Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:677 - Medicaid Recipient Lock-in Program

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.8453,
				21
				C.F.R. 1308.12,
				1308.13,
				1308.14,
				42 C.F.R.
				431.54,
				433.111(b),
				42 U.S.C.
				1396(a),
				1396(a)(2)
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) empowers the
				cabinet, by administrative regulation, to comply with any requirement that may
				be imposed or opportunity presented by federal law for the provision of medical
				assistance to Kentucky's indigent citizenry.
				KRS
				205.8453(4) and
				205.6318(6)
				direct the cabinet to promulgate administrative regulations to identify
				misutilization of Medicaid services, to institute other measures necessary or
				useful in controlling fraud and abuse. This administrative regulation
				establishes the Medicaid lock-in provisions relating to recipient
				overutilization of the Medicaid Services.
Section
			 1. Definitions.
(1) "Advanced
			 practice registered nurse" or "APRN" is defined by
			 KRS
			 314.011(7).
(2) "Cabinet" is defined by
			 KRS
			 205.010(1).
(3) "Controlled substance" means a drug or
			 substance identified in
			 21
			 C.F.R. 1308.12,
			 1308.13, or
			 1308.14.
(4) "Department" means the Department for
			 Medicaid Services or its designee.
(5) "Emergency medical condition" is defined
			 by
			 42
			 U.S.C.
			 1395dd(e)(1).
(6) "Emergency service" is defined by
			 42 C.F.R.
			 447.53.
(7) "Fraud" is defined by
			 KRS
			 205.8451(2).
(8) "Kentucky All Schedule Prescription
			 Electronic Reporting report" or "KASPER report" means a report displaying
			 information regarding:
(a) All the scheduled
			 prescriptions that an individual has had for the time period specified in the
			 report;
(b) The prescriber for each
			 prescription written for the individual during the time period specified in the
			 report; and
(c) The dispenser who
			 dispensed each prescription written for the individual during the time period
			 specified in the report.
(9) "Lock-in program" means a department
			 program which restricts a recipient to receiving Medicaid services from a
			 designated provider.
(10) "Lock-in
			 recipient" means a recipient enrolled in the lock-in program.
(11) "Medicaid Management Information System"
			 means the department's mechanized claims processing and information retrieval
			 system as defined by, and in accordance with,
			 42
			 C.F.R. 433.111(b).
(12) "Nonemergency care" means a service for
			 a nonemergency condition.
(13)
			 "Overutilization" means the receipt of a treatment, drug, medical supply, or
			 other Medicaid service from one (1) or more providers in an amount, duration,
			 or scope that exceeds the amount that would reasonably be expected to result in
			 a medical or health benefit to the recipient.
(14) "Physician" is defined by
			 KRS
			 311.550(12).
(15) "Physician assistant" or "PA" is defined
			 by
			 KRS
			 311.840(3).
(16) "Prescriber" means a health care
			 professional who:
(a) Within the scope of
			 practice under Kentucky licensing laws, has the legal authority to write or
			 order a prescription for the drug that is ordered;
(b) Is enrolled in the Medicaid Program
			 pursuant to
			 907
			 KAR 1:672; and
(c) Is currently participating in the
			 Medicaid Program pursuant to
			 907
			 KAR 1:671.
(d) Prescribes in accordance with his or her
			 current registration with the U.S. Department of Justice's Drug Enforcement
			 Administration.
(17)
			 "Primary care provider" means an advanced practice registered nurse, a
			 physician, or physician assistant.
(18) "Provider" is defined by
			 KRS
			 205.8451(7).
(19) "Provider abuse" is defined by
			 KRS
			 205.8451(8).
(20) "Recipient" is defined by
			 KRS
			 205.8451(9).
(21) "Recipient abuse" is defined by
			 KRS
			 205.8451(10)
(22) "Utilization review" means a department
			 review and analysis:
(a) Of Medicaid claims
			 for a twelve (12) consecutive month period including:
1. A recipient's medical conditions;
			 and
2. Medicaid services received
			 by the recipient; and
(b)
			 To determine if recipient overutilization has occurred.