Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:031 - Payments for home health services

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				42 C.F.R.
				440.70,
				447.325,
				42 U.S.C.
				1396a -d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services, Department for Medicaid Services, has responsibility to
				administer the Kentucky 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 method for determining amounts payable by the
				Medicaid Program for home health agency services that are provided to
				Kentucky's Medicaid-eligible recipients.
Section
			 1. Definitions.
(1) "Allowable
			 cost" means that portion of the home health agency's cost that shall be allowed
			 by the department in establishing reimbursement.
(2) "Cost report" means the Annual Medicaid
			 Home Health/HCB Cost Report.
(3)
			 "Cost report instructions" means the Annual Medicaid Home Health/HCB Cost
			 Report Instructions.
(4)
			 "Department" means the Department for Medicaid Services or its
			 designee.
(5) "Home health agency"
			 or "HHA" means an agency defined pursuant to
			 42 C.F.R.
			 440.70(d).
(6) "Interim rate" means a rate set for a
			 provider for tentative reimbursement, based on reasonable allowable cost of
			 providing a covered service, which may result in reimbursement adjustments
			 after an audit or review determines the actual allowable cost during an
			 accounting period.
(7) "Medicaid
			 upper limit" means the maximum amount the Medicaid Program shall reimburse, on
			 a facility-by-facility basis, for a unit of service.
(8) "Medically necessary" or "medical
			 necessity" means that a covered benefit is determined to be needed in
			 accordance with
			 907
			 KAR 3:130.
(9) "Medicare upper limit" means the maximum
			 reimbursement amount allowed by Medicare specific to:
(a) Each Medicare participating
			 provider;
(b) Each category of
			 service; and
(c) A unit of
			 service.
(10) "Necessary
			 function" means that if an owner of an agency had not provided the services
			 pertinent to the operation of the HHA, the facility would have had to employ
			 another person to perform the service.
(11) "Owner" means a person or a related
			 family member with a cumulative ownership interest of five (5) percent or
			 more.
(12) "Projected cost report"
			 means an Annual Medicaid Home Health/HCB Cost Report that reflects costs that
			 can reasonably be expected to be incurred by a provider for a specific period
			 of time ending in the future.
(13)
			 "Public agency" means an agency operated by a federal, state, county, city or
			 other local governmental agency or instrumentality.
(14) "Rate year" means a twelve (12) month
			 period beginning July 1 and ending the following June 30.
(15) "Related family member" means:
(a) Husband or wife;
(b) Natural or adoptive parent, child, or
			 sibling;
(c) Stepparent, stepchild,
			 stepbrother, stepsister;
(d)
			 Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or
			 sister-in-law;
(e) Grandparent or
			 grandchild;
(f) Spouse of
			 grandparent or grandchild;
(g) Aunt
			 or uncle; or
(h) Spouse of aunt or
			 uncle.
(16) "Settled" or
			 "settlement" means an amount by which a provider's interim Medicaid payment for
			 a specified period of time is adjusted based on an audited or desk reviewed
			 cost report for that same period of time.
(17) "Uniform desk review" or "UDR" means an
			 analysis of a provider's Annual Medicaid Home Health/HCB Cost Report to
			 determine if the data is adequate, complete, accurate, and
			 reasonable.
(18) "Usual and
			 customary charge" means the uniform amount which a medical provider charges the
			 general public for a specific service or procedure.