Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:055 - Payments for primary care center, federally-qualified health center, federally-qualified health center look-alike, and rural health clinic services

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.560,
				216B.010,
				216B.105,
				216B.130,
				216B.990, 42 C.F.R.
				413,
				438.60,
				491, Subpart A, 440.130, 440.230, 447.3251, 45 C.F.R. 74.27, 48 C.F.R. Part 31,
				42 U.S.C.
				1396a, b, d
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 any requirement that may
				be imposed, or opportunity presented, by federal law to qualify for federal
				Medicaid funds. This administrative regulation establishes the Department for
				Medicaid Services' reimbursement policies for primary care center,
				federally-qualified health center, federally-qualified health center
				look-alike, and rural health clinic services.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
			 "APRN" is defined by
			 KRS
			 314.011(7).
(2) "Alternative payment methodology" or
			 "APM" means a reimbursement that is an alternative to the standard
			 reimbursement established in Section 3 of this administrative regulation in
			 accordance with
			 42 U.S.C.
			 1396a(bb)(6).
(3) "Audit" means an examination that may be
			 full or limited in scope of a federally-qualified health center's,
			 federally-qualified health center look-alike's, rural health clinic's, or
			 primary care center's:
(a) Financial
			 transactions, accounts, and reports; and
(b) Compliance with applicable Medicare and
			 Medicaid regulations, manual instructions, and directives.
(4) "Base year" means the first full fiscal
			 year following the effective date of an FQHC's, FQHC look-alike's, or RHC's
			 enrollment in the Medicaid program:
(a) In
			 which the FQHC, FQHC look-alike, or RHC has reached its maximum hours per day,
			 days per week, and weeks per year of intended operation as designated by the
			 FQHC, FQHC look-alike, or RHC; and
(b) Not to exceed twenty-four (24) months
			 past the effective date that the FQHC, FQHC look-alike, or RHC was enrolled
			 with the department.
(5)
			 "Certified psychologist with autonomous functioning" means an individual who is
			 a certified psychologist with autonomous functioning pursuant to
			 KRS
			 319.056.
(6) "Certified social worker" means an
			 individual who meets the requirements established in
			 KRS
			 335.080.
(7) "Change in scope of service" means a
			 change in the type, intensity, duration, or amount of service.
(8) "Department" means the Department for
			 Medicaid Services or its designated agent.
(9) "Enrollee" means a recipient who is
			 enrolled with a managed care organization for the purpose of receiving Medicaid
			 or KCHIP covered services.
(10)
			 "Federal financial participation" is defined in
			 42 C.F.R.
			 400.203.
(11) "Federally-qualified health center" or
			 "FQHC" is defined in
			 42 C.F.R.
			 405.2401.
(12) "Federally-qualified health center
			 look-alike" or "FQHC look-alike" means an entity that is currently approved by
			 the United States Department of Health and Human Services, Health Resources and
			 Services Administration, and the Centers for Medicare and Medicaid Services to
			 be a federally-qualified health center look-alike.
(13) "Final PPS rate" means an all-inclusive
			 reimbursement amount per visit for an FQHC, FQHC look-alike, or RHC that:
(a) Is unique to the FQHC, FQHC look-alike,
			 or RHC;
(b) Encompasses
			 reimbursement for all services rendered during the visit;
(c) Is based on:
1. Twelve (12) full months of Medicaid cost
			 report data in which the FQHC, FQHC look-alike, or RHC has reached its maximum
			 hours per day, days per week, and weeks per year of intended operation:
a. Submitted to the department by the FQHC,
			 FQHC look-alike, or RHC; and
b.
			 That has been reviewed and approved by the department; and
2. A paid claims listing corresponding to the
			 twelve (12) full months of Medicaid cost report data in which the FQHC, FQHC
			 look-alike, or RHC has reached its maximum hours per day, days per week, and
			 weeks per year of intended operation; and
(d) Is established by the
			 department.
(14) "Health
			 care provider" means, for:
(a) A primary care
			 center, an FQHC, an FQHC look-alike, or an RHC:
1. A licensed physician;
2. A licensed osteopathic
			 physician;
3. A licensed
			 podiatrist;
4. A licensed
			 optometrist;
5. An advanced
			 practice registered nurse;
6. A
			 licensed dentist or oral surgeon;
7. A physician assistant;
8. A licensed clinical social
			 worker;
9. A licensed
			 psychologist;
10. A licensed
			 marriage and family therapist;
11.
			 A licensed professional clinical counselor;
12. A licensed psychological
			 practitioner;
13. A certified
			 psychologist with autonomous functioning; or
14. A practitioner who is:
a. Authorized pursuant to
			 907
			 KAR 1:054 to provide services in a PCC, an FQHC, an
			 FQHC look-alike, or an RHC; and
b.
			 Not listed in subparagraphs 1 through 13 of this paragraph; or
(b) An FQHC or FQHC
			 look-alike, in addition to the professionals established in paragraph (a) of
			 this subsection:
1. A resident in the
			 presence of a teaching physician; or
2. A resident without the presence of a
			 teaching physician if:
a. The services are
			 furnished in an FQHC or FQHC look-alike in which the time spent by the resident
			 in performing patient care is included in determining any intermediary payment
			 to a hospital in accordance with
			 42 C.F.R.
			 413.75 through
			 413.83;
b. The resident furnishing the service
			 without the presence of a teaching physician has completed more than six (6)
			 months of an approved residency program;
c. The teaching physician:
(i) Does not direct the care of more than
			 four (4) residents at any given time; and
(ii) Directs care from a proximity that
			 constitutes immediate availability; and
d. The teaching physician:
(i) Has no other responsibilities at the
			 time;
(ii) Has management
			 responsibility for any recipient seen by the resident;
(iii) Ensures that the services furnished are
			 appropriate;
(iv) Reviews with the
			 resident, during or immediately after each visit by a recipient, the
			 recipient's medical history, physical examination, diagnosis, and record of
			 tests or therapies; and
(v)
			 Documents the extent of the teaching physician's participation in the review
			 and direction of the services furnished to each recipient.
(15)
			 "Interim PPS rate" means an all-inclusive per visit reimbursement amount
			 established by the department to pay an FQHC, FQHC look-alike, or an RHC for
			 covered services prior to the establishment of a final PPS rate.
(16) "Licensed clinical social worker" means
			 an individual who is currently licensed in accordance with
			 KRS
			 335.100.
(17) "Licensed marriage and family therapist"
			 is defined by
			 KRS
			 335.300(2).
(18) "Licensed professional clinical
			 counselor" is defined by
			 KRS
			 335.500(3).
(19) "Licensed psychological practitioner"
			 means an individual who meets the requirements established in
			 KRS
			 319.053.
(20) "Managed care organization" 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.
(21) "Medical Group Management Association
			 Medical Directorship and On-Call Compensation Survey" means a report developed
			 and owned by the Medical Group Management Association that:
(a) Highlights the critical relationship
			 between medical director compensation and time spent in the medical director
			 function;
(b) Aligns medical
			 director compensation with time spent as medical director; and
(c) Contains tables illustrating the
			 relationship of medical director salary to time spent in the medical director
			 function.
(22) "Medical
			 Group Management Association Physician Compensation and Production Survey
			 Report" means a report developed and owned by the Medical Group Management
			 Association that:
(a) Highlights the critical
			 relationship between physician salaries and productivity;
(b) Is used to align physician salaries and
			 benefits with provider production; and
(c) Contains:
1. Performance ratios illustrating the
			 relationship between compensation and production; and
2. Comprehensive and summary data tables that
			 cover many specialties.
(23) "Medically necessary" or "medical
			 necessity" means that a covered benefit is determined to be needed in
			 accordance with
			 907
			 KAR 3:130.
(24) "Medicare Economic Index" or "MEI" means
			 the economic index referred to in
			 42 U.S.C.
			 1395u(b)(3)(L).
(25) "Paid claims listing" means a report of
			 claims paid by the department for a given FQHC, FQHC look-alike, or
			 RHC.
(26) "Parent facility" means a
			 federally-qualified health center, federally-qualified health center
			 look-alike, or primary care center that is:
(a) Licensed and operating with a unique
			 Kentucky Medicaid program provider number;
(b) Operating under the same management as a
			 satellite facility; and
(c) The
			 original facility that existed prior to the existence of a satellite
			 facility.
(27) "PCC" or
			 "primary care center" means an entity that is currently licensed as a PCC in
			 accordance with
			 902 KAR 20:058.
(28) "Percentage increase in the MEI" is
			 defined in
			 42 U.S.C.
			 1395u(i)(3).
(29) "Physician assistant" is defined by
			 KRS
			 311.840(3).
(30) "PPS" means prospective payment
			 system.
(31) "Rate year" means, for
			 the purposes of the MEI, the twelve (12) month period beginning July 1 of each
			 year for which a rate is established for an FQHC, FQHC look-alike, or RHC under
			 the prospective payment system.
(32) "Reasonable cost" means:
(a) A cost as determined by the:
1. Applicable Medicare cost reimbursement
			 principles established in 42 C.F.R. Part 413, 45 C.F.R. 74.27, and 48 C.F.R.
			 Part 31 ; and
2. Medical Group
			 Management Association Physician Compensation and Production Survey Report for
			 the applicable year and region; and
(b) Costs determined to be reasonable in
			 accordance with a comprehensive desk review or audit.
(33) "Recipient" is defined by
			 KRS
			 205.8451(9).
(34) "RHC" or "rural health clinic" is
			 defined in
			 42 C.F.R.
			 405.2401(b).
(35) "Satellite facility" means a
			 federally-qualified health center, federally-qualified health center
			 look-alike, or primary care center that:
(a)
			 Is at a different location than the parent facility; and
(b) Operates under the same management as the
			 parent facility.
(36)
			 "Telehealth" means two (2)-way, real time interactive communication between a
			 patient and a physician or practitioner located at a distant site for the
			 purpose of improving a patient's health through the use of interactive
			 telecommunication equipment that includes, at a minimum, audio and video
			 equipment.
(37) "Visit" means an
			 encounter:
(a) Between a recipient or enrollee
			 and a health care provider during which an FQHC, FQHC look-alike, or RHC
			 service is delivered; and
(b) That
			 occurs:
1. In person; or
2. Via telehealth if authorized by
			 907 KAR
			 3:170.