KRS 205.5355: Identification and disenrollment of nonresidents and individuals

concurrently enrolled in multiple states -- Procedures -- Notice -- Penalties.

For the purpose of identifying and, when appropriate, disenrolling individuals from the

Kentucky Medi caid program who are concurrently enrolled, or suspected of being

concurrently enrolled, in one (1) or more other states' Medicaid programs or are

otherwise ineligible for enrollment in the Kentucky Medicaid program because they no

longer reside in Kentucky, to the extent permitted under federal law:

(1) The cabinet shall:

(a) On at least a quarterly basis, review the Public Assistance Reporting

Information System, or PARIS, match files submitted to the state by the

federal Administration for Children and Families;

(b) Identify individuals enrolled in the Kentucky Medicaid program who may be

concurrently enrolled in one (1) or more other states' Medicaid programs;

(c) Notify any individual suspected of being concurrently enrolled in the

Kentucky Medicaid pro gram and one (1) or more other states' Medicaid

programs within thirty (30) days of identification under paragraph (b) of this

subsection. Notifications made under this paragraph shall inform individuals:

1. That they are required to submit proof of curren t residency in the

Commonwealth within thirty (30) days;

2. Of the process for submitting proof of current residency to the cabinet

and the documents required to be submitted to validate current residency

in the Commonwealth; and

3. That failure to submit proof of current residency in the Commonwealth

within thirty (30) days shall result in the individual being disenrolled

from the Medicaid managed care organization in which the individual is

enrolled or assigned;

(d) For individuals who fail to respond as required under paragraph (c) of this

subsection:

1. Disenroll the individual from the Medicaid managed care organization

in which the individual is enrolled or assigned and place the individual

in the Medicaid fee-for-service program; and

2. Make a second attempt to notify the individual within forty -five (45)

days from the date on which the notice required under paragraph (c) of

this subsection was made. Notifications made under this subparagraph

shall inform individuals:

a. That they must submit proof of current residency in the

Commonwealth within thirty (30) days;

b. Of the process for submitting proof of current residency to the

cabinet and the documents required to be submitted to validate

current residency in the Commonwealth; and

c. That failure to submit proof of current residency in the

Commonwealth within thirty (30) days shall result in the

individual being disenrolled from the Kentucky Medicaid

program;

(e) Not make capitation payments to any managed care or ganization with whom

the cabinet contracts for the delivery of Medicaid services on behalf of any

individual disenrolled from managed care in accordance with paragraphs (c)

and (d) of this subsection;

(f) Upon receipt of a notification required under subse ction (2)(b) of this section,

provide notice in accordance with paragraphs (c) and (d) of this subsection to

the individual identified by the managed care organization and disenroll the

individual as required under paragraphs (c) and (d) of this subsection; and

(g) Establish administrative penalties for any managed care organization that fails

to comply with the requirements of subsection (2) of this section;

(2) Each managed care organization with whom the cabinet contracts for the delivery

of Medicaid services shall:

(a) On at least a monthly basis, make all reasonable efforts to identify any

individual who is:

1. Enrolled in the Kentucky Medicaid program;

2. Served by, enrolled with, or assigned to the managed care organization;

and

3. Covered by, insured by, or enrolled with the managed care organization,

the managed care organization's parent company, or any subsidiary of

the managed care organization or its parent company in another state,

regardless of the type of coverage provided in the other state;

(b) Promptly notify the cabinet of any individual identified in accordance with

paragraph (a) of this subsection; and

(c) On a monthly basis, report to the Department for Medicaid Services efforts

and activities undertaken to comply with paragraph (a) of this subsection; and

(3) (a) The cabinet shall impose a penalty of one thousand dollars ($1,000) for each

violation of:

1. Subsection (2)(a) and (c) of this section with each month in which a

managed care organization fails to comply with subsection (2)(a) and (c)

of this section constituting a separate violation; and

2. Subsection (2)(b) of this section.

(b) Penalties collected under this subsection shall be deposited into the Medicaid

managed care organization compliance fund established in KRS 205.5357.