KRS 304.38-240: Solicitation of proposals designating medical necessity criteria for

Medicaid managed care organizations -- Administrative regulation.

(1) (a) The commissioner shall promulgate an administrative regulation to establish

procedures for conduct ing a competitive process to solicit proposals from

publishers of medical necessity criteria to designate for each category of

services which medical necessity criteria Medicaid managed care

organizations, as defined in KRS 205.532, shall use to determine the medical

necessity and clinical appropriateness of proposed services pursuant to the

utilization review plan required by KRS 205.536.

(b) The procedures shall require:

1. The department to provide adequate public notice of the deadline for

publishers of medical necessity criteria to submit proposals; and

2. a. The commissioner to issue a final order at the conclusion of the

competitive process.

b. The order shall designate, for each category of services, one (1) set

of medical necessity criteria determined by the commissioner to be

the most advantageous to the Commonwealth.

c. Nothing in this section shall preclude the commissioner from

designating the same set of medical necessity criteria for two (2) or

more categories of service if the commissioner det ermines, in

accordance with the procedures required by this subsection, that

the designation would be the most advantageous to the

Commonwealth.

(c) The procedures shall permit any person who is aggrieved in connection with

the solicitation of proposals or the commissioner's final order to request a

hearing pursuant to KRS 304.2-310.

(2) (a) For purposes of this subsection, "objective and evidence-based" includes:

1. Methods or systems where:

a. The publisher evaluates and grades the sufficiency of medical

evidence incorporated into the criteria;

b. The publisher reviews and updates the criteria periodically as

appropriate, but no less frequently than annually; and

c. The criteria are evaluated an nually by a panel of one (1) or more

physicians not directly employed by the publisher of the criteria;

and

2. Sufficient unique citations to published medical research and other peer -

reviewed literature to substantiate the criteria's evidentiary basis.

(b) In conducting the competitive process required by subsection (1) of this

section, the commissioner shall only accept proposals from publishers of

medical necessity criteria if the criteria:

1. Are nationally recognized;

2. Are objective and evidence-based; and

3. Are not proprietary property of a Medicaid managed care organization or

a subsidiary of a Medicaid managed care organization, or a corporation

which a Medicaid managed care organization controls or owns more

than five percent (5%) of the stock.

(3) The categories of service shall be limited to:

(a) Physical health services;

(b) Behavioral health services; and

(c) Any other categories of service required under federal law for Medicaid

managed care.

(4) (a) Notwithstanding KRS 13A.3102, any admini strative regulation promulgated

under this section shall expire two (2) years from the last effective date, as

defined in KRS 13A.010, unless the department follows the certification or

amendment process established in KRS 13A.3104.

(b) If the department f iles a certification letter pursuant to KRS 13A.3104, and

does not intend to amend an administrative regulation promulgated under this

section, it shall allow for a public comment period and public hearing on the

certification letter meeting the requirements of KRS 13A.270.

(5) In promulgating any administrative regulation under this section, the commissioner

shall:

(a) Collaborate with the Department for Medicaid Services to ensure that the

regulation is consistent with:

1. Federal requirements relating to Medicaid managed care medical

necessity review criteria; and

2. Any administrative regulation promulgated by the Department for

Medicaid Services that is not inconsistent with this section, relating to

the processes Medicaid managed care organizations are required to

follow when using the medical necessity criteria designated pursuant to

this section;

(b) Set forth in any federal mandate analysis comparison for an administrative

regulation promulgated under this section:

1. A description of any federal req uirements relating to Medicaid managed

care medical necessity review criteria; and

2. A summary of all input provided by the Department for Medicaid

Services to the commissioner relating to the form and content of the

regulation; and

(c) Receive from the D epartment for Medicaid Services the input of healthcare

professionals, which shall include members of the Advisory Council for

Medical Assistance established pursuant to KRS 205.540, in each category of

care in accordance with subsection (3) of this section.