Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 3 - Payment and Services › Section 907 KAR 3:210 - Acquired brain injury long-term care waiver services and reimbursement

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				17.165,
				202A.011,
				205.5605,
				205.5607,
				205.8451,
				205.8477,
				314.011,
				319.010(8),
				319A.010,
				319.056,
				327.010,
				334A.020,
				335.300(2),
				335.500(3),
				620.030, 42 C.F. R. 441 Subpart
				G, 455 Subpart B, 42 U. S.
				C. 1396a,
				1396b,
				1396d,
				1396n
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. KRS
				205.5606(1) requires the
				cabinet to promulgate administrative regulations to establish a
				participant-directed services program to provide an option for the home and
				community-based services waivers. This administrative regulation establishes
				the coverage provisions relating to home- and community- based waiver services
				provided to an individual with an acquired brain injury as an alternative to
				nursing facility services and including a participant-directed services program
				pursuant to KRS
				205.5606. The purpose of acquired brain
				injury long term care waiver services is to provide an alternative to
				institutional care to individuals with an acquired brain injury who require
				maintenance services.
Section 1.
			 Definitions.
(1) "1915(c) home and community
			 based services waiver program" means a Kentucky Medicaid program established
			 pursuant to and in accordance with
			 42 U. S. C.
			 1396n(c).
(2) "ABI" means an acquired brain
			 injury.
(3) "ABI provider" means an
			 entity that meets the criteria established in Section 2 of this administrative
			 regulation.
(4) "ABIB" means the
			 Acquired Brain Injury Branch in the Division of Community Alternatives, in the
			 Cabinet for Health and Family Services.
(5) "Acquired brain injury long term care
			 waiver service" means a home and community based waiver service for an
			 individual who requires long term maintenance and has acquired a brain injury
			 involving the central nervous system that resulted from:
(a) An injury from a physical
			 trauma;
(b) Anoxia or a hypoxic
			 episode; or
(c) Allergic condition,
			 toxic substance, or another acute medical incident.
(6) "ADHC services" means adult day health
			 care services provided on a regularly scheduled basis that ensure optimal
			 functioning of a participant who does not require twenty-four (24) hour care in
			 an institutional setting.
(7)
			 "Assessment" or "reassessment" means a comprehensive evaluation of abilities,
			 needs, and services that:
(a) Serves as the
			 basis for a level of care determination;
(b) Is completed on a MAP 351, Medicaid
			 Waiver Assessment that is uploaded into the MWMA; and
(c) Occurs at least once every twelve (12)
			 months thereafter.
(8)
			 "Axis I diagnosis" means a clinical disorder or other condition which may be a
			 focus of clinical attention.
(9)
			 "Behavior intervention committee" or "BIC" means a group of individuals
			 established to evaluate the technical adequacy of a proposed behavior
			 intervention for a participant.
(10) "Blended services" means a
			 nonduplicative combination of ABI waiver services identified in Section 6 of
			 this administrative regulation and participant-directed services identified in
			 Section 10 of this administrative regulation provided in accordance with the
			 participant's approved person-centered service plan.
(11) "Board certified behavior analyst" means
			 an independent practitioner who is certified by the Behavior Analyst
			 Certification Board, Inc.
(12)
			 "Case manager" means an individual who manages the overall development and
			 monitoring of a participant's person-centered service plan.
(13) "Covered services and supports" is
			 defined by KRS
			 205.5605(3).
(14) "Crisis prevention and response plan"
			 means a plan developed to identify any potential risk to a participant and to
			 detail a strategy to minimize the risk.
(15) "DCBS" means the Department for
			 Community Based Services.
(16)
			 "Department" means the Department for Medicaid Services or its
			 designee.
(17) "Family training"
			 means providing to the family or other responsible person:
(a) Interpretation or explanation of medical
			 examinations and procedures;
(b)
			 Treatment regimens;
(c) Use of
			 equipment specified in the person-centered service plan; or
(d) Advising the family how to assist the
			 participant.
(18) "Good
			 cause" means a circumstance beyond the control of an individual which affects
			 the individual's ability to access funding or services, including:
(a) Illness or hospitalization of the
			 individual which is expected to last sixty (60) days or less;
(b) Death or incapacitation of the primary
			 caregiver;
(c) Required paperwork
			 and documentation for processing in accordance with Section 3 of this
			 administrative regulation that has not been completed but is expected to be
			 completed in two (2) weeks or less; or
(d) The individual not having been accepted
			 for services or placement by a potential provider despite the individual or
			 individual's legal representative having made diligent contact with the
			 potential provider to secure placement or access services within sixty (60)
			 days.
(19) "Human rights
			 committee" means a group of individuals established to protect the rights and
			 welfare of a participant.
(20)
			 "Human rights restriction" means the denial of a basic right or freedom to
			 which all humans are entitled, including the right to life and physical safety,
			 civil and political rights, freedom of expression, equality before the law,
			 social and cultural justice, the right to participate in culture, the right to
			 food and water, the right to work, and the right to education.
(21) "Licensed marriage and family therapist"
			 or "LMFT" is defined by
			 KRS
			 335.300(2).
(22) "Licensed medical professional" means:
(a) A physician;
(b) An advanced practice registered
			 nurse;
(c) A physician
			 assistant;
(d) A registered
			 nurse;
(e) A licensed practical
			 nurse; or
(f) A
			 pharmacist.
(23)
			 "Licensed practical nurse" or "LPN" means a person who:
(a) Meets the definition of
			 KRS
			 314.011(9); and
(b) Works under the supervision of a
			 registered nurse.
(24)
			 "Licensed professional clinical counselor" or "LPCC" is defined by
			 KRS
			 335.500(3).
(25) "Medically necessary" or "medical
			 necessity" means that a covered benefit is determined to be needed in
			 accordance with
			 907 KAR 3:130.
(26) "MWMA" means the Kentucky Medicaid
			 Waiver Management Application internet portal located at http://chfs.
			 Ky.gov/dms/mwma. Htm.
(27) "Nursing
			 supports" means training and monitoring of services by a registered nurse or a
			 licensed practical nurse.
(28)
			 "Occupational therapist" is defined by
			 KRS
			 319A.010(3).
(29) "Occupational therapy assistant" is
			 defined by KRS
			 319A.010(4).
(30) "Participant" means an individual who
			 meets the criteria established in Section 3 of this administrative
			 regulation.
(31)
			 "Participant-directed services" or "PDS" means an option established by
			 KRS
			 205.5606 within the 1915(c) home and
			 community based service waiver programs which allows participants to receive
			 non-medical services in which the individual:
(a) Assists with the design of the
			 program;
(b) Chooses the providers
			 of services; and
(c) Directs the
			 delivery of services to meet their needs.
(32) "Person-centered service plan" means a
			 written individualized plan of services for a participant that meets the
			 requirements established in Section 4 of this administrative
			 regulation.
(33) "Person-centered
			 team" means the participant, the participant's guardian or representative, and
			 other individuals who are natural or paid supports, and who:
(a) Recognize that evidenced based decisions
			 are determined within the basic framework of what is important for the
			 participant and within the context of what is important to the participant
			 based on informed choice;
(b) Work
			 together to identify what roles they will assume to assist the participant in
			 becoming as independent as possible in meeting the participant's needs;
			 and
(c) Include providers who
			 receive payment for services who shall:
1. Be
			 active contributing members of the person centered team meetings;
2. Base their input upon evidence-based
			 information; and
3. Not request
			 reimbursement for person centered team meetings.
(34) "Physical therapist" is
			 defined by KRS
			 327.010(2).
(35) "Physical therapist assistant" means a
			 skilled health care worker who:
(a) Is
			 certified by the Kentucky Board of Physical Therapy; and
(b) Performs physical therapy and related
			 duties as assigned by the supervising physical therapist
(36) "Pro re nata" or "PRN" means as
			 needed.
(37) "Psychologist" is
			 defined by KRS
			 319.010(8).
(38) "Psychologist with autonomous
			 functioning" means an individual who is licensed in accordance with
			 KRS
			 319.056.
(39) "Qualified mental health professional"
			 is defined by KRS
			 202A.011(12).
(40) "Registered nurse" or "RN" means a
			 person who:
(a) Meets the definition
			 established in KRS
			 314.011(5); and
(b) Has one (1) year or more experience as a
			 professional nurse.
(41)
			 "Representative" is defined by
			 KRS
			 205.5605(6).
(42) "Speech-language pathologist" is defined
			 by KRS
			 334A.020(3).
(43) "Support broker" means an individual
			 designated by the department to:
(a) Provide
			 training, technical assistance, and support to a participant; and
(b) Assist a participant in any other aspects
			 of participant-directed services.