911 KAR 1:080. SSI Children's Support Services (SSI/CSS) Program.

 

      RELATES TO: KRS 200.460, 42 C.F.R. Part 51a, 42 U.S.C. 701 et seq., 1381 et seq.

      STATUTORY AUTHORITY: KRS 194A.030(7), 200.460(1)

      NECESSITY, FUNCTION, AND CONFORMITY: 42 USC 701 et seq. (Title V of the Social Security Act, as amended by PL 97-35), authorizes grants to states to provide rehabilitation services for blind and disabled children receiving benefits pursuant to 42 USC 1381 et seq. (Title XVI of the Social Security Act). The Commission for Children with Special Health Care Needs is authorized by KRS 194A.030(7) to promulgate administrative regulations in order to implement programs authorized by federal law that qualify for the receipt of federal funds. This administrative regulation establishes the eligibility criteria and covered services available through the SSI Children's Support Services Program in accordance with federal laws and regulations.

 

      Section 1. Definitions. (1) "Commission" means the Commission for Children with Special Health Care Needs.

      (2) "Medically necessary" or "medical necessity" means a covered benefit is:

      (a) Reasonable and required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition, including pregnancy;

      (b) Clinically appropriate in terms of the service, amount, scope, and duration based on generally-accepted standards of good medical practice;

      (c) Provided for medical reasons rather than primarily for the convenience of the individual, the individual's caregiver, or the health care provider, or for cosmetic reasons;

      (d) Provided in the most appropriate location, with regard to generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and effectively provided; and

      (e) Needed, if used in reference to an emergency medical service, to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard.

      (3) "Supplemental security income" or "SSI" means the federal cash assistance program authorized by 42 USC 1381 et seq.

 

      Section 2. Eligibility Criteria. In order to be eligible for an item or service provided through this program, a child shall:

      (1) Be a resident of Kentucky;

      (2) Qualify for a supplemental security income payment;

      (3) Be under the age of sixteen (16); and

      (4) Have a need that has been determined to be medically necessary pursuant to Section 5(3) of this administrative regulation.

 

      Section 3. SSI Children’s Support Services. (1) A child who applies for SSI with the Social Security Administration shall be provided information at that office regarding services provided by various agencies or organizations.

      (2) In accordance with 42 USC 1382d, if a child is approved for SSI benefits, the Social Security Administration shall refer information regarding the child’s approval for SSI benefits to the commission. Upon receipt of this information, the commission shall comply with this subsection:

      (a)1. If a child is aged from birth through two (2) years, the child shall be screened for eligibility for care coordination, clinical services or early intervention services provided through the commission. Within twenty (20) working days, the parent or legal guardian of the child shall receive a letter that:

      a. Informs him that the commission has received notice of his child’s SSI eligibility;

      b. Provides him with information about potential commission services and how to contact the commission; and

      c. Informs the parent or guardian that regardless of the child’s eligibility for commission services, if his child has a medically-necessary need that cannot be provided under Medicaid, the family may contact their local commission office in order to apply for the SSI/CSS Program.

      2. If the parent or legal guardian chooses to apply for services through this program, and provides the information required by Section 5 of this administrative regulation, the application shall be reviewed within twenty (20) working days.

      3.a. If approved, he shall receive a letter that informs him that the application is approved, and arrangements shall be made to handle the purchase or service delivery through the local commission office nearest the child’s home.

      b. If denied, he shall receive a letter that informs him that the application is denied, which shall include a reason for the denial and an explanation of his rights to request an administrative hearing.

      (b)1. If a child is aged three (3) through fifteen (15) years and has a diagnosis for which care coordination or clinical services are not provided by the commission, within twenty (20) working days of this determination, the parent or legal guardian of the child shall receive a letter that:

      a. Informs him that the commission has received notice of his child’s SSI eligibility;

      b. Provides him with general referral resource information; and

      c. Advises him that if the child has a medically-necessary need that cannot be provided under Medicaid, he may contact his local commission office in order to apply for the SSI/CSS Program.

      2. If the parent or legal guardian chooses to apply for services through this program, and provides the information required by Section 5 of this administrative regulation, the application shall be reviewed within twenty (20) working days.

      3.a. If approved, he shall receive a letter that informs him that the application is approved, and arrangements shall be made to handle the purchase or service delivery through the local commission office nearest the child’s home.

      b. If denied, he shall receive a letter that informs him that the application is denied, which shall include a reason for the denial and an explanation of his rights to request an administrative hearing.

      (c)1. If a child is aged three (3) through fifteen (15) years and has a diagnosis for which care coordination or clinical services are provided through the commission, and for which the child may be eligible, within twenty (20) working days, the parent or legal guardian of the child shall receive a letter that:

      a. Informs him that the commission has received notice of his child’s SSI eligibility;

      b. Provides him with information about potential commission services and how to contact the commission; and

      c. Informs the parent or guardian that regardless of the child’s eligibility for commission services, if his child has a medically-necessary need that cannot be provided under Medicaid, the family may contact their local commission office in order to apply for the SSI/CSS Program.

      2. If the parent or legal guardian chooses to apply for services through this program, and provides the information required by Section 5 of this administrative regulation, the application shall be reviewed within twenty (20) working days.

      3.a. If approved, he shall receive a letter that informs him that the application is approved, and arrangements shall be made to handle the purchase or service delivery through the local commission office nearest the child’s home.

      b. If denied, he shall receive a letter that informs him that the application is denied, which shall include a reason for the denial and an explanation of his rights to request an administrative hearing.

      (3) In order for an item or service to be provided through the SSI Children’s Support Services Program, it shall be determined to be medically necessary in accordance with Section 5(3) of this administrative regulation by:

      (a) The child’s physician; or

      (b) An advanced registered nurse practitioner.

      (4) An item or service shall be prior authorized in accordance with Section 5 of this administrative regulation.

      (5) In accordance with provisions established in Sections 4 and 5 of this administrative regulation, the commission shall provide an item or service if there are sufficient appropriated funds for the current fiscal year.

      (6) An item or service shall not be eligible for reimbursement through another funding source, such as Medicaid, in order to be reimbursed by this program.

      (7) Commission staff may secure an additional service by referring a child to another organization that has qualified personnel that may meet the child’s special needs.

 

      Section 4. Program Fee Schedule and Expenditure Limits. (1) The fee schedule and expenditure limits established in this section shall include shipping and handling for an approved item.

      (2) Expenditure limits established in this section shall be subject to the availability of appropriated funds at the time the request is received.

      (3) A service or item shall be prior authorized by the commission in accordance with Section 5 of this administrative regulation to ensure medical necessity and availability of funds.

      (4) Except for a service specified in subsection (5) of this section, the maximum amount per fiscal year that a child shall have available for a service or item shall be $500.

      (5)(a) Reimbursement for transportation shall be provided at thirty-two (32) cents per mile if the trip is:

      1. For critical medical care; and

      2. More than fifty (50) miles each way.

      (b) Reimbursement for lodging may be authorized if:

      1. An overnight stay is required; and

      2. The trip is for critical medical care.

      (c) Exceptions to the $500 maximum may be provided for transportation or lodging on a case-by-case basis.

      (6) Family support services shall be authorized if:

      (a)1. Circumstances warrant a child’s removal from the home; or

      2. Prevent a child from being discharged from a health care facility to his home; and

      (b) The service will rectify the situation.

      (7) Items that are available for prior authorization in accordance with Sections 3 and 5 of this administrative regulation shall be:

      (a) Adaptive equipment;

      (b) Medical supplies or equipment; and

      (c) Medications, lotions or ointments.

 

      Section 5. Prior Authorization Procedures. In order for an item or service to be approved, a person identified in Section 3(2) of this administrative regulation or the child’s guardian shall contact the Commission for Children with Special Health Care Needs office serving the child’s county and, in accordance with Section 3 of this administrative regulation, provide:

      (1) The child’s name and Medicaid identification number;

      (2) Information as to the exact item or service needed and its cost;

      (3) Proof of medical necessity explaining the need for the service as evidenced by a prescription or a letter signed by a person identified in Section 3(3) of this administrative regulation;

      (4) Except for items or services not covered by Medicaid, evidence that the service or item has been requested and denied by the Medicaid Program; and

      (5) Other documentation necessary to justify the medical necessity of the requested service.

 

      Section 6. Appeal Rights. If dissatisfied with an action taken by the commission, a child, his parent or his guardian shall be entitled to pursue filing a complaint or request an administrative hearing with the cabinet, to be conducted in accordance with KRS Chapter 13B. (11 Ky.R. 105; eff. 8-7-84; 18 Ky.R. 2026; eff. 2-7-92; Recodified from 902 KAR 4:070, 3-1-2001; 28 Ky.R. 2743; 29 Ky.R. 465; eff. 8-12-2002.)