Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 17 - Managed Care › Section 907 KAR 17:005 - Definitions for 907 KAR Chapter 17

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS Chapter 13B, 194A.025(3), 199.555(2), Chapter
				202A, 205.8451-205.8483, 311.550(12), 314.011(7), 387.510(15), 620.020(5),
				42
				U.S.C. 1382c,
				1395tt,
				1396-1396w-5, 20 C.F.R. 416.2101,
				42 C.F.R.
				400.203,
				405.2401(b),
				412.62,
				Part 438,
				440.40(b),
				447.280,
				482.58
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 definitions for 907 KAR Chapter 17.
Section 1. Definitions.
(1) "1915(c) home and community based waiver
			 program" means a Kentucky Medicaid program established pursuant to, and in
			 accordance with,
			 42 U.S.C.
			 1396n(c).
(2) "Advanced practice registered nurse" is
			 defined by
			 KRS
			 314.011(7).
(3) "Adverse action" means the:
(a) Denial or limited authorization of a
			 requested service, including the type or level of service;
(b) Reduction, suspension, or termination of
			 a previously authorized service;
(c) Denial, in whole or in part, of payment
			 for a service;
(d) Failure to
			 provide services in a timely manner; or
(e) Failure of a managed care organization to
			 act within the timeframes provided in
			 42 C.F.R.
			 438.408(b).
(4) "Appeal" means a request for
			 review of an adverse action or a decision by an MCO related to a covered
			 service.
(5) "Authorized
			 representative" means:
(a) For an enrollee who
			 is authorized by Kentucky law to provide written consent, an individual or
			 entity acting on behalf of, and with written consent from, the enrollee;
			 or
(b) A legal guardian.
(6) "Behavioral health service"
			 means a clinical, rehabilitative, or support service in an inpatient or
			 outpatient setting to treat a mental illness, emotional disability, or
			 substance use disorder.
(7) "Blind"
			 is defined by
			 42
			 U.S.C.
			 1382c(a)(2).
(8) "Capitation payment" means the total per
			 enrollee, per month payment amount the department pays an MCO.
(9) "Care coordination" means the integration
			 of all processes in response to an enrollee's needs and strengths to ensure
			 the:
(a) Achievement of desired outcomes;
			 and
(b) Effectiveness of
			 services.
(10) "Case
			 management" means a collaborative process that:
(a) Assesses, plans, implements, coordinates,
			 monitors, and evaluates the options and services required to meet an enrollee's
			 health and human service needs;
(b)
			 Is characterized by advocacy, communication, and resource management;
(c) Promotes quality and cost-effective
			 interventions and outcomes; and
(d)
			 Is in addition to and not in lieu of targeted case management for individuals
			 pursuant to 907 KAR Chapter 15.
(11) "CHFS OIG" means the Cabinet for Health
			 and Family Services, Office of Inspector General.
(12) "Child" means a person who:
(a)
1. Is
			 under the age of eighteen (18) years;
2.
a. Is a
			 full-time student in a secondary school or the equivalent level of vocational
			 or technical training; and
b. Is
			 expected to complete the program before the age of nineteen (19)
			 years;
3. Is not self
			 supporting;
4. Is not a participant
			 in any of the United States Armed Forces; and
5. If previously emancipated by marriage, has
			 returned to the home of his or her parents or to the home of another
			 relative;
(b) Has not
			 attained the age of nineteen (19) years in accordance with
			 42 U.S.C.
			 1396a(l)(1)(D);
(c) Is under the age of nineteen (19) years
			 if the person is a KCHIP recipient; or
(d) Is under the age of twenty-one (21) years
			 for EPSDT.
(13) "Complex
			 or chronic condition" means a physical, behavioral, or developmental condition
			 that:
(a) Seems to have no known
			 cure;
(b) Is progressive;
			 or
(c) Can be debilitating or fatal
			 if left untreated or under-treated.
(14) "Court-ordered commitment" means an
			 involuntary commitment by an order of a court to a psychiatric facility for
			 treatment pursuant to KRS Chapter 202A.
(15) "DAIL" means the Department for Aging
			 and Independent Living.
(16) "DCBS"
			 means the Department for Community Based Services.
(17) "Department" means the Department for
			 Medicaid Services or its designee.
(18) "Disabled" is defined by
			 42
			 U.S.C.
			 1382c(a)(3).
(19) "DSM-IV" means the Diagnostic and
			 Statistical Manual of Mental Disorders, Fourth Editions, published by the
			 American Psychiatric Association that covers all mental health disorders for
			 both children and adults.
(20)
			 "Dual eligible" means an individual eligible for Medicare and Medicaid
			 benefits.
(21) "Early and periodic
			 screening, diagnosis, and treatment" or "EPSDT" is defined by
			 42
			 C.F.R. 440.40(b).
(22) "Emergency service" means "emergency
			 services" as defined by
			 42 U.S.C.
			 1396u-2(b)(2)(B).
(23) "Enrollee" means a recipient who is
			 enrolled with a managed care organization for the purpose of receiving Medicaid
			 or KCHIP covered services.
(24)
			 "Family planning service" means a counseling service, a medical service, or a
			 pharmaceutical supply or device to prevent or delay pregnancy.
(25) "Federally qualified health center" or
			 "FQHC" is defined by
			 42 C.F.R.
			 405.2401(b).
(26) "Federally qualified health center
			 look-alike" or "FQHC look-alike" means an entity that is currently approved by
			 the United States Department of Health and Human Services, Health Resources and
			 Services Administration, and the Centers for Medicare and Medicaid Services to
			 be a federally qualified health center look-alike.
(27) "Fee-for-service" means a reimbursement
			 model in which a health insurer reimburses a provider for each service provided
			 to a recipient.
(28) "Foster care"
			 is defined by
			 KRS
			 620.020(5).
(29) "Fraud" means any act that constitutes
			 fraud under applicable federal law or
			 KRS
			 205.8451 through
			 KRS
			 205.8483.
(30) "Grievance" is defined by
			 42 C.F.R.
			 438.400(b).
(31) "Homeless individual" means an
			 individual who:
(a) Lacks a fixed, regular, or
			 nighttime residence;
(b) Is at risk
			 of becoming homeless in a rural or urban area because the residence is not
			 safe, decent, sanitary, or secure;
(c) Has a primary nighttime residence at a:
1. Publicly or privately operated shelter
			 designed to provide temporary living accommodations; or
2. Public or private place not designed as
			 regular sleeping accommodations; or
(d) Lacks access to routine accommodations
			 due to violence or the threat of violence from a cohabitant.
(32) "Individual with a special
			 health care need" or "ISHCN" means an individual who:
(a) Has, or is at a high risk of having, a
			 chronic physical, developmental, behavioral, neurological, or emotional
			 condition; and
(b) Might require a
			 broad range of primary, specialized, medical, behavioral health, or related
			 services.
(33) "KCHIP"
			 means the Kentucky Children's Health Insurance Program administered in
			 accordance with
			 42 U.S.C.
			 1397aa to jj.
(34) "Managed care organization" or "MCO"
			 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.
(35) "Maternity care" means prenatal,
			 delivery, and postpartum care and includes care related to complications from
			 delivery.
(36) "Medical record"
			 means a single, complete record that documents all of the treatment plans
			 developed for, and medical services received by, an individual.
(37) "Medicare qualified individual group 1
			 (QI-1)" means an eligibility category that includes, pursuant to
			 42 U.S.C.
			 1396a(a)(10)(E)(iv), an
			 individual who would be a Qualified Medicaid beneficiary but for the fact that
			 the individual's income:
(a) Exceeds the
			 income level established in accordance with
			 42
			 U.S.C. 1396d(p)(2);
			 and
(b) Is at least 120 percent,
			 but less than 135 percent, of the federal poverty level for a family of the
			 size involved and who is not otherwise eligible for Medicaid under the state
			 plan.
(38) "Nonqualified
			 alien" means a resident of the United States of America who does not meet the
			 qualified alien requirements established in
			 907
			 KAR 20:005, Section 2(2)(a)2. or 3.
(39) "Nursing facility" means:
(a) A facility:
1. To which the state survey agency has
			 granted a nursing facility license;
2. For which the state survey agency has
			 recommended to the department certification as a Medicaid provider;
			 and
3. To which the department has
			 granted certification for Medicaid participation; or
(b) A hospital swing bed that provides
			 services in accordance with
			 42 U.S.C.
			 1395tt and
			 1396l,
			 if the swing bed is certified to the department as meeting requirements for the
			 provision of swing bed services in accordance with
			 42 U.S.C.
			 1396r(b), (c), and (d) and
			 42 C.F.R. 447.280 and 482.58.
(40) "Olmstead decision" means the court
			 decision of Olmstead v. L.C. and E.W., U.S. Supreme Court, No. 98-536, June 26,
			 1999, in which the U.S. Supreme Court ruled, "For the reasons stated, we
			 conclude that, under Title II of the ADA, States are required to provide
			 community-based treatment for persons with mental disabilities when the State's
			 treatment professionals determine that such placement is appropriate, the
			 affected persons do not oppose such treatment, and the placement can be
			 reasonably accommodated, taking into account the resources available to the
			 State and the needs of others with mental disabilities."
(41) "Open enrollment" means an annual period
			 during which an enrollee can choose a different MCO.
(42) "Out-of-network provider" means a person
			 or entity that has not entered into a participating provider agreement with an
			 MCO or any of the MCO's subcontractors.
(43) "Physician" is defined by
			 KRS
			 311.550(12).
(44) "Post-stabilization services" means
			 covered services related to an emergency medical condition that are provided to
			 an enrollee:
(a) After an enrollee is
			 stabilized in order to maintain the stabilized condition; or
(b) Under the circumstances described in
			 42 C.F.R.
			 438.114(e) to improve or
			 resolve the enrollee's condition.
(45) "Primary care provider" or "PCP" means a
			 licensed or certified health care practitioner who meets the description as
			 established in
			 907
			 KAR 17:010, Section 6(6).
(46) "Prior authorization" means the advance
			 approval by an MCO of a service or item provided to an enrollee.
(47) "Provider" means any person or entity
			 under contract with an MCO or its contractual agent that provides covered
			 services to enrollees.
(48)
			 "Provider network" means the group of physicians, hospitals, and other medical
			 care professionals that a managed care organization has contracted with to
			 deliver medical services to its enrollees.
(49) "QAPI" means the Quality Assessment and
			 Performance Improvement Program established in accordance with 42 C.F.R. 438
			 Subpart D, 438.206 to 438.242.
(50)
			 "Qualified alien" means an alien who, at the time of applying for or receiving
			 Medicaid benefits, meets the requirements established in
			 907
			 KAR 20:005, Section 2(2)(a)2. or 3.
(51) "Qualified disabled and working
			 individual" is defined by
			 42
			 U.S.C. 1396d(s).
(52) "Qualified Medicare beneficiary" or
			 "QMB" is defined by
			 42
			 U.S.C.
			 1396d(p)(1).
(53) "Recipient" is defined by
			 KRS
			 205.8451(9).
(54) "Rural area" means an area not in an
			 urban area.
(55) "Rural health
			 clinic" is defined by
			 42 C.F.R.
			 405.2401(b).
(56) "Specialist" means a provider who
			 provides specialty care.
(57)
			 "Specialty care" means care or a service that is provided by a provider who is
			 not:
(a) A primary care provider; or
(b) Acting in the capacity of a primary care
			 provider while providing the service.
(58) "Specified low-income Medicare
			 beneficiary" means an individual who meets the requirements established in
			 42 U.S.C.
			 1396a(a)(10)(E)(iii).
(59) "State fair hearing" means an
			 administrative hearing provided by the Cabinet for Health and Family Services
			 pursuant to KRS Chapter 13B.
(60)
			 "State plan" is defined by
			 42 C.F.R.
			 400.203.
(61) "State survey agency" means the Cabinet
			 for Health and Family Services, Office of Inspector General, Division of Health
			 Care Facilities and Services.
(62)
			 "State-funded adoption assistance" is defined by
			 KRS
			 199.555(2).
(63) "Supplemental security income benefits"
			 or "SSI benefits" is defined by
			 20
			 C.F.R.
			 416.2101(c).
(64) "Third party liability resource" means a
			 resource available to an enrollee for the payment of expenses:
(a) Associated with the provision of covered
			 services; and
(b) That does not
			 include amounts exempt under Title XIX of the Social Security Act,
			 42 U.S.C.
			 1396 to
			 1396w-5.
(65) "Transport time" means travel
			 time:
(a) Under normal driving conditions;
			 and
(b) With no extenuating
			 circumstances.
(66)
			 "Urban area" is defined by
			 42
			 C.F.R.
			 412.62(f)(1)(ii).
(67) "Urgent care" means care for a condition
			 not likely to cause death or lasting harm but for which treatment should not
			 wait for a normally scheduled appointment.
(68) "Ward" is defined by
			 KRS
			 387.510(15).