Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 7 - Certified Provider Requirements › Section 907 KAR 7:005 - Certified waiver provider requirements

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS Chapter 13B, 194A.515,
				42
				C.F.R. 447.90, 455, 1002, 1003,
				42
				U.S.C. 1320a-3,
				1320a-5,
				1320a-7,
				1395y(o),
				2000d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services, Department for Medicaid Services, has responsibility to
				administer the Medicaid Program.
				KRS
				205.8451 through
				KRS
				205.8483 establish that the Cabinet for
				Health and Family Services and the Department for Medicaid Services shall be
				responsible for the control of Medicaid provider fraud and abuse.
				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. This administrative regulation establishes the certification
				requirements and provisions regarding 1915(c) home and community based service
				waiver providers who are required to be certified.
Section 1. Definitions.
(1) "1915(c) home and community based
			 service" means a service available or provided via a 1915(c) home and community
			 based services waiver program.
(2)
			 "1915(c) home and community based services waiver program" means a Kentucky
			 Medicaid program established pursuant to and in accordance with
			 42 U.S.C.
			 1396n(c).
(3) "Applicant" means an individual or entity
			 applying to be a certified waiver provider.
(4) "Certification period" means a period of
			 time that a provider has been certified or approved by the department to
			 provide, and be reimbursed for, 1915(c) home and community based
			 services.
(5) "Certified waiver
			 provider" means a provider who:
(a) Is
			 currently enrolled in the Medicaid program in accordance with
			 907
			 KAR 1:672;
(b) Is currently participating in the
			 Medicaid program in accordance with
			 907
			 KAR 1:671;
(c) Provides Kentucky Medicaid program
			 covered services to a recipient in a 1915(c) home and community based services
			 waiver program; and
(d) Has been
			 determined by the department to have met the certified waiver provider
			 requirements established in this administrative regulation.
(6) "Citation" means a written
			 document:
(a) Issued by the department to a
			 certified waiver provider; and
(b)
			 Addressing a certified waiver provider's failure to comply with:
1. This administrative regulation;
			 or
2. Any other administrative
			 regulation within Title 907 of the Kentucky Administrative Regulations which
			 establishes provisions and requirements regarding a 1915(c) home and community
			 based services waiver program.
(7) "Contingency" means a circumstance that
			 requires immediate action by a provider to correct a citation that impacts the
			 health, safety, or welfare of a 1915(c) home and community based services
			 waiver program participant prior to the provider submitting a corrective action
			 plan.
(8) "Corrective action plan"
			 means a document submitted by a certified waiver provider to the department
			 that:
(a) States the system changes,
			 processes, or other actions that the provider shall take to prevent a future
			 occurrence of a violation stated in a citation or findings report;
(b) States the timeframe in which the
			 provider shall successfully implement or perform a system change, process, or
			 other action required by the corrective action plan; and
(c) Is not valid or effective until approved
			 by the department.
(9)
			 "Credible allegation of fraud" is defined by
			 42
			 C.F.R. 405.370.
(10) "Department" means the Department for
			 Medicaid Services or its designee.
(11) "Fraud" is defined by
			 KRS
			 205.8451(2).
(12) "Moratorium" means the department's
			 prohibition against a provider providing services to a new 1915(c) home and
			 community based services waiver participant.
(13) "New 1915(c) home and community based
			 services waiver participant" means an individual who has never received 1915(c)
			 home and community based services from a given provider though the individual
			 may have previously received 1915(c) home and community based services from
			 another provider.
(14) "Provider
			 abuse" is defined by
			 KRS
			 205.8451(8).
(15) "Repeat citation" means a citation that
			 was previously issued by the department within the past two (2) years that did
			 not result in a sustainable correction.
(16) "Restriction" means a limitation or
			 condition placed on a provider by:
(a) The
			 professional board governing the provider's profession;
(b) A court of competent
			 jurisdiction;
(c) A federal agency
			 with jurisdiction over the:
1. Medicaid
			 program; or
2. Provider;
			 or
(d) The department in
			 accordance with this administrative regulation.
(17) "Sanction" means an administrative
			 action taken by the department which:
(a)
1. Limits or bars an individual's, agency's,
			 entity's, or organization's participation in the Medicaid program; or
2. Imposes a fiscal penalty against the
			 provider, including the:
a. Imposition of
			 civil penalties or interest imposed at the department's discretion; or
b. Withholding of future payments;
			 and
(b) Does
			 not include:
1. A voluntary
			 moratorium;
2. A decision not to
			 renew a certification;
3. A
			 citation; or
4. Denial of an
			 initial application for certification.
(18) "Unacceptable practice" means:
(a) Conduct which constitutes:
1. Fraud;
2. Provider abuse;
3. Neglect;
4. Exploitation;
5. Willful misrepresentation;
(b) An action resulting in an
			 exclusion, sanction, finding of fact, moratorium, suspension, or termination
			 by:
1. The licensing entity with jurisdiction
			 over the provider's license;
2. The
			 certifying entity with jurisdiction over the provider's certification;
			 or
3. The department;
(c) Failure to disclose required
			 information in accordance with
			 907
			 KAR 1:671,
			 907
			 KAR 1:672, or this administrative
			 regulation;
(d) Making, causing to
			 be made, inducing, or seeking to induce a false, fictitious, or fraudulent
			 statement or misrepresentation of material fact when providing information to
			 the department; or
(e) Conduct
			 which results in a restriction.