Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 17 - Managed Care › Section 907 KAR 17:010 - Managed care organization requirements and policies relating to enrollees

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS Chapter 13B, 194A.025(3), 205.624,
				311.621-311.643, 387.500-387.800,
				42 U.S.C.
				1396a,
				1396n,
				1396u-2,
				42 C.F.R. 422.112, 422.113, 431.51, 431.200-431.250, 433.138, Part 438,
				45 C.F.R.
				233.100
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.
				42 U.S.C.
				1396n(b) and 42 C.F.R. Part
				438 require specific standards relating to managed care. This administrative
				regulation establishes the managed care organization requirements and policies
				relating to individuals enrolled with a Medicaid managed care
				organization.
Section 1. Enrollment of
			 Medicaid or KCHIP Recipients into Managed Care.
(1) Except as established in subsection (3)
			 of this section, enrollment into a managed care organization shall be mandatory
			 for a Medicaid or KCHIP recipient.
(2) The provisions in this administrative
			 regulation shall be applicable to a:
(a)
			 Medicaid recipient; or
(b) KCHIP
			 recipient.
(3) The
			 following recipients shall not be required to enroll, and shall not enroll,
			 into a managed care organization:
(a) A
			 recipient who resides in:
1. A nursing
			 facility for more than thirty (30) calendar days; or
2. An intermediate care facility for
			 individuals with an intellectual disability; or
(b) A recipient who is:
1. Determined to be eligible for Medicaid
			 benefits due to a nursing facility admission;
2. Receiving:
a. Services through the breast and cervical
			 cancer program pursuant to
			 907
			 KAR 20:055;
b. Medicaid benefits in accordance with the
			 spend-down policies established in
			 907
			 KAR 20:020;
c. Services through a 1915(c) home and
			 community based services waiver program; or
d. Hospice services in a nursing facility or
			 intermediate care facility for individuals with an intellectual
			 disability;
3. A
			 Qualified Medicare beneficiary who is not otherwise eligible for Medicaid
			 benefits;
4. A specified low-income
			 Medicare beneficiary who is not otherwise eligible for Medicaid
			 benefits;
5. A Medicare qualified
			 individual group 1 (QI-1) individual;
6. A qualified disabled and working
			 individual;
7. A qualified alien
			 eligible for Medicaid benefits for a limited period of time; or
8. A nonqualified alien eligible for Medicaid
			 benefits for a limited period of time.
(4)
(a) The
			 department shall assign a recipient to an MCO based upon an algorithm that
			 considers:
1. Continuity of care;
			 and
2. Enrollee preference of an
			 MCO provider.
(b) An
			 assignment shall focus on a need of a child or an individual with a special
			 health care need.
(5)
(a) A newly eligible recipient or a recipient
			 who has had a break in eligibility of greater than two (2) months shall have an
			 opportunity to choose an MCO during the eligibility application
			 process.
(b) If a recipient does
			 not choose an MCO during the eligibility application process, the department
			 shall assign the recipient to an MCO in accordance with subsections (4) and (6)
			 of this section.
(6)
			 Each member of a household shall be assigned to the same MCO.
(7) The effective date of enrollment for a
			 recipient established in subsection (5) of this section shall be the date of
			 Medicaid eligibility.
(8) A
			 recipient shall be given a choice of MCOs.
(9) A recipient enrolled with an MCO who
			 loses Medicaid eligibility for less than two (2) months shall be automatically
			 reenrolled with the same MCO upon redetermination of Medicaid
			 eligibility.
(10) A newborn who has
			 been deemed eligible for Medicaid shall be automatically enrolled with the
			 newborn's mother's MCO as an individual enrollee for up to sixty (60) calendar
			 days.
(11)
(a) An enrollee may change an MCO for any
			 reason, regardless of whether the MCO was selected by the enrollee or assigned
			 by the department:
1. Within ninety (90)
			 calendar days of the effective date of enrollment;
2. Annually during an open enrollment
			 period;
3. Upon automatic
			 enrollment under subsection (9) of this section, if a temporary loss of
			 Medicaid eligibility caused the recipient to miss the annual opportunity in
			 subparagraph 2. of this paragraph; or
4. If the Commonwealth of Kentucky imposes an
			 intermediate sanction established in
			 42 C.F.R.
			 438.702(a)(3).
(b) An MCO shall accept an
			 enrollee who changes MCOs under this section.
(12) Only the department may enroll a
			 Medicaid recipient with an MCO in accordance with this section.
(13) Upon enrollment with an MCO, an enrollee
			 shall receive an identification card issued by the MCO.
(14)
(a)
			 Within five (5) business days after receipt of notification of a new enrollee,
			 an MCO shall send, by a method that shall not take more than three (3) calendar
			 days to reach the enrollee, a confirmation letter to an enrollee.
(b) The confirmation letter shall include at
			 least:
1. The effective date of
			 enrollment;
2. The name, location,
			 and contact information of the PCP;
3. How to obtain a referral;
4. Care coordination;
5. The benefits of preventive health
			 care;
6. The enrollee
			 identification card;
7. A member
			 handbook; and
8. A list of covered
			 services.
(15) Enrollment with an MCO shall be without
			 restriction.
(16) An MCO shall:
(a) Have continuous open enrollment for new
			 enrollees; and
(b) Accept enrollees
			 regardless of overall enrollment.
(17)
(a)
			 Except as established in paragraphs (b) through (e) of this subsection, a
			 recipient eligible to enroll with an MCO shall be enrolled beginning with the
			 first day of the month that the enrollee applied for Medicaid.
(b) A newborn shall be enrolled beginning
			 with the newborn's date of birth.
(c) An unemployed parent shall be enrolled
			 beginning with the date the unemployed parent met the definition of
			 unemployment in accordance with
			 45 C.F.R.
			 233.100.
(d)
1.
			 Except as established in paragraph (e) of this subsection, if an enrollee is
			 retroactively determined eligible for Medicaid, the retroactive eligibility
			 shall be for a period up to three (3) months prior to the month that the
			 enrollee applied for Medicaid.
2.
			 An MCO shall be responsible for reimbursing for covered services provided to a
			 retroactively determined eligible individual established in subparagraph 1. of
			 this paragraph during the individual's retroactive eligibility
			 period.
(e) If an
			 enrollee is retroactively determined eligible for Medicaid as a result of being
			 determined retroactively eligible for SSI benefits:
1. The individual's enrollment date with an
			 MCO shall be the first of the month following the month in which the department
			 is notified of the individual's retroactive eligibility for SSI benefits;
			 and
2. The department shall be
			 responsible for reimbursing for any services provided during the retroactive
			 eligibility period for an individual determined to be retroactively eligible
			 for SSI benefits.
(18) For an enrollee whose eligibility
			 resulted from a successful appeal of a denial of eligibility, the enrollment
			 period shall begin on the first day of the month of:
(a) The original application for eligibility;
			 or
(b) Retroactive eligibility as
			 referenced in subsection (17)(d) or (e) of this section, if
			 applicable.
(19) A
			 provider shall be responsible for verifying an individual's eligibility for
			 Medicaid and enrollment in a managed care organization when providing a
			 service.