907 KAR 8:025. Physical therapy service reimbursement

provisions and requirements.

 

      RELATES TO: KRS 205.520

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

194A.050(1), 205.520(3), 42 C.F.R. 440.130, 42 U.S.C. 1396d(a)(13)(C)

      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 the Department for

Medicaid Services’ reimbursement provisions and requirements regarding physical

therapy services provided by an independent physical therapist, or physical therapist

assistant working under the direct supervision of an independent physical

therapist, to Medicaid recipients who are not enrolled with a managed care

organization.

 

      Section 1. General Requirements. For the

department to reimburse for physical therapy under this administrative

regulation, the:

      (1) Physical therapist shall meet the

provider requirements established in 907 KAR 8:020; and

      (2) Physical therapy shall meet the

coverage and related requirements established in 907 KAR 8:020.

 

      Section 2. Reimbursement. (1) The

department shall reimburse for a physical therapy service provided by a:

      (a) Physical therapist, in accordance

with 907 KAR 8:020 and this section, at 63.75 percent of the rate for the service

listed on the current Kentucky-specific Medicare Physician Fee Schedule; or

      (b) Physical therapist assistant working

for a physical therapist, in accordance with 907 KAR 8:020 and this section, at

37.5 percent of the rate for the service listed on the current Kentucky-specific

Medicare Physician Fee Schedule.

      (2)(a) The current Kentucky-specific

Medicare Physician Fee Schedule shall be the Kentucky-specific Medicare

Physician Fee Schedule used by the Centers for Medicare and Medicaid Services

on the date that the service is provided.

      (b) For example, if a physical therapy

service is provided on a date when the Centers for Medicare and Medicaid Services’:

      1. Interim Kentucky-specific Medicare

Physician Fee Schedule for a given year is in effect, the reimbursement for the

service shall be the amount established on the interim Kentucky-specific

Medicare Physician Fee Schedule for the year; or

      2. Final Kentucky-specific Medicare

Physician Fee Schedule for a given year is in effect, the reimbursement for the

service shall be the amount established on the final Kentucky-specific Medicare

Physician Fee Schedule for the year.

 

      Section 3. Not Applicable to Managed Care

Organizations. A managed care organization shall not be required to reimburse

in accordance with this administrative regulation for a service covered

pursuant to:

      (1) 907 KAR 8:020; and

      (2) This administrative regulation.

 

      Section 4. Federal Approval and Federal

Financial Participation. The

department’s reimbursement for services pursuant to this administrative

regulation shall be contingent upon:

      (1) Receipt of federal financial

participation for the reimbursement; and

      (2) Centers for Medicare and Medicaid Services’

approval for the reimbursement.

 

      Section 5. Appeal Rights. A provider may

appeal an action by the department as established in 907 KAR 1:671. (40 Ky.R. 2048; 2550; 2768; eff. 7-7-2014.)