††††† 907 KAR 15:015. Reimbursement provisions and requirements for behavioral health services provided by individual behavioral health providers, behavioral health provider groups, or behavioral health multi-specialty groups.

 

††††† RELATES TO: KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 1396a(a)(23), 1396a(a)(30)(A)

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.6311

††††† NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has a 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 to qualify for federal Medicaid funds. This administrative regulation establishes the reimbursement provisions and requirements regarding Medicaid Program behavioral health services provided by certain licensed individual behavioral health professionals who are independently enrolled in the Medicaid Program, practitioners working for or under the supervision of the individual behavioral health providers, and individual behavioral health professionals and practitioners under supervision working in behavioral health provider groups or in behavioral health multi-specialty groups, to Medicaid recipients who are not enrolled with a managed care organization.

 

††††† Section 1. General Requirements. For the department to reimburse for a service covered under this administrative regulation, the service shall be:

††††† (1) Covered in accordance with 907 KAR 15:010; and

††††† (2) Billed to the department by an individual behavioral health provider, behavioral health provider group, or behavioral health multi-specialty group recognized as a Medicaid Program provider in accordance with 907 KAR 15:010.

 

††††† Section 2. Reimbursement. (1) One (1) unit of service shall be:

††††† (a) Fifteen (15) minutes in length unless a different unit of service exists for the service in the corresponding:

††††† 1. Current procedural terminology code; or

††††† 2. Healthcare common procedure coding system code; or

††††† (b) The unit amount identified in the corresponding:

††††† 1. Current procedural terminology code if an amount is identified in the current procedural terminology code; or

††††† 2. Healthcare common procedure coding system code if an amount is identified in the healthcare common procedure coding system code.

††††† (2) Except as provided by subsection (3) of this section, the rate per unit for a covered service shall be:

††††† (a) Seventy-five (75) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

††††† 1. Physician; or

††††† 2. Psychiatrist;

††††† (b) 63.75 percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by:

††††† 1. An advanced practice registered nurse; or

††††† 2. A licensed psychologist;

††††† (c) Sixty (60) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

††††† 1. Licensed professional clinical counselor;

††††† 2. Licensed clinical social worker;

††††† 3. Licensed psychological practitioner;

††††† 4. Certified psychologist with autonomous functioning;

††††† 5. Licensed marriage and family therapist;

††††† 6. Licensed professional art therapist;

††††† 7. Licensed behavior analyst; or

††††† 8. Licensed clinical alcohol and drug counselor;

††††† (d) Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

††††† 1. Marriage and family therapy associate;

††††† 2. Licensed professional counselor associate;

††††† 3. Licensed psychological associate;

††††† 4. Certified social worker;

††††† 5. Physician assistant;

††††† 6. Licensed professional art therapist associate;

††††† 7. Licensed assistant behavior analyst;

††††† 8. Certified psychologist; or

††††† 9. Licensed clinical alcohol and drug counselor associate; or

††††† (e) Thirty-seven and five-tenths (37.5) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a certified alcohol and drug counselor.

††††† (3) Reimbursement for the following services shall be as established on the Behavioral Health and Substance Abuse Services Outpatient (Non-facility) Fee Schedule:

††††† (a) Screening, brief intervention, and referral to treatment (SBIRT);

††††† (b) Service planning;

††††† (c) Day treatment;

††††† (d) Comprehensive community support services;

††††† (e) Peer support services;

††††† (f) Intensive outpatient program services; or

††††† (g) Therapeutic rehabilitation program services.

††††† (4)(a) The department shall use the current version of the Kentucky-specific Medicare Physician Fee Schedule for reimbursement purposes.

††††† (b) For example, if the Kentucky-specific Medicare Physician Fee Schedule currently published and used by the Centers for Medicare and Medicaid Services for the Medicare Program is:

††††† 1. An interim version, the department shall use the interim version until the final version has been published; or

††††† 2. The final version, the department shall use the final version.

††††† (5) The department shall not reimburse for a service billed by or on behalf of an entity or individual that is not a billing provider.

 

††††† Section 3. Not Applicable to Managed Care Organizations. A managed care organization shall not be required to reimburse in accordance with this administrative regulation for a service covered pursuant to:

††††† (1) 907 KAR 15:010; and

††††† (2) This administrative regulation.

 

††††† Section 4. Federal Approval and Federal Financial Participation. The departmentís reimbursement for services pursuant to this administrative regulation shall be contingent upon:

††††† (1) Receipt of federal financial participation for the reimbursement; and

††††† (2) Centers for Medicare and Medicaid Servicesí approval for the reimbursement.

 

††††† Section 5. Incorporation by Reference. (1) "Behavioral Health and Substance Abuse Services Outpatient (Non-Facility) Fee Schedule", June 2016, is incorporated by reference.

††††† (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at:

††††† (a) The Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky, 40601, Monday through Friday, 8:00 a.m. to 4:30 p.m.; or

††††† (b) Online at the departmentís Web site at http://www.chfs.ky.gov/dms/incorporated.htm. (40 Ky.R. 2076; 2577; 2788; eff. 7-7-2014; 43 Ky.R. 1098; 1619; 1971; eff. 6-2-2017.)