{"data":{"id":"us-ky/krs-205.560","jurisdiction":"us-ky","citation":"KRS 205.560","heading":"Scope of care to be designated by administrative regulations --","body":"Reimbursements mandated or prohibited -- Payments to community mental\nhealth centers -- Participation of providers in Medical Assistance Program.\n(1) The scope of medical care fo r which the Cabinet for Health and Family Services\nundertakes to pay shall be designated and limited by regulations promulgated by the\ncabinet, pursuant to the provisions in this section. Within the limitations of any\nappropriation therefor, the provision of complete upper and lower dentures to\nrecipients of Medical Assistance Program benefits who have their teeth removed by\na dentist resulting in the total absence of teeth shall be a mandatory class in the\nscope of medical care. Payment to a dentist of any  Medical Assistance Program\nbenefits for complete upper and lower dentures shall only be provided on the\ncondition of a preauthorized agreement between an authorized representative of the\nMedical Assistance Program and the dentist prior to the removal of t he teeth. The\nselection of another class or other classes of medical care shall be recommended by\nthe council to the secretary for health and family services after taking into\nconsideration, among other things, the amount of federal and state funds availab le,\nthe most essential needs of recipients, and the meeting of such need on a basis\ninsuring the greatest amount of medical care as defined in KRS 205.510 consonant\nwith the funds available, including but not limited to the following categories,\nexcept where the aid is for the purpose of obtaining an abortion:\n(a) Hospital care, including drugs, and medical supplies and services during any\nperiod of actual hospitalization;\n(b) Nursing-home care, including medical supplies and services, and drugs during\nconfinement therein on prescription of a physician, dentist, or podiatrist;\n(c) Drugs, nursing care, medical supplies, and services during the time when a\nrecipient is not in a hospital but is under treatment and on the prescription of a\nphysician, dentist, or  podiatrist. For purposes of this paragraph, drugs shall\ninclude products for the treatment of inborn errors of metabolism or genetic,\ngastrointestinal, and food allergic conditions, consisting of therapeutic food,\nformulas, supplements, amino acid -based e lemental formula, or low -protein\nmodified food products that are medically indicated for therapeutic treatment\nand are administered under the direction of a physician, and include but are\nnot limited to the following conditions:\n1. Phenylketonuria;\n2. Hyperphenylalaninemia;\n3. Tyrosinemia (types I, II, and III);\n4. Maple syrup urine disease;\n5. A-ketoacid dehydrogenase deficiency;\n6. Isovaleryl-CoA dehydrogenase deficiency;\n7. 3-methylcrotonyl-CoA carboxylase deficiency;\n8. 3-methylglutaconyl-CoA hydratase deficiency;\n9. 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMG -CoA lyase\ndeficiency);\n10. B-ketothiolase deficiency;\n11. Homocystinuria;\n12. Glutaric aciduria (types I and II);\n13. Lysinuric protein intolerance;\n14. Non-ketotic hyperglycinemia;\n15. Propionic acidemia;\n16. Gyrate atrophy;\n17. Hyperornithinemia/hyperammonemia/homocitrullinuria syndrome;\n18. Carbamoyl phosphate synthetase deficiency;\n19. Ornithine carbamoyl transferase deficiency;\n20. Citrullinemia;\n21. Arginosuccinic aciduria;\n22. Methylmalonic acidemia;\n23. Argininemia;\n24. Food protein allergies;\n25. Food protein-induced enterocolitis syndrome;\n26. Eosinophilic disorders; and\n27. Short bowel syndrome;\n(d) Physician, podiatric, and dental services;\n(e) Optometric services for all age groups shall be limited to prescription\nservices, services to frames and lenses, and diagnostic services provided by an\noptometrist, to the extent the optometrist is licensed to perform the services\nand to the extent the services are covered in the ophthalmologist portion of the\nphysician's program. Eyeglasses shall be provided only to children under age\ntwenty-one (21);\n(f) Drugs on the prescription of a physician used to prevent  the rejection of\ntransplanted organs if the patient is indigent; and\n(g) Nonprofit neighborhood health organizations or clinics where some or all of\nthe medical services are provided by licensed registered nurses or by\nadvanced medical students presently enrolled in a medical school accredited\nby the Association of American Medical Colleges and where the students or\nlicensed registered nurses are under the direct supervision of a licensed\nphysician who rotates his services in this supervisory capacity betw een two\n(2) or more of the nonprofit neighborhood health organizations or clinics\nspecified in this paragraph.\n(2) Payments for hospital care, nursing -home care, and drugs or other medical,\nophthalmic, podiatric, and dental supplies shall be on bases which relate the amount\nof the payment to the cost of providing the services or supplies. It shall be one (1)\nof the functions of the council to make recommendations to the Cabinet for Health\nand Family Services with respect to the bases for payment. In determining the rates\nof reimbursement for long -term-care facilities participating in the Medical\nAssistance Program, the Cabinet for Health and Family Services shall, to the extent\npermitted by federal law, not allow the following items to be considered as a cost to\nthe facility for purposes of reimbursement:\n(a) Motor vehicles that are not owned by the facility, including m otor vehicles\nthat are registered or owned by the facility but used primarily by the owner or\nfamily members thereof;\n(b) The cost of motor vehicles, including vans or trucks, used for facility business\nshall be allowed up to fifteen thousand dollars ($15, 000) per facility, adjusted\nannually for inflation according to the increase in the consumer price index -u\nfor the most recent twelve (12) month period, as determined by the United\nStates Department of Labor. Medically equipped motor vehicles, vans, or\ntrucks shall be exempt from the fifteen thousand dollar ($15,000) limitation.\nCosts exceeding this limit shall not be reimbursable and shall be borne by the\nfacility. Costs for additional motor vehicles, not to exceed a total of three (3)\nper facility, may be approved by the Cabinet for Health and Family Services if\nthe facility demonstrates that each additional vehicle is necessary for the\noperation of the facility as required by regulations of the cabinet;\n(c) Salaries paid to immediate family members of the  owner or administrator, or\nboth, of a facility, to the extent that services are not actually performed and\nare not a necessary function as required by regulation of the cabinet for the\noperation of the facility. The facility shall keep a record of all wor k actually\nperformed by family members;\n(d) The cost of contracts, loans, or other payments made by the facility to owners,\nadministrators, or both, unless the payments are for services which would\notherwise be necessary to the operation of the facility an d the services are\nrequired by regulations of the Cabinet for Health and Family Services. Any\nother payments shall be deemed part of the owner's compensation in\naccordance with maximum limits established by regulations of the Cabinet for\nHealth and Family Services. Interest paid to the facility for loans made to a\nthird party may be used to offset allowable interest claimed by the facility;\n(e) Private club memberships for owners or administrators, travel expenses for\ntrips outside the state for owners or a dministrators, and other indirect\npayments made to the owner, unless the payments are deemed part of the\nowner's compensation in accordance with maximum limits established by\nregulations of the Cabinet for Health and Family Services; and\n(f) Payments made to related organizations supplying the facility with goods or\nservices shall be limited to the actual cost of the goods or services to the\nrelated organization, unless it can be demonstrated that no relationship\nbetween the facility and the supplier exists . A relationship shall be considered\nto exist when an individual, including brothers, sisters, father, mother, aunts,\nuncles, and in -laws, possesses a total of five percent (5%) or more of\nownership equity in the facility and the supplying business. An exc eption to\nthe relationship shall exist if fifty -one percent (51%) or more of the supplier's\nbusiness activity of the type carried on with the facility is transacted with\npersons and organizations other than the facility and its related organizations.\n(3) No vendor payment shall be made unless the class and type of medical care\nrendered and the cost basis therefor has first been designated by regulation.\n(4) The rules and regulations of the Cabinet for Health and Family Services shall\nrequire that a written statement, including the required opinion of a physician, shall\naccompany any claim for reimbursement for induced premature births. This\nstatement shall indicate the procedures used in providing the medical services.\n(5) The range of medical care benefit s tandards provided and the quality and quantity\nstandards and the methods for determining cost formulae for vendor payments\nwithin each category of public assistance and other recipients shall be uniform for\nthe entire state, and shall be designated by regu lation promulgated within the\nlimitations established by the Social Security Act and federal regulations. It shall\nnot be necessary that the amount of payments for units of services be uniform for\nthe entire state but amounts may vary from county to county  and from city to city,\nas well as among hospitals, based on the prevailing cost of medical care in each\nlocale and other local economic and geographic conditions, except that insofar as\nallowed by applicable federal law and regulation, the maximum amounts\nreimbursable for similar services rendered by physicians within the same specialty\nof medical practice shall not vary according to the physician's place of residence or\nplace of practice, as long as the place of practice is within the boundaries of the\nstate.\n(6) Nothing in this section shall be deemed to deprive a woman of all appropriate\nmedical care necessary to prevent her physical death.\n(7) To the extent permitted by federal law, no medical assistance recipient shall be\nrecertified as qualifying for a level of long -term care below the recipient's current\nlevel, unless the recertification includes a physical examination conducted by a\nphysician licensed pursuant to KRS Chapter 311 or by an advanced practice\nregistered nurse licensed pursuant to KRS Cha pter 314 and acting under the\nphysician's supervision.\n(8) (a) If payments made to community mental health centers, established pursuant to\nKRS Chapter 210, for services provided to the intellectually disabled exceed\nthe actual cost of providing the servic e, the balance of the payments shall be\nused solely for the provision of other services to the intellectually disabled\nthrough community mental health centers.\n(b) Except as provided in KRS 210.370(4) and (5)(c), if a community mental\nhealth center, established pursuant to KRS Chapter 210, provides services to a\nrecipient of Medical Assistance Program benefits outside of the community\nmental health center's regional service area, as established in KRS 210.370,\nthe community mental health center shall not be  reimbursed for such services\nin accordance with the department's fee schedule for community mental\nhealth centers but shall instead be reimbursed in accordance with the\ndepartment's fee schedule for behavioral health service organizations.\n(c) As used in this subsection, \"community mental health center\" means a\nregional community services program as defined in KRS 210.005.\n(9) No long-term-care facility, as defined in KRS 216.510, providing inpatient care to\nrecipients of medical assistance under Title XIX  of the Social Security Act on July\n15, 1986, shall deny admission of a person to a bed certified for reimbursement\nunder the provisions of the Medical Assistance Program solely on the basis of the\nperson's paying status as a Medicaid recipient. No person shall be removed or\ndischarged from any facility solely because they became eligible for participation in\nthe Medical Assistance Program, unless the facility can demonstrate the resident or\nthe resident's responsible party was fully notified in writing tha t the resident was\nbeing admitted to a bed not certified for Medicaid reimbursement. No facility may\ndecertify a bed occupied by a Medicaid recipient or may decertify a bed that is\noccupied by a resident who has made application for medical assistance.\n(10) Family-practice physicians practicing in geographic areas with no more than one\n(1) primary-care physician per five thousand (5,000) population, as reported by the\nUnited States Department of Health and Human Services, shall be reimbursed one\nhundred twe nty-five percent (125%) of the standard reimbursement rate for\nphysician services.\n(11) The Cabinet for Health and Family Services shall make payments under the\nMedical Assistance Program for services which are within the lawful scope of\npractice of a chir opractor licensed pursuant to KRS Chapter 312, to the extent the\nMedical Assistance Program pays for the same services provided by a physician.\n(12) (a) The Medical Assistance Program shall use the appropriate form and\nguidelines for enrolling those provid ers applying for participation in the\nMedical Assistance Program, including those licensed and regulated under\nKRS Chapters 311, 312, 314, 315, and 320, any facility required to be\nlicensed pursuant to KRS Chapter 216B, and any other health care practitioner\nor facility as determined by the Department for Medicaid Services through an\nadministrative regulation promulgated under KRS Chapter 13A. A Medicaid\nmanaged care organization shall use the forms and guidelines established\nunder KRS 304.17A -545(5) to cre dential a provider. For any provider who\ncontracts with and is credentialed by a Medicaid managed care organization\nprior to enrollment, the cabinet shall complete the enrollment process and\ndeny, or approve and issue a Provider Identification Number (PID)  within\nfifteen (15) business days from the time all necessary completed enrollment\nforms have been submitted and all outstanding accounts receivable have been\nsatisfied.\n(b) Within forty -five (45) days of receiving a correct and complete provider\napplication, the Department for Medicaid Services shall complete the\nenrollment process by either denying or approving and issuing a Provider\nIdentification Number (PID) for a behavioral health provider who provides\nsubstance use disorder services, unless the depa rtment notifies the provider\nthat additional time is needed to render a decision for resolution of an issue or\ndispute.\n(c) Within forty-five (45) days of receipt of a correct and complete application for\ncredentialing by a behavioral health provider providing substance use disorder\nservices, a Medicaid managed care organization shall complete its contracting\nand credentialing process, unless the Medicaid managed care organization\nnotifies the provider that additional time is needed to render a decision. If\nadditional time is needed, the Medicaid managed care organization shall not\ntake any longer than ninety (90) days from receipt of the credentialing\napplication to deny or approve and contract with the provider.\n(d) A Medicaid managed care organization sha ll adjudicate any clean claims\nsubmitted for a substance use disorder service from an enrolled and\ncredentialed behavioral health provider who provides substance use disorder\nservices in accordance with KRS 304.17A-700 to 304.17A-730.\n(e) The Department of  Insurance may impose a civil penalty of one hundred\ndollars ($100) per violation when a Medicaid managed care organization fails\nto comply with this section. Each day that a Medicaid managed care\norganization fails to pay a claim may count as a separate violation.\n(13) Dentists licensed under KRS Chapter 313 shall be excluded from the requirements\nof subsection (12) of this section. The Department for Medicaid Services shall\ndevelop a specific form and establish guidelines for assessing the credentials of\ndentists applying for participation in the Medical Assistance Program.","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=54185","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:03Z","sha256":"892cc7ef39f91828b31d13cdb8e66561bd973c336e7c81530b63a65ce928fc49","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.5591","next":"us-ky/krs-205.5601"},"notice":"GroundRules: Original legal text. Not legal advice."}