907 KAR 9:005. Level I and II psychiatric residential
treatment facility service and coverage policies.
RELATES TO: KRS 205.520, 216B.450,
216B.455, 216B.459
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 42 C.F.R. 440.160, 42 U.S.C. 1396a-d
NECESSITY, FUNCTION, AND CONFORMITY: The
Cabinet for Health and Family Services, Department for Medicaid Services, has a
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. This administrative regulation establishes Medicaid program
coverage policies regarding Level I and Level II psychiatric residential treatment
facility services.
Section 1. Definitions. (1) "Active
treatment" means a covered Level I or II psychiatric residential treatment
facility service provided:
(a) In accordance with an individual plan
of care as specified in 42 C.F.R. 441.154; and
(b) By an individual employed or
contracted by a Level I or II PRTF including a:
1. Qualified mental health personnel;
2. Qualified mental health professional;
3. Mental health associate; or
4. Direct care staff person.
(2) "Acute care hospital" is
defined by KRS 205.639(1).
(3) "Behavioral health
professional" means:
(a) A psychiatrist;
(b) A physician licensed in Kentucky to
practice medicine or osteopathy, or a medical officer of the government of the
United States while engaged in the practice of official duties;
(c) A psychologist licensed and
practicing in accordance with KRS 319.050;
(d) A certified psychologist with
autonomous functioning or licensed psychological practitioner certified and
practicing in accordance with KRS 319.056;
(e) A clinical social worker licensed and
practicing in accordance with KRS 335.100;
(f) An advanced practice registered nurse
licensed and practicing in accordance with KRS 314.042;
(g) A marriage and family therapist
licensed and practicing in accordance with KRS 335.300;
(h) A licensed professional clinical
counselor licensed and practicing in accordance with KRS 335.500;
(i) A professional art therapist
certified and practicing in accordance with KRS 309.130; or
(j) An alcohol and drug counselor certified
and practicing in accordance with KRS 309.080 to 309.089.
(4) "Behavioral health professional
under clinical supervision" means:
(a) A psychologist certified and
practicing in accordance with KRS 319.056;
(b) A licensed psychological associate
licensed and practicing in accordance with KRS 319.064;
(c) A marriage and family therapist
associate permitted and practicing in accordance with KRS 335.300;
(d) A social worker certified and
practicing in accordance with KRS 335.080; or
(e) A licensed professional counselor
associate licensed and practicing in accordance with KRS 335.500.
(5) "Child with a severe emotional
disability" is defined by KRS 200.503(2).
(6)"Department" means the
Department for Medicaid Services or its designee.
(7) "Diagnostic and assessment
services" means at least one (1) face-to-face specialty evaluation or
specialty evaluation performed via telemedicine of a recipient’s medical,
social, and psychiatric status provided by a physician or qualified mental
health professional that shall:
(a) Include:
1. Interviewing and evaluating; or
2. Testing;
(b) Be documented and record all contact
with the recipient and other interviewed individuals; and
(c) Result in a:
1. Medical data code in accordance with
45 C.F.R. 162.1000; and
2. Specific treatment recommendation.
(8) "Federal financial
participation" is defined by 42 C.F.R. 400.203.
(9) "Intensive treatment
services" means a program:
(a) For a child:
1. With a severe emotional disability;
and
a.
An intellectual disability;
b. A severe and persistent aggressive
behavior;
c. Sexually acting out behavior; or
d. A developmental disability;
2. Who requires a treatment-oriented
residential environment; and
3. Between the ages of four (4) to
twenty-one (21) years; and
(b) That provides psychiatric and
behavioral health services two (2) or more times per week to a child referenced
in paragraph (a) of this subsection:
1. As indicated by the child’s
psychiatric and behavioral health needs; and
2. In accordance with the child’s
therapeutic plan of care.
(10) "Interdisciplinary team"
means:
(a) For a recipient who is under the age
of eighteen (18) years:
1. A parent, legal guardian, or caregiver
of the recipient;
2. The recipient;
3. A qualified mental health professional;
and
4. A staff person, if available, who
worked with the recipient during the recipient’s most recent placement if the
recipient has previously been in a Level I or II PRTF; or
(b) For a recipient who is eighteen (18)
years of age or older:
1. The recipient;
2. A qualified mental health
professional; and
3. A staff person, if available, who
worked with the recipient during the recipient’s most recent placement if the
recipient has previously been in a Level I or II PRTF.
(11) "Level I PRTF" means a psychiatric
residential treatment facility that meets the criteria established in KRS
216B.450(5)(a).
(12) "Level II PRTF" means a
psychiatric residential treatment facility that meets the criteria established
in KRS 216B.450(5)(b).
(13) "Medicaid payment status"
means a circumstance in which:
(a) The person:
1. Is eligible for and receiving Medicaid
benefits; and
2. Meets patient status criteria for
Level I or II psychiatric residential treatment facility services; and
(b) The facility is billing the Medicaid
program for services provided to the person.
(14) "Medically necessary" or
"medical necessity" means that a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.
(15) "Mental health associate" means:
(a)1. An individual with a minimum of a
bachelor's degree in a mental health related field;
2. A registered nurse; or
3. A licensed practical nurse with at
least one (1) year's experience in a psychiatric inpatient or residential
treatment setting for children; or
(b) An individual with:
1. A high school diploma or an
equivalence certificate; and
2. At least two (2) years work experience
in a psychiatric inpatient or residential treatment setting for children.
(16) "Physician" is defined by
KRS 311.550(12).
(17) "Private psychiatric
hospital" is defined by KRS 205.639(2).
(18) "Psychiatric residential
treatment facility" or "PRTF" is defined by KRS 216B.450(5).
(19) "Psychiatric services"
means:
(a) An initial psychiatric evaluation of
a recipient which shall include:
1. A review of the recipient’s:
a. Personal history;
b. Family history;
c. Physical health;
d. Prior treatment; and
e. Current treatment;
2. A mental status examination
appropriate to the age of the recipient;
3. A meeting with the family or any designated
significant person in the recipient’s life; and
4. Ordering and reviewing:
a. Laboratory data;
b. Psychological testing results; or
c. Any other ancillary health or mental
health examinations;
(b) Development of an initial plan of
treatment which shall include:
1. Prescribing and monitoring of
psychotropic medications; or
2. Providing and directing therapy to the
recipient;
(c) Implementing, assessing, monitoring,
or revising the treatment as appropriate to the recipient’s psychiatric status;
(d) Providing a subsequent psychiatric
evaluation as appropriate to the recipient’s psychiatric status;
(e) Consulting, if determined to be
necessary by the psychiatrist responsible for providing or overseeing the
recipient’s psychiatric services, with another physician, an attorney, police, regarding
the recipient’s care and treatment; or
(f) Ensuring that the psychiatrist
responsible for providing or overseeing the recipient’s psychiatric services
has access to the information referenced in paragraph (e) of this subsection.
(20) "Qualified mental health
personnel" is defined by KRS 216B.450(6).
(21) "Qualified mental health
professional" is defined by KRS 216B.450(7).
(22) "Review agency" means for
a review, evaluation, or authorization decision regarding an individual who is:
(a) Not enrolled with a managed care
organization:
1. The department; or
2. An entity under contract with the
department; or
(b) Enrolled with a managed care
organization:
1. The managed care organization with
which the enrollee is enrolled; or
2. An entity under contract with the
managed care organization with which the enrollee is enrolled.
(23) "State mental hospital" is defined by
KRS 205.639(3).
(24) "Telemedicine" means two-way,
real time interactive communication between a patient and a physician or
practitioner located at a distant site for the purpose of improving a patient’s
health through the use of interactive telecommunications equipment that
includes, at a minimum, audio and video equipment.
(25) "Treatment plan" means a plan
created for the care and treatment of a recipient that:
(a) Is developed in a face-to-face
meeting by the recipient’s interdisciplinary team;
(b) Describes a comprehensive,
coordinated plan of medically necessary behavioral health services that
specifies a modality, frequency, intensity, and duration of services sufficient
to maintain the recipient in a PRTF setting; and
(c) Identifies:
1. A program of therapies, activities,
interventions, or experiences designed to accomplish the plan;
2. A qualified mental health
professional, a mental health associate, or qualified mental health personnel
who shall manage the continuity of care;
3. Interventions by caregivers in the
PRTF and school setting that support the recipient’s ability to be maintained
in a PRTF setting;
4. Behavioral, social, and physical
problems with interventions and objective, measurable goals;
5. Discharge criteria that specifies the:
a. Recipient-specific behavioral
indicators for discharge from the service;
b. Expected service level that would be
required upon discharge; and
c. Identification of the intended
provider to deliver services upon discharge;
6. A crisis action plan that progresses
through a continuum of care that is designed to reduce or eliminate the
necessity of inpatient services;
7. A plan for:
a. Transition to a lower intensity of
services; and
b. Discharge from PRTF services;
8. An individual behavior management
plan;
9. A plan for the involvement and
visitation of the recipient with the birth family, guardian, or other
significant person, unless prohibited by a court, including therapeutic
off-site visits pursuant to the treatment plan; and
10. Services and planning, beginning at
admission, to facilitate the discharge of the recipient to an identified plan
for home-based services or a lower level of care.
Section 2. Provider Participation. (1)(a)
In order to participate, or continue to participate, in the Kentucky Medicaid
Program, a Level I PRTF shall:
1. Have a utilization review plan for
each recipient consisting of, at a minimum, a pre-admission certification
review submitted via telephone or electronically to the review agency prior to
admission of the recipient;
2. Perform and place in each recipient’s
record:
a. A medical evaluation;
b. A social evaluation; and
c. A psychiatric evaluation;
3. Establish a plan of care for each
recipient which shall be placed in the recipient’s record;
4. Appoint a utilization review committee
which shall:
a. Oversee and implement the utilization
review plan; and
b. Evaluate each Medicaid admission and
continued stay prior to the expiration of the Medicaid certification period to
determine if the admission or stay is or remains medically necessary;
5. Comply with staffing requirements
established in 902 KAR 20:320;
6. Be located in the Commonwealth of
Kentucky;
7. Maintain accreditation by the Joint
Commission on Accreditation of Health Care Organizations or the Council on
Accreditation of Services for Families and Children or any other accrediting
body with comparable standards that is recognized by the state; and
8. Comply with all conditions of Medicaid
provider participation established in 907 KAR 1:671 and 907 KAR 1:672.
(b) In order to participate, or continue
to participate, in the Kentucky Medicaid Program, a Level II PRTF shall:
1. Have a utilization review plan for
each recipient;
2. Establish a utilization review process
which shall evaluate each Medicaid admission and continued stay prior to the
expiration of the Medicaid certification period to determine if the admission
or stay is or remains medically necessary;
3. Comply with staffing requirements
established in 902 KAR 20:320;
4. Be located in the Commonwealth of
Kentucky;
5. Maintain accreditation by the Joint
Commission on Accreditation of Health Care Organizations or the Council on
Accreditation of Services for Families and Children or any other accrediting
body with comparable standards that is recognized by the state;
6. Comply with all conditions of Medicaid
provider participation established in 907 KAR 1:671 and 907 KAR 1:672;
7. Perform and place in each recipient’s
record a:
a. Medical evaluation;
b. Social evaluation; and
c. Psychiatric evaluation; and
8. Establish a plan of care for each
recipient which shall:
a. Address in detail the intensive
treatment services to be provided to the recipient; and
b. Be placed in the recipient’s record.
(2)(a) A pre-admission certification
review for a Level I PRTF shall:
1. Contain:
a. The recipient’s valid Medicaid
identification number;
b. A valid MAP-569, Certification of Need
by Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21) which satisfies the
requirements of 42 C.F.R. 44.152 and 42 C.F.R. 441.153 for patients age
twenty-one (21) and under;
c. A DMS-IV R diagnosis on all five (5)
axes, except that failure to record an axis IV or V diagnosis shall be used as
the basis for a denial only if those diagnoses are critical to establish the
need for Level I PRTF treatment;
d. A description of the initial treatment
plan relating to the admitting symptoms;
e. Current symptoms requiring inpatient
treatment;
f. Information to support the medical
necessity and clinical appropriateness of the services or benefits of the
admission to a Level I PRTF in accordance with 907 KAR 3:130;
g. Medication history;
h. Prior hospitalization;
i. Prior alternative treatment;
j. Appropriate medical, social, and
family histories; and
k. Proposed aftercare placement;
2. Remain in effect for the days
certified by the review agency; and
3. Be completed within thirty (30) days.
(b) A pre-admission certification review
for a Level II PRTF for a non-emergent admission shall:
1. Contain:
a. The recipient’s valid Medicaid
identification number;
b. A valid MAP-569, Certification of Need
by Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21) which satisfies the
requirements of 42 C.F.R. 44.152 and 42 C.F.R. 441.153 for patients age
twenty-one (21) and under;
c. A DSM-IV-R diagnosis on all five (5)
axes, except that failure to record an axis IV or V diagnosis shall be used as
the basis for a denial only if those diagnoses are critical to establish the
need for Level II PRTF treatment;
d. A description of the initial treatment
plan relating to the admitting symptoms;
e. Current symptoms requiring inpatient
treatment;
f. Information to support the medical
necessity and clinical appropriateness of the services or benefits of the
admission to a Level II PRTF in accordance with 907 KAR 3:130;
g. Medication history;
h. Prior hospitalization;
i. Prior alternative treatment;
j. Appropriate medical, social, and
family histories; and
k. Proposed aftercare placement;
2. Remain in effect for the days
certified by the review agency; and
3. Be completed within thirty (30) days.
(3) Failure to admit a recipient within
the recipient’s certification period shall require a new pre-admission certification
review request.
(4) A utilization review plan for an
emergency admission to a Level II PRTF shall contain:
(a) A completed MAP-570, Medicaid
Certification of Need for Inpatient Psychiatric Services for Individuals Under
Age Twenty-One (21):
1. Completed by the facility’s
interdisciplinary team; and
2. Placed in the recipient’s medical
record;
(b) Documentation, provided by telephone
or electronically to the review agency within two (2) days of the recipient’s
emergency admission, justifying:
1. The recipient’s emergency admission;
2. That ambulatory care resources in the
recipient’s community and placement in a Level I PRTF do not meet the
recipient’s needs;
3. That proper treatment of the
recipient’s psychiatric condition requires services provided by a Level II PRTF
under the direction of a physician; and
4. That the services can reasonably be
expected to improve the recipient’s condition or prevent further regression so
that the services are no longer needed;
(c) The recipient’s valid Medicaid
identification number;
(d) A valid MAP-569, Certification of
Need by Independent Team Psychiatric Preadmission Review of Elective Admissions
for Kentucky Medicaid Recipients Under Age Twenty-One (21) which satisfies the
requirements of 42 C.F.R. 441.152 and 42 C.F.R. 441.153 for recipients age
twenty-one (21) and under;
(e) A DMS-IV-R diagnosis on all five (5)
axes, except that failure to record an axis IV or V diagnosis shall be used as
the basis for a denial only if those diagnoses are critical to establish the
need for Level II PRTF treatment;
(f)1. A description of the initial
treatment plan relating to the admitting symptom; and
2. As part of the initial treatment plan,
a full description of the intensive treatment services to be provided to the
recipient;
(g) Current symptoms requiring
residential treatment;
(h) Medication history;
(i) Prior hospitalization;
(j) Prior alternative treatment;
(k) Appropriate medical, social, and
family histories; and
(l) Proposed aftercare placement.
(5) For an individual who becomes
Medicaid eligible after admission, a Level I or II PRTF's interdisciplinary
team shall complete a MAP-570, Medicaid Certification of Need for Inpatient
Psychiatric Services for Individuals Under Age Twenty-One (21), and the form
shall be placed in the recipient's medical record.
(6) For a recipient, a Level I or II PRTF
shall maintain medical records that shall:
(a) Be:
1. Current;
2. Readily retrievable;
3. Organized;
4. Complete; and
5. Legible;
(b) Reflect sound medical recordkeeping
practice in accordance with:
1. 902 KAR 20:320;
2. KRS 194A.060;
3. KRS 434.840 through 860;
4. KRS 422.317; and
5. 42 C.F.R. 431 Subpart F;
(c) Document the need for admission and
appropriate utilization of services;
(d) Be maintained, including information
regarding payments claimed, for a minimum of six (6) years or until an audit
dispute or issue is resolved, whichever is longer; and
(e) Be made available for inspection or
copying or provided to the following upon request:
1. A representative of the United States
Department for Health and Human Services or its designee;
2. The United States Office of the
Attorney General or its designee;
3. The Commonwealth of Kentucky, Office
of the Attorney General or its designee;
4. The Commonwealth of Kentucky, Office
of the Auditor of Public Accounts or its designee;
5. The Commonwealth of Kentucky, Cabinet
for Health and Family Services, Office of the Inspector General or its
designee;
6. The department; or
7. A managed care organization with whom
the department has contracted if the recipient is enrolled with the managed
care organization.
Section 3. Covered Admissions. (1) A
covered admission for a Level I PRTF:
(a) Shall be prior authorized by a review
agency; and
(b)1.Shall be limited to those for a
child age six (6) through twenty (20) years of age who meets Medicaid payment
status criteria; or
2. May continue based on medical
necessity, for a recipient who is receiving active treatment in a Level I PRTF
on the recipient’s twenty-first (21st) birthday if the recipient has not
reached his or her twenty-second (22nd) birthday.
(2) A covered admission for a Level II
PRFT shall be:
(a) Prior authorized;
(b) Limited to those for a child:
1.a. Age four (4) through twenty-one (21)
years who meets Medicaid payment status criteria; and
b. Whose coverage may continue, based on
medical necessity, if the recipient is receiving active treatment in a Level II
PRTF on the recipient’s twenty-first (21st) birthday and the recipient has not
reached his or her twenty-second (22nd) birthday;
2. With a severe emotional disability in
addition to severe and persistent aggressive behaviors, an intellectual
disability, sexually acting out behaviors, or a developmental disability; and
3.a. Who does not meet the medical
necessity criteria for an acute care hospital, private psychiatric hospital, or
state mental hospital; and
b. Whose treatment needs cannot be met in
an ambulatory care setting, Level I PRTF, or in any other less restrictive environment;
and
(c) Reimbursed pursuant to 907 KAR 9:010.
Section 4. PRTF Covered Services. (1)(a)
There shall be a treatment plan developed for each recipient.
(b) A treatment plan shall specify:
1. The amount and frequency of services
needed; and
2. The number of therapeutic pass days
for a recipient, if the treatment plan includes any therapeutic pass days.
(2) To be covered by the department:
(a) The following services shall be available
to a recipient covered under Section 3 of this administrative regulation and shall
meet the requirements established in paragraph (b) of this subsection:
1. Diagnostic and assessment services;
2. Treatment plan development, review, or
revision;
3. Psychiatric services;
4. Nursing services which shall be provided
in compliance with 902 KAR 20:320;
5. Medication which shall be provided in
compliance with 907 KAR 1:019;
6. Evidence-based treatment
interventions;
7. Individual therapy which shall comply
with 902 KAR 20:320;
8. Family therapy or attempted contact
with family which shall comply with 902 KAR 20:320;
9. Group therapy which shall comply with
902 KAR 20:320;
10. Individual and group interventions
that shall focus on additional and harmful use or abuse issues and relapse
prevention if indicated;
11. Substance abuse education;
12. Activities that:
a. Support the development of an
age-appropriate daily living skill including positive behavior management or
support; or
b. Support and encourage the parent’s
ability to re-integrate the child into the home;
13. Crisis intervention which shall
comply with:
a. 42 C.F.R. 483.350 through 376; and
b. 902 KAR 20:320;
14. Consultation with other professionals
including case managers, primary care professionals, community support workers,
school staff, or others;
15. Educational activities; or
16. Non-medical transportation services
as needed to accomplish objectives;
(b) A Level I PRTF service listed in
paragraph (a) of this subsection shall be:
1. Provided under the direction of a
physician;
2. If included in the recipient’s
treatment plan, described in the recipient’s current treatment plan;
3. Medically necessary; and
4. Clinically appropriate pursuant to the
criteria established in 907 KAR 3:130;
(c) A Level I PRTF service listed in
subparagraph (a)7, 8, 9, 11, or 13 shall be provided by a qualified mental
health professional, behavioral health professional, or behavioral health
professional under clinical supervision; or
(d) A Level II PRTF service listed in
paragraph (a) of this subsection shall be:
1. Provided under the direction of a
physician;
2. If included in the recipient’s
treatment plan, described in the recipient’s current treatment plan;
3. Provided at least once a week:
a. Unless the service is necessary twice
a week, in which case the service shall be provided at least twice a week; or
b. Except for diagnostic and assessment
services which shall have no weekly minimum requirement;
4. Medically necessary; and
5. Clinically appropriate pursuant to the
criteria established in 907 KAR 3:130.
(3) A Level II PRTF service listed in
subparagraph (a)7, 8, 9, 11, or 13 shall be provided by a qualified mental
health professional, behavioral health professional, or behavioral health
professional under clinical supervision.
Section 5. Determining Patient Status.
(1) The department shall review and evaluate the health status and care needs
of a recipient in need of Level I or II PRTF care using the criteria identified
in 907 KAR 3:130 to determine if a service or benefit is clinically appropriate.
(2) The care needs of a recipient shall
meet the patient status criteria for:
(a) Level I PRTF care if the recipient
requires:
1. Long term inpatient psychiatric care
or crisis stabilization more suitably provided in a PRTF than in a psychiatric
hospital; and
2. Level I PRTF services on a continuous
basis as a result of a severe mental or psychiatric illness, including a severe
emotional disturbance; or
(b) Level II PRTF care if the recipient:
1. Is a child with a severe emotional
disability;
2. Requires long term inpatient
psychiatric care or crisis stabilization more suitably provided in a PRTF than
a psychiatric hospital;
3. Requires Level II PRTF services on a
continuous basis as a result of a severe emotional disability in addition to a severe
and persistent aggressive behavior, an intellectual disability, a sexually
acting out behavior, or a developmental disability; and
4. Does not meet the medical necessity
criteria for an acute care hospital or a psychiatric hospital and has treatment
needs which cannot be met in an ambulatory care setting, Level I PRTF, or other
less restrictive environment.
Section 6. Durational Limit,
Re-evaluation, and Continued Stay. (1) A recipient’s stay, including the
duration of the stay, in a Level I or II PRTF shall be subject to the
department’s approval.
(2)(a) A recipient in a Level I PRTF
shall be re-evaluated at least once every thirty (30) days to determine if the
recipient continues to meet Level I PRTF patient status criteria established in
Section 5(2) of this administrative regulation.
(b) A Level I PRTF shall complete a
review of each recipient’s treatment plan at least once every thirty (30) days.
(c) The review referenced in paragraph
(b) of this subsection shall include:
1. Dated signatures of:
a. Appropriate staff; and
b. If present for the treatment plan
meeting, a parent,
guardian, legal custodian, or conservator;
2. An assessment of progress toward each
treatment plan goal and objective with revisions indicated; and
3. A statement of justification for the
level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
(d) If a recipient no longer meets Level
I PRTF patient status criteria, the department shall only reimburse through the
last day of the individual’s current approved stay.
(e) The re-evaluation referenced in
paragraph (a) of this subsection shall be performed by a review agency.
(3) A Level II PRTF shall complete by no
later than the third (3rd) business day following an admission, an initial
review of services and treatment provided to a recipient which shall include:
(a) Dated signatures of appropriate
staff, parent, guardian, legal custodian, or conservator;
(b) An assessment of progress toward each
treatment plan goal and objective with revisions indicated; and
(c) A statement of justification for the
level of services needed including:
1. Suitability for treatment in a
less-restrictive environment; and
2. Continued services.
(4)(a) For a recipient aged four (4) to
five (5) years, a Level II PRTF shall complete a review of the recipient’s
treatment plan of care at least once every fourteen (14) days after the initial
review referenced in subsection (3) of this section.
(b)The review referenced in paragraph (a)
of this subsection shall include:
1. Dated signatures of appropriate staff,
parent, guardian, legal custodian, or conservator;
2. An assessment of progress toward each
treatment plan goal and objective with
revisions indicated; and
3. A statement of justification for the
level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
(5)(a) For a recipient aged six (6) to
twenty-two (22) years, a Level II PRTF shall complete a review of the
recipient’s treatment plan of care at least once every thirty (30) days after
the initial review referenced in subsection (3) of this section.
(b) The review referenced in paragraph
(a) of this subsection shall include:
1. Dated signatures of appropriate staff,
parent, guardian, legal custodian, or conservator;
2. An assessment of progress toward each
treatment plan goal and objective with revisions indicated; and
3. A statement of justification for the
level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
Section 7. Exclusions and Limitations in
Coverage. (1) The following shall not be covered as Level I or II PRTF
services:
(a)1. Chemical dependency treatment
services if the need for the services is the primary diagnosis of the
recipient, except chemical dependency treatment services shall be covered as
incidental treatment if minimal chemical dependency treatment is necessary for
successful treatment of the primary diagnosis;
(b) Outpatient services;
(c) Pharmacy services, which shall be
covered in accordance with 907 KAR 1:019;
(d) Durable medical equipment, which
shall be covered in accordance with 907 KAR 1:479;
(e) Hospital emergency room services, which
shall be covered in accordance with 907 KAR 10:014;
(f) Acute care hospital inpatient
services, which shall be covered in accordance with 907 KAR 10:012;
(g) Laboratory and radiology services,
which shall be covered in accordance with 907 KAR 10:014 or 907 KAR 1:028;
(h) Dental services, which shall be
covered in accordance with 907 KAR 1:026;
(i) Hearing and vision services, which
shall be covered in accordance with 907 KAR 1:038; or
(j) Ambulance services, which shall be
covered in accordance with 907 KAR 1:060.
(2) A Level I or II PRTF shall not charge
a recipient or responsible party representing a recipient any difference
between private and semiprivate room charges.
(3) The department shall not reimburse
for Level I or II PRTF services for a recipient if appropriate alternative
services are available for the recipient in the community.
(4) The following shall not qualify as
reimbursable in a PRTF setting:
(a) An admission that is not medically
necessary;
(b) Services for an individual:
1. With a major medical problem or minor
symptoms;
2. Who might only require a psychiatric
consultation rather than an admission to a PRTF; or
3. Who might need only adequate living
accommodations, economic aid, or social support services.
Section 8. Reserved Bed and Therapeutic
Pass Days. (1)(a) The department shall cover a bed reserve day for an acute
hospital admission, a state mental hospital admission, a private psychiatric
hospital admission, or an admission to a psychiatric bed in an acute care hospital
for a recipient’s absence from a Level I or II PRTF if the recipient:
1. Is in Medicaid payment status in a
Level I or II PRTF;
2. Has been in the Level I or II PRTF
overnight for at least one (1) night;
3. Is reasonably expected to return
requiring Level I or II PRTF care; and
4.a. Has not exceeded the bed reserve day
limit established in paragraph (b) of this subsection; or
b. Received an exception to the limit in
accordance with paragraph (c) of this subsection.
(b) The annual bed reserve day limit per
recipient shall be five (5) days per calendar year in aggregate for any
combination of bed reserve days associated with an acute care hospital
admission, a state mental hospital admission, a private psychiatric hospital
admission, or an admission to a psychiatric bed in an acute care hospital.
(c) The department shall allow a
recipient to exceed the limit established in paragraph (b) of this subsection,
if the department determines that an additional bed reserve day is in the best
interest of the recipient.
(2)(a) The department shall cover a
therapeutic pass day for a recipient’s absence from a Level I or II PRTF if the
recipient:
1. Is in Medicaid payment status in a Level I
or II PRTF;
2. Has been in the Level I or II PRTF overnight
for at least one (1) night;
3. Is reasonably expected to return requiring
Level I or II PRTF care; and
4.a. Has not exceeded the therapeutic pass day
limit established in paragraph (b) of this subsection; or
b. Received an exception to the limit in
accordance with paragraph (c) of this subsection.
(b) The annual therapeutic pass day limit
per recipient shall be fourteen (14) days per calendar year.
(c) The department shall allow a recipient
to exceed the limit established in paragraph (b) of this subsection, if the
department determines that an additional therapeutic pass day is in the best
interest of the recipient.
(3)(a) The bed reserve day and
therapeutic pass day count for each recipient shall be zero (0) upon the
effective date of this administrative regulation.
(b) For subsequent calendar years, the
bed reserve day and therapeutic pass day count for each recipient shall begin
at zero (0) on January 1 of the calendar year.
(4) An authorization decision regarding a
bed reserve day or therapeutic pass day in excess of the limits established in
this section shall be performed by a review agency.
(5)(a) An acute care hospital bed reserve
day shall be a day when a recipient is temporarily absent from a Level I or II
PRTF due to an admission to an acute care hospital.
(b) A state mental hospital bed reserve
day, private psychiatric hospital bed reserve day, or psychiatric bed in an
acute care hospital bed reserve day, respectively, shall be a day when a
recipient is temporarily absent from a Level I or II PRTF due to receiving
psychiatric treatment in a state mental hospital, private psychiatric hospital,
or psychiatric bed in an acute care hospital respectively.
(c) A therapeutic pass day shall be a day
when a recipient is temporarily absent from a Level I or II PRTF for a
therapeutic purpose that is:
1. Stated in the recipient’s treatment
plan; and
2. Approved by the recipient’s treatment
team.
(6)(a) A Level I or II PRTF’s occupancy
percent shall be based on a midnight census.
(b) An absence from a Level I or II PRTF that
is due to a bed reserve day for an acute hospital admission, a state mental
hospital admission, a private psychiatric hospital admission, or an admission
to a psychiatric bed in an acute care hospital shall count as an absence for census
purposes.
(c) An absence from a Level I or II PRTF
that is due to a therapeutic pass day shall not count as an absence for census
purposes.
Section 9. Federal Financial
Participation. A policy established in this administrative regulation shall be
null and void if the Centers for Medicare and Medicaid Services:
(1) Denies or does not provide federal
financial participation for the policy; or
(2) Disapproves the policy.
Section 10. Appeal Rights. (1) An appeal
of a negative action regarding a Medicaid beneficiary shall be in accordance
with 907 KAR 1:563.
(2) An appeal of a negative action
regarding Medicaid eligibility of an individual shall be in accordance with 907
KAR 1:560.
(3) An appeal of a negative action
regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.
Section 11. Incorporation by Reference.
(1) The following material is incorporated by reference:
(a) "MAP-569, Certification of Need
by Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21)", revised 5/90; and
(b) "MAP-570, Medicaid Certification
of Need for Inpatient Psychiatric Services for Individuals Under Age Twenty-one
(21)", revised 5/90.
(2) This material may be inspected,
copied, or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, Cabinet for Health and Family Services, 275 East Main
Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m.
(18 Ky.R. 600; eff. 10-6-91; Am. 19 Ky.R. 2340; eff. 6-16-93; 22 Ky.R. 1906;
eff. 6-6-96; 27 Ky.R. 2910; 3267; eff. 6-8-2001; T. Am.; eff. 5-3-11;
Recodified from 907 KAR 1:505; eff. 3-20-2012; TAm eff. 3-20-12; 39 Ky.R. 629;
1218; 1413; eff. 3-8-2013.)
