{"data":{"id":"us-ky/krs-304.38-240","jurisdiction":"us-ky","citation":"KRS 304.38-240","heading":"Solicitation of proposals designating medical necessity criteria for","body":"Medicaid managed care organizations -- Administrative regulation.\n(1) (a) The commissioner shall promulgate an administrative regulation to establish\nprocedures for conduct ing a competitive process to solicit proposals from\npublishers of medical necessity criteria to designate for each category of\nservices which medical necessity criteria Medicaid managed care\norganizations, as defined in KRS 205.532, shall use to determine the medical\nnecessity and clinical appropriateness of proposed services pursuant to the\nutilization review plan required by KRS 205.536.\n(b) The procedures shall require:\n1. The department to provide adequate public notice of the deadline for\npublishers of medical necessity criteria to submit proposals; and\n2. a. The commissioner to issue a final order at the conclusion of the\ncompetitive process.\nb. The order shall designate, for each category of services, one (1) set\nof medical necessity criteria determined by the commissioner to be\nthe most advantageous to the Commonwealth.\nc. Nothing in this section shall preclude the commissioner from\ndesignating the same set of medical necessity criteria for two (2) or\nmore categories of service if the commissioner det ermines, in\naccordance with the procedures required by this subsection, that\nthe designation would be the most advantageous to the\nCommonwealth.\n(c) The procedures shall permit any person who is aggrieved in connection with\nthe solicitation of proposals or  the commissioner's final order to request a\nhearing pursuant to KRS 304.2-310.\n(2) (a) For purposes of this subsection, \"objective and evidence-based\" includes:\n1. Methods or systems where:\na. The publisher evaluates and grades the sufficiency of medical\nevidence incorporated into the criteria;\nb. The publisher reviews and updates the criteria periodically as\nappropriate, but no less frequently than annually; and\nc. The criteria are evaluated an nually by a panel of one (1) or more\nphysicians not directly employed by the publisher of the criteria;\nand\n2. Sufficient unique citations to published medical research and other peer -\nreviewed literature to substantiate the criteria's evidentiary basis.\n(b) In conducting the competitive process required by subsection (1) of this\nsection, the commissioner shall only accept proposals from publishers of\nmedical necessity criteria if the criteria:\n1. Are nationally recognized;\n2. Are objective and evidence-based; and\n3. Are not proprietary property of a Medicaid managed care organization or\na subsidiary of a Medicaid managed care organization, or a corporation\nwhich a Medicaid managed care organization controls or owns more\nthan five percent (5%) of the stock.\n(3) The categories of service shall be limited to:\n(a) Physical health services;\n(b) Behavioral health services; and\n(c) Any other categories of service required under federal law for Medicaid\nmanaged care.\n(4) (a) Notwithstanding KRS 13A.3102, any admini strative regulation promulgated\nunder this section shall expire two (2) years from the last effective date, as\ndefined in KRS 13A.010, unless the department follows the certification or\namendment process established in KRS 13A.3104.\n(b) If the department f iles a certification letter pursuant to KRS 13A.3104, and\ndoes not intend to amend an administrative regulation promulgated under this\nsection, it shall allow for a public comment period and public hearing on the\ncertification letter meeting the requirements of KRS 13A.270.\n(5) In promulgating any administrative regulation under this section, the commissioner\nshall:\n(a) Collaborate with the Department for Medicaid Services to ensure that the\nregulation is consistent with:\n1. Federal requirements relating to  Medicaid managed care medical\nnecessity review criteria; and\n2. Any administrative regulation promulgated by the Department for\nMedicaid Services that is not inconsistent with this section, relating to\nthe processes Medicaid managed care organizations are  required to\nfollow when using the medical necessity criteria designated pursuant to\nthis section;\n(b) Set forth in any federal mandate analysis comparison for an administrative\nregulation promulgated under this section:\n1. A description of any federal req uirements relating to Medicaid managed\ncare medical necessity review criteria; and\n2. A summary of all input provided by the Department for Medicaid\nServices to the commissioner relating to the form and content of the\nregulation; and\n(c) Receive from the D epartment for Medicaid Services the input of healthcare\nprofessionals, which shall include members of the Advisory Council for\nMedical Assistance established pursuant to KRS 205.540, in each category of\ncare in accordance with subsection (3) of this section.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=47795","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:57Z","sha256":"67f1fbc567e888f8d60659124584a6adb51f3e0401b6d23e71b9872596d53b30","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.38-230","next":"us-ky/krs-304.38-500"},"notice":"GroundRules: Original legal text. Not legal advice."}