††††† 907 KAR 10:014. Outpatient hospital service coverage.

 

††††† RELATES TO: KRS 205.520, 42 C.F.R. 447.53

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.560, 205.6310, 205.8453

††††† 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 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 establishes the provisions relating to outpatient hospital services for which payment shall be made by the medical assistance program on behalf of the categorically needy and medically needy.

 

††††† Section 1. Definitions. (1) "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;

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

††††† 5. The Acquired Brain Injury Long Term Care Waiver Program in accordance with 907 KAR 3:210; or

††††† 6. The Michelle P. Waiver Program in accordance with 907 KAR 1:835; and

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

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

††††† (3) "Emergency" means that a condition or situation requires an emergency service pursuant to 42 C.F.R. 447.53.

††††† (4) "Emergency medical condition" is defined by 42 U.S.C. 1395dd(e)(1).

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

††††† (a) Is covered pursuant to:

††††† 1. 42 U.S.C. 1396a(a)(10)(A)(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.

††††† (6) "Global choices" means the department's 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 and are deprived due to death, incapacity, or absence;

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

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

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

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

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

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

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

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

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

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

††††† 2. SSP, 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; or

††††† (h) Pregnant women.

††††† (7) "Lock-in recipient" means a recipient enrolled in the department's lock-in program pursuant to 907 KAR 1:677.

††††† (8) "Medical necessity" or "medically necessary" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

††††† (9) "Nonemergency" means that a condition or situation does not require an emergency service pursuant to 42 C.F.R. 447.53.

††††† (10) "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 patient status criteria established in 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.

††††† (11) "Recipient" is defined by KRS 205.8451(9).

††††† (12) "Unlisted procedure or service" means a procedure for which there is not a specific CPT code and which is billed using a CPT code designated for reporting unlisted procedures or services.

 

††††† Section 2. Coverage Criteria. (1) To be covered by the department:

††††† (a) The following services shall be prior authorized and meet the requirements established in paragraph (b) of this subsection:

††††† 1. Magnetic resonance imaging (MRI);

††††† 2. Magnetic resonance angiogram (MRA);

††††† 3. Magnetic resonance spectroscopy;

††††† 4. Positron emission tomography (PET);

††††† 5. Cineradiography/videoradiography;

††††† 6. Xeroradiography;

††††† 7. Ultrasound subsequent to second obstetric ultrasound;

††††† 8. Myocardial imaging;

††††† 9. Cardiac blood pool imaging;

††††† 10. Radiopharmaceutical procedures;

††††† 11. Gastric restrictive surgery or gastric bypass surgery;

††††† 12. A procedure that is commonly performed for cosmetic purposes;

††††† 13. A surgical procedure that requires completion of a federal consent form; or

††††† 14. An unlisted procedure or service; and

††††† (b) An outpatient hospital service, including those identified in paragraph (a) of this subsection, shall be:

††††† 1. Medically necessary; and

††††† 2. Clinically appropriate pursuant to the criteria established in 907 KAR 3:130.

††††† 3. For a lock-in recipient:

††††† a. Provided by the lock-in recipientís designated hospital pursuant to 907 KAR 1:677; or

††††† b. A screening or emergency service that meets the requirements of subsection (6)(a) of this subsection.

††††† (2) The prior authorization requirements established in subsection (1) of this section shall not apply to:

††††† (a) An emergency service;

††††† (b) A radiology procedure if the recipient has a cancer or transplant diagnosis code; or

††††† (c) A service provided to a recipient in an observation bed.

††††† (3) A referring physician, a physician who wishes to provide a given service, or an advanced practice registered nurse may request prior authorization from the department.

††††† (4) The following covered hospital outpatient services shall be furnished by or under the supervision of a duly licensed physician, or if applicable, a duly-licensed dentist:

††††† (a) A diagnostic service ordered by a physician;

††††† (b) A therapeutic service, except for occupational therapy, ordered by a physician;

††††† (c) An emergency room service provided in an emergency situation as determined by a physician; or

††††† (d) A drug, biological, or injection administered in the outpatient hospital setting.

††††† (5) A covered hospital outpatient service for maternity care may be provided by:

††††† (a) An advanced practice registered nurse (APRN) who has been designated by the Kentucky Board of Nursing as a nurse midwife; or

††††† (b) A registered nurse who holds a valid and effective permit to practice nurse midwifery issued by the Cabinet for Health and Family Services.

††††† (6) The department shall cover:

††††† (a) A screening of a lock-in recipient to determine if the lock-in recipient has an emergency medical condition; or

††††† (b) An emergency service to a lock-in recipient if the department determines that the lock-in recipient had an emergency medical condition when the service was provided.

 

††††† Section 3. Hospital Outpatient Services Not Covered by the Department. The following services shall not be considered a covered hospital outpatient service:

††††† (1) An item or service that does not meet the requirements established in Section 2(1) of this administrative regulation;

††††† (2) A service for which:

††††† (a) An individual has no obligation to pay; and

††††† (b) No other person has a legal obligation to pay;

††††† (3) A medical supply or appliance, unless it is incidental to the performance of a procedure or service in the hospital outpatient department and included in the rate of payment established by the Medical Assistance Program for hospital outpatient services;

††††† (4) A drug, biological, or injection purchased by or dispensed to a patient;

††††† (5) A routine physical examination; or

††††† (6) A nonemergency service, other than a screening in accordance with Section 2(6)(a) of this administrative regulation, provided to a lock-in recipient:

††††† 1. In an emergency department of a hospital; or

††††† 2. If provided by a hospital that is not the lock-in recipient's designated hospital pursuant to 907 KAR 1:677.

 

††††† Section 4. Therapy Limits. (1) Speech therapy shall be limited to:

††††† (a) Ten (10) visits per twelve (12) months for a recipient of the Global Choices benefit package; or

††††† (b) Thirty (30) visits per twelve (12) months for a recipient of the:

††††† 1. Comprehensive Choices benefit package; or

††††† 2. Optimum Choices benefit package.

††††† (2) Physical therapy shall be limited to:

††††† (a) Fifteen (15) visits per twelve (12) months for a recipient of the Global Choices benefit package; or

††††† (b) Thirty (30) visits per twelve (12) months for a recipient of the:

††††† 1. Comprehensive Choices benefit package; or

††††† 2. Optimum Choices benefit package.

††††† (3) The therapy limits established in subsections (1) and (2) of this section shall be over-ridden if the department determines that additional visits beyond the limit are medically necessary.

††††† (a) To request an override:

††††† 1. The provider shall telephone or fax the request to the department; and

††††† 2. The department shall review the request in accordance with the provisions of 907 KAR 3:130 and notify the provider of its decision.

††††† (b) An appeal of a denial regarding a requested override shall be in accordance with 907 KAR 1:563.

††††† (4) Except for recipients under age twenty-one (21), prior authorization shall be required for each visit that exceeds the limit established in subsections (1) and (2) of this section.

††††† (5) The limits established in subsections (1) and (2) of this section shall not apply to a recipient under twenty-one (21) years of age. (Recodified from 904 KAR 1:014, 5-6-86; Am. 17 Ky.R. 557; eff. 10-14-90; 33 Ky.R. 578; 1550; eff. 1-5-2007; 37 Ky.R. 984; eff. 11-05-2010; Recodified from 907 KAR 1:014, eff. 5-3-11; TAm 7-16-2013.)