Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:675 - Program integrity

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.8451,
				205.8453,
				42 C.F.R. 431 Subpart E, 455.12, 455.13, 455.16(c)(4)
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
				July 9, 2004, reorganized the Cabinet for Health Services and placed the
				Department for Medicaid Services and the Medicaid Program under the Cabinet for
				Health and Family Services. The Cabinet for Health and Family Services,
				Department for Medicaid Services, has responsibility to administer the Medicaid
				Program.
				KRS
				205.520(3) empowers 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.
				KRS
				205.8453(4) directs the
				Cabinet for Health Services to institute other measures necessary or useful in
				controlling fraud and abuse. This administrative regulation establishes an
				administrative process which provides due process prior to disqualification or
				request for repayment of Medicaid benefits paid on behalf of a recipient. This
				administrative regulation establishes the provisions relating to enhanced
				program integrity of the Medicaid Program and applies to all Kentucky Medicaid
				recipients.
Section 1. Definitions.
(1) "Benefit" is defined in
			 KRS
			 205.8451(1).
(2) "Department" means the Department for
			 Medicaid Services or its designated agent.
(3) "Disqualification hearing" means a
			 hearing conducted by a Cabinet for Health Services hearing officer if:
(a) An adult recipient or responsible party
			 has been found, through an investigative process, to have committed MA IPV;
			 and
(b) The individual has appealed
			 the finding.
(4)
			 "Extraordinary circumstance" means a medical condition other than pregnancy or
			 postpartum which results from a communicable disease or other condition that
			 creates a risk to public health, or a condition which, if not treated, could
			 result in immediate grave bodily harm.
(5) "Judicial review" means a review of a
			 final agency order by the appropriate circuit court, plus further appeal to the
			 Kentucky Court of Appeals or Kentucky Supreme Court.
(6) "Medicaid intentional program violation"
			 or "MA IPV" means an action in which a recipient or responsible party makes a
			 false or misleading statement, or misrepresents, conceals or withholds a fact
			 or commits a violation of a state or federal law relating to the Medicaid
			 program which results in a financial loss to the department.
(7) "Penalty" means an administrative action
			 taken by the department which restricts or revokes a recipient's participation
			 in the Medicaid Program or requires the repayment of the value of the benefits
			 received.
(8) "Recipient" is
			 defined in
			 KRS
			 205.8451.
(9) "Responsible party" means an individual
			 who is either:
(a) A parent or legal guardian
			 of a minor child who is a Medicaid recipient;
(b) A Medicaid recipient who is eighteen (18)
			 years old or older;
(c) A spouse
			 aged eighteen (18) years old or older of a Medicaid recipient;
(d) An individual who possesses a power of
			 attorney for the Medicaid recipient; or
(e) A legal guardian for an incompetent adult
			 Medicaid recipient.