and
2. Individuals from consumer
advocacy groups or the community who represent the interests of enrollees in
the MCO; and
(b) Submit to the department
annually a list of enrollee representatives participating in the QMAC.
(2) A QMAC shall be responsible for
reviewing:
(a) Quality and access standards;
(b) The grievance and appeals
process;
(c) Policy modifications needed
based on reviewing aggregate grievance and appeals data;
(d) The member handbook;
(e) Enrollee education materials;
(f) Community outreach activities;
and
(g) MCO and department policies that
affect enrollees.
(3) The QMAC shall provide the
results of its reviews to the MCO.
Section 52. External Quality Review.
(1) In accordance with 42 U.S.C. 1396a(a)(30), the department shall have an
independent external quality review organization (EQRO) annually review the
quality of services provided by an MCO.
(2) An MCO shall:
(a) Provide information to the EQRO
as requested to fulfill the requirements of the mandatory and optional
activities required in 42 C.F.R. Parts 433 and 438; and
(b) Cooperate and participate in
external quality review activities in accordance with the protocol established
in 42 C.F.R. 438 Subpart E, 438.310 to 438.370.
(3) The department shall have the
option of using information from a Medicare or private accreditation review of
an MCO in accordance with 42 C.F.R. 438.360.
(4) If an adverse finding or
deficiency is identified by an EQRO conducting an external quality review, an
MCO shall correct the finding or deficiency.
Section 53. Health Care Outcomes. An
MCO shall:
(1) Comply with the requirements
established in 42 C.F.R. 438.240 relating to quality assessment and performance
improvement;
(2) Collaborate with the department
to establish a set of unique Kentucky Medicaid managed care performance
measures which shall:
(a) Be aligned with national and
state preventive initiatives; and
(b) Focus on improving health;
(3) In collaboration with the
department and the EQRO, develop a performance measure specific to individuals
with special health care needs;
(4) Report activities on performance
measures in the QAPI work plan established in Section 49 of this administrative
regulation;
(5) Submit an annual report to the
department after collecting performance data which shall be stratified by:
(a) Medicaid eligibility category;
(b) Race;
(c) Ethnicity;
(d) Gender; and
(e) Age;
(6) Collect and report HEDIS data
annually; and
(7) Submit to the department:
(a) The final auditor’s report
issued by the NCQA certified audit organization;
(b) A copy of the interactive data
submission system tool used by the MCO; and
(c) The reports specified in MCO
Reporting Requirements.
Section 54. Performance Improvement
Projects (PIPs). (1) An MCO shall:
(a) Implement PIPs to address
aspects of clinical care and non-clinical services;
(b) Collaborate with local health
departments, behavioral health agencies, and other community-based health or
social service agencies to achieve improvements in priority areas;
(c) Initiate a minimum of two (2)
PIPs each year with at least one (1) PIP relating to physical health and at
least one (1) PIP relating to behavioral health;
(d) Report on a PIP using
standardized indicators;
(e) Specify a minimum performance
level for a PIP; and
(f) Include the following for a PIP:
1. The topic and its importance to
enrolled members;
2. Methodology for topic selection;
3. Goals of the PIP;
4. Data sources and collection
methods;
5. An intervention; and
6. Results and interpretations.
(2) A clinical PIP shall address
preventive and chronic healthcare needs of enrollees including:
(a) The enrollee population;
(b) A subpopulation of the enrollee
population; and
(c) Specific clinical need of
enrollees with conditions and illnesses that have a higher prevalence in the
enrolled population.
(3) A non-clinical PIP shall address
improving the quality, availability, and accessibility of services provided by
an MCO to enrollees and providers.
(4) The department may require an
MCO to implement a PIP specific to the MCO if:
(a) A finding from an EQRO review
referenced in Section 52 of this administrative regulation or an audit
indicates a need for a PIP; or
(b) Directed by CMS.
(5) The department shall be
authorized to require an MCO to assist in a statewide PIP which shall be
limited to providing the department with data from the MCO’s service area.
Section 55. Enrollee and Provider Surveys.
(1) An MCO shall:
(a) Conduct an annual survey of
enrollee and provider satisfaction of the quality and accessibility to a
service provided by an MCO;
(b) Satisfy a member satisfaction
survey requirement by participating in the Agency for Health Research and
Quality’s current Consumer Assessment of Healthcare Providers and Systems
Survey (CAHPS) for Medicaid Adults and Children, which shall be administered by
an NCQA-certified survey vendor;
(c) Provide a copy of the current
CAHPS survey referenced in paragraph (b) of this subsection to the department;
(d) Annually assess the need for
conducting other surveys to support quality and performance improvement initiatives;
(e) Submit to the department for
approval the survey tool used to conduct the survey referenced in paragraph (a)
of this subsection; and
(f) Provide to the department:
1. A copy of the results of the
enrollee and provider surveys referenced in paragraph (a) of this subsection;
2. A description of a methodology to
be used to conduct surveys;
3. The number and percentage of
enrollees and providers surveyed;
4. Enrollee and provider survey
response rates;
5. Enrollee and provider survey findings;
and
6. Interventions conducted or
planned by the MCO related to activities in this section.
(2) The department shall:
(a) Approve enrollee and provider
survey instruments prior to implementation; and
(b) Approve or disapprove an MCO’s
provider survey tool within fifteen (15) days of receipt of the survey tool.
(3) If an MCO conducts a survey that
targets a subpopulation’s perspective or experience with access, treatment, or
services, the MCO shall comply with the requirements established in subsection
(1)(e) and (f) of this section.
Section 56. Prompt Payment of
Claims. (1) In accordance with 42 U.S.C. 1396a(a)(37), an MCO shall have
prepayment and postpayment claims review procedures that ensure the proper and
efficient payment of claims and management of the program.
(2) An MCO shall:
(a) Comply with the prompt payment
provisions established in:
1. 42 C.F.R. 447.45; and
2. KRS 205.593, KRS 304.14-135, and
KRS 304.17A-700 to 304.17A-730; and
(b) Notify a requesting provider of
a decision to:
1. Deny a claim; or
2. Authorize a service in an amount,
duration, or scope that is less than requested.
(3) The payment provisions in this
section shall apply to a payment to:
(a) A provider within the MCO
network; and
(b) An out-of-network provider.
Section 57. Payments to an MCO. (1)
The department shall provide an MCO a per enrollee, per month capitation
payment whether or not the enrollee receives a service during the period
covered by the payment except for an enrollee whose eligibility is determined
due to being unemployed in accordance with 45 C.F.R. 233.100.
(2) The monthly capitation payment
for an enrollee whose eligibility is determined due to being unemployed shall
be prorated from the date of eligibility.
(3) A capitation rate referenced in
subsection (1) of this section shall:
(a) Meet the requirements of 42
C.F.R. 438.6(c); and
(b) Be approved by the Centers for
Medicare and Medicaid Services.
(4)(a) The department shall apply a
risk adjustment to a capitation rate in an amount that shall be budget neutral
to the department.
(b) The department shall use the
latest version of the Chronic Illness and Disability Payment System to
determine the risk adjustment referenced in paragraph (a) of this subsection.
Section 58. Recoupment of Payment
from an Enrollee for Fraud, Waste, or Abuse. (1) If an enrollee is determined
to be ineligible for Medicaid through an administrative hearing or adjudication
of fraud by the CHFS OIG, the department shall recoup a capitation payment it
has made to an MCO on behalf of the enrollee.
(2) An MCO shall request a refund
from the enrollee referenced in subsection (1) of this section of a payment the
MCO has made to a provider for the service provided to the enrollee.
(3) If an MCO has been unable to collect
a refund referenced in subsection (2) of this section within six (6) months,
the Commonwealth shall have the right to recover the refund from the enrollee.
Section 59. MCO Administration. An
MCO shall have executive management responsible for operations and functions of
the MCO that shall include:
(1) An executive director who shall:
(a) Act as a liaison to the
department regarding a contract between the MCO and the department;
(b) Be authorized to represent the
MCO regarding an inquiry pertaining to a contract between the MCO and the department;
(c) Have decision making authority;
and
(d) Be responsible for following up
regarding a contract inquiry or issue;
(2) A medical director who shall be:
(a) A physician licensed to practice
medicine in Kentucky;
(b) Actively involved in all major
clinical programs and quality improvement components of the MCO; and
(c) Available for after-hours
consultation;
(3) A dental director who shall be:
(a) Licensed by a dental board of
licensure in any state;
(b) Actively involved in all oral
health programs of the MCO; and
(c) Available for after-hours
consultation;
(4)(a) A finance officer who shall
oversee the MCO’s budget and accounting systems; and
(b) An internal auditor who shall
ensure compliance with adopted standards and review expenditures for
reasonableness and necessity;
(5) A quality improvement director
who shall be responsible for the operation of:
(a) The MCO’s quality improvement program;
and
(b) A subcontractor’s quality
improvement program;
(6) A behavioral health director who
shall be:
(a) A behavioral health
practitioner;
(b) Actively involved in all of the
MCO’s programs or initiatives relating to behavioral health; and
(c) Responsible for the coordination
of behavioral health services provided by the MCO or any of its behavioral
health subcontractors;
(7) A case management coordinator
who shall be responsible for coordinating and overseeing case management
services and continuity of care for MCO enrollees;
(8) An early and periodic screening,
diagnosis, and treatment (EPSDT) coordinator who shall coordinate and arrange
for the provision of EPSDT services and EPSDT special services for MCO
enrollees;
(9) A foster care and subsidized
adoption care liaison who shall serve as the MCO’s primary liaison for meeting
the needs of an enrollee who is:
(a) A child in foster care; or
(b) A child receiving state-funded
adoption assistance;
(10) A guardianship liaison who
shall serve as the MCO’s primary liaison for meeting the needs of an enrollee
who is a ward of the Commonwealth;
(11) A management information
systems director who shall oversee, manage, and maintain the MCO’s management
information system;
(12) A program integrity coordinator
who shall coordinate, manage, and oversee the MCO’s program integrity
functions;
(13) A pharmacy director who shall
coordinate, manage, and oversee the MCO’s pharmacy program;
(14) A compliance director who shall
be responsible for the MCO’s:
(a) Financial and programmatic
accountability, transparency, and integrity; and
(b) Compliance with:
1. All applicable federal and state
law;
2. Any administrative regulation
promulgated by the department relating to the MCO; and
3. The requirements established in
the contract between the MCO and the department;
(15) A member services director who
shall:
(a) Coordinate communication with
MCO enrollees; and
(b) Respond in a timely manner to an
enrollee seeking a resolution of a problem or inquiry;
(16) A provider services director
who shall:
(a) Coordinate communication with
MCO providers and subcontractors; and
(b) Respond in a timely manner to a
provider seeking a resolution of a problem or inquiry; and
(17) A claims processing director
who shall ensure the timely and accurate processing of claims.
Section 60. MCO Reporting
Requirements. An MCO shall:
(1) Submit to the department a
report as required by MCO Reporting Requirements;
(2) Verify the accuracy of data and
information on a report submitted to the department;
(3) Analyze a required report to
identify an early pattern of change, a trend, or an outlier before submitting
the report to the department; and
(4) Submit the analysis required in
subsection (3) of this section with a required report.
Section 61. Health Care Data
Submission and Penalties. (1)(a) An MCO shall submit an original encounter
record and denial encounter record, if any, to the department weekly.
(b) An original encounter record or
a denial encounter record shall be considered late if not received by the
department within four (4) calendar days from the weekly due date.
(c) Beginning on the fifth calendar
day late, the department shall withhold $500 per day for each day late from an
MCO’s total capitation payments for the month following non-submission of an
original encounter record and denial encounter record.
(2)(a) If an MCO fails to submit
health care data derived from processed claims or encounter data in a form or
format established in the MCO Reporting Requirements for one (1) calendar
month, the department shall withhold an amount equal to five (5) percent of the
MCO’s capitation payment for the month following non-submission.
(b) The department shall retain the
amount referenced in paragraph (a) of this subsection until the data is
received and accepted by the department, less $500 per day for each day late.
(3)(a) The department shall transmit
to an MCO an encounter record with an error for correction by the MCO.
(b) An MCO shall have ten (10) days
to submit a corrected encounter record to the department.
(c) If an MCO fails to submit a
corrected encounter record within the time frame specified in paragraph (b) of
this subsection, the department shall be able to assess and withhold for the
month following the non-submission, an amount equal to one-tenth of a percent
of the MCO’s total capitation payments per day until the corrected encounter
record is received and accepted by the department.
Section 62. Program Integrity. An
MCO shall comply with:
(1) 42 C.F.R. 438.608;
(2) 42 U.S.C. 1396a(a)(68); and
(3) The requirements established in
the MCO Program Integrity Requirements.
Section 63. Third Party Liability
and Coordination of Benefits. (1) Medicaid shall be the payer of last resort
for a service provided to an enrollee.
(2) An MCO shall:
(a) Exhaust a payment by a third
party prior to payment for a service provided to an enrollee;
(b) Be responsible for determining a
legal liability of a third party to pay for a service provided to an enrollee;
(c) Actively seek and identify a
third party liability resource to pay for a service provided to an enrollee in
accordance with 42 C.F.R. 433.138; and
(d) Assure that Medicaid shall be
the payer of last resort for a service provided to an enrollee.
(3) In accordance with 907 KAR 1:011
and KRS 205.624, an enrollee shall:
(a) Assign, in writing, the
enrollee’s rights to an MCO for a medical support or payment from a third party
for a medical service provided by the MCO; and
(b) Cooperate with an MCO in
identifying and providing information to assist the MCO in pursuing a third
party that shall be liable to pay for a service provided by the MCO.
(4) If an MCO becomes aware of a
third party liability resource after payment for a service provided to an
enrollee, the MCO shall seek recovery from the third party resource.
(5) An MCO shall have a process for
third party liability and coordination of benefits in accordance with Third
Party Liability and Coordination of Benefits.
Section 64. Management Information
System. (1) An MCO shall:
(a) Have a management information system
that shall:
1. Provide support to the MCO
operations; and
2. Except as provided in subsection
(2) of this section, include a:
a. Member subsystem;
b. Third party liability subsystem;
c. Provider subsystem;
d. Reference subsystem;
e. Claim processing subsystem;
f. Financial subsystem;
g. Utilization and quality
improvement subsystem; and
h. Surveillance utilization review
subsystem; and
(b) Transmit data to the department
in accordance with 42 C.F.R. 438.242and the Management Information System
Requirements.
(2) An MCO’s management information
system shall not be required to have the subsystems listed in subsection
(1)(a)2. of this section if the MCO’s management information system:
(a) Has the capacity to:
1. Capture and provide the required
data captured by the subsystems listed in subsection (1)(a)2. of this section;
and
2. Provide the data in formats and
files that shall be consistent with the subsystems listed in subsection
(1)(a)2. of this section; and
(b) Meets the requirements
established in paragraph (a) of this subsection in a way which shall be mapped
to the subsystem concept established in subsection (1)(a)2. of this section.
(3) If an MCO subcontracts for
services, the MCO shall provide guidelines for its subcontractor to the
department for approval.
Section 65. Kentucky Health
Information Exchange (KHIE). (1) An MCO shall:
(a) Submit to the KHIE:
1. An adjudicated claim within
twenty-four (24) hours of the final claim adjudication; and
2. Clinical data as soon as it is
available;
(b) Make an attempt to have a PCP in
the MCO’s network connect to KHIE within:
1. One (1) year of enrollment in the
MCO’s network; or
2. A timeframe approved by the department
if greater than one (1) year; and
(c) Encourage a provider in its
network to establish connectivity with the KHIE.
(2) The department shall:
(a) Administer an electronic health
record incentive payment program; and
(b) Inform an MCO of a provider that
has received an electronic health record incentive payment.
Section 66. MCO Qualifications and
Maintenance of Records. (1) An MCO shall:
(a) Be licensed by the Department of
Insurance as a health maintenance organization or an insurer;
(b) Have a governing body;
(c) Have protection against
insolvency in accordance with:
1. 806 KAR 3:190; and
2. 42 C.F.R. 438.116;
(d) Maintain all books, records, and
information related to MCO providers, recipients, or recipient services, and
financial transactions for:
1. A minimum of five (5) years in
accordance with 907 KAR 1:672; and
2. Any additional time period as
required by federal or state law; and
(e) Submit a request for disclosure
of information subject to open records laws, KRS 61.870 to 61.884, received
from the public to the department within twenty-four (24) hours.
(2) Information shall not be
disclosed by an MCO pursuant to a request it received pursuant to subsection
(1)(e) of this section without prior written authorization from the department.
(3) The books, records, and
information referenced in subsection (1)(d) of this section shall be available
upon request of a reviewer or auditor during routine business hours at the
MCO’s place of operations.
(4) MCO staff shall be available
upon request of a reviewer or auditor during routine business hours at the
MCO’s place of operations.
Section 67. Prohibited Affiliations.
The policies or requirements:
(1) Imposed on a managed care entity
in 42 U.S.C. 1396u-2(d)(1) shall apply to an MCO; and
(2) Established in 42 C.F.R. 438.610
shall apply to an MCO.
Section 68. Termination of MCO
Participation in the Medicaid Program. If necessary, a contract with an MCO
shall be terminated and the termination shall be in accordance with KRS Chapter
45A.
Section 69. Incorporation by
Reference. (1) The following material is incorporated by reference:
(a) "MCO Reporting
Requirements", July 2011 edition;
(b) "MCO Program Integrity
Requirements", July 2011 edition;
(c) "Early and Periodic
Screening, Diagnosis and Treatment Program Periodicity Schedule", July
2011 edition;
(d) "Third Party Liability and
Coordination of Benefits", July 2011 edition; and
(e) "Management Information
Systems Requirements", July 2011 edition.
(2) This
material may be inspected, copied, or obtained, subject to applicable copyright
law, at the Department for Medicaid Services, 275 East Main Street, Frankfort,
Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m., or from its Web
site at http://www.chfs.ky.gov/dms/incorporated.htm.] (38 Ky.R.
1249; 1588; 1738; eff. 5-4-12.)907 KAR 17:005
LAWRENCE KISSNER, Commissioner
AUDREY TAYSE HAYNES, Secretary
APPROVED BY AGENCY: December 18, 2012
FILED WITH LRC: December 21, 2012 at 4 p.m.
PUBLIC HEARING AND PUBLIC COMMENT PERIOD: A public hearing on this administrative regulation shall, if requested, be held on February 21, 2013 at 9:00 a.m. in the Health Services Auditorium, Health Services Building, First Floor, 275 East Main Street, Frankfort, Kentucky 40621. Individuals interested in attending this hearing shall notify this agency in writing by February 14, 2013, five (5) workdays prior to the hearing, of their intent to attend. If no notification of intent to attend the hearing is received by that date, the hearing may be canceled. The hearing is open to the public. Any person who attends will be given an opportunity to comment on the proposed administrative regulation. A transcript of the public hearing will not be made unless a written request for a transcript is made. If you do not wish to attend the public hearing, you may submit written comments on the proposed administrative regulation. You may submit written comments regarding this proposed administrative regulation until close of business February 28, 2013. Send written notification of intent to attend the public hearing or written comments on the proposed administrative regulation to:
CONTACT PERSON: Jill Brown, Office of Legal Services, 275 East Main Street 5 W-B, Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573, email jill.brown@ky.gov.
REGULATORY IMPACT ANALYSIS And Tiering Statement
Contact Person: Stuart Owen
(1) Provide a brief summary of:
(a) What this administrative regulation does: This administrative regulation currently establishes Kentucky Medicaid program managed care policies [excluding MCO policies for region three (3) of Kentucky.] Region three (3) is a sixteen (16) county region which includes Jefferson County and previously only contained one (1) MCO. A separate regulation, 907 KAR 1:705, established the requirements and policies for the lone MCO in region three (3). The contract between DMS and the lone MCO in region three (3) is expiring and earlier this year DMS published a request for proposal for bids to perform MCO responsibilities in region three (3). Through that process DMS awarded contracts with four (4) entities – including the incumbent entity that was the sole region three (3) entity. As a result DMS is repealing 907 KAR 1:705 and establishing uniform requirements and policies for MCOs for all regions – one set of requirements and policies. DMS is doing this by addressing MCO requirements and policies across six (6) administrative regulations rather than this lone administrative regulation. DMS is dividing the policies across multiple regulations in response to urging from the Administrative Regulation Review Subcommittee when it reviewed 907 KAR 17:005 earlier this year. This administrative regulation; thus, will contain the definitions for Medicaid managed care administrative regulations. The other administrative regulations are new administrative regulations (907 KAR 17:010, 907 KAR 17:015, 907 KAR 17:020, 907 KAR 17:025 and 907 KAR 17:030) which will address subjects previously addressed in this administrative regulation and are all being promulgated concurrently along with this amended administrative regulation.
(b) The necessity of this administrative regulation: This administrative regulation is necessary to establish the definitions for chapter 17 of title 907 – which is the chapter that contains Kentucky Medicaid program managed care regulations. The definitions are not being amended from what is currently stated in this administrative regulation. DMS is establishing MCO requirements and policies in multiple administrative regulations rather than in this lone administrative regulation. DMS is doing this in response to urging from the Administrative Regulation Review Subcommittee and staff when this administrative regulation was reviewed by the committee earlier this year.
(c) How this administrative regulation conforms to the content of the authorizing statutes: This administrative regulation conforms to the content of the authorizing statutes by establishing the definitions for chapter 17 of title 907 – which is the chapter that contains Kentucky Medicaid program managed care regulations.
(d) How this administrative regulation currently assists or will assist in the effective administration of the statutes: This administrative regulation will assist in the effective administration of the authorizing statutes by establishing the definitions for chapter 17 of title 907 – which is the chapter that contains Kentucky Medicaid program managed care regulations.
(2) If this is an amendment to an existing administrative regulation, provide a brief summary of:
(a) How the amendment will change this existing administrative regulation: This administrative regulation currently establishes Kentucky Medicaid program managed care policies but is being amended to establish the definitions for chapter 17 of title 907 – which is the chapter that contains Kentucky Medicaid program managed care regulations. The Department for Medicaid Services (DMS) is dividing the current regulation into four (4) regulations.
(b) The necessity of the amendment to this administrative regulation: DMS is dividing the administrative regulation into four (4) in response to a request by the Administrative Regulation Review Subcommittee and staff when the regulation previously was reviewed by the Subcommittee.
(c) How the amendment conforms to the content of the authorizing statutes: The amendment conforms to the content of the authorizing statutes by establishing the definitions for chapter 17 of title 907 – which is the chapter that contains Kentucky Medicaid program managed care regulations.
(d) How the amendment will assist in the effective administration of the statutes: The amendment will assist in the effective administration of the authorizing statutes by establishing the definitions for chapter 17 of title 907 – which is the chapter that contains Kentucky Medicaid program managed care regulations..
(3) List the type and number of individuals, businesses, organizations, or state and local government affected by this administrative regulation: Medicaid providers who participate with any or all managed care organizations, Medicaid recipients enrolled in managed care (currently there are over 700,000 such individuals) and the four (4) managed care organizations providing Medicaid covered services under contract with the Commonwealth will be affected by the administrative regulation.
(4) Provide an analysis of how the entities identified in question (3) will be impacted by either the implementation of this administrative regulation, if new, or by the change, if it is an amendment, including:
(a) List the actions that each of the regulated entities identified in question (3) will have to take to comply with this administrative regulation or amendment: No action is required.
(b) In complying with this administrative regulation or amendment, how much will it cost each of the entities identified in question (3). No cost is imposed.
(c) As a result of compliance, what benefits will accrue to the entities identified in question (3). The administrative regulation establishes definitions for managed care regulation. Definitions will benefit the affected entities by providing clarity to terms used in the Medicaid managed care regulations.
(5) Provide an estimate of how much it will cost to implement this administrative regulation:
(a) Initially: No cost is necessary to implement the amendment to this administrative regulation. DMS’s projected managed care expenditures for state fiscal year (SFY 2013) are $3,198,870,633.
(b) On a continuing basis: No cost is necessary to implement the amendment to this administrative regulation. DMS’s projected managed care expenditures for state fiscal year (SFY 2013) are $3,303,448,347.
(6) What is the source of the funding to be used for the implementation and enforcement of this administrative regulation: The sources of revenue to be used for implementation and enforcement of this administrative regulation are federal funds authorized under Title XIX of the Social Security Act and state matching funds comprised of general fund and restricted fund appropriations.
(7) Provide an assessment of whether an increase in fees or funding will be necessary to implement this administrative regulation, if new, or by the change if it is an amendment: Neither an increase in fees nor funding are necessary.
(8) State whether or not this administrative regulation establishes any fees or directly or indirectly increases any fees: This administrative regulation neither establishes nor directly or indirectly increases any fees.
(9) Tiering: Is tiering applied? Tiering is neither applied nor necessary as the administrative regulation establishes definitions to be used for regulations contains in chapter 17 of title 907 of the Kentucky Administrative Regulations.
FEDERAL MANDATE ANALYSIS COMPARISON
1. Federal statute or regulation constituting the federal mandate. A managed care program is not federally mandated for Medicaid programs; however, there are federal requirements for states which implement managed care and those requirements are contained in 42 C.F.R. Part 438.
2. State compliance standards. KRS 205.520(3) states, "Further, it is the policy of the Commonwealth to take advantage of all federal funds that may be available for medical assistance. To qualify for federal funds the secretary for health and family services may by regulation comply with any requirement that may be imposed or opportunity that may be presented by federal law. Nothing in KRS 205.510 to 205.630 is intended to limit the secretary's power in this respect."
3. Minimum or uniform standards contained in the federal mandate. A managed care program is not federally mandated for Medicaid programs; however, there are federal requirements for states which implement managed care and those requirements are contained in 42 C.F.R. Part 438.
4. Will this administrative regulation impose stricter requirements, or additional or different responsibilities or requirements, than those required by the federal mandate? No, this change relates to provision of managed care but does not impose additional or stricter requirements.
5. Justification for the imposition of the stricter standard, or additional or different responsibilities or requirements. A managed care method of administering the program is being implemented but stricter requirements are not imposed. A managed care program is not federally mandated for Medicaid programs.
FISCAL NOTE ON STATE OR LOCAL GOVERNMENT
1. What units, parts or divisions of state or local government (including cities, counties, fire departments, or school districts) will be impacted by this administrative regulation? The Department for Medicaid Services will be affected by this administrative regulation. Additionally, county-owned hospitals, university hospitals, local health departments, and primary care centers owned by government entities will be affected by this administrative regulation.
2. Identify each state or federal regulation that requires or authorizes the action taken by the administrative regulation. 42 C.F.R. 438 and this administrative regulation authorizes the action taken by this administrative regulation.
3. Estimate the effect of this administrative regulation on the expenditures and revenues of a state or local government agency (including cities, counties, fire departments, or school districts) for the first full year the administrative regulation is to be in effect.
(a) How much revenue will this administrative regulation generate for the state or local government (including cities, counties, fire departments, or school districts) for the first year? None.
(b) How much revenue will this administrative regulation generate for the state or local government (including cities, counties, fire departments, or school districts) for subsequent years? None.
(c) How much will it cost to administer this program for the first year? No cost is necessary to implement this amended administrative regulation. DMS’s projected managed care expenditures for SFY 2013 are $3,198,870,633.
(d) How much will it cost to administer this program for subsequent years? No cost is necessary to implement this amended administrative regulation. DMS’s projected managed care expenditures for SFY 2014 are $3,303,448,347.
Note: If specific dollar estimates cannot be determined, provide a brief narrative to explain the fiscal impact of the administrative regulation.
Revenues (+/-):
Expenditures (+/-):
Other Explanation: