907 KAR 1:084.
Payment for medical assistance services furnished out of state.
RELATES TO: KRS
KRS 194A.030(2), 194A.050(1), 42 C.F.R. 447 Subpart B, 42 U.S.C. 1396a, b, d,
AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet
for Health Services and placed the Department for Medicaid Services and the
Medicaid Program under the Cabinet for Health and Family Services. The Cabinet
for Health and Family Services has responsibility to administer the program of
Medical Assistance. KRS 205.520(3) empowers the cabinet, by administrative
regulation, to comply with any requirement that may be imposed, or opportunity
presented, by federal law for the provision of medical assistance to Kentucky's
indigent citizenry. This administrative regulation sets forth the conditions
under which the Medicaid Program shall pay for covered medical services
furnished eligible recipients who are out of state.
Section 1. General.
Medicaid services provided to an eligible Medicaid recipient who is a resident
of Kentucky while that resident is in another state shall be reimbursed in
accordance with Section 2 of this administrative regulation.
Section 2. Criteria
for Coverage while Out of State. (1) Payment shall be made if covered medical
services are needed because of a medical emergency.
(2) Payment shall be
made if medical services are needed because the recipient's health would be
endangered if he were required to travel to Kentucky for the medical service.
With regard to long-term care patients, it shall be the policy of the cabinet
to pay for the medical services only until the time when the patient's medical
condition has stabilized so the patient return to Kentucky; it is expected that
the period of coverage shall be sixty (60) days or less; continuation of
payment shall be contingent upon presentation of medical evidence acceptable to
the cabinet which justifies an additional stay in a facility outside the state.
(3) Payment shall be
made when the state determines, on the basis of medical advice, that the needed
medical services, or necessary supplementary resources, are more readily
available in the other state; provided, however, that this provision shall not
be construed or interpreted in a manner which circumvents or negates the
provisions and intent of this administrative regulation.
(4) Payment shall be
made when it is general practice for recipients in a particular locality to use
medical resources in another state.
Section 3. Exception.
For individuals in long-term care out of state prior to the effective date of
this administrative regulation, and for whom the cabinet is at that time paying
for the cost of care, the cabinet may continue to pay for the cost of care if
the cabinet deems the payments to be appropriate. Children in subsidized
adoption or foster care status shall be exempt from the restrictions shown in
this administrative regulation.
Cooperation with other States. The cabinet shall facilitate the furnishing of
medical services to individuals who are present in Kentucky and are eligible
for Medicaid under another state's Medicaid plan. (Recodified from 904 KAR
1:084, 5-6-86; Am. Ky.R. 1632; eff. 1-10-92.)