907 KAR 12:020. Reimbursement for New
Supports for Community Living Waiver Services.
RELATES
TO: KRS 205.520, 42 C.F.R. 441, Subpart G, 447.272, 42 U.S.C. 1396a, b, d, n
STATUTORY
AUTHORITY: KRS 142.363, 194A.030(3), 194A.050(1), 205.520(3), 205.6317
NECESSITY,
FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services,
Department for Medicaid Services, is required to administer the Medicaid
Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation,
to comply with any requirement that may be imposed, or opportunity presented,
by federal law to qualify for federal Medicaid funds. This administrative
regulation establishes the reimbursement policies for SCL waiver services provided
to individuals pursuant to the new Supports for Community Living (SCL) waiver program
established by 907 KAR 12:010 rather than the program established pursuant to
907 KAR 1:145.
Section
1. Definitions. (1) "Allocation" means the dollar amount designated
to meet a participant’s identified needs.
(2)
"DBHDID" means the Department for Behavioral Health, Developmental
and Intellectual Disabilities.
(3)
"Department" means the Department for Medicaid Services or its
designee.
(4) "Developmental
disability" means a disability that:
(a) Is manifested prior to the age of twenty-two
(22);
(b) Constitutes a substantial disability to the
affected individual; and
(c) Is attributable either to an intellectual disability
or a condition related to an intellectual disability that:
1. Results in an impairment of general
intellectual functioning and adaptive behavior similar to that of a person with
an intellectual disability; and
2. Is a direct result of, or is influenced by, the
person’s cognitive deficits.
(5)
"Exceptional support" means a service:
(a)
Requested by a participant and the participant’s team; and
(b)
That due to an extraordinary circumstance related to a participant’s physical
health, psychiatric issue, or behavioral health issue is necessary to:
1.
Be provided in excess of the upper payment limit for the service for a
specified amount of time; and
2.
Meet the assessed needs of the participant.
(6) "Immediate family member" is defined by KRS 205.8451(3).
(7) "Intellectual disability"
or "ID" means:
(a) A demonstration:
1. Of significantly sub-average
intellectual functioning and an intelligence quotient (IQ) of approximately
seventy (70) or below; and
2. Of concurrent deficits or
impairments in present adaptive functioning in at least two (2) of the
following areas:
a. Communication;
b. Self-care;
c. Home living;
d. Social or interpersonal skills;
e. Use of community resources;
f. Self-direction;
g. Functional academic skills;
h. Work;
i. Leisure; or
j. Health and safety; and
(b) An intellectual disability that
had an onset before eighteen (18) years of age.
(8) "Legally responsible individual" means an
individual who has a duty under state law to care for another person and
includes:
(a) A parent (biological, adoptive, or foster) of a minor
child who provides care to the child;
(b) The guardian of a minor child who provides care to the
child; or
(c) A spouse of a participant.
(9) "Participant" means a Medicaid
recipient who:
(a)
Meets patient status criteria for an intermediate care facility for an
individual with an intellectual disability as established in 907 KAR 1:022;
(b)
Is authorized by the department to receive SCL waiver services; and
(c)
Utilizes SCL waiver services and supports in accordance with a person centered
plan of care.
(10) "Participant directed service" means
an option to receive a service which is based on the principles of
self-determination and person-centered thinking.
(11) "POC" means Plan of Care.
(12) "State plan" is defined by 42 C.F.R.
430.10.
(13) "Supports for community living
services" or "SCL services" means community-based waiver
services for a participant who has an intellectual or developmental disability.
Section
2. Coverage. (1) The department shall reimburse a participating SCL provider
for a covered service provided to a participant.
(2)
In order to be reimbursable by the department, a service shall be:
(a)
Provided in accordance with the terms and conditions specified in 907 KAR 12:010;
and
(b)
Prior authorized by the department.
(3)(a)
The reimbursement provisions established in this administrative regulation
shall apply after a recipient transitions to the new SCL waiver program
established in 907 KAR 12:010.
(b)
Prior to that transition, the services provided pursuant to 907 KAR 1:145 shall
be reimbursed pursuant to 907 KAR 1:155.
(c)
Funding for the SCL waiver program shall be associated with and generated
through SCL waiver program participants rather than SCL waiver service
providers.
Section
3. SCL Reimbursement and Limits. (1) Except as established in Section 4 of this
administrative regulation, the department shall reimburse for an SCL service
provided in accordance with 907 KAR 12:010 to a participant:
(a)
The amount of the charge billed by the provider; and
(b)
Not to exceed the fixed upper payment limit for the service.
(2)
The upper payment limits listed in the following table shall be the upper
payment limits for the corresponding services listed in the following table:
Service
Unit
of Service
Upper
Payment Limit
Case
Management
1
month
$320.00
Community
Access-Individual
15
minutes
$8.00
Community
Access-Group
15
minutes
$4.00
Community
Guide
15
minutes
$8.00
Consultative,
Clinical and Therapeutic
15
minutes
$22.50
Day
Training through December 31, 2013
15
minutes
$2.50
Day
Training effective January 1, 2014
15
minutes
$2.20
Day
Training (Licensed Adult Day Health Center)
15
minutes
$3.00
Occupational
therapy by occupational therapist
15
minutes
$22.17
Occupational
therapy by certified occupational therapy assistant
15
minutes
$16.63
Physical
therapy by physical therapist
15
minutes
$22.17
Physical
therapy by physical therapy assistant
15
minutes
$16.63
Person
Centered Coach
15
minutes
$5.75
Personal
Assistance
15
minutes
$5.54
Positive
Behavior Support
1
positive behavior support plan
$665.00
Residential
Level I (4 to 8 residents)
24
hours
$130.35
Residential
Level I (3 or less residents)
24
hours
$172.46
Residential
-Technology Assisted
24
hours
$79.00
Residential
Level II -12 or more hours of supervision
24
hours
$141.69
Residential
Level II-fewer than 12 hours of supervision
24
hours
$79.00
Respite
15
minutes
$2.77
Speech
therapy
15
minutes
$22.17
Supported
Employment
15
minutes
$10.25
(3)
Any combination of a day training service, a community access service, personal
assistance, supported employment, and a participant’s hours of employment shall
not exceed sixteen (16) hours per day.
(4)
Community access services shall not exceed 160 units per week.
(5)
Community guide services shall not exceed 576 units per one (1) year authorized
POC period.
(6)
Community transition shall be based on prior authorized cost not to exceed
$2,000 per approved transition.
(7)
Consultative clinical and therapeutic services shall not exceed 160 units per
one (1) year authorized POC period.
(8)
Day training and supported employment alone or in combination shall not exceed
160 units per week.
(9)
Environmental accessibility shall be:
(a)
Based on a prior authorized, estimated cost; and
(b)
Limited to an $8,000 lifetime maximum.
(10)
Goods and services shall not exceed $1,800 per one (1) year authorized POC period.
(11)
Natural support training shall be based on a prior authorized, estimated cost
not to exceed $1,000 per one (1) year authorized POC period.
(12)
Person centered coaching shall not exceed 1,320 units per year.
(13)
Physical therapy and physical therapy by a physical therapy assistant shall in
combination not exceed fifty-two (52) units per month.
(14)
Occupational therapy and occupational therapy by an occupational therapy assistant
shall in combination not exceed fifty-two (52) units per month.
(15)
Respite shall be limited to 3,320 units (830 hours) per one (1) year authorized
POC period.
(16)
Shared living shall be based on a prior authorized amount not to exceed $600
per month.
(17)
Speech therapy shall not exceed fifty-two (52) units per month.
(18)
A vehicle adaptation shall be limited to $6,000 per
five (5) years per participant.
(19)
Transportation shall be reimbursed:
(a)1.
If provided as a participant directed service:
a.
Based on the mileage; and
b.
At two thirds of the rate established in 200 KAR 2:006, Section 8(2)(d), if
provided by an individual. The rate shall be adjusted quarterly in accordance
with 200 KAR 2:006, Section 8(2)(d); or
2.
If provided by a public transportation service provider, at the cost per trip
as documented by the receipt for the specific trip; and
(b)
A maximum of $265 per calendar month.
(20)
An estimate for a supply item requested under specialized medical equipment or
goods and services shall be based on the actual price to be charged to the
provider, participant, or individual by a retailer or manufacturer.
(21)
Specialized medical equipment or goods and services shall not include equipment
and supplies covered under the Kentucky Medicaid program’s state plan including:
(a)
Durable medical equipment;
(b)
Early and Periodic Screening, Diagnosis, and Treatment Services;
(c)
Orthotics and prosthetics; or
(d)
Hearing services.
(22)
A participant shall not receive multiple SCL services during the same segment
of time except in the case of the following collateral services that shall be
allowed to overlap other SCL services:
(a)
Community guide services;
(b)
Consultative clinical and therapeutic services; or
(c)
Person centered coaching.
Section
4. Exceptional Supports. (1) A service listed in subsection (2) or (3) of this
section, regardless of delivery method, shall qualify as an exceptional
support:
(a)
Based on the needs of the participant for whom the exceptional support is requested;
(b)
For a limited period of time not to exceed a full POC year;
(c)
If the service meets the requirements for an exceptional support in accordance
with the Kentucky Exceptional Supports Protocol; and
(d)
If approved by DBHDID to be an exceptional support.
(2)(a)
The following shall qualify as an exceptional support and be reimbursed at a
rate higher than the upper payment limit established in Section 3 of this
administrative regulation if meeting the criteria established in subsection (1)
of this section:
1.
Community access services;
2.
Day training that is not provided in an adult day health care center;
3.
Personal assistance;
4.
Respite;
5.
Residential Level I – three (3) or fewer residents;
6.
Residential Level I - four (4) to eight (8) residents; or
7.
Residential Level II – twelve (12) or more hours.
(b)
A rate increase for a service authorized as an exceptional support shall:
1.
Be based on the actual cost of providing the service; and
2.
Not exceed twice the upper payment limit established for the service in Section
3 of this administrative regulation.
(3)
The following shall qualify as an exceptional support and be provided in excess
of the unit limits established in Section 3 of this administrative regulation
if meeting the criteria established in subsection (1) of this section:
1.
Consultative clinical and therapeutic services;
2.
Person centered coaching;
3.
Personal assistance; or
4.
Respite.
(4)
A service that qualifies as an exceptional support shall:
(a)1.
Be authorized to be reimbursed at a rate higher than the upper payment limit
established for the service in Section 3 of this administrative regulation; or
2.
Be authorized to be provided in excess of the unit limit established for the
service in Section 3 of this administrative regulation; and
(b)
Not be authorized to be reimbursed at a higher rate than the upper payment
limit and in excess of the service limit established for the service in Section
3 of this administrative regulation.
Section
5. Allocation. A participant shall be designated an allocated amount of funding
to cover SCL waiver expenses for the participant’s POC period based on assessment
of the participant’s needs performed by DBHDID.
Section
6. Participant Directed Services. (1) A reimbursement rate for a participant
directed service shall:
(a)
Not exceed the upper payment limit established for the service in Section 3 of
this administrative regulation unless the service qualifies as an exceptional
support in accordance with Section 4(2)(a) of this administrative regulation;
and
(b)
Include:
1.
All applicable local, state, and federal withholdings; and
2.
Any applicable employment related administrative costs which shall be the
responsibility of the participant who is directing the service.
(2)
An employee who provides a participant directed service shall not be approved
to provide more than forty (40) hours of service per week unless authorized to
do so by the department.
(3)
A legally responsible individual or immediate family member shall not be
authorized to be reimbursed for more than forty (40) hours of participant
directed services per week.
Section
7. Auditing and Reporting. An SCL provider shall maintain fiscal records and
incident reports in accordance with the requirements established in 907 KAR 12:010.
Section
8. Appeal Rights. A provider may appeal a department decision regarding the
application of this administrative regulation in accordance with 907 KAR 1:671.
Section
9. Incorporation by Reference. (1) The "Kentucky Exceptional Supports
Protocol", November 2012 edition, is incorporated by reference.
(2)
This material may be inspected, copied, or obtained, subject to applicable copyright
law, at the Department for Medicaid Services, 275 East Main Street, Frankfort,
Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (39 Ky.R. 716; 1266;
1457; eff. 2-1-2013.)
