Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:045 - Reimbursement provisions and requirements regarding community mental health center services

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.520(3),
				205.8451,
				210.370-210.485,
				42 C.F.R.
				400.203, 413,
				438.2,
				447.325,
				42 U.S.C.
				1396n(c),
				1396r-8(a)
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.
				KRS
				205.6313(4) requires the
				cabinet to promulgate administrative regulations to implement Medicaid
				reimbursement for primary care practitioners at community mental health
				centers. This administrative regulation establishes the reimbursement
				provisions and requirements regarding community mental health center services
				provided to Medicaid recipients who are not enrolled with a managed care
				organization.
Section 1. Definitions.
(1) "1915(c) home and community based waiver
			 services provider" means a Kentucky Medicaid program established pursuant to,
			 and in accordance with,
			 42 U.S.C.
			 1396n(c).
(2) "Allowable costs" means that portion of a
			 facility's cost that may be allowed by the department for reimbursement
			 purposes.
(3) "Community board for
			 mental health or individuals with an intellectual disability" means a board
			 established pursuant to
			 KRS
			 210.380.
(4) "Community mental health center" or
			 "CMHC" means a facility that meets the community mental health center
			 requirements established in
			 902
			 KAR 20:091.
(5) "CPT code" means a code used for
			 reporting procedures and services performed by medical practitioners and
			 published annually by the American Medical Association in Current Procedural
			 Terminology.
(6) "Department" means
			 the Department for Medicaid Services or its designee.
(7) "Enrollee" means a recipient who is
			 enrolled with a managed care organization.
(8) "Federal financial participation" is
			 defined by
			 42 C.F.R.
			 400.203.
(9) "Federal indirect rate" means the rate
			 approved by the United States Department for Health and Human Services (HHS)
			 for grantee institutions to be used to calculate indirect costs as a percentage
			 of direct costs.
(10) "Federal
			 Register" means the official journal of the United States federal government
			 that publishes government agency rules and public notices.
(11) "Healthcare Common Procedure Coding
			 System code" means a billing code:
(a)
			 Recognized by Medicare; and
(b)
			 Monitored by the Centers for Medicare and Medicaid Services.
(12) "Interim reimbursement" means
			 a reimbursement:
(a) In effect for a temporary
			 period of time; and
(b) That does
			 not represent final reimbursement for services provided during the period of
			 time.
(13)
			 "Kentucky-specific Medicare Physician Fee Schedule" means the list of current
			 reimbursement rates for physician services established by the Centers for
			 Medicare and Medicaid Services and available on the CMS Web site at
www.cms.go
.
(14) "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.
(15) "Medicaid allowable costs" means the
			 costs:
(a) Associated with the
			 Medicaid-covered services covered pursuant to
			 907
			 KAR 1:047 and
			 907
			 KAR 1:044:
1.
			 Rendered to recipients who are not enrollees; and
2. Not rendered as a 1915(c) home and
			 community based waiver services provider; and
(b) Determined to be allowable costs by the
			 department.
(16) "Medical
			 Group Management Association (MGMA) 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.
(17) "Medically necessary" means that a
			 covered benefit is determined to be needed in accordance with
			 907
			 KAR 3:130.
(18) "Medicare Economic Index" means a
			 measure of inflation:
(a) Associated with the
			 costs of physicians' practices; and
(b) Published in the Federal
			 Register.
(19) "Outreach
			 services" means provider programs:
(a)
			 Specifically designed to:
1. Engage recipients
			 for the purposes of supporting Medicaid or Children's Health Insurance Program
			 (CHIP) enrollment efforts;
2.
			 Assist recipients with finding healthcare or coverage options; and
3. Promote preventive services for
			 recipients; and
(b) That
			 are directly assigned or allocated to a cost report line that is not cost
			 settled by the department.
(20) "Payment plan request" means a request
			 to pay an amount owed to the department over a period of time that is agreed to
			 by the department.
(21) "Physician
			 administered drug" or "PAD" means any rebateable covered outpatient drug that
			 is:
(a) Provided or administered to a Medicaid
			 recipient;
(b) Billed by a provider
			 other than a pharmacy provider through the medical benefit, including providers
			 who are physician offices or another outpatient clinical setting; and
(c) An injectable or noninjectable drug
			 furnished incident to provider services that are billed separately to
			 Medicaid.
(22) "Primary
			 care services" means services covered as established in
			 907
			 KAR 1:047.
(23) "Provider" is defined by
			 KRS
			 205.8451(7).
(24) "Rebateable" means a drug for which the
			 drug manufacturer has entered into and has in effect a rebate agreement in
			 accordance with
			 42 U.S.C.
			 1396r-8(a).
(25) "Recipient" is defined by
			 KRS
			 205.8451(9).
(26) "State fiscal year" means the period
			 beginning on July 1 of a calendar year and ending on June 30 of the following
			 calendar year.