907 KAR 3:100. Payments for acquired brain injury services.
RELATES TO: 42 C.F.R. 441 Subpart G, 42 U.S.C. 1396a, b, d, n
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)
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 payment provisions relating to home- and community-based waiver services provided to an individual with an acquired brain injury as an alternative to nursing facility services for the purpose of rehabilitation and retraining for reentry into the community with existing resources.
Section 1. Definitions. (1) "Acquired brain injury waiver services" or "ABI waiver services" means home- and community-based waiver services provided to a Medicaid eligible individual aged twenty-one (21) to sixty-five (65) who has acquired a brain injury to his central nervous system of the following nature:
(a) Injury from a physical trauma;
(b) Damage from anoxia or from a hypoxic episode; or
(c) Damage from an allergic condition, toxic substance or another acute medical incident.
(2) "Department" means the Department for Medicaid Services or its designated agent.
Section 2. Coverage. (1) The department shall reimburse a participating provider for an ABI waiver service provided to a Medicaid eligible person who meets the ABI Waiver Program requirements as established in 907 KAR 3:090.
(2) The department shall reimburse an ABI participating provider for a prior-authorized ABI waiver service, if the service is:
(a) Included in the plan of care and is medically necessary, as defined in 907 KAR 3:130; and
(b) Essential for the rehabilitation and retraining of the recipient.
Section 3. Exclusions to Acquired Brain Injury Waiver Program. Under the ABI Waiver Program, the department shall not reimburse a provider for a service provided:
(1) To an individual who has a condition identified in 907 KAR 3:090, Section 2; or
(2) Which has not been prior authorized as a part of the plan of care.
Section 4. Payment Amounts. (1) A participating ABI waiver service provider shall be reimbursed a fixed rate for reasonable and medically necessary services for a prior-authorized unit of service provided to a recipient.
(2) A participating ABI waiver service provider certified in accordance with 907 KAR 3:090 shall be reimbursed at the lesser of:
(a) The provider’s usual and customary charge; or
(b) The Medicaid fixed upper payment limit per unit of service as established in Section 5 of this administrative regulation.
Section 5. Fixed Upper Payment Limits. (1) The following rates shall be the fixed upper payment limits, in effect on July 1, 2001, for ABI waiver services in conjunction with the corresponding units of service:
|
Service |
Unit of Service |
Upper Payment Limit |
|
Case Management |
1 month |
$434.00 |
|
Personal Care |
15 minutes |
$5.56 |
|
Respite Care |
1 hour (not to exceed 168 hours per six (6) month period) |
$15.98 (maximum of $150.00 per day) |
|
Companion |
15 minutes |
$5.56 |
|
Structured Day Program |
1 hour (not to exceed forty (40) hours per week |
$16.11 |
|
Supported Employment |
1 hour |
$31.92 |
|
Behavior Programming |
15 minutes |
$33.61 |
|
Counseling - Individual Counseling - Group |
15 minutes 15 minutes |
$23.84 $5.75 |
|
Occupational Therapy |
15 minutes |
$25.90 |
|
Speech, Hearing and Language Services |
15 minutes |
$28.41 |
|
Specialized Medical Equipment and Supplies (see subsection (2) of this section) |
Per Item |
As Negotiated by the Department |
|
Environmental Modification |
Per Modification |
Actual cost not to exceed $1,000.00 per 6 month period |
|
Community Residential Service (Staffed Residence) |
Not Applicable |
$200.00 |
|
Community Residential Service (Group Home) |
Not Applicable |
$90.00 |
(2) Specialized medical equipment and supplies shall be reimbursed on a per-item basis based on a reasonable cost as negotiated by the department if they meet the following criteria:
(a) They are not covered through the Medicaid Durable Medical Equipment Program established in 907 KAR 1:479; and
(b) They are provided to an individual participating in the ABI Waiver Program.
(3) Respite care may exceed 168 hours per six (6) month period if an individual’s normal care giver is unable to provide care due to a death in the family, serious illness, or hospitalization.
(4) Payment for respite care provided in a setting other than a nursing facility shall not include the cost of room and board. If an ABI recipient is placed in a nursing facility to receive respite care, the department shall pay the nursing facility its per diem rate for that individual.
(5) If supported employment services are provided at a work site in which persons without disabilities are employed, payment shall be made only for the supervision and training required as the result of the ABI recipient’s disabilities and shall not include payment for supervisory activities normally rendered.
(6) The department shall only pay for supported employment services for an individual if supported employment services are unavailable under a program funded by either the Rehabilitation Act of 1973 (29 U.S.C. Chapter 16) or Pub.L. 94-142 (34 C.F.R. Subtitle B, Chapter III). For an individual receiving supported employment services, documentation shall be maintained in his or her record demonstrating that the services are not otherwise available under a program funded by either the Rehabilitation Act of 1973 (29 U.S.C. Chapter 16) or Pub.L. 94-142 (34 C.F.R. Subtitle B, Chapter III).
(7) Except for state fiscal years (SFY) 2002 and 2003, the Medicaid fixed upper payment limits established in this section shall be adjusted by the department annually for inflation using the Standard and Poor’s DRI Medical Index.
Section 6. Payment Exclusions. Payment shall not include:
(1) The cost of room and board, unless provided as part of respite care in a Medicaid certified nursing facility. If an ABI recipient is placed in a nursing facility to receive respite care, the department shall pay the nursing facility its per diem rate for that individual;
(2) The cost of maintenance, upkeep, an improvement, or an environmental modification to a group home or other licensed facility;
(3) Excluding an environmental modification as established in the Acquired Brain Injury Services and Reimbursement Program Manual, the cost of maintenance, upkeep, or an improvement to a recipient’s place of residence;
(4) The cost of a service that is not listed in the approved plan of care; or
(5) A service provided by a family member.
Section 7. Records Maintenance. A participating provider shall:
(1) Maintain fiscal and service records for a period of at least five (5) years;
(2) Provide, as requested by the department, a copy of, and access to, each record of the ABI Waiver Program retained by the provider pursuant to:
(a) Subsection (1) of this section; or
(b) 907 KAR 1:672, Sections 2, 3, and 4; and
(3) Upon request, make available service and financial records to a representative or designee of:
(a) The Commonwealth of Kentucky, Cabinet for Health and Family Services or its designated agent;
(b) The United States Department for Health and Human Services, Comptroller General;
(c) The United States Department for Health and Human Services, the Centers for Medicare and Medicaid Services (CMS);
(d) The General Accounting Office;
(e) The Commonwealth of Kentucky, Office of the Auditor of Public Accounts; or
(f) The Commonwealth of Kentucky, Office of the Attorney General.
Section 8. Payment Rate for State Fiscal Year (SFY) 2002. With the exception of rates for community residential services, which shall be as established in Section 5 of this administrative regulation, effective July 1, 2001 the payment rate that was in effect on June 30, 2001, for an ABI service shall remain in effect.
Section 9. Payment Rate for State Fiscal Year (SFY) 2003. Effective July 1, 2002, the payment rate that was in effect on June 30, 2002 for an ABI service shall remain in effect.
Section 10. Appeal Rights. An ABI wavier provider may appeal department decisions as to the application of the administrative regulation as it impacts the provider's reimbursement in accordance with 907 KAR 1:671, Sections 8 and 9.
Section 11. Incorporation by Reference. (1) "Acquired Brain Injury Services and Reimbursement Program Manual", Department for Medicaid Services, "September 2001 Edition", is incorporated by reference.
(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (25 Ky.R. 2993; Am. 26 Ky.R. 402; eff. 8-16-99; 28 Ky.R. 987; eff. 12-19-2001; 29 Ky.R. 1141; 1657; eff. 12-18-02.)