Back to 8-K [form8-kream1toamendedandre.htm]
Exhibit 10.1 [ex101amendment1toamandresk.htm]

FIRST AMENDMENT TO THE
AMENDED MANAGED CARE CONTRACTS

BETWEEN

THE COMMONWEALTH OF KENTUCKY
ON BEHALF OF
DEPARTMENT FOR MEDICAID SERVICES
AND

WELLCARE OF KENTUCKY, INC.
REGION 3 AND STATE-WIDE

--------------------------------------------------------------------------------

This Amendment to the Amended Medicaid Managed Care Contracts State-Wide and
Region 3 (the “Contracts”) entered into on September 30, 2013 by and between the
Commonwealth of Kentucky, through the Cabinet for Finance and Administration, on
behalf of the Cabinet for Heath and Family Services, Department for Medicaid
Services (collectively herein “Commonwealth”) and WellCare of Kentucky, Inc., to
address Affordable Care Act issues (the “ACA Amendment”) shall be effective the
1st day of January, 2014 pursuant to Section 39.16 of the Contracts.

Section 1. The following Contract sections and/or subsections shall be amended
as follows:
11.2    Rate Adjustments
Prospective adjustments to the rates may be required if there are mandated
changes in Medicaid services as a result of legislative, executive, regulatory,
or judicial action. Changes mandated by state or federal legislation, or
executive, regulatory or judicial mandates, will take effect on the dates
specified in the legislation or mandate. In the event of such changes, any rate
adjustments shall be made through the Contract amendment process. The Department
has finalized its internal review to determine adjustments that need to be made
to the Department’s Covered Benefits to ensure compliance with the Essential
Benefits requirement of the Affordable Care Act. The revised Appendix I lists
the adjustments to Covered Benefits and Appendix B-2 contains the increase in
the Capitation Rates for those adjustments, which increase is contingent upon
approval by CMS.. The adjustments are detailed in the State Plan Amendments
submitted to CMS on October 1, 2013 with some revisions filed on November 15,
2013, and the new or revised Regulations which will be adopted as Emergency
Regulations on or before December 31, 2013. The rates have been determined to be
actuarially sound by the Department’s actuary. If the actuarially sound rate
adjustments are not acceptable to Contractor, then the Department shall allow
the Contractor to exit the program without penalty imposed by the Department or
recourse by the Contractor to the Department for any incurred expenses by the
Contractor.

The health insurers’ premium fee under the ACA will come due in September 2014
for calendar year 2013 premiums and each year thereafter unless otherwise

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modified. If the Contractor is subject to the health insurer’s premium fee for
the Capitation Payments being made under the existing Managed Care Contract(s)
with the Commonwealth, as amended, the Commonwealth shall compensate the
Contractor for that fee and for any federal taxes resulting from such
compensation. To facilitate this payment, the Contractor shall provide the
Department with the Insurer’s Premium Fee assessment received from the Federal
Government and the pro rata portion attributed to the Contractor’s Capitation
Payments under its Contract(s) for the preceding calendar year. In addition the
Contractor shall provide a certified statement from its Chief Financial Officer
as to the effective Federal Tax Rate paid for the past five tax periods. These
shall be submitted to the Department no later than September 1 of each year that
the Insurer’s premium fee is imposed. The Department will make a one-time
payment on or before September 30 to the Contractor for the Commonwealth’s share
of the Insurers’ premium fee and the Contractor’s Federal Tax payment attributed
to this one-time payment using the average of the Federal Tax Rate the
Contractor paid for the past five tax periods. This payment method is contingent
upon receipt of federal financial participation for the payment and CMS
approval.

28.1    Network Providers to Be Enrolled
The Contractor’s Network shall include Providers from throughout the provider
community. The Contractor shall comply with the any willing provider statute as
described in 907 KAR 1:672 or as amended and KRS 304.17A-270. Neither the
Contractor nor any of its Subcontractors shall require a Provider to enroll
exclusively with its network to provide Covered Services under this Contract(s)
as such would violate the requirement of 42 CFR Part 438 to provide Members with
continuity of care and choice. The Contractor shall enroll at least one (1)
Federally Qualified Health Centers (FQHCs) into its network if there is a FQHC
appropriately licensed to provide services in the region or service area and at
least one teaching hospital.

In addition the Contractor shall enroll the following types of providers who are
willing to meet the terms and conditions for participation established by the
Contractor: physicians, psychiatrists, advanced practice registered nurses,
physician assistants, free-standing birthing centers, dentists, primary care
centers including, home health agencies, rural health clinics, opticians,
optometrists, audiologists, hearing aid vendors, speech therapists, physical
therapists, occupational therapists, private duty nursing agency, pharmacies,
durable medical equipment suppliers, podiatrists, renal dialysis clinics,
ambulatory surgical centers, family planning providers, emergency medical
transportation provider, non-emergency medical transportation providers as
specified by the Department, other laboratory and x-ray providers, individuals
and clinics providing Early and Periodic Screening, Diagnosis, and Treatment
services, chiropractors, community mental health centers, psychiatric
residential treatment facilities, hospitals (including acute care, critical
access, rehabilitation, and psychiatric hospitals), local health departments,
and providers of EPSDT Special Services. The Contractor shall also enroll,

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Psychologists, Licensed Professional Clinical Counselors, Licensed Marriage and
Family Therapists, Licensed Psychological Practitioners, Behavioral Health
Multi-Specialty Groups, Certified Peer Support Providers, Certified Parental
Support Providers, and Licensed Clinical Social Workers,. The Contractor may
also enroll other providers, which meet the credentialing requirements, to the
extent necessary to provide covered services to the Members. Enrollment forms
shall include those used by the Kentucky Medicaid Program as pertains to the
provider type. The Contractor shall use such enrollment forms as required by the
Department.

The Department will continue to enroll and certify hospitals, nursing
facilities, home health agencies, independent laboratories, preventive health
care providers, FQHC, RHC and hospices. The Medicaid provider file will be
available for review by the Contractor so that the Contractor can ascertain the
status of a Provider with the Medicaid Program and the provider number assigned
by the Kentucky Medicaid Program.

Providers performing laboratory tests are required to be certified under the
CLIA. The Department will continue to update the provider file with CLIA
information from the OSCAR file provided by the Centers for Medicare & Medicaid
Services for all appropriate providers. This will make laboratory certification
information available to the Contractor on the Medicaid provider file.

The Contractor shall have written policies and procedures regarding the
selection and retention of Contractor’s Network. The policies and procedures
regarding selection and retention must not discriminate against providers who
service high-risk populations or who specialize in conditions that require
costly treatment or based upon that Provider’s licensure or certification.

If the Contractor declines to include individuals or groups of providers in its
network, it shall give affected providers written notice of the reason for its
decision.

The Contractor must offer participation agreements with currently enrolled
Medicaid providers who have received electronic health record incentive funds
who are willing to meet the terms and conditions for participation established
by the Contractor.

33.    Behavioral Health Services

33.1    Department for Behavioral Health, Developmental and Intellectual
Disabilities (DBHDID) Responsibilities

The Department for Behavioral Health, Developmental and Intellectual
Disabilities (DBHDID) is responsible for planning and overseeing behavioral
health, intellectual disability, and developmental disability services using
state and federal funds. Behavioral health services have been provided through
fourteen (14) regional

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mental health centers and four psychiatric hospitals (three of which are state
operated and one private) to assure that community and inpatient behavioral
health services are available to Kentucky citizens. DBHDID works collaboratively
with Department, to assure that Medicaid Members receive quality services.

DBHDID will work with the Contractor to insure that evidence-based practices
(EBPs) are routinely used in all behavior health services and that they meet the
standards of national models.

33.2    DBHDID Goals for Behavioral Health Services

DBHDID will work with the Contractor who will engage in behavioral health
promotion efforts, psychotropic medication management, suicide prevention and
overall person centered treatment approaches, to lower morbidity among Members
with serious mental illnesses, including Members with co-occurring developmental
disabilities, substance use disorders and smoking cessation.

The Contractor in its design and operation of behavioral health services shall
incorporate these core values for Medicaid Members:

A.
Maintaining basic personal rights. Individuals with mental illness have the same
rights and obligations as other citizens of the Commonwealth. Consumers have the
right to retain the fullest possible control over their own lives.

B.
Being responsive to the consumer and community. The Contractor’s provision of
behavioral health services shall be responsive to the people it serves,
coherently organized, and accessible to those who require behavioral healthcare.

C.
Providing care in the most appropriate setting. The Contractor shall provide the
most normative care in the least restrictive setting and permit Members to be
served in the community when appropriate.

D.
Having well-managed services. The Contractor shall promote cost effective
services and hold all components accountable by requiring monitoring and
self-evaluation, responding rapidly to identify weaknesses, adapting to changing
needs, and improving technology.

E.
The Contractor shall place a high priority on measuring Members’ satisfaction
with the services they receive. Outcome measures are a key component for
evaluating program effectiveness.

33.3    General Behavioral Health Requirements

The Department requires the Contractor’s provision of behavioral health services
to be recovery and resiliency focused. This means that services will be provided
to allow individuals, or in the case of a minor, family or guardian, to have the
greatest

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opportunities for decision making and participation in the individual’s
treatment and rehabilitation plans.

33.4    Covered Behavioral Health Services

The Contractor shall assure the provision of all Medically Necessary Behavioral
Health Services for Members. These services are described in Appendix I.
“Covered Services.” All Behavioral Health services shall be provided in
conformance with the access standards established by the Department. When
assessing Members for Behavioral Health Services, the Contractor and its
providers shall use the DSM-V classification. The Contractor may require use of
other diagnostic and assessment instrument/outcome measures in addition to the
DMS-V. Providers shall document DSM-V diagnosis and assessment/outcome
information in the Member’s medical record.

33.5    Behavioral Health Provider Network

The Contractor must emphasize access to services, utilization management,
assuring the services authorized are provided, are medically necessary and
produce positive health outcomes. The Department and DBHDID will coordinate on
the requirement of data collection and reporting to assure that state and
federal funds utilized in financing behavioral health services are efficiently
utilized and meet the overall goals of health outcomes.

The Contractor shall utilize ICD-9/10 coding and DSM-V classification for
Behavioral Health billings.

The Contractor shall provide access to psychiatrists, psychologists, and other
behavioral health service providers. Community Mental Health Centers (CMHCs)
located within the Contractor service region shall be offered participation in
the Contractor provider network. Other eligible providers of behavioral health
services include Licensed Professional Clinical Counselor and/or Group, Licensed
Marriage and Family Therapist and/or Group, Licensed Psychological Practitioner
and/or Group, Behavioral Health Multi-Specialty Group, Licensed Clinical Social
Worker, Licensed Psychologist and/or Group, Certified Peer and Parental Support
Providers. . To the extent that non-psychiatrists and other providers of
Behavioral health services may also be provided as a component of FQHC and RHC
services, these facilities shall be offered the opportunity to participate in
the Behavioral Health network. FQHC and RHC providers can continue to provide
the same services they currently provide under their licenses.

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The Contractor shall ensure accessibility and availability of qualified
providers to all Members. In order to ensure such accessibility, the Contractor
shall, prior to March 1, 2014, submit credentialing documents for no fewer than
one hundred fifty (150) behavioral health providers distributed throughout the
state.1

The Contractor shall maintain a Member education process to help Members know
where and how to obtain Behavioral Health Services.

The Contractor shall permit Members to participate in the selection of the
appropriate behavioral health individual practitioner(s) who will serve them and
shall provide the Member with information on accessible in-network Providers
with relevant experience.

(33.6 & 33.7 no change)

33.8    Follow-up after Hospitalization for Behavioral Health Services
The Contractor shall require, through Provider contract provision, that all
Members receiving inpatient behavioral health services are scheduled for
outpatient follow-up and/or continuing treatment prior to discharge. The
outpatient treatment must occur within seven (7) days from the date of
discharge. The Contractor shall ensure that Behavioral Health Service Providers
contact Members who have missed appointment within twenty-four (24) hours to
reschedule appointments.

(33.9 no change)

33.10    Continuity of Care Upon Discharge from a Psychiatric Hospital

A.
The Contractor shall coordinate with providers of behavioral health services,
and state operated or state contracted psychiatric hospitals and nursing
facilities regarding admission and discharge planning, treatment objectives and
projected length of stay for Members admitted to the state psychiatric hospital.
The Contractor shall enter into a collaborative agreement with the state
operated or state contracted psychiatric hospital assigned to their region in
accordance with 908 KAR 3:040 and in accordance with federal Olmstead law. At a
minimum the agreement shall include responsibilities of the Behavioral Health
Service Provider to assure continuity of care for successful transition back
into community-based supports. In addition, the Contractor’s Behavioral Health
Service Providers shall participate in quarterly Continuity of Care meetings
hosted by the state operated or state contracted psychiatric hospital.

____________
1 Region 3 shall have no fewer than thirty (30) behavioral health providers.

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B.
The Contractor shall ensure Behavioral Health Service Providers assign a case
manager prior to or on the date of discharge and provide basic, targeted or
intensive case management services as medically necessary to Members with severe
mental illness and co-occurring developmental disabilities who are discharged
from a state operated or state contracted psychiatric facility or state operated
nursing facility for Members with severe mental illness. The Case Manager and
other identified behavioral health service providers shall participate in
discharge planning meetings to ensure compliance with federal Olmstead and other
applicable laws. Appropriate discharge planning shall be focused on ensuring
needed supports and services are available in the least restrictive environment
to meet the Member’s behavioral and physical health needs, including
psychosocial rehabilitation and health promotion. Appropriate follow up by the
Behavioral Health Service Provider shall occur to ensure the community supports
are meeting the needs of the Member discharged from a state operated or state
contracted psychiatric hospital. The Contractor shall ensure the Behavioral
Health Service Providers assist Members in accessing free or discounted
medication through the Kentucky Prescription Assistance Program (KPAP) or other
similar assistance programs.

(33.11 & 33.12 no change)

34.    Case Management and Care Coordination
34.1    Health Risk Assessment (HRA)

The Contractor shall have programs and processes in place to address the
preventive and chronic physical and behavioral health care needs of its
population. The Contractor shall implement processes to assess, monitor, and
evaluate services to all subpopulations, including but not limited to, the
on-going special conditions that require a course of treatment or regular care
monitoring, Medicaid eligibility category, type of disability or chronic
conditions, race, ethnicity, gender and age.

The Contractor shall conduct initial health screening assessments, including
mental health and substance use disorders screenings, of new Members who have
not been enrolled in the prior twelve (12) month period for the purpose of
accessing the Members’ health care needs within ninety (90) days of Enrollment.
If the Contractor has a reasonable belief a Member is pregnant, the Member shall
be screened within thirty (30) days of Enrollment, and if pregnant, referred for
appropriate prenatal care. The Contractor agrees to make all reasonable efforts
to contact new Members in person, by telephone, or by mail to have Members
complete the initial health

8

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screening questionnaire and the survey instrument for both substance use and
mental health disorders.

Information to be collected shall include demographic information, current
health and behavioral health status to determine the Member’s need for care
management, disease management, behavioral health services and/or any other
health or community services.

The Contractor shall use appropriate health care professionals in the assessment
process. Members shall be offered assistance in arranging an initial visit to
their PCP for a baseline medical assessment and other preventive services,
including an assessment or screening of the Members potential risk, if any, for
specific diseases or conditions, including substance use and mental health
disorders.

The Contractor shall submit a quarterly report on the number of new Member
assessment; number of assessment completed; number of assessment not completed
after reasonable effort; number of refusals.

Prior to July 1, 2014, the Contractor shall make reasonable efforts to update
health screening assessment for Members who were not initially screened for
substance use disorder or mental health disorder prior.

The Contractor shall be responsible for the management and continuity of health
care for all Members.

35.4    Children in Foster Care

Upon Enrollment with the Contractor, each child in Foster Care shall have a
service plan prepared by DCBS. DCBS shall forward a copy of the service plan to
the Contractor on each newly enrolled Foster Care child. No less than monthly,
DCBS staff shall meet with Contractor’s staff to identify, discuss and resolve
any health care issues and needs of the child as identified in the service plan.
Examples of these issues include needed specialized Medicaid Covered Services,
community services and whether the child’s current primary and specialty care
providers are enrolled in the Contractor’s Network.
If DCBS service plan identifies the need for case management or DCBS staff
requests case management for a Member, the foster parent and/or DCBS staff will
work with Contractor’s staff to develop a case management care plan.
The Contractor will consult with DCBS staff before the development of a new case
management care plan (on a newly identified health care issue) or modification
of an existing case management care plan.

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The DCBS and designated Contractor staff will sign each service plan to indicate
their agreement with the plan. If the DCBS and Contractor staff cannot reach
agreement on the service plan for a Member, information about that Member’s
physical health care needs, unresolved issues in developing the case management
plan, and a summary of resolutions discussed by the DCBS and Contractor staff
will be forwarded to the designated county DCBS worker. That DCBS staff member
shall work with the designated Contractor representative and a designated
Department representative, if needed, to agree on a service plan. If agreement
is not reached through mediation, the service plan shall be referred to the
Department for resolution through the appeals process.
The Contractor shall notify the Department and DCBS no later than forty-eight
(48) hours prior to the decertification of a foster child certified for services
at a hospital or other residential facility located in Kentucky and no later
than seven (7) days prior to the decertification of a foster child for services
at a hospital or other residential facility located out of state. The Department
and DCBS shall provide the Contractor with the office or division, the
individual(s) and the contact information for such notification upon the
execution of this Amendment and provide updated contact information as
necessary.  If the Contractor fails to notify the Department and DCBS at least
forty-eight (48) hours or seven (7) days as applicable prior to the
decertification and the foster child remains in the facility because
arrangements for placement cannot be made, the Contractor shall be responsible
for the time the foster child remains in the facility up to forty-eight hours or
seven days as applicable. 

The Contractor shall require in its contracts with Providers that the Provider
provide basic, targeted or intensive case management services as medically
necessary to foster children who are discharged from a hospital or other
residential facility.  The Contractor shall require the case manager and
Provider to participate in appropriate discharge planning, focused on ensuring
that the needed supports and services to meet the Member’s behavioral and
physical health needs will be provided outside of the hospital or other
residential facility. 

Section 2.    Appendix B shall be amended by the addition of the attached ACA
Benefits Capitation Rate schedule as Appendix B-2.
Section 3.    Appendix I shall be amended as indicated on “Appendix I Revised”
attached hereto.
Section 4.    Appendix S shall be amended as indicated on “Appendix S Revised”
attached hereto.

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Approvals:

This Amendment to the Contracts is subject to the terms and conditions as
stated. The parties certify that they are authorized to bind this agreement
between parties and that they accept the terms of this agreement.

CONTRACTOR:
 
WELLCARE OF KENTUCKY, INC.

/s/ Kelly A. Munson
 
State President
SIGNATURE
 
TITLE

Kelly A. Munson
 
12-23-13
PRINTED NAME
 
DATE

COMMONWEALTH OF KENTUCKY
CABINET FOR FINANCE AND ADMINISTRATION

/s/ Donald R. Speer
 
Executive Director
SIGNATURE
 
TITLE

Donald R. Speer
 
1/3/2014
PRINTED NAME
 
DATE

Approved As To Form And Legality:

/s/ Geri Grigsby    
GENERAL COUNSEL
CABINET FOR FINANCE AND ADMINISTRATION

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APPENDIX B-2
Kentucky Medicaid
Cabinet for Health and Family Services
Capitation Rate Development - ACA Benefit Adjustments
Rates Effective January 1, 2014 through June 30, 2015
ACA Benefit Changes
Existing Medicaid Rate Cells
All ACA Benefit Changes
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
ZC101
Families and Children Infant (age under 1)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC102
Families and Children Child (age 1 through 5)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC103
Families and Children Child (age 6 through 12)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC104
Families and Children Child (age 13 through 18) – Female
$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

ZC105
Families and Children Child (age 13 through 18) – Male
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC106
Families and Children Adult (age 19 through 24) - Female
$
9.04

$
8.37

$
9.04

$
7.97

$
10.43

$
8.44

$
8.86

$
9.39

ZC107
Families and Children Adult (age 19 through 24) - Male
$
8.87

$
8.20

$
8.87

$
7.80

$
10.26

$
8.27

$
8.70

$
9.22

ZC108
Families and Children Adult (age 25 through 39) – Female
$
9.04

$
8.37

$
9.04

$
7.97

$
10.43

$
8.44

$
8.86

$
9.39

ZC109
Families and Children Adult (age 25 through 39) - Male
$
8.87

$
8.20

$
8.87

$
7.80

$
10.26

$
8.27

$
8.70

$
9.22

ZC110
Families and Children Adult (age 40 or Older) – Female
$
9.04

$
8.37

$
9.04

$
7.97

$
10.43

$
8.44

$
8.86

$
9.39

ZC111
Families and Children Adult (age 40 or Older) - Male
$
8.87

$
8.20

$
8.87

$
7.80

$
10.26

$
8.27

$
8.70

$
9.22

ZC201
SSI without Medicare Adult (age 19 through 24) - Female
$
14.01

$
11.67

$
16.90

$
10.89

$
16.20

$
11.28

$
13.78

$
14.95

ZC202
SSI without Medicare Adult (age 19 through 24) - Male
$
13.85

$
11.50

$
16.73

$
10.72

$
16.03

$
11.11

$
13.61

$
14.78

ZC203
SSI without Medicare Adult (age 25 through 44) - Female
$
14.01

$
11.67

$
16.90

$
10.89

$
16.20

$
11.28

$
13.78

$
14.95

ZC204
SSI without Medicare Adult (age 25 through 44) - Male
$
13.85

$
11.50

$
16.73

$
10.72

$
16.03

$
11.11

$
13.61

$
14.78

ZC205
SSI without Medicare Adult (age 45 or older) - Female
$
14.01

$
11.67

$
16.90

$
10.89

$
16.20

$
11.28

$
13.78

$
14.95

ZC206
SSI without Medicare Adult (age 45 or older) - Male
$
13.85

$
11.50

$
16.73

$
10.72

$
16.03

$
11.11

$
13.61

$
14.78

ZC301
Dual Eligible – Female
$
8.04

$
10.51

$
10.51

$
8.52

$
9.99

$
9.46

$
10.89

$
8.90

ZC302
Dual Eligible – Male
$
8.04

$
10.51

$
10.51

$
8.52

$
9.99

$
9.46

$
10.89

$
8.90

ZC401
SSI Infant (age under 1)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC402
SSI Child (age 1 through 5)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC403
SSI Child (age 6 through 18)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC501
Foster Care Infant (age under 1)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC502
Foster Care (age 1 through 5)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC503
Foster Care (age 6 through 12)
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
ZC504
Foster Care (age 13 or older) – Female
$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

$
0.17

ZC505
Foster Care (age 13 or older) – Male
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Composite
$
3.10

$
3.24

$
3.43

$
3.20

$
3.96

$
2.60

$
4.44

$
5.32

 
 
 
 
 
 
 
 
$
3.84

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Medicaid Expansion Rate Cells
All ACA Benefit Changes
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
ZC506
Former Foster Care Child (>=18 <21) – Female
$
2.74

$
2.74

$
2.74

$
2.74

$
2.74

$
2.74

$
2.74

$
2.74

ZC507
Former Foster Care Child (>=18 <21) – Male
$
2.57

$
2.57

$
2.57

$
2.57

$
2.57

$
2.57

$
2.57

$
2.57

ZC508
Former Foster Care Child (>=21 <26) – Female
$
44.14

$
63.08

$
44.14

$
63.08

$
48.10

$
43.26

$
22.56

$
45.90

ZC509
Former Foster Care Child (>=21 <26) – Male
$
43.97

$
62.91

$
43.97

$
62.91

$
47.93

$
43.09

$
22.39

$
45.73

ZC601
MAGI Adult (age through 18) - Female
$
15.04

$
11.65

$
15.04

$
9.64

$
22.08

$
12.03

$
14.17

$
16.80

ZC602
MAGI Adult (age through 18) - Male
$
14.88

$
11.49

$
14.88

$
9.48

$
21.91

$
11.86

$
14.00

$
16.63

ZC603
MAGI Adult (age 19 through 24) - Female
$
15.04

$
11.65

$
15.04

$
9.64

$
22.08

$
12.03

$
14.17

$
16.80

ZC604
MAGI Adult (age 19 through 24) – Male
$
14.88

$
11.49

$
14.88

$
9.48

$
21.91

$
11.86

$
14.00

$
16.63

ZC605
MAGI Adult (age 25 through 39) – Female
$
15.04

$
11.65

$
15.04

$
9.64

$
22.08

$
12.03

$
14.17

$
16.80

ZC606
MAGI Adult (age 25 through 39) – Male
$
14.88

$
11.49

$
14.88

$
9.48

$
21.91

$
11.86

$
14.00

$
16.63

ZC607
MAGI Adult (age 40 or older) – Female
$
15.04

$
11.65

$
15.04

$
9.64

$
22.08

$
12.03

$
14.17

$
16.80

ZC608
MAGI Adult (age 40 or older) – Male
$
14.88

$
11.49

$
14.88

$
9.48

$
21.91

$
11.86

$
14.00

$
16.63

Composite
$
15.16

$
11.86

$
15.15

$
9.94

$
22.15

$
12.31

$
14.10

$
16.81

Statewide Composite- Expansion (n=167,546)
 
 
 
 
 
 
 
$
15.49

Adult Composite - Existing Plus Expansion
 
 
 
 
 
 
 
$
13.66

--------------------------------------------------------------------------------

Appendix I (Revised)

Covered Services

I.
Contractor Covered Services

A.
Ambulatory Surgical Center Services

B.
Allergy Testing and Treatment for Adults (in addition to these services provided
to Children and Pregnant and Postpartum Women)

C.
Chiropractic Services

D.
Community Mental Health Center Services

E.
Dental Services, including Oral Surgery, Orthodontics and Prosthodontics

F.
Durable Medical Equipment, including Prosthetic and Orthotic Devices, and
Disposable Medical Supplies

G.
Early and Periodic Screening, Diagnosis & Treatment (EPSDT) screening and
special services

H.
End Stage Renal Dialysis Services

I.
Family Planning Clinic Services in accordance with federal and state law and
judicial opinion

J.
Freestanding Birth Center Services

K.
Hearing Services, including Hearing Aids for Members Under age 21

L.
Home Health Services

M.
Hospice Services (non-institutional only)

N.
Impact Plus Services

O.
Independent Laboratory Services

P.
Inpatient Hospital Services

Q.
Inpatient Mental Health Services

R.
Meals and Lodging for Appropriate Escort of Members

S.
Medical Detoxification, meaning management of symptoms during the acute
withdrawal phrase from a substance to which the individual has been addicted.

T.
Medical Services, including but not limited to, those provided by Physicians,
Advanced Practice Registered Nurses, Physicians Assistants and FQHCs, Primary
Care Centers and Rural Health Clinics

U.
Organ Transplant Services not Considered Investigational by FDA

V.
Other Laboratory and X-ray Services

W.
Outpatient Hospital Services

X.
Outpatient Behavioral Health Services

Y.
Pharmacy and Limited Over-the-Counter Drugs including Behavioral Health Drugs

Z.
Podiatry Services

AA.
Preventive Health Services, including those currently provided in Public Health
Departments, FQHCs/Primary Care Centers, and Rural Health Clinics and including
BRCA1 and BRCA2 testing

BB.
Private Duty Nursing Services

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CC.
Psychiatric Residential Treatment Facilities (Level I and Level II)

DD.
Specialized Case Management Services for Members with Complex Chronic Illnesses
(Includes adult and child targeted case management)

EE.
Therapeutic Evaluation and Treatment, including Physical Therapy, Speech
Therapy, Occupational Therapy

FF.
Transportation to Covered Services, including Emergency and Ambulance Stretcher
Services

GG.
Substance Use Disorder Services, including Residential Treatment, Intense
Out-Patient Treatment, Therapy, Case Management, and Peer and Parental Support

HH.
Urgent and Emergency Care Services

II.
Vision Care, including Vision Examinations, Services of Opticians, Optometrists
and Ophthalmologists, including eyeglasses for Members Under age 21

JJ.
Specialized Children’s Services Clinics

II.
Member Covered Services and Summary of Benefits Plan

A.
General Requirements and Limitations

The Contractor shall provide, or arrange for the provision of, health services,
including Emergency Medical Services, to the extent services are covered for
Members under the then current Kentucky Medicaid Program State Plan, as
designated by the department in administrative regulations adopted in accordance
with KRS Chapter 13A and as required by federal and state regulations,
guidelines, transmittals, and procedures.

This Appendix was developed to provide, for illustration purposes only, the
Contractor with a summary of currently covered Kentucky Medicaid services and to
communicate guidelines for the submission of specified Medicaid reports. The
summary is not meant to act, nor serve as a substitute for the then current
administrative regulations and the more detailed information relating to
services which is contained in administrative regulations governing provision of
Medicaid services (Title 907 of the Kentucky Administrative Regulations (KAR)
and in individual Medicaid program services benefits summaries incorporated by
reference in the administrative regulations. If the Contractor questions whether
a service is a Covered Service or Non-Covered Service, the Department reserves
the right to make the final determination, based on the then current
administrative regulations in effect at the time of the contract.

Administrative regulations and incorporated by reference Medicaid program
services benefits summaries may be accessed by contacting:

Kentucky Cabinet for Health and Family Services

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Department for Medicaid Services
275 East Main Street, 6th Floor
Frankfort, Kentucky 40621

Kentucky’s administrative regulations are also accessible via the Internet at
http://www.lrc.state.ky.us/kar/title907.htm

Kentucky Medicaid covers only Medically Necessary services. (907 KAR 3:130)
These services are considered by the Department to be those which are reasonable
and necessary to establish a diagnosis and provide preventive, palliative,
curative or restorative treatment for physical or mental conditions in
accordance with the standards of health care generally accepted at the time
services are provided, including but not limited to services for children in
accordance with 42 USC 1396d(r). Each service must be sufficient in amount,
duration, and scope to reasonably achieve its purpose. The amount, duration, or
scope of coverage must not be arbitrarily denied or reduced solely because of
the diagnosis, scope of illness, or condition.

The Contractor shall provide any Covered Services ordered to be provided to a
Member by a Court, to the extent not in conflict with federal laws. The
Department shall provide written notification to the Contractor of any
court-ordered service. The Contractor shall additionally cover forensic
pediatric and adult sexual abuse examinations performed by health care
professional(s) credentialed to perform such examinations and any physical and
sexual abuse examination(s) for any Member when the Department for Community
Based Services is conducting an investigation and determines that the
examination(s) is necessary.

III.
EMERGENCY CARE SERVICES (42 CFR 431.52)

The Contractor must provide, or arrange for the provision of, all covered
emergency care immediately using health care providers most suitable for the
type of injury or illness in accordance with Medicaid policies and procedures,
even when services are provided outside the Contractor’s region or are not
available using Contractor enrolled providers. Conditions related to provision
of emergency care are shown in 42 CFR 438.144.

IV.
MEDICAID SERVICES COVERED AND NOT COVERED BY THE CONTRACTOR

The Contractor must provide Covered Services under current administrative
regulations. The scope of services may be expanded with approval of the
Department and as necessary to comply with federal mandates and state laws.
Certain Medicaid services are currently excluded from the Contractor benefits

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package, but continue to be covered through the traditional fee-for-service
Medicaid Program. The Contractor will be expected to be familiar with these
Contractor excluded services, designated Medicaid “wrap-around” services and to
coordinate with the Department’s providers in the delivery of these services to
Members.

Information relating to these excluded services’ programs may be accessed by the
Contractor from the Department to aid in the coordination of the services.

A.
Health Services Not Covered Under Kentucky Medicaid

Under federal law, Medicaid does not receive federal matching funds for certain
services. Some of these excluded services are optional services that the
Department may or may not elect to cover. The Contractor is not required to
cover services that Kentucky Medicaid has elected not to cover for Members.

Following are services currently not covered by the Kentucky Medicaid Program:
•
Any laboratory service performed by a provider without current certification in
accordance with the Clinical Laboratory Improvement Amendment (CLIA). This
requirement applies to all facilities and individual providers of any laboratory
service;

•
Cosmetic procedures or services performed solely to improve appearance;

•
Hysterectomy procedures, if performed for hygienic reasons or for sterilization
only;

•
Medical or surgical treatment of infertility (e.g., the reversal of
sterilization, invitro fertilization, etc.);

•
Induced abortion and miscarriage performed out-of-compliance with federal and
Kentucky laws and judicial opinions;

•
Paternity testing;

•
Personal service or comfort items;

•
Post mortem services;

•
Services, including but not limited to drugs, that are investigational, mainly
for research purposes or experimental in nature;

•
Sex transformation services;

•
Sterilization of a mentally incompetent or institutionalized member;

•
Services provided in countries other than the United States, unless approved by
the Secretary of the Kentucky Cabinet for Health and Family Services;

•
Services or supplies in excess of limitations or maximums set forth in federal
or state laws, judicial opinions and Kentucky Medicaid program regulations
referenced herein;

•
Services for which the Member has no obligation to pay and for which no other
person has a legal obligation to pay are excluded from coverage; and

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V.
Health Services Limited by Prior Authorization

The following services are currently limited by Prior Authorization of the
Department for Members. Other than the Prior Authorization of organ transplants,
the Contractor may establish its own policies and procedures relating to Prior
Authorization.

•
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Special Services

The Contractor is responsible for providing and coordinating Early and Periodic
Screening, Diagnosis and Treatment Services (EPSDT), and EPSDT Special Services,
through the primary care provider (PCP), for any Member under the age of
twenty-one (21) years.

EPSDT Special Services must be covered by the Contractor and include any
Medically Necessary health care, diagnostic, preventive, rehabilitative or
therapeutic service that is Medically Necessary for a Member under the age of
twenty-one (21) years to correct or ameliorate defects, physical and mental
illness, or other conditions whether the needed service is covered by the
Kentucky Medicaid State Plan in accordance with Section 1905 (a) of the Social
Security Act.

•
Transplantation of Organs and Tissue (Currently found at 907 KAR 1:350

•
Other Prior Authorized Medicaid Services

Other Medicaid services limited by Prior Authorization are identified in the
individual program coverage areas in Section VI.

VI.
Current Medicaid Programs’ Services and Extent of Coverage

The Contractor shall cover all services for its Members at the appropriate
level, in the appropriate setting and as necessary to meet Members’ needs to the
extent services are included in Covered Services. The Contractor may expand
coverage to include other services not routinely covered by Kentucky Medicaid,
if the expansion is approved by the Department, if the services are deemed cost
effective and Medically Necessary, and as long as the costs of the additional
services do not affect the Capitation Rate.

The Contractor shall provide covered services as required by the following
statutes or administrative regulations:

•
Medical Necessity and Clinical Appropriate Determination Basis

(907 KAR 3:130)
•
Freestanding Birth Center Services (907 KAR 1:180)

•
Allergy Testing and Treatment for Adults (907 KAR 3:005)

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•
Ambulatory Surgical Center and Anesthesia Services (907 KAR 1:008)

•
Chiropractic Services (907 KAR 3:125)

•
Commission for Children with Special Health Care Needs

(907 KAR 1:440)
•
Community Mental Health Center Services (907 KAR 1:044 and 907 KAR 3:110)

•
Dental Health Services (907 KAR 1:026)

•
Dialysis Center Services (907 KAR 1:400)

•
Durable Medical Equipment, Medical Supplies, Orthotic and Prosthetic Devices
(907 KAR 1:479)

•
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services (907 KAR
11:034)

•
Family Planning Clinic Services (907 KAR 1:048 & 1:434)

•
Hearing Program Services (907 KAR 1:038)

•
Home Health Services (907 KAR 1:030)

•
Hospice Services – non-institutional (907 KAR 1:330 & 1: 436)

•
Hospital Inpatient Services (907 KAR 10:012)

•
Hospital Outpatient Services (907 KAR 10:014)

•
Laboratory Services (907 KAR 1:028)

•
Medicare Non-Covered Services (907 KAR 1:006)

•
Behavioral Health Inpatient Services (907 KAR 10:016)

•
Behavioral Health Outpatient Services ( 907 KAR 15:010) Nursing Facility
Services (907 KAR 1:022)Other Laboratory and X-ray Provider Services (907 KAR
1:028)

•
Outpatient Pharmacy Prescriptions and Over-the-Counter Drugs including

•
Mental/Behavioral Health Drugs (907 KAR 1:019, KRS 205.5631, 205.5632,KRS
205.560)

•
Out-Patient Physical Therapy, Speech Therapy, Occupational Therapy, (907 KAR
8:010, Occupational therapy services, 907 KAR 8:020, Physical therapy services,
907 KAR 8:030, Speech therapy services)

•
Psychiatric Residential Treatment Facility Services – (907 KAR 9:005)

•
Physicians and Nurses in Advanced Practice Medical Services (907 KAR 3:005 and
907 KAR 1:102)

•
Podiatry Services (907 KAR 1:270)

•
Preventive Health Services (907 KAR 1:360)

•
Primary Care and Rural Health Center Services (907 KAR 1:054, 1:082, 1:418 and
1:427)

•
Private Duty Nursing (907 KAR 13:010)

•
Sterilization, Hysterectomy and Induced Termination of Pregnancy Procedures
(Sterilizations of both male and female Members are covered only when performed
in compliance with federal regulations 42 CFR 441.250.)

•
Substance Use Disorder Services (907 KAR 15:020)

•
Targeted Case Management Services (907 KAR 1:515, 907 KAR 1:525, 907 KAR 1:550
and 907 KAR 1:555)

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•
Transportation, including Emergency and Non-emergency Ambulance (907 KAR 1:060)

•
Vaccines for Children (VFC) Program (907 KAR 1:680)

•
Vision Services (907 KAR 1:038)

•
Specialized Children’s Services Clinics (907 KAR 3:160)

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APPENDIX S. (Revised)
TRANSITION/COORDINATION OF CARE PLANS

Upon receipt of a HIPAA 834 indicating that a Member is transferring from one
Medicaid Managed Care Organization (Former MCO) to another MCO (New MCO), the
Former MCO shall be responsible to contact the New MCO, the recipient and the
recipient’s providers in order to transition existing care. A Prior
Authorization (PA) shall be honored by the New MCO for 90 days or until the
recipient or provider is contacted by the New MCO regarding the PA. If the
recipient and provider are not contacted by the New MCO, the existing Medicaid
PA shall be honored until expired.

Hospital Admission Prior to the Member’s Transition.

If the Member is an in-patient in any facility at the time of transition, the
entity responsible for the Member’s care at the time of admission shall continue
to provide coverage for the Member at that facility, including all Professional
Services, until the recipient is discharged from the facility for the current
admission. An inpatient admission within fourteen (14) calendar days of
discharge for the same diagnosis shall be considered a “current admission.” The
“same diagnosis” is defined as the first five digits of a diagnosis code.

Outpatient Facility Services and Non-Facility Services

Effective on the Member’s Transition date, the New MCO will be responsible for
outpatient services both facility and non-facility. Outpatient reimbursement
includes outpatient hospital, ambulatory surgery centers, and renal dialysis
centers.

Nursing Homes

Eligibility for Long Term Care in a Nursing Facility (NF) includes some
financial requirements not needed for basic Medicaid eligibility.  When an
eligible member enters an NF the facility must receive a Level of Care (LOC)
determination to ensure the member meets medical criteria for Nursing Facility. 
That LOC is passed electronically to the DCBS eligibility worker, triggering the
eligibility determination for this additional benefit.  That determination can
generally be completed within thirty days.  Once LTC eligible, worker entries
exempt the member from managed care effective with the next feasible month.  If
the worker action is completed prior to cut off (eight business days before the
end of the month), managed care ends at the last day of current month.  If the
action is after cut off, managed care ends the last day of the following month. 
During this transition, the MCO will be responsible for ancillary, physician and
pharmaceuticals charges and the Department will reimburse for those services
billed by Nursing Facility.  Once exempt from Managed Care, the Department will
be responsible for all eligible services associated with this recipient.

Waiver Participation

1915(c) Home and Community Based Services Wavier programs are simply added
benefits for eligible members; however, the action that exempts those members
from being subject to Managed Care resides with the DCBS eligibility worker. 
These services require a Level of Care (LOC).  The LOC is passed electronically
to the DCBS eligibility worker; receipt of

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the LCO triggers the eligibility worker to complete entries within the
eligibility system.   Those entries exempt the member from managed care
effective the next feasible month.  If the worker action is completed prior to
cut off (eight business days before the end of the month), managed care ends at
the last day of current month.  If the action is after cut off, managed care
ends the last day of the following month.  During this transition, the MCO will
be responsible for all services except the additional Waiver benefits.  The
Waiver Services will be paid by the Department as fee for service.  Coding in
our billing system allows the Wavier Service to be processed during the
transition period, once the eligibility worker has completed the necessary
entries.   Once exempt from Managed Care the Department will be responsible for
all services associated with this recipient.

Transplants

Follow up care provided on or after the Member’s Transition that is billed
outside the Global Charges, will be the responsibility of the New MCO.

Eligibility Issues

For a Member who loses eligibility during an inpatient stay, an MCO is
responsible for the care through discharge if the hospital is compensated under
a DRG methodology or through the day of ineligibility if the hospital is
comenstated under a per deum methodology.

375