††††† 907 KAR 1:102. Advanced practice registered nurse services.

 

††††† RELATES TO: KRS 205.520

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 C.F.R. Part 493, 42 U.S.C. 1396a, b, c, d, 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 for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the provisions relating to advanced practice registered nurse services for which payment shall be made by the Medicaid Program in behalf of both the categorically needy and the medically needy.

 

††††† Section 1. Definitions. (1) "Advanced practice registered nurse" or "APRN" is defined in KRS 314.011(7).

††††† (2) "Common practice" means a contractual partnership in which a physician and an APRN jointly administer health care services.

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

††††† (4) "Emergency medical condition" means a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part.

††††† (5) "Emergency services" means covered inpatient or outpatient services, including emergency ambulance transport, furnished by a qualified provider if the services are needed to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard.

††††† (6) "Medically necessary" or "medical necessity" means that a covered benefit shall be:

††††† (a) Provided in accordance with 42 C.F.R. 440.230;

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

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

††††† (d) Provided for medical reasons rather than primarily for the convenience of the recipient, caregiver, or the provider;

††††† (e) 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;

††††† (f) 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; and

††††† (g) If applicable, provided in accordance with early and periodic screening, diagnosis, and treatment (EPSDT) requirements established in 42 U.S.C. 1396d(r) and 42 C.F.R. Part 441 Subpart B for individuals under twenty-one (21) year of age.

††††† (7) "New patient" means one who has not received professional services from the provider within a three (3) year period.

††††† (8) "Prudent layperson standard" means the criterion used to determine the existence of an emergency medical condition whereby a prudent layperson, who possesses an average knowledge of health and medicine, determines that a medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) that the person could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part.

††††† (9) "Recipient" means an individual who has been determined by the Kentucky Department of Community Based Services to be eligible to have the Kentucky Medicaid Program make reimbursement for covered services.

 

††††† Section 2. Conditions of Participation. (1) An APRN may participate in Kentucky Medicaid by complying with the terms and conditions established in 907 KAR 1:671 and 907 KAR 1:672.

††††† (2) A service provided by an APRN to a Kentucky Medicaid recipient shall be substantiated by medical records signed by the APRN which correspond to the date and service reported on the claim submitted for payment to Kentucky Medicaid.

††††† (3) In addition to the requirements established in subsection (2) of this section, the APRN shall document in the medical record of a hospitalized Kentucky Medicaid recipient that the APRN performed one (1) or more of the following:

††††† (a) A personal review of the recipientís medical history;

††††† (b) A physical examination;

††††† (c) A confirmation or revision of the recipientís diagnosis;

††††† (d) A visit with the recipient; or

††††† (e) A discharge service for the recipient.

 

††††† Section 3. APRN Covered Services. (1) An APRN covered service shall be:

††††† (a) A medically-necessary service furnished by an APRN through direct practitioner-patient interaction; and

††††† (b) A service which is:

††††† 1. Within the legal scope of practice of the APRN as specified in 201 KAR 20:057; and

††††† 2. Eligible for reimbursement by Kentucky Medicaid.

††††† (2) Administration of anesthesia by an APRN shall be a covered service.

††††† (3) Prescribing of drugs by an APRN shall be in accordance with 907 KAR 1:019. If a specific brand of prescription is determined by the APRN to be medically necessary for a patient, the certification procedure shall conform with the requirements established in 907 KAR 3:005.

††††† (4)(a) The cost of the following injectables administered in a physician or independent practitioner's office shall be covered:

††††† 1. Rho (D) immune globulin injection;

††††† 2. Injectable anticancer chemotherapy administered to a recipient in accordance with 907 KAR 3:005;

††††† 3. Depo-Provera contraceptive injection if provided in an office setting;

††††† 4. Penicillin G and ceftriaxone injectable antibiotics; and

††††† 5. Epidural injection if administered in accordance with the requirements established in 907 KAR 3:005.

††††† (b) The cost of injectables not specified in paragraph (a) of this subsection shall be covered in accordance with 907 KAR 1:019, Section 2.

††††† (5) An outpatient laboratory procedure performed by an APRN who has been certified in accordance with 42 C.F.R. Part 493 shall be covered.

††††† (6) An obstetrical and gynecological service shall be covered as follows:

††††† (a) An annual gynecological examination;

††††† (b) Prenatal care;

††††† (c) A delivery service, which shall include:

††††† 1. Admission to the hospital;

††††† 2. Admission history;

††††† 3. Physical examination;

††††† 4. Anesthesia;

††††† 5. Management of uncomplicated labor;

††††† 6. Vaginal delivery; and

††††† 7. Postpartum care;

††††† (d) A routine newborn service to an infant born to a Kentucky Medicaid eligible recipient;

††††† (e) An insertion of an intrauterine device (IUD), including the cost of the device, or removal of the IUD; or

††††† (f) The insertion of an implantable contraceptive capsule, including the cost of the contraceptive capsule and related supplies, or removal of the contraceptive capsule.

††††† (7) An EPSDT screening service provided in compliance with the periodicity schedule established in 907 KAR 11:034 shall be covered.

††††† (8) The standard for determining the existence of an emergency medical condition and the need for emergency services shall be:

††††† (a) In accordance with 42 U.S.C. 1396u-2; and

††††† (b) Based on the prudent layperson standard.

 

††††† Section 4. Service Limitations. (1) A limitation on a service provided by a physician in accordance with 907 KAR 3:005 shall apply if the service is provided by an APRN.

††††† (2) The same service performed by an APRN and a physician on the same day within a common practice shall be considered as one (1) covered service.

 

††††† Section 5. Appeal Rights. (1) An appeal of a negative action taken by the department regarding a Medicaid beneficiary shall be in accordance with 907 KAR 1:563.

††††† (2) 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.

††††† (3) An appeal of a negative action taken by the department regarding a Medicaid provider shall be in accordance with 907 KAR 1:671. (17 Ky.R. 2365; eff. 5-3-91; Am. 19 Ky.R. 1453; eff. 1-27-93; 27 Ky.R. 245; 811; eff. 9-11-2000; TAm eff. 4-28-2011.)