KRS 205.6310: Cabinet to establish system to reduce unnecessary hospital emergency

room utilization and costs.

The Cabinet for Health and Family Services shall establish a system within the Medical

Assistance Program to reduce unnecessary hospital emergency room u tilization and costs

by redefining and controlling hospital emergency utilization. The cabinet shall establish

by promulgation of administrative regulations, pursuant to KRS Chapter 13A, the

following:

(1) Criteria and procedures, at least annually updated , that differentiate children and

adults, and which conform to the Federal Emergency Medical Treatment and Active

Labor Act (42 U.S.C. sec. 1395dd), as amended, and any other applicable federal

law or regulation for determining if a medical emergency exists;

(2) Reimbursement rates that provide for nominal reimbursement of emergency room

care for care that does not meet the criteria established for a medical emergency;

(3) Reimbursement, at rates determined by the cabinet, for ancillary services which,

based upon the symptoms of the patient, are medically appropriate to determine if a

medical emergency exists;

(4) Except for emergency room services rendered to children under the age of six (6),

prohibition of reimbursement at hospital emergency room rates fo r diagnosis and

treatment for a condition that does not meet the criteria established for a medical

emergency; and

(5) The provisions of this section shall apply to any managed care program for

Medicaid recipients.

The cabinet or its designated peer review organization shall review all claims for payment

of nonemergency hospital care and deny payment for any ancillary services determined as

not medically appropriate.