KRS 205.560: Scope of care to be designated by administrative regulations --

Reimbursements mandated or prohibited -- Payments to community mental

health centers -- Participation of providers in Medical Assistance Program.

(1) The scope of medical care fo r which the Cabinet for Health and Family Services

undertakes to pay shall be designated and limited by regulations promulgated by the

cabinet, pursuant to the provisions in this section. Within the limitations of any

appropriation therefor, the provision of complete upper and lower dentures to

recipients of Medical Assistance Program benefits who have their teeth removed by

a dentist resulting in the total absence of teeth shall be a mandatory class in the

scope of medical care. Payment to a dentist of any Medical Assistance Program

benefits for complete upper and lower dentures shall only be provided on the

condition of a preauthorized agreement between an authorized representative of the

Medical Assistance Program and the dentist prior to the removal of t he teeth. The

selection of another class or other classes of medical care shall be recommended by

the council to the secretary for health and family services after taking into

consideration, among other things, the amount of federal and state funds availab le,

the most essential needs of recipients, and the meeting of such need on a basis

insuring the greatest amount of medical care as defined in KRS 205.510 consonant

with the funds available, including but not limited to the following categories,

except where the aid is for the purpose of obtaining an abortion:

(a) Hospital care, including drugs, and medical supplies and services during any

period of actual hospitalization;

(b) Nursing-home care, including medical supplies and services, and drugs during

confinement therein on prescription of a physician, dentist, or podiatrist;

(c) Drugs, nursing care, medical supplies, and services during the time when a

recipient is not in a hospital but is under treatment and on the prescription of a

physician, dentist, or podiatrist. For purposes of this paragraph, drugs shall

include products for the treatment of inborn errors of metabolism or genetic,

gastrointestinal, and food allergic conditions, consisting of therapeutic food,

formulas, supplements, amino acid -based e lemental formula, or low -protein

modified food products that are medically indicated for therapeutic treatment

and are administered under the direction of a physician, and include but are

not limited to the following conditions:

1. Phenylketonuria;

2. Hyperphenylalaninemia;

3. Tyrosinemia (types I, II, and III);

4. Maple syrup urine disease;

5. A-ketoacid dehydrogenase deficiency;

6. Isovaleryl-CoA dehydrogenase deficiency;

7. 3-methylcrotonyl-CoA carboxylase deficiency;

8. 3-methylglutaconyl-CoA hydratase deficiency;

9. 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMG -CoA lyase

deficiency);

10. B-ketothiolase deficiency;

11. Homocystinuria;

12. Glutaric aciduria (types I and II);

13. Lysinuric protein intolerance;

14. Non-ketotic hyperglycinemia;

15. Propionic acidemia;

16. Gyrate atrophy;

17. Hyperornithinemia/hyperammonemia/homocitrullinuria syndrome;

18. Carbamoyl phosphate synthetase deficiency;

19. Ornithine carbamoyl transferase deficiency;

20. Citrullinemia;

21. Arginosuccinic aciduria;

22. Methylmalonic acidemia;

23. Argininemia;

24. Food protein allergies;

25. Food protein-induced enterocolitis syndrome;

26. Eosinophilic disorders; and

27. Short bowel syndrome;

(d) Physician, podiatric, and dental services;

(e) Optometric services for all age groups shall be limited to prescription

services, services to frames and lenses, and diagnostic services provided by an

optometrist, to the extent the optometrist is licensed to perform the services

and to the extent the services are covered in the ophthalmologist portion of the

physician's program. Eyeglasses shall be provided only to children under age

twenty-one (21);

(f) Drugs on the prescription of a physician used to prevent the rejection of

transplanted organs if the patient is indigent; and

(g) Nonprofit neighborhood health organizations or clinics where some or all of

the medical services are provided by licensed registered nurses or by

advanced medical students presently enrolled in a medical school accredited

by the Association of American Medical Colleges and where the students or

licensed registered nurses are under the direct supervision of a licensed

physician who rotates his services in this supervisory capacity betw een two

(2) or more of the nonprofit neighborhood health organizations or clinics

specified in this paragraph.

(2) Payments for hospital care, nursing -home care, and drugs or other medical,

ophthalmic, podiatric, and dental supplies shall be on bases which relate the amount

of the payment to the cost of providing the services or supplies. It shall be one (1)

of the functions of the council to make recommendations to the Cabinet for Health

and Family Services with respect to the bases for payment. In determining the rates

of reimbursement for long -term-care facilities participating in the Medical

Assistance Program, the Cabinet for Health and Family Services shall, to the extent

permitted by federal law, not allow the following items to be considered as a cost to

the facility for purposes of reimbursement:

(a) Motor vehicles that are not owned by the facility, including m otor vehicles

that are registered or owned by the facility but used primarily by the owner or

family members thereof;

(b) The cost of motor vehicles, including vans or trucks, used for facility business

shall be allowed up to fifteen thousand dollars ($15, 000) per facility, adjusted

annually for inflation according to the increase in the consumer price index -u

for the most recent twelve (12) month period, as determined by the United

States Department of Labor. Medically equipped motor vehicles, vans, or

trucks shall be exempt from the fifteen thousand dollar ($15,000) limitation.

Costs exceeding this limit shall not be reimbursable and shall be borne by the

facility. Costs for additional motor vehicles, not to exceed a total of three (3)

per facility, may be approved by the Cabinet for Health and Family Services if

the facility demonstrates that each additional vehicle is necessary for the

operation of the facility as required by regulations of the cabinet;

(c) Salaries paid to immediate family members of the owner or administrator, or

both, of a facility, to the extent that services are not actually performed and

are not a necessary function as required by regulation of the cabinet for the

operation of the facility. The facility shall keep a record of all wor k actually

performed by family members;

(d) The cost of contracts, loans, or other payments made by the facility to owners,

administrators, or both, unless the payments are for services which would

otherwise be necessary to the operation of the facility an d the services are

required by regulations of the Cabinet for Health and Family Services. Any

other payments shall be deemed part of the owner's compensation in

accordance with maximum limits established by regulations of the Cabinet for

Health and Family Services. Interest paid to the facility for loans made to a

third party may be used to offset allowable interest claimed by the facility;

(e) Private club memberships for owners or administrators, travel expenses for

trips outside the state for owners or a dministrators, and other indirect

payments made to the owner, unless the payments are deemed part of the

owner's compensation in accordance with maximum limits established by

regulations of the Cabinet for Health and Family Services; and

(f) Payments made to related organizations supplying the facility with goods or

services shall be limited to the actual cost of the goods or services to the

related organization, unless it can be demonstrated that no relationship

between the facility and the supplier exists . A relationship shall be considered

to exist when an individual, including brothers, sisters, father, mother, aunts,

uncles, and in -laws, possesses a total of five percent (5%) or more of

ownership equity in the facility and the supplying business. An exc eption to

the relationship shall exist if fifty -one percent (51%) or more of the supplier's

business activity of the type carried on with the facility is transacted with

persons and organizations other than the facility and its related organizations.

(3) No vendor payment shall be made unless the class and type of medical care

rendered and the cost basis therefor has first been designated by regulation.

(4) The rules and regulations of the Cabinet for Health and Family Services shall

require that a written statement, including the required opinion of a physician, shall

accompany any claim for reimbursement for induced premature births. This

statement shall indicate the procedures used in providing the medical services.

(5) The range of medical care benefit s tandards provided and the quality and quantity

standards and the methods for determining cost formulae for vendor payments

within each category of public assistance and other recipients shall be uniform for

the entire state, and shall be designated by regu lation promulgated within the

limitations established by the Social Security Act and federal regulations. It shall

not be necessary that the amount of payments for units of services be uniform for

the entire state but amounts may vary from county to county and from city to city,

as well as among hospitals, based on the prevailing cost of medical care in each

locale and other local economic and geographic conditions, except that insofar as

allowed by applicable federal law and regulation, the maximum amounts

reimbursable for similar services rendered by physicians within the same specialty

of medical practice shall not vary according to the physician's place of residence or

place of practice, as long as the place of practice is within the boundaries of the

state.

(6) Nothing in this section shall be deemed to deprive a woman of all appropriate

medical care necessary to prevent her physical death.

(7) To the extent permitted by federal law, no medical assistance recipient shall be

recertified as qualifying for a level of long -term care below the recipient's current

level, unless the recertification includes a physical examination conducted by a

physician licensed pursuant to KRS Chapter 311 or by an advanced practice

registered nurse licensed pursuant to KRS Cha pter 314 and acting under the

physician's supervision.

(8) (a) If payments made to community mental health centers, established pursuant to

KRS Chapter 210, for services provided to the intellectually disabled exceed

the actual cost of providing the servic e, the balance of the payments shall be

used solely for the provision of other services to the intellectually disabled

through community mental health centers.

(b) Except as provided in KRS 210.370(4) and (5)(c), if a community mental

health center, established pursuant to KRS Chapter 210, provides services to a

recipient of Medical Assistance Program benefits outside of the community

mental health center's regional service area, as established in KRS 210.370,

the community mental health center shall not be reimbursed for such services

in accordance with the department's fee schedule for community mental

health centers but shall instead be reimbursed in accordance with the

department's fee schedule for behavioral health service organizations.

(c) As used in this subsection, "community mental health center" means a

regional community services program as defined in KRS 210.005.

(9) No long-term-care facility, as defined in KRS 216.510, providing inpatient care to

recipients of medical assistance under Title XIX of the Social Security Act on July

15, 1986, shall deny admission of a person to a bed certified for reimbursement

under the provisions of the Medical Assistance Program solely on the basis of the

person's paying status as a Medicaid recipient. No person shall be removed or

discharged from any facility solely because they became eligible for participation in

the Medical Assistance Program, unless the facility can demonstrate the resident or

the resident's responsible party was fully notified in writing tha t the resident was

being admitted to a bed not certified for Medicaid reimbursement. No facility may

decertify a bed occupied by a Medicaid recipient or may decertify a bed that is

occupied by a resident who has made application for medical assistance.

(10) Family-practice physicians practicing in geographic areas with no more than one

(1) primary-care physician per five thousand (5,000) population, as reported by the

United States Department of Health and Human Services, shall be reimbursed one

hundred twe nty-five percent (125%) of the standard reimbursement rate for

physician services.

(11) The Cabinet for Health and Family Services shall make payments under the

Medical Assistance Program for services which are within the lawful scope of

practice of a chir opractor licensed pursuant to KRS Chapter 312, to the extent the

Medical Assistance Program pays for the same services provided by a physician.

(12) (a) The Medical Assistance Program shall use the appropriate form and

guidelines for enrolling those provid ers applying for participation in the

Medical Assistance Program, including those licensed and regulated under

KRS Chapters 311, 312, 314, 315, and 320, any facility required to be

licensed pursuant to KRS Chapter 216B, and any other health care practitioner

or facility as determined by the Department for Medicaid Services through an

administrative regulation promulgated under KRS Chapter 13A. A Medicaid

managed care organization shall use the forms and guidelines established

under KRS 304.17A -545(5) to cre dential a provider. For any provider who

contracts with and is credentialed by a Medicaid managed care organization

prior to enrollment, the cabinet shall complete the enrollment process and

deny, or approve and issue a Provider Identification Number (PID) within

fifteen (15) business days from the time all necessary completed enrollment

forms have been submitted and all outstanding accounts receivable have been

satisfied.

(b) Within forty -five (45) days of receiving a correct and complete provider

application, the Department for Medicaid Services shall complete the

enrollment process by either denying or approving and issuing a Provider

Identification Number (PID) for a behavioral health provider who provides

substance use disorder services, unless the depa rtment notifies the provider

that additional time is needed to render a decision for resolution of an issue or

dispute.

(c) Within forty-five (45) days of receipt of a correct and complete application for

credentialing by a behavioral health provider providing substance use disorder

services, a Medicaid managed care organization shall complete its contracting

and credentialing process, unless the Medicaid managed care organization

notifies the provider that additional time is needed to render a decision. If

additional time is needed, the Medicaid managed care organization shall not

take any longer than ninety (90) days from receipt of the credentialing

application to deny or approve and contract with the provider.

(d) A Medicaid managed care organization sha ll adjudicate any clean claims

submitted for a substance use disorder service from an enrolled and

credentialed behavioral health provider who provides substance use disorder

services in accordance with KRS 304.17A-700 to 304.17A-730.

(e) The Department of Insurance may impose a civil penalty of one hundred

dollars ($100) per violation when a Medicaid managed care organization fails

to comply with this section. Each day that a Medicaid managed care

organization fails to pay a claim may count as a separate violation.

(13) Dentists licensed under KRS Chapter 313 shall be excluded from the requirements

of subsection (12) of this section. The Department for Medicaid Services shall

develop a specific form and establish guidelines for assessing the credentials of

dentists applying for participation in the Medical Assistance Program.