907 KAR 3:020. Coverage and payments for targeted case management and rehabilitative services provided through an agreement with the state Title V agency.

 

      RELATES TO: KRS 205.520

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 C.F.R. 431.615, 440.130, 447 Subpart B, 42 U.S.C. 1396a-d, 1396s, 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) empowers 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 provides for coverage and payments for targeted case management and rehabilitative services provided through an agreement with the state Title V agency, the Department for Public Health.

 

      Section 1. Definitions. (1) "Department" means the Department for Medicaid Services.

      (2) "Rehabilitative services" means medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level.

      (3) "Targeted case management services" means a set of activities which assist an individual in accessing needed medical, social, educational, and other support services.

      (4) "Title V agency" means the Department for Public Health.

 

      Section 2. Interagency Agreement. Services provided pursuant to this administrative regulation shall be in accordance with an interagency agreement between the department and the Title V agency.

 

      Section 3. Coverage. Services provided shall be the following:

      (1) Targeted case management services provided to the following:

      (a) Medicaid-eligible children under the age of twenty-one (21) who meet the Department for Social Services' conditions and circumstances to be defined as a child in the custody of, or under the supervision of or at risk of being in the custody of the state; and

      (b) Medicaid-eligible adults (persons twenty-one (21) years of age or older) who meet the Department for Social Services' conditions and circumstances to be defined as an adult in need of protective services.

      (2) Rehabilitative services provided to Medicaid-eligible children under the age of twenty-one (21) who meet the Department for Social Services' conditions and circumstances as a child in the custody of, or under the supervision of or at risk of being in the custody of the state.

 

      Section 4. Provider Qualifications and Conditions for Participation. The following provider qualifications and conditions for participation shall be applicable for services provided pursuant to this administrative regulation.

      (1) The Title V agency may provide services directly or through agreement with the Department for Social Services as the state agency responsible for the provision of child and adult protective services, which includes the following:

      (a) Children in the custody of the state; or

      (b) Under the supervision of the state; or

      (c) At risk of being in the custody of the state; and

      (d) Adults who may receive protective services from the state as a component of the Title V Maternal and Child Health Program.

      (2) Services which are provided by the Department for Social Services and its subcontractors shall meet appropriate requirements for the service, including as appropriate a plan of care, supervision, and reporting.

      (3) Providers and subcontractors shall maintain records to document services provided for not less than five (5) years or until any audit dispute or issue is resolved if beyond five (5) years.

 

      Section 5. Access to Records, Providers, and Recipients. (1) The treatment and financial records of providers and subcontractors shall be made available to the department upon request to verify services provided and the cost of the services.

      (2) Inspection may be on site or through the submittal of written or electronic materials as determined to be appropriate by the department.

      (3) The department shall have the right to interview all current or previous provider or subcontractor staff with regard to services provided pursuant to this administrative regulation and all recipients of targeted case management or rehabilitative services with regard to services received pursuant to this administrative regulation.

      (4) Access to provider or subcontractor records relating to services provided shall be required for:

      (a) Representatives of the United States Department of Health and Human Services;

      (b) The state Attorney General's Office; and

      (c) The state Auditor's Office.

      (5) Providers or subcontractors shall be required to provide to the department and representatives of those agencies or offices referenced in this section of this administrative regulation, on request, any information maintained by the provider to document the service provided and any information regarding payments claimed by the provider for furnishing services.

 

      Section 6. Reimbursement. The following reimbursement provisions shall be applicable:

      (1) Payments shall be based on cost.

      (2) An interim rate based on projected cost shall be used as necessary with a settlement to cost at the end of the state fiscal year.

      (3) A billable unit of service shall include all services of that type (targeted case management or rehabilitative services) provided during the month.

 

      Section 7. Incorporation by Reference of the Provider Manual. (1) "The Policies and Procedures Manual for Title V Services provided by the Department for Social Services", dated July 1996, shall be incorporated by reference in this administrative regulation.

      (2) The manual shall be on file in the Office of the Commissioner, Department for Medicaid Services, 275 East Main Street, Third Floor East, Frankfort, Kentucky 40621.

      (3) The manual shall be available for review during the normal business week, Monday through Friday, 8 a.m. through 4:30 p.m. (eastern time), excluding state holidays.

      (4) Each participating provider shall be provided one (1) copy of the manual and appropriate manual updates following their incorporation by reference. Additional copies may be obtained from the Department for Medicaid Services upon payment of an appropriate fee which approximates cost in accordance with KRS 61.872.

 

      Section 8. Implementation Date. The provisions of this administrative regulation shall be applicable with regard to services provided on or after July 1, 1996. (23 Ky.R. 2656; eff. 2-19-97.)