907 KAR 17:005. Definitions for 907 KAR Chapter 17.

 

      RELATES TO: 194A.025(3), 42 U.S.C. 1396n(c), 42 C.F.R. 438

      STATUTORY AUTHORITY: KRS 194A.010(1), 194A.025(3), 194A.030(2), 194A.050(1), 205.520(3), 205.560, 42 U.S.C. 1396n(b), 42 C.F.R. Part 438

      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 a requirement that may be imposed or opportunity presented by federal law to qualify for federal Medicaid funds. 42 U.S.C. 1396n(b) and 42 C.F.R. Part 438 establish requirements relating to managed care. This administrative regulation establishes the definitions for 907 KAR Chapter 17, which apply to the policies and procedures relating to the provision of Medicaid services through contracted managed care organizations pursuant to, and in accordance with, 42 U.S.C. 1396n(b) and 42 C.F.R. Part 438.

 

      Section 1. Definitions. (1) "1915(c) home and community based waiver program" means a Kentucky Medicaid program established pursuant to, and in accordance with, 42 U.S.C. 1396n(c).

      (2) "Advanced practice registered nurse" is defined by KRS 314.011(7).

      (3) "Adverse action" means:

      (a) The denial or limited authorization of a requested service, including the type or level of service;

      (b) The reduction, suspension, or termination of a previously authorized service;

      (c) The denial, in whole or in part, of payment for a service;

      (d) The failure to provide services in a timely manner; or

      (e) The failure of a managed care organization to act within the timeframes provided in 42 C.F.R. 438.408(b).

      (4) "Aged" means at least sixty-five (65) years of age.

      (5) "Appeal" means a request for review of an adverse action or a decision by an MCO related to a covered service.

      (6) "Authorized representative" means:

      (a) For an enrollee who is authorized by Kentucky law to provide written consent, an individual or entity acting on behalf of, and with written consent from, the enrollee; or

      (b) A legal guardian.

      (7) "Behavioral health service" means a clinical, rehabilitative, or support service in an inpatient or outpatient setting to treat a mental illness, emotional disability, or substance abuse disorder.

      (8) "Blind" is defined by 42 U.S.C. 1382c(a)(2).

      (9) "Capitation payment" means the total per enrollee, per month payment amount the department pays an MCO.

      (10) "Capitation rate" means the negotiated amount to be paid on a monthly basis by the department to an MCO:

      (a) Per enrollee; and

      (b) Based on the enrollee’s aid category, age, and gender.

      (11) "Care coordination" means the integration of all processes in response to an enrollee’s needs and strengths to ensure the:

      (a) Achievement of desired outcomes; and

      (b) Effectiveness of services.

      (12) "Case management" means a collaborative process that:

      (a) Assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an enrollee’s health and human service needs;

      (b) Is characterized by advocacy, communication, and resource management;

      (c) Promotes quality and cost-effective interventions and outcomes; and

      (d) Is in addition to and not in lieu of targeted case management for:

      1. Adults with a chronic mental illness pursuant to 907 KAR 1:515; or

      2. Children with a severe emotional disability pursuant to 907 KAR 1:525.

      (13) "CHFS OIG" means the Cabinet for Health and Family Services, Office of Inspector General.

      (14) "Child" means a person who:

      (a)1. Is under the age of eighteen (18) years;

      2.a. Is a full-time student in a secondary school or the equivalent level of vocational or technical training; and

      b. Is expected to complete the program before the age of nineteen (19) years;

      3. Is not self supporting;

      4. Is not a participant in any of the United States Armed Forces; and

      5. If previously emancipated by marriage, has returned to the home of his or her parents or to the home of another relative;

      (b) Has not attained the age of nineteen (19) years in accordance with 42 U.S.C. 1396a(l)(1)(D); or

      (c) Is under the age of nineteen (19) years if the person is a KCHIP recipient.

      (15) "Chronic Illness and Disability Payment System" means a diagnostic classification system that Medicaid programs use to make health-based, capitated payments for TANF and Medicaid beneficiaries with a disability.

      (16) "Commission for Children with Special Health Care Needs" or "CCSHCN" means the Title V agency which provides specialty medical services for children with specific diagnoses and health care needs that make them eligible to participate in programs sponsored by the CCSHCN, including the provision of medical care.

      (17) "Community mental health center" means a facility which meets the community mental health center requirements established in 902 KAR 20:091.

      (18) "Complex or chronic condition" means a physical, behavioral, or developmental condition which:

      (a) May have no known cure;

      (b) Is progressive; or

      (c) Can be debilitating or fatal if left untreated or under-treated.

      (19) "Consumer Assessment of Healthcare Providers and Systems" or "CAHPS" means a program that develops standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care.

      (20) "Court-ordered commitment" means an involuntary commitment by an order of a court to a psychiatric facility for treatment pursuant to KRS Chapter 202A.

      (21) "DAIL" means the Department for Aging and Independent Living.

      (22) "DCBS" means the Department for Community Based Services.

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

      (24) "Disabled" is defined by 42 U.S.C. 1382c(a)(3).

      (25) "DSM-IV" means a manual published by the American Psychiatric Association that covers all mental health disorders for both children and adults.

      (26) "Dual eligible" means an individual eligible for Medicare and Medicaid benefits.

      (27) "Early and periodic screening, diagnosis and treatment" or "EPSDT" is defined by 42 C.F.R. 440.40(b).

      (28) "Emergency service" means "emergency services" as defined by 42 U.S.C. 1396u-2(b)(2)(B).

      (29) "Encounter" means a health care visit of any type by an enrollee to a provider of care, drugs, items, or services.

      (30) "Enrollee" means a recipient who is enrolled with a managed care organization for the purpose of receiving Medicaid or KCHIP covered services.

      (31) "External quality review organization" or "EQRO":

      (a) Is defined by 42 C.F.R. 438.320; and

      (b) Includes any affiliate or designee of the EQRO.

      (32) "Family planning service" means a counseling service, medical service, or

a pharmaceutical supply or device to prevent or delay pregnancy.

      (33) "Federally qualified health center" or "FQHC" is defined by 42 C.F.R. 405.2401(b).

      (34) "Fee-for-service" means a reimbursement model in which a health insurer reimburses a provider for each service provided to a recipient.

      (35) "Foster care" is defined by KRS 620.020(5).

      (36) "Fraud" means any act that constitutes fraud under applicable federal law or KRS 205.8451 to KRS 205.8483.

      (37) "Grievance" is defined by 42 C.F.R. 438.400.

      (38) "Grievance system" means a system that includes a grievance process, an appeal process, and access to the Commonwealth of Kentucky’s fair hearing system.

      (39) "Health maintenance organization" is defined by KRS 304.38-030(5).

      (40) "Health risk assessment" or "HRA" means a health questionnaire used to provide individuals with an evaluation of their health risks and quality of life.

      (41) "Healthcare Effectiveness Data and Information Set" or "HEDIS" means a tool used to measure performance regarding important dimensions of health care or services.

      (42) "Homeless individual" means an individual who:

      (a) Lacks a fixed, regular, or nighttime residence;

      (b) Is at risk of becoming homeless in a rural or urban area because the residence is not safe, decent, sanitary, or secure;

      (c) Has a primary nighttime residence at a:

      1. Publicly or privately operated shelter designed to provide temporary living accommodations; or

      2. Public or private place not designed as regular sleeping accommodations; or

      (d) Lacks access to normal accommodations due to violence or the threat of violence from a cohabitant.

      (43) "Individual with a special health care need" or "ISHCN" means an individual who:

      (a) Has, or is at a high risk of having, a chronic physical, developmental, behavioral, neurological, or emotional condition; and

      (b) May require a broad range of primary, specialized, medical, behavioral health, or related services.

      (44) "Initial implementation" means the process of transitioning a current Medicaid or KCHIP recipient from fee-for-service into managed care.

      (45) "KCHIP" means the Kentucky Children’s Health Insurance Program administered in accordance with 42 U.S.C. 1397aa to jj.

      (46) "Kentucky Health Information Exchange" or "KHIE" means the name given to the system that will support the statewide exchange of health information among healthcare providers and organizations according to nationally-recognized standards.

      (47) "Managed care organization" or "MCO" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined in 42 C.F.R. 438.2.

      (48) "Marketing" means any activity conducted by or on behalf of an MCO in which information regarding the services offered by the MCO is disseminated in order to educate enrollees or potential enrollees about the MCO’s services.

      (49) "Maternity care" means prenatal, delivery, and postpartum care and includes care related to complications from delivery.

      (50) "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 SSI benefits;

      (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 20:020; and

      (e) Meets the resource standards established in 907 KAR 20:025.

      (51) "Medical record" means a single, complete record that documents all of the treatment plans developed for, and medical services received by, an individual.

      (52) "Medically necessary" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

      (53) "Medicare qualified individual group 1 (QI-1)" means an eligibility category that includes, pursuant to 42 U.S.C. 1396a(a)(10)(E)(iv), an individual who would be a Qualified Medicaid beneficiary but for the fact that the individual’s income:

      (a) Exceeds the income level established in accordance with 42 U.S.C. 1396d(p)(2); and

      (b) Is at least 120 percent, but less than 135 percent, of the federal poverty level for a family of the size involved and who is not otherwise eligible for Medicaid under the state plan.

      (54) "National Practitioner Data Bank" means an electronic repository that collects:

      (a) Information on adverse licensure activities, certain actions restricting clinical privileges, and professional society membership actions taken against physicians, dentists, and other practitioners; and

      (b) Data on payments made on behalf of physicians in connection with liability settlements and judgments.

      (55) "Nonqualified alien" means a resident of the United States of America who does not meet the qualified alien requirements established in 907 KAR 1:011, Section 5(12).

      (56) "Nursing facility" means:

      (a) A facility:

      1. To which the state survey agency has granted a nursing facility license;

      2. For which the state survey agency has recommended to the department certification as a Medicaid provider; and

      3. To which the department has granted certification for Medicaid participation; or

      (b) A hospital swing bed that provides services in accordance with 42 U.S.C. 1395tt and 1396l, if the swing bed is certified to the department as meeting requirements for the provision of swing bed services in accordance with 42 U.S.C. 1396r(b), (c), and (d) and 42 C.F.R. 447.280 and 482.66.

      (57) "Olmstead decision" means the court decision of Olmstead v. L.C. and E.W., U.S. Supreme Court, No. 98–536, June 26, 1999 in which the U.S. Supreme Court ruled, "For the reasons stated, we conclude that, under Title II of the ADA, States are required to provide community-based treatment for persons with mental disabilities when the State's treatment professionals determine that such placement is appropriate, the affected persons do not oppose such treatment, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities."

      (58) "Open enrollment" means an annual period during which an enrollee can choose a different MCO.

      (59) "Out-of-network provider" means a person or entity that has not entered into a participating provider agreement with an MCO or any of the MCO’s subcontractors.

      (60) "Physician" is defined by KRS 311.550(12).

      (61) "Post-stabilization services" means covered services related to an emergency medical condition that are provided to an enrollee:

      (a) After an enrollee is stabilized in order to maintain the stabilized condition; or

      (b) Under the circumstances described in 42 C.F.R. 438.114(e) to improve or resolve the enrollee’s condition.

      (62) "Primary care center" means an entity that meets the primary care center requirements established in 902 KAR 20:058.

      (63) "Primary care provider" or "PCP" means a licensed or certified health care practitioner who meets the description as established in 907 KAR 17:010, Section 7(6).

      (64) "Prior authorization" means the advance approval by an MCO of a service or item provided to an enrollee.

      (65) "Provider" means any person or entity under contract with an MCO or its contractual agent that provides covered services to enrollees.

      (66) "Provider network" means the group of physicians, hospitals, and other medical care professionals that a managed care organization has contracted with to deliver medical services to its enrollees.

      (67) "QAPI" means the Quality Assessment and Performance Improvement Program established in accordance with 907 KAR 17:025, Section 5.

      (68) "Qualified alien" means an alien who, at the time of applying for or receiving Medicaid benefits, meets the requirements established in 907 KAR 1:011, Section 5(12).

      (69) "Qualified disabled and working individual" is defined by 42 U.S.C. 1396d(s).

      (70) "Qualified Medicare beneficiary" or "QMB" is defined by 42 U.S.C. 1396d(p)(1).

      (71) "Quality improvement" or "QI" means the process of assuring that covered services provided to enrollees are appropriate, timely, accessible, available, and medically necessary and the level of performance of key processes and outcomes of the healthcare delivery system is improved through the MCO’s policies and procedures.

      (72) "Recipient" is defined in KRS 205.8451(9).

      (73) "Region eight (8)" means the region containing Bell, Breathitt, Clay, Floyd, Harlan, Johnson, Knott, Knox, Laurel, Lee, Leslie, Letcher, Magoffin, Martin, Owsley, Perry, Pike, Whitley, and Wolfe Counties.

      (74) "Region five (5)" means the region containing Anderson, Bourbon, Boyle, Clark, Estill, Fayette, Franklin, Garrard, Harrison, Jackson, Jessamine, Lincoln, Madison, Mercer, Montgomery, Nicholas, Owen, Powell, Rockcastle, Scott, and Woodford Counties.

      (75) "Region four (4)" means the region containing Adair, Allen, Barren, Butler, Casey, Clinton, Cumberland, Edmonson, Green, Hart, Logan, McCreary, Metcalfe, Monroe, Pulaski, Russell, Simpson, Taylor, Warren, and Wayne Counties.

      (76) "Region one (1)" means the region containing Ballard, Caldwell, Calloway, Carlisle, Crittenden, Fulton, Graves, Hickman, Livingston, Lyon, Marshall, and McCracken Counties.

      (77) "Region seven (7)" means the region containing Bath, Boyd, Bracken, Carter, Elliott, Fleming, Greenup, Lawrence, Lewis, Mason, Menifee, Morgan, Robertson, and Rowan Counties.

      (78) "Region six (6)" means the region containing Boone, Campbell, Gallatin, Grant, Kenton, and Pendleton Counties.

      (79) "Region three (3)" means the region containing Breckenridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble, and Washington Counties.

      (80) "Region two (2)" means the region containing Christian, Daviess, Hancock, Henderson, Hopkins, McLean, Muhlenberg, Ohio, Todd, Trigg, Union, and Webster Counties.

      (81) "Risk adjustment" means a corrective tool to reduce both the negative financial consequences for a managed care organization that enrolls high-risk users and the positive financial consequences for a managed care organization that enrolls low-risk users.

      (82) "Rural area" means an area not in an urban area.

      (83) "Rural health clinic" is defined by 42 C.F.R. 405.2401(b).

      (84) "Specialist" means a provider who provides specialty care.

      (85) "Specialty care" means care or a service that is provided by a provider who is not:

      (a) A primary care provider; or

      (b) Acting in the capacity of a primary care provider while providing the service.

      (86) "Specified low-income Medicare beneficiary" means an individual who meets the requirements established in 42 U.S.C. 1396a(a)(10)(E)(iii).

      (87) "State fair hearing" means an administrative hearing provided by the Cabinet for Health and Family Services pursuant to KRS Chapter 13B and 907 KAR 1:563.

      (88) "State plan" is defined by 42 C.F.R. 400.203.

      (89) "State survey agency" means the Cabinet for Health and Family Services, Office of Inspector General, Division of Health Care Facilities and Services.

      (90) "State-funded adoption assistance" is defined by KRS 199.555(2).

      (91) "Subcontract" means an agreement entered into, directly or indirectly, by an MCO to arrange for the provision of covered services, or any administrative, support or other health service, but does not include an agreement with a provider.

      (92) "Supplemental security income benefits" or "SSI benefits" is defined by 20 C.F.R. 416.2101.

      (93) "Teaching hospital" means a hospital which has a teaching program approved as specified in 42 U.S.C. 1395x(b)(6).

      (94) "Temporary Assistance for Needy Families" or "TANF" means a block grant program which is designed to:

      (a) Assist needy families so that children can be cared for in their own homes;

      (b) Reduce the dependency of needy parents by promoting job preparation, work, and marriage;

      (c) Prevent out-of-wedlock pregnancies; and

      (d) Encourage the formation and maintenance of two-parent families.

      (95) "Third party liability resource" means a resource available to an enrollee for the payment of expenses:

      (a) Associated with the provision of covered services; and

      (b) That does not include amounts exempt under Title XIX of the Social Security Act, 42 U.S.C. 1396 to 1396v.

      (96) "Transport time" means travel time:

      (a) Under normal driving conditions; and

      (b) With no extenuating circumstances.

      (97) "Urban area" is defined by 42 C.F.R. 412.62(f)(1)(ii).

      (98) "Urgent care" means care for a condition not likely to cause death or lasting harm but for which treatment should not wait for a normally scheduled appointment.

      (99) "Ward" is defined in KRS 387.510(15).

      (100) "Women, Infants and Children program" means a federally-funded health and nutrition program for women, infants, and children. (38 Ky.R. 1249; 1588; 1738; eff. 5-4-2012; 39 Ky.R. 1792; 2322; eff. 9-19-2013; TAm eff. 9-30-2013.)