907 KAR 1:026. Dental services’ coverage provisions and requirements

Link to law: http://www.lrc.ky.gov/kar/907/001/026reg.htm
Published: 2015

CABINET FOR HEALTH AND

FAMILY SERVICES

Department for Medicaid

Services

Division of Policy and

Operations

(Amended After Comments)

 

      907 KAR 1:026. Dental services’ coverage provisions and

requirements.

 

      RELATES TO: KRS 205.520, 205.8451, 42

U.S.C. 1396a-d

      STATUTORY AUTHORITY: KRS 194A.030(2),

194A.050(1), 205.520(3), 42 U.S.C. 1396a-d[, Pub.L. 109-171]

      NECESSITY, FUNCTION, AND

CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid

Services, has the responsibility 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[for the provision of medical assistance

to Kentucky's indigent citizenry]. This administrative regulation

establishes the Kentucky Medicaid Program provisions and requirements

regarding the coverage of[provisions relating to] dental services.

 

      Section 1. Definitions. (1)

"Comprehensive orthodontic" means a medically necessary dental

service for treatment of a dentofacial malocclusion which requires the application

of braces for correction.

      (2) "Current Dental

Terminology" or "CDT" means a publication by the American Dental

Association of codes used to report dental procedures or services.

      (3) "Debridement" means a

preliminary procedure that:

      (a) Entails the gross removal of

plaque and calculus that interfere with the ability of a dentist to perform a

comprehensive oral evaluation; and

      (b) Does not preclude the need for

further procedures[a procedure that is performed:

      (a) For removing thick or dense

deposits on the teeth which is required if tooth structures are so deeply

covered with plaque and calculus that a dentist or staff cannot check for decay,

infections, or gum disease]; and

      (c) Is separate[(b) Separately]

from a regular cleaning and is usually a preliminary or first treatment when an

individual has developed very heavy plaque or calculus.

      (4) "Department" means the

Department for Medicaid Services or its designee.

      (5) "Direct practitioner

contact" means the billing dentist or oral surgeon is physically present

with and evaluates, examines, treats, or diagnoses the recipient.

      (6) "Disabling malocclusion"

means[that a patient has] a condition that meets the criteria

established in Section 13(7) of this administrative regulation.

      (7) "Electronic signature"

is defined by KRS 369.102(8).

      (8) "Federal

financial participation" is defined in 42 C.F.R. 400.203.

      (9) "Incidental" means that

a medical procedure:

      (a) Is performed at the same time

as a primary procedure; and

      (b)1.[:

      (a)] Requires little additional

practitioner resources; or

      2.[(b)] Is clinically

integral to the performance of the primary procedure.

      (10)[(8)] "Integral"

means that a medical procedure represents a component of a more complex

procedure performed at the same time.

      (11) "Locum tenens dentist"

means a substitute dentist:

      (a) Who temporarily assumes

responsibility for the professional practice of a dentist participating in the

Kentucky Medicaid Program; and

      (b) Whose services are paid under the

participating dentist’s provider number.

      (12) "Managed

care organization" means an entity for which the Department for Medicaid

Services has contracted to serve as a managed care organization as defined in

42 C.F.R. 438.2.

      (13)[(9)] "Medically

necessary" or "medical necessity" means that a covered benefit

is determined to be needed in accordance with 907 KAR 3:130.

      (14)[(10)] "Mutually

exclusive" means that two (2) procedures:

      (a) Are not reasonably performed in

conjunction with one (1) another during the same patient encounter on

the same date of service;

      (b) Represent two (2) methods of

performing the same procedure;

      (c) Represent medically impossible or

improbable use of CDT codes; or

      (d) Are described in CDT as inappropriate

coding of procedure combinations.

      (15)[(11)] "Other

licensed medical professional" or "OLMP" means a health

care provider other than a dentist who has been approved to practice a medical specialty

by the appropriate licensure board.

      (16)[(12)] "Prepayment

review" or "PPR" means a departmental review of a claim regarding

a recipient who is not enrolled with a managed care organization to

determine if the requirements of this administrative regulation have been met

prior to authorizing payment.

      (17)[(13)] "Prior

authorization" or "PA" means approval which a provider shall

obtain from the department before being reimbursed for a covered service.

      (18)[(14)] "Provider"

is defined in KRS 205.8451(7).

      (19) "Public health hygienist"

means an individual who:

      (a) Is a dental hygienist as defined

in KRS 313.010(6);

      (b) Meets the public health hygienist

requirements established in KRS 313.040(8);

      (c) Meets the requirements for a

public health registered dental hygienist established in 201 KAR 8:562; and

      (d) Is employed by or through:

      1. The Department for Public Health;

or

      2. A governing board of health.

      (20)[(15)] "Recipient"

is defined in KRS 205.8451(9).

      (21)[(16)] "Resident"

is defined in 42 C.F.R. 415.152.

      (22)[(17)] "Timely

filing" means receipt of a claim by Medicaid:

      (a) Within twelve (12) months of the date

the service was provided;

      (b) Within twelve (12) months of the date

retroactive eligibility was established; or

      (c) Within six (6) months of the Medicare

adjudication date if the service was billed to Medicare.

 

      Section 2. Conditions of Participation.

(1) A participating provider shall:

      (a) Be licensed as a provider in

the state in which the practice is located;

      (b)[. (2) A participating

provider shall] Comply with the terms and conditions established in the

following administrative regulations:

      1.[(a)] 907 KAR 1:005;

      2.[(b)] 907 KAR 1:671; and

      3.[(c)] 907 KAR 1:672;

      (c)[.

      (3) A participating provider shall]

Comply with the requirements to maintain the confidentiality of personal

medical records pursuant to 42 U.S.C. 1320d and 45 C.F.R. Parts 160 and 164;

and

      (d) Comply with all applicable state

and federal laws.

      (2)(a)[(4)] A participating

provider shall:

      1. Have the freedom to choose

whether to accept an eligible Medicaid recipient; and

      2.[shall] Notify the

recipient of the decision prior to the delivery of service.

      (b) If the provider accepts the

recipient, the provider:

      1.[(a)] Shall bill Medicaid

rather than the recipient for a covered service;

      2.[(b)] May bill the

recipient for a service not covered by Kentucky Medicaid, if the provider

informed the recipient of noncoverage prior to providing the service; and

      3.[(c)] Shall not bill the

recipient for a service that is denied by the department for:

      a.[1.] Being:

      (i)[a.] Incidental;

      (ii)[b.] Integral; or

      (iii)[c.] Mutually

exclusive;

      b.[2.] Incorrect billing

procedures, including incorrect bundling of procedures;

      c.[3.] Failure to obtain

prior authorization for the service; or

      d.[4.] Failure to meet

timely filing requirements.

      (3)(a) In accordance with

907 KAR 17:015, Section 3(3), a provider of a service to an enrollee shall not

be required to be currently participating in the fee-for-service Medicaid Program.

      (b) A provider

of a service to an enrollee shall be enrolled in the Medicaid Program.

      (4)(a) If a provider receives any

duplicate or overpayment from the department or managed care organization,

regardless of reason, the provider shall return the payment to the department

or managed care organization.

      (b) Failure to return a payment to the

department in accordance with paragraph (a) of this subsection may be:

      1. Interpreted to be fraud or abuse;

and

      2. Prosecuted in accordance with

applicable federal or state law.

      (c) Nonduplication of payments and

third-party liability shall be in accordance with 907 KAR 1:005.

      (d) A provider shall comply with KRS

205.622.

 

      Section 3. Record Maintenance. (1)(a)

A provider shall maintain comprehensive legible medical records which

substantiate the services billed.

      (b) A dental record shall be

considered a medical record.

      (2) A medical record shall be signed on

the date of service by the:

      (a) Provider; or

      (b) Other practitioner authorized to

provide the service in accordance with:

      1. KRS 313.040; and

      2. 201 KAR 8:562[and dated to

reflect the date of service].

      (3) An X-ray shall be:

      (a) Of diagnostic quality;

and

      (b) Maintained in a manner that

identifies[shall include] the:

      1.[(a)] Recipient's name;

      2.[(b)] Service date; and

      3.[(c)] Provider's name.

      (4) A treatment regimen shall be

documented to include:

      (a) Diagnosis;

      (b) Treatment plan;

      (c) Treatment and follow-up; and

      (d) Medical necessity.

      (5) Medical records, including X-rays,

shall be maintained in accordance with 907 KAR 1:672[, Section 4(3) and (4)].

 

      Section 4. General and Certain Service

Coverage Requirements. (1) A covered service shall be:

      (a) Medically necessary; and

      (b) Except as provided in subsection (3)[(2)]

of this section, furnished to a recipient through direct practitioner contact.

      (2) Dental visits shall be limited to

twelve (12) visits per year[; and

      (c) Unless a recipient's provider

demonstrates that dental services in excess of the following service

limitations are medically necessary, limited to:

      1. Two (2) prophylaxis per twelve (12)

month period for a recipient under age twenty-one (21);

      2. One (1) dental visit per month]

per provider for a recipient who is at least[age] twenty-one (21)

years of age[and over; and

      3. One (1) prophylaxis per twelve (12)

month period for a recipient age twenty-one (21) years and over].

      (3)[(2)] A covered service

provided by an[individual who meets the definition of] other licensed

medical professional shall be covered if the:

      (a) OLMP[Individual] is

employed by the supervising oral surgeon, dentist, or dental group;

      (b) OLMP[Individual] is

licensed in the state of practice; and

      (c) Supervising provider has direct

practitioner contact with the recipient, except for a service provided by a

dental hygienist if the dental hygienist provides the service under general

supervision of a practitioner in accordance with KRS 313.040[313.310].

      (4)[(3)](a) A medical

resident may provide and the department shall cover services if provided

under the direction of a program participating teaching physician in accordance

with 42 C.F.R. 415.170, 415.172, and 415.174.

      (b) A dental resident, student, or dental

hygiene student may provide and the department shall cover services

under the direction or supervision of a program participating

provider in or affiliated with an American Dental Association accredited institution.

      (5) Services provided by a locum

tenens dentist shall be covered:

      (a) If the locum tenens dentist:

      1. Has a national provider identifier

(NPI) and provides the NPI to the department;

      2. Does not have a pending criminal or

civil investigation regarding the provision of services;

      3. Is not subject to a formal

disciplinary sanction from the Kentucky Board of Dentistry; and

      4. Is not subject to any federal or

state sanction or penalty that would bar the dentist from Medicare or Medicaid

participation; and

      (b) For no more than sixty (60)

continuous days.

      (6) Preventative services provided by

a public health hygienist shall be covered.

      (7) The department shall cover the

oral pathology procedures listed on the DMS Dental Fee Schedule if provided by

an oral pathologist who meets the condition of participation requirements established

in Section 2 of this administrative regulation.

      (8)[(4)] Coverage shall be

limited to the procedures or services:

      (a) Identified on the DMS

Dental Fee Schedule; or

      (b) Established in this administrative

regulation.

      (9) The department shall not cover a

service provided by a provider or practitioner that exceeds the scope of

services established for the provider or practitioner in:

      (a) Kentucky Revised Statutes; or

      (b) Kentucky administrative regulations[in

907 KAR 1:626, Section 3, in the following CDT categories:

      (a) Diagnostic;

      (b) Preventive;

      (c) Restorative;

      (d) Endodontics;

      (e) Periodontics;

      (f) Removable prosthodontics;

      (g) Maxillofacial prosthetics;

      (h) Oral and maxillofacial surgery;

      (i) Orthodontics; or

      (j) Adjunctive general services].

 

      Section 5. Diagnostic Service Coverage

Limitations. (1)(a) Except as provided in paragraph (b) of this subsection, coverage

for a comprehensive oral evaluation shall be limited to one (1) per twelve (12)

month period, per recipient, per provider.

      (b) The department shall cover a second

comprehensive oral evaluation if the evaluation is provided in conjunction with

a prophylaxis to an individual under twenty-one (21) years of age.

      (c) A comprehensive oral evaluation shall

not be covered in conjunction with the following:

      1. A limited oral evaluation for trauma

related injuries;

      2. A space maintainer[maintainers];

      3.[Root canal therapy;

      4.] Denture relining;

      4. A[5.] transitional appliance[appliances];

      5.[6.] A prosthodontic

service;

      6.[7.] Temporomandibular

joint therapy;

      7.[8.] An orthodontic

service;

      8.[9.] Palliative treatment;[or]

      9. An extended care facility call;

      10. A house[hospital] call;

or

      11. A hospital call.

      (2)(a) Coverage for a limited oral

evaluation shall:

      1. Be limited to a trauma related injury

or acute infection; and

      2. Be limited to one (1) per date of

service, per recipient, per provider[; and

      3. Require a prepayment review].

      (b) A limited oral evaluation shall not

be covered in conjunction with another service except for:

      1. A periapical X-ray;

      2. A bitewing X-ray[X-rays];

      3. A panoramic X-ray;

      4. Resin, anterior;

      5. A simple or surgical extraction;

      6. Surgical removal of a residual tooth

root;

      7. Removal of a foreign body;

      8. Suture of a recent small wound;

      9. Intravenous sedation; or

      10. Incision and drainage of infection.

      (3)(a) Except as provided in paragraph

(b) of this subsection, the following limitations shall apply to coverage of a

radiograph service:

      1. Bitewing X-rays shall be limited to

four (4) per twelve (12) month period, per recipient, per provider;

      2. Periapical X-rays shall be limited to

fourteen (14) per twelve (12) month period, per recipient, per provider;

      3. An intraoral complete X-ray series

shall be limited to one (1) per twenty-four (24)[twelve (12)]

month period, per recipient, per provider;

      4. Periapical and bitewing X-rays shall

not be covered in the same twelve (12) month period as an intraoral complete X-ray

series per recipient, per provider;

      5. A panoramic film shall:

      a. Be limited to one (1) per twenty-four

(24) month period, per recipient, per provider; and

      b. Require prior authorization in

accordance with Section 15(1), (2), and (3) of this

administrative regulation for a recipient under the age of six

(6) years;

      6. A cephalometric film shall be limited

to one (1) per twenty-four (24) month period, per recipient, per provider; or

      7. A cephalometric and panoramic X-ray[X-rays]

shall not be covered separately in conjunction with a comprehensive

orthodontic consultation.

      (b) The limits established in paragraph

(a) of this subsection shall not apply to:

      1. An X-ray necessary for a root canal or

oral surgical procedure; or

      2. An X-ray that:

      a. Exceeds the established service

limitations; and

      b. Is determined by the department

to be medically necessary.

 

      Section 6. Preventive Service Coverage

Limitations. (1)(a) Coverage of a prophylaxis shall be limited to:

      1. For an individual who is at least

twenty-one (21) years of age[and over], one (1) per twelve (12) month

period, per recipient; and

      2. For an individual under twenty-one

(21) years of age, one (1)[two (2)] per six (6)[twelve

(12)] month period, per recipient.

      (b) A prophylaxis shall not be covered in

conjunction with periodontal scaling or root planing.

      (2)(a) Coverage of a sealant shall be

limited to:

      1. A recipient of the age five (5)

through twenty (20) years;

      2. Each six (6) and twelve (12) year

molar once every four (4) years with a lifetime limit of three (3) sealants per

tooth, per recipient; and

      3. An occlusal surface that is noncavitated[noncarious].

      (b) A sealant shall not be covered in

conjunction with a restorative procedure for the same tooth on the same

surface on the same date of service.

      (3)(a) Coverage of a space maintainer

shall:

      1. Be limited to a recipient under the

age of twenty-one (21) years; and

      2. Require the following:

      a. Fabrication;

      b. Insertion;

      c. Follow-up visits;

      d. Adjustments; and

      e. Documentation in the recipient's

medical record to:

      (i) Substantiate the use for maintenance

of existing interdental[intertooth] space; and

      (ii) Support the diagnosis and a plan of

treatment that includes follow-up visits.

      (b) The date of service for a space

maintainer shall be considered to be the date the appliance is placed on the

recipient.

      (c) Coverage of a space maintainer, an

appliance therapy specified in the CDT orthodontic category, or a combination of

the two (2)[thereof] shall not exceed two (2) per twelve (12) month

period, per recipient.

 

      Section 7. Restorative Service Coverage

Limitations. (1) A four (4) or more surface resin-based anterior composite

procedure shall not be covered if performed for the purpose of cosmetic bonding

or veneering.

      (2) Coverage of a prefabricated crown

shall[be]:

      (a) Be limited to a recipient

under the age of twenty-one (21) years; and

      (b) Include[Inclusive of] any

procedure performed for restoration of the same tooth.

      (3) Coverage of a pin retention procedure

shall be limited to:

      (a) A permanent molar;

      (b) One (1) per tooth, per date of

service, per recipient; and

      (c) Two (2) per permanent molar, per

recipient.

      (4) Coverage of a restorative procedure

performed in conjunction with a pin retention procedure shall be limited to one

(1) of the following:

      (a) An amalgam encompassing[,]

three (3) or more surfaces;

      (b) A permanent prefabricated resin

crown; or

      (c) A prefabricated stainless steel

crown.

 

      Section 8. Endodontic Service Coverage

Limitations. (1) Coverage of the following endodontic procedures shall be

limited to a recipient under the age of twenty-one (21) years:

      (a) A pulp cap direct;

      (b) Therapeutic pulpotomy; or

      (c) Root canal therapy.

      (2) A therapeutic pulpotomy shall not be

covered if performed in conjunction with root canal therapy.

      (3)(a) Coverage of root canal therapy

shall require:

      1. Treatment of the entire tooth;

      2. Completion of the therapy; and

      3. An x-ray taken before and after

completion of the therapy.

      (b) The following root canal therapy

shall not be covered:

      1. The Sargenti method of root canal

treatment; or

      2. A root canal that does not treat

all root canals on[one (1) root of] a multi-rooted

tooth[molar].

 

      Section 9. Periodontic Service Coverage

Limitations. (1) Coverage of a gingivectomy or gingivoplasty procedure shall

require prepayment review and shall be limited to:

      (a) A recipient with gingival[gigival]

overgrowth due to a:

      1. Congenital condition;

      2. Hereditary condition; or

      3. Drug-induced condition; and

      (b) One (1) per tooth or per quadrant,

per provider, per recipient per twelve (12) month period.

      1. Coverage of a quadrant procedure shall

require a minimum of a four (4)[three (3)] tooth area within the

same quadrant.

      2. Coverage of a per-tooth procedure

shall be limited to no more than three (3)[two (2)] teeth within

the same quadrant.

      (2) Coverage of a gingivectomy or

gingivoplasty procedure shall require documentation in the recipient's medical

record that includes:

      (a) Pocket-depth measurements;

      (b) A history of nonsurgical services;

and

      (c) A prognosis.

      (3) Coverage for a periodontal scaling

and root planing procedure shall:

      (a) Not exceed one (1) per quadrant, per

twelve (12) months, per recipient, per provider;

      (b) Require prior authorization in

accordance with Section 15(1), (2), and (4) of this administrative

regulation; and

      (c) Require documentation to include:

      1. A periapical film or bitewing X-ray;[and]

      2. Periodontal charting of preoperative

pocket depths; and

      3. A photograph if applicable.

      (4)(a) Coverage of a quadrant

procedure shall require a minimum of a four (4)[three (3)] tooth

area within the same quadrant.

      (b) Coverage of a per-tooth procedure

shall be limited to no more than three (3) teeth.

      (5) Periodontal scaling and root planing

shall not be covered if performed in conjunction with dental prophylaxis.

      (6)(a) A full mouth debridement shall

only be covered for a pregnant woman.

      (b) More than[Only] one (1)

full mouth debridement per pregnancy shall not be covered.

 

      Section 10. Prosthodontic Service

Coverage Limitations. (1) A removable prosthodontic or denture repair shall be

limited to a recipient under the age of twenty-one (21) years.

      (2) A denture repair in the following

categories shall not exceed three (3) repairs per twelve (12) month period, per

recipient:

      (a) Repair resin denture base; or

      (b) Repair cast framework.

      (3) Coverage for the following services

shall not exceed one (1) per twelve (12) month period, per recipient:

      (a) Replacement of a broken tooth on a

denture;

      (b) Laboratory relining of:

      1. Maxillary dentures; or

      2. Mandibular dentures;

      (c) An interim maxillary partial denture;

or

      (d) An interim mandibular partial

denture.

      (4) An interim maxillary or mandibular

partial denture shall be limited to use:

      (a) During a transition period from a

primary dentition to a permanent dentition;

      (b) For space maintenance or space

management; or

      (c) As interceptive or preventive

orthodontics.

 

      Section 11. Maxillofacial Prosthetic

Service Coverage Limitations. The following services shall be covered if

provided by a board eligible or board certified prosthodontist:

      (1) A nasal prosthesis;

      (2) An auricular prosthesis;

      (3) A facial prosthesis;

      (4) A mandibular resection prosthesis;

      (5) A pediatric speech aid;

      (6) An adult speech aid;

      (7) A palatal augmentation prosthesis;

      (8) A palatal lift prosthesis;

      (9) An oral surgical splint; or

      (10) An unspecified maxillofacial

prosthetic.

 

      Section 12. Oral and Maxillofacial

Service Coverage Limitations. (1) The simple use of a dental elevator shall not

constitute a surgical extraction.

      (2) Root removal shall not be covered on

the same date of service as the extraction of the same tooth.

      (3) Coverage of surgical access of an

unerupted tooth shall:

      (a) Be limited to exposure of the tooth

for orthodontic treatment; and

      (b) Require prepayment review.

      (4) Coverage of alveoplasty shall:

      (a) Be limited to one (1) per quadrant,

per lifetime, per recipient; and

      (b) Require a minimum of a four (4)[three

(3)] tooth area within the same quadrant.

      (5) An occlusal orthotic device shall:

      (a) Be covered for tempormandibular joint

therapy;

      (b) Require prior authorization in

accordance with Section 15(1), (2), and (5) of this administrative

regulation;

      (c) Be limited to a recipient under the

age of twenty-one (21) years; and

      (d) Be limited to one (1) per lifetime,

per recipient.

      (6) Frenulectomy shall be limited to two

(2)[one (1)] per date of service.

      (7) Coverage shall be limited to one (1)

per lifetime, per recipient, for removal of the following:

      (a) Torus palatinus (maxillary arch);

      (b) Torus mandibularis (lower left

quadrant); or

      (c) Torus mandibularis (lower right

quadrant).

      (8)(a) A dental service that is

covered by the Kentucky Medicaid Program and provided by an oral surgeon shall

be reimbursed in accordance with 907 KAR 1:626 unless the given service is:

      1. Not reimbursed pursuant to 907 KAR 1:626;

and

      2. Reimbursed pursuant to 907 KAR 3:010.

      (b) A dental service that is covered

by the Kentucky Medicaid Program and provided by an oral surgeon but not

reimbursed pursuant to 907 KAR 1:626 shall be reimbursed in accordance with 907

KAR 3:010[Except as specified in subsection (9) of this section, a

service provided by an oral surgeon shall be covered in accordance with 907 KAR

3:005.

      (9) If performed by an oral surgeon,

coverage of a service identified in CDT shall be limited to:

      (a) Extractions;

      (b) Impactions; and

      (c) Surgical access of an unerupted

tooth].

 

      Section 13. Orthodontic Service Coverage

Limitations. (1) Coverage of an orthodontic service shall:

      (a) Be limited to a recipient under the

age of twenty-one (21) years; and

      (b) Require prior authorization except

as established in Section 15(1)(b) of this administrative regulation.

      (2) The combination of space maintainers

and appliance therapy shall be limited to two (2) per twelve (12) month period,

per recipient.

      (3) Space maintainers and appliance

therapy shall not be covered in conjunction with comprehensive orthodontics.

      (4) The department shall only cover new

orthodontic brackets or appliances.

      (5) An appliance for minor tooth guidance

shall not be covered for the control of harmful habits.

      (6) In addition to the limitations specified in

subsection (1) of this section, a comprehensive orthodontic service shall:

      (a) Require a referral by a dentist; and

      (b) Be limited to[: 1.] the

correction of a disabling malocclusion for transitional, full permanent

dentition, or[; or

      2. Transitional or full permanent

dentition unless for] treatment of a cleft palate or severe facial anomaly.

      (7) A disabling malocclusion shall:

      (a) Exist if a patient:

      1. Exhibits a severe[(a) Has a

deep impinging] overbite encompassing one (1) or more teeth in[that

shows] palatal impingement diagnosed by a lingual view of orthodontic

models (stone or digital) showing palatal soft tissue contact[the

majority of the lower incisors];

      2. Exhibits[(b) Has] a true

anterior open bite:

      a.[,] Either skeletal or

habitual in nature[,]

that if

left untreated will result in:

      (i)[a.]

The open bite persisting; or

      (ii)[b.] A

medically documented speech impediment; and

      b. That does not include:

      (i) One (1) or two (2) teeth slightly

out of occlusion; or

      (ii) Where the incisors have not fully

erupted;

      3.[does not include:

      1. One (1) or two (2) teeth slightly

out of occlusion; or

      2. Where the incisors have not fully

erupted;

      (c)] Demonstrates a significant

antero-posterior discrepancy (Class II or III malocclusion that is comparable

to at least one (1) full tooth Class II or III):

      a.[,] Dental or skeletal[)];

and

      b. If skeletal, requires a traced

cephalometric radiograph supporting significant skeletal malocclusion;

      4.[(d)] Has an anterior

crossbite that involves:

      a.[1.] More than two (2)

teeth within the same arch[in crossbite]; or

      b. A single tooth crossbite if there

is evident detrimental changes in supporting tissues including:

      (i)[2.] Obvious gingival

stripping; or

      (ii) A functional shift of the

mandible or severe dental attrition for an individual under the age of twelve

(12) years[3. Recession related to the crossbite]; or

      c. An edge to edge crossbite if there

is severe dental attrition due to a traumatic occlusion;

      5.[(e)] Demonstrates a

handicapping posterior transverse discrepancy that:

      a. May include several teeth, one

(1) of which shall be a molar; and

      b. Is handicapping in a function

fashion as follows:

      (i) Functional shift;

      (ii) Facial asymmetry; or[Involving

at least two (2) posterior teeth; and

      b. Demonstrating:

      (i) An arch collapse;

      (ii) A lateral functional shift;]

      (iii)[A skeletal

restriction; or

      (iv)] A[discrepancies which:

      1. May include several teeth, one (1)

of which shall be a molar; and

      2. Is handicapping in a function

fashion as follows:

      a. Functional shift;

      b. Facial asymmetry;

      c.] complete buccal or lingual

crossbite;

      6. Demonstrates a medically documented

speech pathology resulting from the malocclusion[or

      d. Speech concern];

      7. Demonstrates[(f) Has] a

significant posterior open bite that does not involve:

      a.[1.] Partially erupted

teeth; or

      b.[2.] One (1) or two (2)

teeth slightly out of occlusion;

      8.[(g)] Except for third

molars, demonstrates an[has] impacted tooth[teeth]

that:

      a. Will not erupt into the arch[arches]

without orthodontic or surgical intervention; and

      b.(i) Shows a documented pathology; or

      (ii) Poses a significant threat to the

integrity of the remaining dentition or to the health of the patient;

      9.[(h)] Has an extreme

overjet in excess of eight (8)[to nine (9)] millimeters and one (1) of

the skeletal conditions specified in subparagraphs 1 through 8[paragraphs

(a) through (g)] of this paragraph[subsection];

      10.[(i)] Has trauma or

injury resulting in severe misalignment of the teeth or alveolar structures[,]

and does not include simple loss of teeth with no other affects;

      11.[(j)] Has a congenital

or developmental disorder giving rise to a handicapping malocclusion; or

      12.[(k)] Has a significant

facial discrepancy requiring a combined orthodontic and orthognathic surgery

treatment approach; and

      (b) Not include:

      1. One (1) or two (2) teeth being

slightly out of occlusion;

      2. Incisors not having fully erupted;

or

      3. A bimaxillary protrusion; or

      (c) Exist if a patient[(l)]

has developmental anodontia in which several congenitally missing teeth result

in a handicapping malocclusion or arch deformation.

      (8) Coverage of comprehensive orthodontic

treatment shall not include[be inclusive of] orthognathic

surgery.

      (9) If comprehensive orthodontic

treatment is discontinued prior to completion, the provider shall submit to the

department:

      (a) Documentation of the[A]

referral referenced in subsection (6) of this section[form, if

applicable]; and

      (b) A letter detailing:

      1. Treatment provided, including dates of

service;

      2. Current treatment status of the

patient; and

      3. Charges for the treatment provided.

      (10) Remaining portions of comprehensive

orthodontic treatment may be authorized for prorated coverage upon compliance

with[submission of] the prior authorization requirements specified

in Section 15(1), (2), and (7) of this administrative regulation

if treatment:

      (a) Is transferred to another provider;

or

      (b) Began prior to Medicaid eligibility.

 

      Section 14. Adjunctive General Service

Coverage Limitations. (1)(a) Coverage of palliative treatment for dental pain

shall be limited to one (1) per date of service, per recipient, per provider.

      (b) Palliative treatment for dental pain

shall not be covered in conjunction with another service except for a

radiograph[radiographs].

      (2)[(a)] Coverage of a hospital or

ambulatory surgical center call or extended care facility call shall

be limited to one (1) per date of service, per recipient, per provider.

      (b) A hospital call, ambulatory

surgical center call, or extended care facility call shall not be covered

in conjunction with:

      1. Limited oral evaluation;

      2. Comprehensive oral evaluation; or

      3. Treatment of dental pain.

      (3)[(a) Coverage of

intravenous sedation shall be limited to a recipient under the age of

twenty-one (21) years.

      (b)] Intravenous sedation

shall not be covered for local anesthesia or nitrous oxide.

 

      Section 15. Prior Authorization. (1)(a)

The prior authorization requirements established in this administrative

regulation shall apply to services for a recipient who is not enrolled with a

managed care organization.

      (b) A managed care organization shall

not be required to apply the prior authorization requirements established in

this administrative regulation for a recipient who is enrolled with a managed

care organization.

      (c) Prior authorization shall be

required for the following:

      1.[(a)] A panoramic film

for a recipient under the age of six (6) years;

      2.[(b)] Periodontal scaling

and root planing;

      3.[(c)] An occlusal

orthotic device;

      4.[(d)] A preorthodontic

treatment visit;

      5.[(e)] Removable appliance

therapy;

      6.[(f)] Fixed appliance

therapy; or

      7.[(g)] A comprehensive

orthodontic service.

      (2) A provider shall request prior authorization

by submitting the following information to the department:

      (a) A MAP-9, Prior Authorization for

Health Services;

      (b) Additional forms or information as

specified in subsections (3) through (7) of this section; and

      (c) Additional information required to

establish medical necessity if requested by the department.

      (3) A request for prior authorization of

a panoramic film shall include a letter of medical necessity.

      (4) A request for prior authorization of

periodontal scaling and root planing shall include periodontal charting of

preoperative pocket depths.

      (5) A request for prior authorization of

an occlusal orthotic device shall include a MAP 306, Temporomandibular Joint

(TMJ) Assessment Form.

      (6) A request for prior authorization of

removable and fixed appliance therapy shall include:

      (a) A MAP 396, Kentucky Medicaid Program

Orthodontic Evaluation Form;

      (b) Panoramic film or intraoral complete

series; and

      (c) Dental models or the digital equivalent

of dental models.

      (7) A request for prior authorization for

comprehensive orthodontic services shall include:

      (a) A MAP 396, Kentucky Medicaid Program

Orthodontic Evaluation Form;

      (b) A MAP 9A, Kentucky Medicaid Program

Orthodontic Services Agreement;

      (c) A cephalometric X-ray[x-rays]

with tracing;

      (d) A panoramic X-ray;

      (e) Intraoral and extraoral facial

frontal and profile pictures;

      (f) An occluded and trimmed dental

model or the digital equivalents of a model[model];

      (g) An oral surgeon's pretreatment work

up notes if orthognathic surgery is required;

      (h) After six (6) monthly visits are

completed, but not later than twelve (12) months after the banding date of

service:

      1. A MAP 559, Six (6) Month Orthodontic

Progress Report; and

      2. An additional MAP 9, Prior

Authorization for Health Services; and

      (i) Within three (3) months following

completion of the comprehensive orthodontic treatment:

      1. Beginning and final records; and

      2. A MAP 700, Kentucky Medicaid Program

Orthodontic Final Case Submission.

      (8) Upon receipt and review of the materials

required in subsection (7)(a) through (g) of this section, the department may

request a second opinion from another provider regarding the proposed comprehensive

orthodontic treatment.

      (9) If a service that requires prior

authorization is provided before the prior authorization is received, the

provider shall assume the financial risk that the prior authorization may not

be subsequently approved.

      (10)(a) Prior authorization shall

not be a guarantee of recipient eligibility.

      (b) Eligibility verification shall

be the responsibility of the provider.

      (11) Upon review and determination by the

department that removing a prior authorization requirement shall

be in the best interest of a Medicaid recipient[recipients],

the prior authorization requirement for a specific covered benefit shall be

discontinued, at which time the covered benefit shall be available to all

recipients without prior authorization.

 

      Section 16. Use

of Electronic Signatures. (1) The creation, transmission, storage, and other

use of electronic signatures and documents shall comply with the requirements established

in KRS 369.101 to 369.120.

      (2) A dental

service provider that chooses to use electronic signatures shall:

      (a) Develop and

implement a written security policy that shall:

      1. Be adhered to

by each of the provider's employees, officers, agents, or contractors;

      2. Identify each

electronic signature for which an individual has access; and

      3. Ensure that

each electronic signature is created, transmitted, and stored in a secure

fashion;

      (b) Develop a

consent form that shall:

      1. Be completed

and executed by each individual using an electronic signature;

      2. Attest to the

signature's authenticity; and

      3. Include a

statement indicating that the individual has been notified of his or her responsibility

in allowing the use of the electronic signature; and

      (c) Provide the

department, immediately upon request, with:

      1. A copy of the

provider's electronic signature policy;

      2. The signed

consent form; and

      3. The original

filed signature.

 

      Section 17. Auditing Authority. (1)

The department or the managed care organization in which an enrollee is

enrolled shall have the authority to audit any:

      (a) Claim;

      (b) Medical record; or

      (c) Documentation associated with any

claim or medical record.

      (2) A dental record shall be

considered a medical record.

 

      Section 18. Federal

Approval and Federal Financial Participation. The coverage provisions and

requirements established in this administrative regulation shall be contingent

upon:

      (1) Receipt of federal

financial participation for the coverage; and

      (2) Centers for

Medicare and Medicaid Services’ approval of the coverage.

 

      Section 19. Appeal Rights.[(1)]

An appeal of a department decision regarding a Medicaid recipient who is:

      (1) Enrolled with a managed care

organization shall be in accordance with 907 KAR 17:010; or

      (2) Not enrolled with a managed care

organization[based upon an application of this administrative regulation]

shall be in accordance with 907 KAR 1:563.

 

      Section 20[(2) An appeal of a

department decision regarding Medicaid eligibility of an individual shall be in

accordance with 907 KAR 1:560.

      (3) An appeal of a department decision

regarding a Medicaid provider based upon an application of this administrative

regulation shall be in accordance with 907 KAR 1:671.

      Section 17]. Incorporation by

Reference. (1) The following material is incorporated by reference:

      (a) "MAP 9, Prior Authorization for

Health Services", December 1995[edition];

      (b) "MAP 9A, Kentucky Medicaid Program

Orthodontic Services Agreement", December 1995[edition];

      (c) "MAP 306, Temporomandibular

Joint (TMJ) Assessment Form", December 1995[edition];

      (d) "MAP 396, Kentucky Medicaid

Program Orthodontic Evaluation Form", March 2001[edition];

      (e) "MAP 559, Six (6) Month

Orthodontic Progress Report", December 1995[edition];[and]

      (f) "MAP 700, Kentucky Medicaid

Program Orthodontic Final Case Submission", December 1995; and

      (g) "DMS

Dental Fee Schedule", September[June]

2015[edition].

      (2) This material may be inspected,

copied, or obtained, subject to applicable copyright law:

      (a)[,] At the Department

for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday

through Friday, 8 a.m. to 4:30 p.m.; or

      (b) Online at the department’s Web site

located at http://www.chfs.ky.gov/dms/incorporated.htm.

 

LISA LEE, Commissioner

AUDREY TAYSE HAYNES, Secretary

      APPROVED BY AGENCY: September 9, 2015

      FILED WITH LRC: September 11, 2015 at 3 p.m.

      CONTACT PERSON: Tricia Orme, tricia.orme@ky.gov, Office of Legal Services, 275 East Main

Street 5 W-B, Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502)

564-7573.

 

REGULATORY IMPACT

ANALYSIS And Tiering Statement

 

Contact person: Stuart Owen

      (1) Provide a brief summary of:

      (a) What this administrative regulation

does: This administrative regulation establishes the Kentucky Medicaid Program provisions

and requirements regarding the coverage of dental services.

      (b) The necessity of this administrative regulation:

This administrative regulation is necessary to establish the Kentucky Medicaid

Program provisions and requirements regarding the coverage of dental services.

      (c) How this administrative regulation

conforms to the content of the authorizing statutes: This administrative

regulation conforms to the content of the authorizing statutes by establishing

the Kentucky Medicaid Program provisions and requirements regarding the coverage

of dental services.

      (d) How this administrative regulation

currently assists or will assist in the effective administration of the

statutes: This administrative regulation will assist in the effective

administration of the authorizing statutes by establishing the Kentucky

Medicaid Program provisions and requirements regarding the coverage of dental

services.

      (2) If this is an amendment to an

existing administrative regulation, provide a brief summary of:

      (a) How the amendment will change this

existing administrative regulation: Amendments include altering the definition

of debridement; inserting a definition of electronic signature and inserting

electronic signature usage requirements; inserting a definition of locum tenens

dentist and establishing Medicaid coverage of dental services provided by locum

tenens dentists; inserting a definition of public health hygienist and

establishing Medicaid coverage of dental services provided by public health

hygienists; inserting general program integrity and records maintenance requirements;

replacing the limit of one (1) dental visit per month to twelve (12) per year; incorporating

by reference a dental fee schedule which lists covered procedures; allowing

root canal therapy to be provided in conjunction with a comprehensive oral examination;

establishing that a comprehensive oral evaluation shall not be covered in

conjunction with an extended care facility; establishing that an intraoral

complete x-ray series shall be limited to one (1) per twenty-four (24) months

rather than per twelve (12) months; not covering a root canal on just one (1)

root of a multi-rooted tooth; requiring a quadrant procedure to span at least

four (4) teeth rather than three (3); requiring a per-tooth procedure to be

limited to no more than three (3) teeth within the same quadrant rather than

two (2);eliminating the requirement for prepayment review for a limited oral

evaluation; instead of only covering maxillofacial prosthetic services provided

by a board certified prosthodontist paying for such procedures if performed by

a board eligible prosthodontist (as well as board-certified prosthodontist); clarifying

that a medical record shall be signed on the date of service and that another

licensed medical professional can sign a medical record; clarifying that the

Kentucky Medicaid Program will cover a second periodic examination per twelve

(12) months [for those under twenty-one (21)] if the examination is provided in

conjunction with a prophylaxis; clarifying that a cephalometric and panoramic

x-ray shall not be covered separately in conjunction with a complete

orthodontic consultation; establishing that required documentation shall

include a photograph if applicable; clarifying policy regarding a disabling

malocclusion; allowing for the digital equivalent of dental models to be used

for prior authorization purposes; establishing that a dental service provided

by an oral surgeon shall be reimbursed per the Medicaid dental reimbursement

administrative regulation (907 KAR 1:626) unless there is no reimbursement for

the service per that administrative regulation - in which case it will be

reimbursed per the Medicaid physician’s reimbursement regulation (907 KAR

3:010); and additional clarifications. The amendment after comments revises the

DMS Dental Fee Schedule incorporated by reference into the administrative

regulation by adding a current dental terminology (CDT) code - D0145 - for oral

evaluation of a child under three (3) years of age along with counseling of the

primary caregiver; adds a CDT code for house/extended care facility calls

(D9410); adds a CDT code (D7471) for a procedure related to bony ridges; increases

reimbursement for a procedure [(D5620 – repair cast framework) related to

preparing for dentures] from $97.50 to $210.00; expands coverage of intravenous

sedation (on the DMS Dental Fee Schedule) to be covered for adults; revises the

prophylaxis coverage limit for individuals under twenty-one (21) two (2)

prophylaxis per recipient per twelve (12) months to one (1) per recipient per

six (6) months; revises the coverage criteria for a sealant and simultaneous

restorative procedure to allow for a sealant and simultaneous restorative

procedure on the same tooth as long as it is not on the same surface of the

tooth; revises the root canal criteria; deletes the age limit - twenty-one (21)

– for intravenous sedation; and re-inserts prior criteria regarding a disabling

malocclusion (criteria related to orthodontic procedures.)

      (b) The necessity of the amendment to

this administrative regulation: The amendment that establishes that paying for

dental services provided by oral surgeons per the dental reimbursement

regulation if the dental reimbursement regulation contains a rate for the service

(rather than the physicians’ reimbursement regulation) is necessary to ensure

consistency of payment among provider types; altering the definition of debridement

is necessary to comport with the current dental terminology (CDT) description

of debridement; authorizing the use of electronic signatures is necessary to

modernize requirements; requiring a medical record to be signed on the date of

service is necessary to strengthen program integrity; clarifying that a

licensed medical professional other than the provider may sign the medical

record is necessary to comport with Kentucky law and the Board of Dentistry

regulation establishing dental hygienist requirements (201 KAR 8:562); covering

an extra periodic examination within twelve (12) months if provided in

conjunction with a prophylaxis [for individuals under twenty-one (21)] is necessary

to conform with American Association of Pediatric Dentistry guidelines; establishing

that a comprehensive oral evaluation shall not be covered as part of an extended

care facility call is necessary as such an evaluation is appropriately performed

in a dental office with all necessary equipment available; changing the limit

of limited oral x-rays from one (1) per twelve (12) months to one (1) per

twenty-four (24) months is necessary as more frequent of such x-rays is

inappropriate and unnecessary; clarifying that a cephalometric and panoramic x-ray shall

not be covered separately in conjunction with a complete orthodontic

consultation is necessary as such a x-ray is appropriately encompassed in the

complete consultation rather than unbundled as a separate service; establishing

that required documentation shall include a photograph if applicable is necessary

for program integrity and enhancing the recipient’s medical record; the revision regarding a

disabling malocclusion is necessary to clarify policy/language; allowing for a

digital equivalent of dental models is necessary to modernize in accord with

new technology; establishing that DMS won’t cover a root canal on just one (1)

root of a multi-rooted tooth is necessary to prevent inappropriate utilization;

requiring a

quadrant procedure to span at least four (4) teeth rather than three (3) is

necessary to comport with the relevant current dental terminology (CDT) code requirements

for the procedure; requiring a per-tooth procedure to be limited to no more

than three (3) teeth within the same quadrant rather than two (2) is necessary

to comport with the relevant current dental terminology (CDT) code requirements

for the procedure; creating a locum tenens option for dentists and covering preventive

services by public health hygienists is necessary to expand/enhance the

Medicaid provide base; allowing root canal therapy to be provided in

conjunction with a comprehensive oral examination is necessary as it is appropriate

for an individual to receive the therapy at the same time as an examination and

would increase the likelihood of the recipient receiving the service rather

than asking the recipient to return on another day for the therapy; eliminating

the prepayment review requirement for a limited oral examination is necessary

as the exams are necessary in the circumstance and prepayment review would be

an unnecessary burden; and

other amendments or clarifications are necessary to reflect current practice.

Adding the CDT code for oral evaluation of a child under the age of three (3)

years along with counseling of the primary caregiver is necessary to enhance

oral health care for children. Adding the CDT code for house/extended care

facility calls to the fee schedule is necessary as the administrative regulation

establishes that DMS covers the services but the corresponding CDT code was not

included on the fee schedule. Adding the CDT code related to bony ridges dental

work is necessary as the procedure is an appropriate medically necessary

procedure. Increasing the rate for repair cast framework is necessary as the

prior rate was less than half of the costs experienced by dentists in performing

the service. Expanding intravenous sedation to be covered for adults is appropriate

and fiscally responsible as DMS currently covers a much more expensive option –

general anesthesia for dental procedures in a hospital. Expanding intravenous

sedation to be covered for adults will enable adults to be sedated in dental

offices and receive dental treatment rather than have such treatment performed

in a hospital. Revising the prophylaxis limit for individuals under twenty-one

(21) from two (2) per twelve (12) months to one (1) per six (6) months is

necessary to address a problem of mobile dental vans performing such services

at schools within six (6) months which also precludes the child’s primary

dentist from providing such care to the child at least once a year. Revising

the coverage restriction for a sealant and simultaneous restorative procedure

is necessary as it would be appropriate to have a simultaneous restorative

procedure on the same tooth but not on the same surface of the tooth. Revising

the root canal criteria is necessary to ensure that the entire tooth is treated

as a result of the procedure. Deleting the age limit for intravenous sedation

is necessary as this is an appropriate covered service for adults and DMS

currently covers a more expensive option – general anesthesia provided in a

hospital for dental work. Re-inserting prior criteria regarding a disabling

malocclusion is being done in response to public comments for clarity.

      (c) How the amendment conforms to the

content of the authorizing statutes: The amendments conform to the content of

the authorizing statutes by clarifying policies, accommodating the use of new

technology, enhancing program integrity, adopting policies consistent with the

industry standards, and by adopting policies appropriate for eliminating

unnecessary utilization of services.

      (d) How the amendment will assist in the

effective administration of the statutes: The amendments will assist in the

effective administration of the authorizing statutes by clarifying policies,

accommodating the use of new technology, enhancing program integrity, adopting

policies consistent with the industry standards, and by adopting policies appropriate

for eliminating unnecessary utilization of services.

      (3) List the type and number of

individuals, businesses, organizations, or state and local government affected

by this administrative regulation: Medicaid-participating dental service

providers will be affected by the amendments. Currently, there are 1,078 individual

dentists, 158 group dental practices, sixty-nine (69) individual physicians who

perform oral surgery, and nine (9) group physician practices that perform oral

surgery enrolled in Kentucky’s Medicaid program.

      (4) Provide an analysis of how the

entities identified in question (3) will be impacted by either the

implementation of this administrative regulation, if new, or by the change, if

it is an amendment, including:

      (a) List the actions that each of the

regulated entities identified in question (3) will have to take to comply with

this administrative regulation or amendment. Dental providers will need to

ensure that they provide services within the limits established in the

administrative regulation if they wish to be reimbursed for services.

      (b) In complying with this administrative

regulation or amendment, how much will it cost each of the entities identified

in question (3). The amendment imposes no cost on the regulated entities.

      (c) As a result of compliance, what

benefits will accrue to the entities identified in question (3). Dental providers will

benefit from the Medicaid provisions comporting with current dental terminology

(CDT) guidelines and from modernizing coverage to include coverage of the

digital equivalent of dental models. Oral pathologists will benefit from DMS

expanding coverage to include oral pathology services/procedures. Recipients

will benefit from root canal therapy being covered in conjunction with an oral

examination rather than the recipient having to reappear at the dental office

on another day to receive the therapy.

      (5) Provide an estimate of how much it

will cost to implement this administrative regulation:

      (a) Initially: The Department for

Medicaid Services (DMS) anticipates no additional costs as a result of the

amendments.

      (b) On a continuing basis: DMS

anticipates no additional costs as a result of the amendments.

      (6) What is the source of the funding to

be used for the implementation and enforcement of this administrative

regulation: The sources of revenue to be used for implementation and

enforcement of this administrative regulation are federal funds authorized

under the Social Security Act, Title XIX and matching funds of general fund

appropriations.

      (7) Provide an assessment of whether an

increase in fees or funding will be necessary to implement this administrative

regulation, if new, or by the change if it is an amendment. Neither an increase

in fees nor funding is necessary to implement the amendment to this administrative

regulation.

      (8) State whether or not this

administrative regulation establishes any fees or directly or indirectly

increases any fees: This administrative regulation neither establishes nor increases

any fees.

      (9) Tiering: Is tiering applied? Tiering

is not applied as the provisions apply equally to the regulated entities.

 

FEDERAL MANDATE ANALYSIS

COMPARISON

 

      1. Federal statute or regulation

constituting the federal mandate. 42 U.S.C. 1396d(r)(3)

      2. State compliance standards. KRS

194A.050(1) states, "The secretary shall promulgate, administer, and

enforce those administrative regulations necessary to implement programs

mandated by federal law, or to qualify for the receipt of federal funds and

necessary to cooperate with other state and federal agencies for the proper

administration of the cabinet and its programs." KRS 205.520(3) states: "...

it is the policy of the Commonwealth to take advantage of all federal funds

that may be available for medical assistance. To qualify for federal funds the

secretary for health and family services may by regulation comply with any

requirement that may be imposed or opportunity that may be presented by federal

law. Nothing in KRS 205.510 to 205.630 is intended to limit the secretary's

power in this respect."

      3. Minimum or uniform standards contained

in the federal mandate. Coverage of dental services is not mandated on Medicaid

programs except through the early and periodic screening, diagnosis and treatment

(EPSDT) program for individuals under age twenty-one (21.)

      4. Will this administrative regulation

impose stricter requirements, or additional or different responsibilities or

requirements, than those required by the federal mandate? The administrative

regulation does not impose stricter than federal requirements.

      5. Justification for the imposition of

the stricter standard, or additional or different responsibilities or

requirements. The administrative regulation does not impose stricter than

federal requirements.

 

FISCAL NOTE ON STATE OR

LOCAL GOVERNMENT

 

      1. What units, parts or divisions of

state or local government (including cities, counties, fire departments, or

school districts) will be impacted by this administrative regulation? The

Department for Medicaid Services will be affected by the amendment to this

administrative regulation.

      2. Identify each state or federal statute

or federal regulation that requires or authorizes the action taken by the

administrative regulation. KRS 194A.050(1), 205.520(3), 42 U.S.C. 1396d(r)(3).

      3. Estimate the effect of this

administrative regulation on the expenditures and revenues of a state or local

government agency (including cities, counties, fire departments, or school

districts) for the first full year the administrative regulation is to be in

effect.

      (a) How much revenue will this

administrative regulation generate for the state or local government (including

cities, counties, fire departments, or school districts) for the first year? The

amendment is not expected to generate revenue for state or local government.

      (b) How much revenue will this

administrative regulation generate for the state or local government (including

cities, counties, fire departments, or school districts) for subsequent years?

The amendment is not expected to generate revenue for state or local government.

      (c) How much will it cost to administer

this program for the first year? The Department for Medicaid Services

anticipates no additional costs as a result of the amendments.

      (d) How much will it cost to administer

this program for subsequent years? The Department for Medicaid Services

anticipates no additional costs as a result of the amendments.

      Note: If specific dollar estimates cannot

be determined, provide a brief narrative to explain the fiscal impact of the

administrative regulation.

      Revenues (+/-):

      Expenditures (+/-):

      Other Explanation:
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