CABINET FOR HEALTH AND FAMILY SERVICES

Department for Medicaid Services

Division of Policy and Operations

(As Amended at ARRS, February 10, 2014)

 

††††† 907 KAR 20:050. Presumptive eligibility[for pregnant women].

 

††††† RELATES TO: KRS 205.520(3), 205.592, 42 U.S.C. 1396a(a)(47), r-1

††††† STATUTORY AUTHORITY: KRS 194A.030(3), 194A.050(1), 205.520(3)[(2), EO 2004-726]

††††† NECESSITY, FUNCTION, AND CONFORMITY:[EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services.] The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law to qualify for federal Medicaid funds[for the provision of medical assistance to Kentucky's indigent citizenry]. KRS 205.592 establishes Medicaid eligibility requirements for pregnant women and children up to age one (1). This administrative regulation establishes requirements for the determination of presumptive eligibility and the provision of services to individuals[pregnant women] deemed presumptively eligible for Medicaid-covered services.

 

††††† Section 1.[Definitions. (1) "Ambulatory prenatal care" means health-related care furnished to a presumed eligible pregnant woman provided in an outpatient setting.

††††† (2) "Cabinet" means the Cabinet for Health and Family Services.

††††† (3) "DCBS" means the Department for Community Based Services.

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

††††† (5) "Presumptive eligibility" means eligibility granted for Medicaid-covered services as specified in Section 6 of this administrative regulation to a qualified pregnant woman based on an income screening performed by a qualified provider.

††††† (6) "Qualified provider" means a provider who:

††††† (a) Is currently enrolled with the department;

††††† (b) Has been trained and certified by the department to grant presumptive eligibility to pregnant women; and

††††† (c) Provides services of the type described in 42 U.S.C. 1396d(a)(2)(A) or (B) or (9).

 

††††† Section 2.] Providers Eligible to Grant Presumptive Eligibility. (1) A determination of presumptive eligibility regarding:

††††† (a) A pregnant woman shall be made by a qualified provider who is:

††††† 1.[(1)] A family or general practitioner;

††††† 2.[(2)] A pediatrician;

††††† 3.[(3)] An internist;

††††† 4.[(4)] An obstetrician or gynecologist;

††††† 5.[(5)] A physician assistant;

††††† 6.[(6)] A certified nurse midwife;

††††† 7.[(7)] An advanced practice registered nurse[ practitioner];

††††† 8.[(8)] A federally-qualified health care center;

††††† 9.[(9)] A primary care center;

††††† 10.[(10)] A rural health clinic; or

††††† 11.[(11)] A local health department; or

††††† (b) An individual whose income standard for Medicaid eligibility purposes is a modified adjusted gross income shall be made by an inpatient hospital participating in the Medicaid Program.

††††† (2) An individual whose Medicaid eligibility is determined using the modified adjusted gross income as an income standard shall be an individual identified in 907 KAR 20:100 as having a modified adjusted gross income as the Medicaid income eligibility standard[as established in][:

††††† (a) An individual:

††††† 1. Who is:

††††† a. A child under the age of nineteen (19) years, excluding children in foster care;

††††† b. A caretaker relative with income up to 133 percent of the federal poverty level;

††††† c. A pregnant woman, with income up to 185 percent of the federal poverty level, including the postpartum period up to sixty (60) days after delivery;

††††† d. An adult under age sixty-five (65) with income up to 133 percent of the federal poverty level who:

††††† (i) Does not have a dependent child under the age of nineteen (19) years; and

††††† (ii) Is not otherwise eligible for Medicaid benefits; or

††††† e. A targeted low-income child with income up to 150 percent of the federal poverty level; and

††††† (b) In accordance with][907 KAR 20:100].

 

††††† Section 2.[3.] Provider Responsibilities. (1) A qualified provider who determines that an individual[a pregnant woman] is presumptively eligible for Medicaid based on criteria established in Section 3[4] of this administrative regulation shall:

††††† (a) Notify the department and obtain an authorization number;

††††† (b) Inform the individual[woman] at the time the determination is made that the individual[she] is required to make an application for Medicaid benefits through the individualís[her] local DCBS office;

††††† (c) Inform the individual of the location of the individualís local DCBS office;

††††† (d) Issue presumptive eligibility identification to the presumed eligible individual[woman]; and

††††† (e)[(d)] Maintain a record of the presumptive eligibility screening for each applicant.

††††† (2) If an individual[a woman] is determined not to be presumptively eligible, the qualified provider shall inform the individual[woman] of the following in writing:

††††† (a) The reason for the determination;

††††† (b) That the individual[she] may file an application for Medicaid if the individual[she] wishes to have a formal determination made; and

††††† (c) The location of the individualís[her] local DCBS office.

 

††††† Section 3.[4.] Eligibility Criteria. Presumptive eligibility shall[may] be granted to:

††††† (1) A woman if she:

††††† (a)[(1)] Is pregnant;

††††† (b)[(2)] Is a Kentucky resident;

††††† (c) Does not have income exceeding 195[185] percent of the federal poverty level established annually by the United States Department of Health and Human Services pursuant to 42 U.S.C. 9902(2)[(3) Meets income guidelines established in 907 KAR 1:640, Section 2(2)(a)];

††††† (d)[(4)] Does not currently have a pending Medicaid application on file with the DCBS;

††††† (e)[(5)] Is not currently enrolled in Medicaid;

††††† (f)[(6)] Has not been previously granted presumptive eligibility for the current pregnancy; and

††††† (g)[(7)] Is not an inmate of a public institution, except as established in 907 KAR 20:005, Section 7(2); or

††††† (2) An individual whose Medicaid income eligibility standard is a modified adjusted gross income if the individual:

††††† (a) Is a Kentucky resident;

††††† (b) Does not have income exceeding:

††††† 1. 133 percent of the federal poverty level established annually by the United States Department of Health and Human Services pursuant to 42 U.S.C. 9902(2); or

††††† 2. 150 percent of the federal poverty level established annually by the United States Department of Health and Human Services pursuant to 42 U.S.C. 9902(2), if the individual is a targeted low-income child;

††††† (c) Does not currently have a pending Medicaid application on file with the DCBS;

††††† (d) Is not currently enrolled in Medicaid; and

††††† (e) Is not an inmate of a public institution except as established in 907 KAR 20:005, Section 7(2).

 

††††† Section 4.[5.] Presumptive Eligibility Period. (1) Presumptive eligibility for an individual shall begin on the date on which a qualified provider:

††††† (a) Determines that the individual[a woman] is presumptively eligible based on the criteria specified in Section 3[4] of this administrative regulation if the qualified provider obtains an authorization number from the department on:

††††† 1. That day; or

††††† 2. If the department is closed, the next business day the department is open; or

††††† (b) Obtains an authorization number from the department if it is not the day specified in paragraph (a) of this subsection.

††††† (2) The presumptive eligibility period shall end on:

††††† (a) The day preceding the date the presumptively-eligible individual[woman] is granted full eligibility in the Medicaid Program by the DCBS; or

††††† (b) The last day of the[second] month following the month in which a qualified provider made the presumptive eligibility determination if the[a] presumed eligible individual[woman]:

††††† 1. Does not apply for the full Medicaid benefit package; or

††††† 2. Applies for and is found ineligible for the full Medicaid benefit package.

††††† (3) To illustrate the presumptive eligibility period, if an individual became presumptively eligible on July 7, 2014, the individual shall[would] remain presumptively eligible through August 31[September 30], 2014.

††††† (4) For a woman who gains presumptive eligibility by being pregnant, only one (1) presumptive eligibility period shall be granted for each episode of pregnancy.

 

††††† Section 5.[6.] Covered Services. (1)(a) Payment for a covered service provided to a presumptively-eligible individual[pregnant woman] shall be in accordance with the current Medicaid reimbursement policy for the service unless the service is provided to an individual who is enrolled with a managed care organization[reimbursement].

††††† (b) A managed care organization:

††††† 1. Shall not be required to reimburse in the same manner or amount as the department reimburses for a Medicaid-covered service provided to a presumptively eligible individual; or

††††† 2. May elect to reimburse in the same manner or amount as the department reimburses for a Medicaid-covered service provided to a presumptively eligible individual.

††††† (2) Covered services for a presumptively-eligible:

††††† (a) Pregnant woman shall be limited to ambulatory prenatal care services delivered in an outpatient setting and shall include:

††††† 1.[(a)] Services furnished by a primary care provider, including:

††††† a.[1.] A family or general practitioner;

††††† b.[2.] A pediatrician;

††††† c.[3.] An internist;

††††† d.[4.] An obstetrician or gynecologist;

††††† e.[5.] A physician assistant;

††††† f.[6.] A certified nurse midwife; or

††††† g.[7.] An advanced practice registered nurse[practitioner];

††††† 2.[(b)] Laboratory services provided in accordance with 907 KAR 10:014[1:014] and 907 KAR 1:028;

††††† 3.[(c)] Radiological[X-ray] services provided in accordance with 907 KAR 10:014[1:014] and 907 KAR 1:028;

††††† 4.[(d)] Dental services provided in accordance with 907 KAR 1:026[, Section 2(1) and (2)];

††††† 5.[(e)] Emergency room services provided in accordance with 907 KAR 10:014[, Section 1(1)(c)];

††††† 6.[(f)] Emergency and nonemergency transportation provided in accordance with 907 KAR 1:060;

††††† 7.[(g)] Pharmacy services provided in accordance with 907 KAR 1:019[1:019E];

††††† 8.[(h)] Services delivered by rural health clinics provided in accordance with 907 KAR 1:082;

††††† 9.[(i)] Services delivered by primary care centers,[and] federally-qualified health [care] centers, and federally-qualified health center look-alikes provided in accordance with 907 KAR 1:054; or

††††† 10.[(j)] Primary care services delivered by local health departments provided in accordance with 907 KAR 1:360; or

††††† (b) Individual who is not a pregnant woman shall include:

††††† 1. Services furnished by a primary care provider, including:

††††† a. A family or general practitioner;

††††† b. A pediatrician;

††††† c. An internist;

††††† d. An obstetrician or gynecologist;

††††† e. A physician assistant;

††††† f. A certified nurse midwife; or

††††† g. An advanced practice registered nurse;

††††† 2. Laboratory services provided in accordance with 907 KAR 10:014 and 907 KAR 1:028;

††††† 3. Radiological[X-ray] services provided in accordance with 907 KAR 10:014 and 907 KAR 1:028;

††††† 4. Dental services provided in accordance with 907 KAR 1:026[, Section 2(1) and (2)];

††††† 5. Emergency room services provided in accordance with 907 KAR 10:014;

††††† 6. Emergency and nonemergency transportation provided in accordance with 907 KAR 1:060;

††††† 7. Pharmacy services provided in accordance with 907 KAR 1:019;

††††† 8. Services delivered by rural health clinics provided in accordance with 907 KAR 1:082;

††††† 9. Services delivered by primary care centers,[and] federally-qualified health [care] centers, and federally-qualified health center look-alikes provided in accordance with 907 KAR 1:054;

††††† 10. Primary care services delivered by local health departments provided in accordance with 907 KAR 1:360; or

††††† 11. Inpatient or outpatient hospital services provided by a hospital.

 

††††† Section 6.[7.] Appeal Rights. (1) The appeal rights of the Medicaid Program shall not apply if an individual[a woman] is:

††††† (a) Determined not to be presumptively eligible; or

††††† (b) Determined to be presumptively eligible but fails to file an application for Medicaid with the DCBS before the individualís[her] presumptive eligibility ends and therefore is determined to be ineligible for Medicaid benefits.

††††† (2) The appeal rights of the Medicaid Program shall apply if an individual[a woman] is:

††††† (a) Determined to be presumptively eligible; and

††††† (b) Files an application with the DCBS but is determined ineligible for Medicaid benefits.

††††† (3) Except as specified in subsection (1) of this section, an appeal of a negative action taken by the department regarding a Medicaid recipient shall be in accordance with:

††††† (a) 907 KAR 1:563 if the individual is:

††††† 1. Not enrolled with a managed care organization; or

††††† 2. Enrolled with a managed care organization and the individual has exhausted the MCO internal appeal process in accordance with 907 KAR 17:010 and requests an appeal of an adverse decision by the MCO; or

††††† (b) 907 KAR 17:010 if the individual is enrolled with a managed care organization.

††††† (4) Except as specified in subsection (1) of this section, an appeal of a negative action taken by the department regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

††††† (5) An appeal of a negative action regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.

 

††††† Section 7.[8.] Quality Assurance and Utilization Review. The cabinet shall evaluate, on a continuing basis, access, continuity of care, health outcomes, and services arranged or provided by a Medicaid provider to a presumptively eligible individual[presumed eligible woman] in accordance with accepted standards of practice for medical service.

 

LAWRENCE KISSNER, Commissioner

AUDREY TAYSE HAYNES, Secretary

††††† APPROVED BY AGENCY: January 13, 2014

††††† FILED WITH LRC: January 14, 2014 at 1 p.m.

††††† CONTACT PERSON: Tricia Orme, Office of Legal Services, 275 East Main Street 5 W-B, Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573, email tricia.orme@ky.gov.