Kansas Administrative Regulations › Agency 30 - KANSAS DEPARTMENT FOR CHILDREN AND FAMILIES › Article 5 - PROVIDER PARTICIPATION, SCOPE OF SERVICES, AND REIMBURSEMENTS FOR THE MEDICAID (MEDICAL ASSISTANCE) PROGRAM › Section 30-5-300 - Definitions

Current through Register Vol. 43, No. 28, July 11, 2024
(a) The following
			 words and terms for home-and community-based services (HCBS), when used in this
			 article, shall have the following meanings, unless the context clearly
			 indicates otherwise.
(1) "Accept medicare
			 assignment" means that the provider will accept the medicare-allowed payment
			 rate as payment in full for services provided to a consumer.
(2) "Activities of daily living (ADLs)" means
			 the following:
(A) Bathing;
(B) dressing;
(C) toileting;
(D) transferring;
(E) ambulating; and
(F) eating.
(3) "Agency" means the Kansas department of
			 social and rehabilitation services.
(4) "Area agency on aging" means the agency
			 or organization within a planning and service area that has been designated by
			 the secretary of the Kansas department on aging (KDOA) to develop, implement,
			 and administer a plan for the delivery of a comprehensive and coordinated
			 system of services to older persons in the planning and service area.
(5) "Assessment" means the
			 face-to-face interview and evaluation of a home-and community-based services
			 consumer by an authorized case manager, assessor, or independent living
			 counselor to determine the consumer's care needs and support systems and to
			 develop a service plan.
(6) "Case
			 management services" means a comprehensive service comprised of a variety of
			 specific tasks and activities designed to coordinate and integrate all other
			 services required in the individual's plan of care.
(7) "Client obligation" means the monthly
			 amount collected from an HCBS consumer by the service provider for the cost of
			 a service.
(8) "Conflict of
			 interest" means any relationship between two or more parties in which one party
			 has the ability to influence another party to the transaction in a way that one
			 or more of the transacting parties might fail to fully pursue the party's or
			 parties' own separate interests. Related parties shall include parties related
			 by family, business, or financial association, or by common ownership or
			 control. Transactions between related parties shall not be considered to have
			 arisen through arm's-length negotiations. Transactions or agreements that are
			 illusory or a sham shall not be recognized.
(9) "Cost cap" means the average HCBS monthly
			 service cost limit per consumer, including primary and acute care costs. The
			 average HCBS monthly service cost limit shall be based on and compared to the
			 average monthly cost that the consumer would incur in a nursing facility.
(10) "Cost-efficient" means that
			 all of the formal and informal service systems available to meet individual
			 needs are used before HCBS services are used.
(11) "Cost-effective" means that the cost of
			 utilizing a service is recovered by the savings generated from avoiding the
			 necessary utilization of a more expensive service.
(12) "Direct cost" means any cost that can be
			 identified specifically with a particular cost objective.
(13) "Documentation" means maintenance of the
			 HCBS consumer's case file, which shall include the following:
(A) A current assessment or reassessment;
(B) a plan of care;
(C) a service plan;
(D) an activity log; and
(E) a financial eligibility communication
			 form, including current client obligation information.
(14) "Effective date" means the date on which
			 a program or service begins and on which a provider can be reimbursed for
			 services.
(15) "Formal service"
			 means any needed service as documented in the plan of care and funded by
			 medicaid.
(16) "Frail elderly
			 waiver" means a medicaid HCBS services waiver authorized by and through the
			 Kansas department on aging services in accordance with a federally approved
			 waiver to the Kansas medicaid state plan for individuals age 65 and older who
			 meet the medicaid long-term care threshold.
(17) "Home health aide service" means the
			 direct care provided by a person with minimum training to consumers who are
			 unable to care for themselves or who need assistance in accomplishing the
			 activities of daily living. The home health aide service direct care provider
			 shall be under the supervision of a registered nurse employed by a home health
			 agency.
(18) "Home health agency"
			 means a public or private agency or organization that provides, for a fee, one
			 or more home health services at the residence of a consumer.
(19) "Housing options" means all home and
			 residential environments in which individuals would be eligible to receive HCBS
			 services.
(20) "Instrumental
			 activities of daily living (IADLs)" means the following:
(A) Meal preparation;
(B) shopping;
(C) medication monitoring and treatments;
(D) laundry and housekeeping;
(E) money management;
(F) telephone use; and
(G) transportation.
(21) "Independent living center" means a
			 public or private agency or organization recognized by the agency whose primary
			 function is to provide independent living services, including the following:
(A) Independent living skills training;
(B) advocacy;
(C) peer counseling; and
(D) information and referral.
(22) "Independent living
			 counseling" means a service provided through the HCBS/physically disabled
			 waiver that assesses need, negotiates care plans and service plans, and teaches
			 independent living skills.
(23)
			 "Indirect costs" means the administrative costs of long-term care (LTC)
			 programs or their functional components, including the costs of supplying
			 goods, services, and facilities to those programs or their functional
			 components.
(24) "Ineligible
			 provider" means a provider who is not enrolled in the medicaid/medikan program
			 due to one or more of the reasons set forth in K.A.R. 30-5-60, or because the
			 provider committed civil or criminal fraud in another state or another program.
(25) "Informal service" means any
			 needed or desired service provided voluntarily to a consumer by one or more
			 organizations, agencies, or families, at no cost to the medicaid program.
(26) "Level of care" means the
			 functional needs of consumers, as determined through an assessment or
			 reassessment, based on impairments in ADLs and IADLs.
(27) "Medicaid home-and community-based
			 services (HCBS)" means services provided in accordance with a federally
			 approved waiver to the Kansas medicaid state plan that are designed to prevent
			 unnecessary utilization of services and to reduce health care-related costs.
			 Any individual who has a primary diagnosis of mental illness and who is 21
			 years of age or older, but less than 65 years old, shall not be eligible.
(28) "Medicaid home-and
			 community-based services for persons with mental retardation or other
			 developmental disabilities (HCBS/MRDD)" means services provided in accordance
			 with a federally approved waiver to the Kansas medicaid state plan. These
			 services shall be designed as alternatives to services otherwise provided in
			 intermediate care facilities for the mentally retarded (ICF/MR) for individuals
			 who have mental retardation or other developmental disabilities.
(29) "Medicaid home-and community-based
			 services for head-injured persons (HCBS/HI)" means medicaid services that meet
			 these requirements:
(A) Are provided in
			 accordance with a federally approved waiver to the Kansas medicaid state plan;
			 and
(B) are designed as an
			 alternative to services in brain injury rehabilitation facilities for
			 individuals who meet these requirements:
(i)
			 Have external, traumatic brain injuries; and
(ii) are 18 years of age or older, but are
			 less than 55 years of age. Any person receiving HCBS/HI waiver services may
			 continue to receive these services after reaching age 55 if the Kansas medicaid
			 HCBS program manager determines that the person is continuing to show progress
			 in rehabilitation and increased independence.
(30) "Medicaid long-term care threshold"
			 means the level-of-care criteria, as established by the agency and approved in
			 the waiver to the medicaid state plan for HCBS, that are used to determine
			 eligibility for medicaid long-term care programs.
(31) "Nursing facility (NF)" means a facility
			 that meets these criteria:
(A) Meets state
			 licensure standards;
(B) provides
			 health-related care and services, prescribed by a physician; and
(C) provides residents with licensed nursing
			 supervision 24 hours per day and seven days per week for ongoing observation,
			 treatment, or care for long-term illness or injury.
(32) "Normal rhythms of the day" means the
			 average time frame in which an individual without a physical disability
			 typically completes clusters of ADL and IADL activities.
(33) "Organized health care delivery system"
			 means a system, at least one component of which is organized for the purpose of
			 delivering health care, that furnishes at least one service under a
			 medicaid-covered waiver or the state plan.
(34) "Other developmental disability" means a
			 condition or illness that meets these requirements:
(A) Is manifested before age 22;
(B) can reasonably be expected to continue
			 indefinitely;
(C) results in
			 substantial limitations in any three or more of the following areas of life
			 functioning:
(i) Self-care;
(ii) understanding and the use of language;
(iii) learning and adapting;
(iv) mobility;
(v) self-direction in setting goals and
			 undertaking activities to accomplish those goals;
(vi) living independently; or
(vii) economic self-sufficiency; and
(D) reflects the need
			 for a combination and sequence of special, interdisciplinary, or generic care,
			 treatment, or other services that are of extended or lifelong duration and are
			 individually planned and coordinated.
(35) "Physically disabled (PD) waiver" means
			 services provided in accordance with a federally approved waiver to the Kansas
			 medicaid state plan for any individual who meets these requirements:
(A) Is 16 years of age or older. Consumers
			 who turn 65 years of age while on the physically disabled waiver may remain on
			 the waiver past age 65;
(B) is
			 physically disabled according to social security disability standards;
(C) meets the medicaid LTC
			 threshold; and
(D) requires
			 assistance with normal rhythms of the day.
(36) "Plan of care (POC)" means a document
			 that states and prescribes the responsibilities of providers to ensure that the
			 providers meet the health and safety needs of HCBS consumers. The document
			 shall include the following information:
(A)
			 A statement identifying the need for care;
(B) the estimated length of the service or
			 program;
(C) a description of the
			 prescribed treatment, modalities, and methodology to be used;
(D) a description of the expected results;
(E) the name of the provider; and
(F) the cost of the program or
			 services.
(37) "Prior
			 authorization" means that a service to be provided shall be reimbursed only
			 when approval is given by the agency before the service is provided.
(38) "Program" means the Kansas
			 medicaid/medikan program.
(39)
			 "Provider enrollment" means the process through which the agency determines
			 whether or not an applicant meets the requirements for persons or agencies to
			 provide services to the medicaid program.
(40) "Reassessment" means an annual review
			 and evaluation of an HCBS consumer's continued need for services.
(41) "Reimbursement rate" means the dollar
			 value assigned by the secretary for a covered service.
(42) "Risk factor" means any condition that
			 can increase an individual's functional impairment. The risk factor is used to
			 determine needs for services, as appropriate for the individual's level of
			 care.
(43) "Self-directed care"
			 means an option under the HCBS program that allows an individual in need of
			 care to live in a home environment and direct the attendant services that are
			 essential to the maintenance of the individual's health and safety.
(44) "Service plan" means a document that
			 describes specific tasks to be performed, based on the needs of the consumer.
			 The description shall include the type of service, the frequency, and the
			 provider.
(45) "Severe emotional
			 disturbance waiver" means services provided in accordance with a federally
			 approved waiver to the Kansas medicaid state plan for any individual who meets
			 these requirements:
(A) Is under 18 years of
			 age or, if the individual is under 22 years of age, has continually received
			 intensive community-based services for at least six months before the date of
			 the initial application for the waiver;
(B) has received a DSM-IV diagnosis under
			 axis 1 (clinical disorders);
(C)
			 meets the criteria for a severe emotional disturbance;
(D) meets the following severity index
			 criteria:
(i) On a child behavior checklist
			 (CBCL), a score of at least 70 on one subscale; and
(ii) on a child and adolescent functional
			 assessment scale (CAFAS), an overall score of 100, or at least 30 for each of
			 two subscales; and
(E)
			 according to clinical judgment, is in need of a state mental health hospital
			 (SMHH).
(46)
			 "Technology-assisted child" means a chronically ill or medically fragile child
			 who meets these requirements:
(A) Is 17 years
			 of age or younger;
(B) has an
			 illness or disability that, in the absence of home care services, would require
			 admission to or a prolonged stay in a hospital;
(C) needs both a medical device to compensate
			 for the loss of a vital body function and substantial, continuous care by a
			 nurse or other caretaker under the supervision of a nurse in order to avert
			 death or further disability;
(D)
			 is dependent at least part of each day on mechanical ventilators for survival;
			 and
(E) requires prolonged
			 intravenous administration of nutritional substances or drugs, or requires
			 other medical devices to compensate for the loss of a vital body function.
(47) "Terminally ill"
			 means the medical condition of an individual whose life expectancy is six
			 months or less, as determined and documented by a physician.
(48) "Traumatic brain injury" means
			 non-degenerative, structural brain damage resulting in residual deficits and
			 disability that have been acquired by external physical injury.
(49) "Termination date" means the last day on
			 which a program or service shall be reimbursed. For HCBS, this date shall not
			 extend beyond the last date of medicaid eligibility.