††††† 907 KAR 1:900. KyHealth Choices benefit plans.

 

††††† RELATES TO: KRS 205.520, 205.560, 205.6312, 205.6481-6497, 205.8451, 319A.010, 327.010, 334A.020, 20 C.F.R. 416.2001, 42 C.F.R. 433.56, 435, 436.3, 440.30, 440.40, 440.60, 440.70, 440.110, 440.120, 440.130, 440.170, 441.20, 441.21, 441.35, 441.40, 457.310, 45 C.F.R. 233.100, 42 U.S.C. 416, 423, 1382c, 1383c, 1396a, b, c, d, o, r-6, r-8, 1396a(10)(A), 1396a(a)(52), 1396a(aa), 1396a(l)(1)(B), (C), (D), 1396d(a)(4)(C), 1396d(o), 1396u-1, 1397aa

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)

††††† 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 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 Medicaid Program KyHealth Choices benefit plans.

 

††††† Section 1. Definitions. (1) "Benchmark plan" means the Global Choices benefit plan.

††††† (2) "Benefit plan" means the health plan provided to recipients under comprehensive choices, family choices, global choices, or optimum choices.

††††† (3) "Caretaker relative" means a relative:

††††† (a) With whom a child is, or shall be, placed by the Cabinet for Health and Family Services; and

††††† (b) Who is seeking to qualify as a kinship caregiver.

††††† (4) "Comprehensive choices" means a benefit plan for an individual who:

††††† (a) Meets the nursing facility patient status criteria established in 907 KAR 1:022;

††††† (b) Receives services through either:

††††† 1. A nursing facility in accordance with 907 KAR 1:022;

††††† 2. The Acquired Brain Injury Waiver Program in accordance with 907 KAR 3:090;

††††† 3. The Home and Community Based Waiver Program in accordance with 907 KAR 1:160; or

††††† 4. The Model Waiver II Program in accordance with 907 KAR 1:595; and

††††† (c) Has a designated package code of F, G, H, I, J, K, L, M, O, P, Q, or R.

††††† (5) "Department" means the Department for Medicaid Services or its designee.

††††† (6) "Family choices" means a benefit plan for an individual who:

††††† (a) Is covered pursuant to:

††††† 1. 42 U.S.C. 1396a(a)(10)(i)(I) and 1396u-1;

††††† 2. 42 U.S.C. 1396a(a)(52) and 1396r-6 (excluding children eligible under Part A or E of title IV, codified as 42 U.S.C. 601 to 619 and 670 to 679b);

††††† 3. 42 U.S.C. 1396a(a)(10)(A)(i)(IV) as described in 42 U.S.C. 1396a(l)(1)(B);

††††† 4. 42 U.S.C. 1396a(a)(10)(A)(i)(VI) as described in 42 U.S.C. 1396a(l)(1)(C);

††††† 5. 42 U.S.C. 1396a(a)(10)(A)(i)(VII) as described in 42 U.S.C. 1396a(l)(1)(D); or

††††† 6. 42 C.F.R. 457.310; and

††††† (b) Has a designated package code of 2, 3, 4, or 5.

††††† (7) "Global choices" means the departmentís default benefit plan, consisting of individuals designated with a package code of A, B, C, D, or E and who are included in one (1) of the following populations:

††††† (a) Caretaker relatives who:

††††† 1. Receive K-TAP benefits and are deprived due to death, incapacity, or absence;

††††† 2. Do not receive K-TAP benefits and are deprived due to death, incapacity, or absence; or

††††† 3. Do not receive K-TAP benefits and are deprived due to unemployment;

††††† (b) Individuals aged sixty-five (65) and over who receive SSI benefits and:

††††† 1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022; or

††††† 2. Receive SSP benefits and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (c) Blind individuals who receive SSI benefits and:

††††† 1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022; or

††††† 2. SSP benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (d) Disabled individuals who receive SSI benefits and:

††††† 1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022, including children; or

††††† 2. SSP benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (e) Individuals aged sixty-five (65) and over who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (f) Blind individuals who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status in accordance with 907 KAR 1:022;

††††† (g) Disabled individuals who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status in accordance with 907 KAR 1:022;

††††† (h) Pregnant women; or

††††† (i) Medicaid works individuals.

††††† (8) "Kinship caregiver" means the qualified caretaker relative of a child with whom the child is placed by the Cabinet for Health and Family Services as an alternative to foster care.

††††† (9) "K-TAP" means Kentuckyís version of the federal block grant program of Temporary Assistance for Needy Families (TANF), a money payment program for children who are deprived of parental support or care due to:

††††† (a) Death;

††††† (b) Continued voluntary or involuntary absence;

††††† (c) Physical or mental incapacity of one (1) parent or stepparent if two (2) parents are in the home; or

††††† (10) "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 supplemental security income;

††††† (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.

††††† (11) "Model Waiver II" means a department program established in 907 KAR 1:595.

††††† (12) "Optimum choices" means a benefit plan for an individual who:

††††† (a) Meets the intermediate care facility for individuals with an intellectual disability patient status criteria established in 907 KAR 1:022;

††††† (b) Receives services through either:

††††† 1. An intermediate care facility for individuals with an intellectual disability in accordance with 907 KAR 1:022; or

††††† 2. The Supports for Community Living Waiver Program in accordance with 907 KAR 1:145; and

††††† (c) Has a designated package code of S, T, U, V, W, X, Z, 0, or 1.

††††† (13) "Package code" means a unique code which identifies a specific service under each benefit plan.

††††† (14) "Recipient" is defined in KRS 205.8451 and applies to an individual who has been determined eligible to receive benefits under the stateís Title XIX or Title XXI Program in accordance with 907 KAR Chapters 1 through 4.

††††† (15) "SSI" means the Social Security Administration program called supplemental security income.

††††† (16) "SSP" means state supplemental payments for individuals who are aged, blind or disabled and in accordance with 921 KAR 2:015.

 

††††† Section 2. Benefit Plan Assignment. (1)(a) The department shall assign each recipient, including those excluded from mandatory participation pursuant to 42 U.S.C. 1396u-7(a)(2)(B), to an appropriate benefit package. The four (4) benefit plans shall:

††††† 1. Include comprehensive choices, family choices, global choices, or optimum choices pursuant to the definitions established in Section 1(4), (6), (7), (12) of the administrative regulation; and

††††† 2. Be based on the recipientís medical needs or circumstances.

††††† (b) An individual excluded from mandatory participation pursuant to 42 U.S.C. 1396u-7(a)(2)(B):

††††† 1. May enroll in the benchmark plan; and

††††† 2. Shall be subject to the cost-sharing, service limit, and any other provisions established for the benchmark plan effective beginning with the date the individual requested to be enrolled in the benchmark plan.

††††† (2) If a recipientís medical needs or circumstances evolve to the extent another benefit plan is a more appropriate change, the department shall assign the recipient to the more appropriate benefit plan.

††††† (3)(a) A recipient whose medical needs or circumstances are appropriate for the comprehensive or optimum choices benefit plan may elect to not be assigned to the comprehensive or optimum choices benefit plan.

††††† (b) The department shall assign a recipient who elects to not be assigned to the comprehensive or optimum choices benefit plan to the global choices benefit plan, unless the individual elects to opt out of all coverage.

††††† (4)(a) A recipient may request to be assigned to a different benefit plan by notifying the department.

††††† (b) If a recipient requests to be assigned to a different benefit plan, the department shall examine the recipientís medical needs or circumstances and determine the appropriateness of placing the individual in a different benefit plan.

 

††††† Section 3. Benefit Plan Covered Services and Cost Sharing. (1) Benefit plan covered service provisions shall be as established in the respective program administrative regulations located in 907 KAR Chapters 1 and 3.

††††† (2) Benefit plan cost-sharing provisions shall be as established in 907 KAR 1:604.

 

††††† Section 4. Appeals. A recipient may appeal a department decision in accordance with 907 KAR 1:563. (33 Ky.R. 660; 1398; 1578; eff. 1-5-2007; 34 Ky.R. 1857; 2127; eff. 4-4-2008; TAm 7-16-2013.)