907 KAR 9:010. Reimbursement for non-outpatient Level I and II psychiatric residential treatment facility services

Link to law: http://www.lrc.ky.gov/kar/907/009/010reg.htm
Published: 2015

Subscribe to a Global-Regulation Premium Membership Today!

Key Benefits:

Subscribe Now
CABINET FOR HEALTH AND

FAMILY SERVICES

Department for Medicaid

Services

Division of Policy and

Operations

(As Amended at ARRS,

August 11, 2015)

 

      907

KAR 9:010. Reimbursement for non-outpatient Level I and II psychiatric

residential treatment facility services.

 

      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

responsibility to administer the Medicaid Program. KRS 205.520(3) empowers the

cabinet, by administrative regulation, to comply with any requirement that may

be imposed or opportunity presented by federal law to qualify for federal

Medicaid funds. This administrative regulation establishes Medicaid

reimbursement policies for non-outpatient Level I and Level II

psychiatric residential treatment facility services provided to a Medicaid

recipient who is not enrolled in a managed care organization[and both

required and optional reimbursement policies for Level I and Level II

psychiatric residential treatment facility services provided to a Medicaid

recipient who is enrolled in a managed care organization].

 

      Section 1. Definition (1) "Department"

means the Department for Medicaid Services or its designee.

      (2) "Federal financial

participation" is defined by 42 C.F.R. 400.203.

      (3) "Level I PRTF" means a

psychiatric residential treatment facility that meets the criteria established

in KRS 216B.450(5)(a).

      (4) "Level II PRTF" means a

psychiatric residential treatment facility that meets the criteria established

in KRS 216B.450(5)(b).

      (5) "Managed care organization"

means an entity for which the department has contracted to serve as a managed

care organization as defined in 42 C.F.R. 438.2.

      (6) "Per diem rate" means a

Level I or II PRTF’s total daily reimbursement as calculated by the department.

      (7) "Recipient" is defined by

KRS 205.8451(9).

 

      Section 2. Reimbursement for Level I PRTF

Services and Costs. (1) To be reimbursable under the Medicaid Program, Level I

PRTF services and associated costs, respectively, shall be provided to or

associated[, respectively,] with a recipient receiving

Level I PRTF services in accordance with 907 KAR 9:005.

      (2) The department shall reimburse for

Level I PRTF services and costs referenced in subsection (4) of this section

for a recipient not enrolled in a managed care organization:

      (a) At the lesser of:

      1. A per diem rate of $274.01; or

      2. The usual and customary charge; and

      (b) An amount not to exceed the

prevailing charges, in the locality where the Level I PRTF is located, for

comparable services provided under comparable circumstances.

      (3) The per diem rate referenced in

subsection (2) of this section shall be increased each biennium by 2.22

percent.

      (4) The reimbursement[per

diem rate] referenced in subsection (2) of this section[,

or the usual and customary charge if less than the per diem rate,]

shall represent the total Medicaid reimbursement for Level I PRTF services and

costs:

      (a) Including all care and treatment

costs;

      (b) Including costs for all ancillary

services;

      (c) Including capital costs;

      (d) Including room and board costs; and

      (e) Excluding the costs of drugs as drugs

shall be:

      1. Covered in accordance with 907 KAR

1:019; and

      2. Reimbursed via the department’s

pharmacy program in accordance with 907 KAR 1:018.

 

      Section 3. Reimbursement for Level II

PRTF Services and Costs. (1) To be reimbursable under the Medicaid program, Level

II PRTF services and associated costs, respectively, shall be provided to or

associated[, respectively,] with a recipient receiving

Level II PRTF services in accordance with 907 KAR 9:005.

      (2) The department shall reimburse at

the lesser of the usual and customary charge or a per diem rate as

follows for Level II PRTF services and costs for a recipient not enrolled in a

managed care organization:

      (a) $345 for Level II PRTF services to a

recipient who meets the rate group one (1) criteria established in subsection

(3)(a) of this section;

      (b) $365 for Level II PRTF services to a

recipient who meets the rate group two (2) criteria established in subsection

(3)(b) of this section;

      (c) $385 for Level II PRTF services to a

recipient who meets the rate group three (3) criteria established in subsection

(3)(c) of this section; or

      (d) $405 for Level II PRTF services to a

recipient who meets the rate group four (4) criteria established in subsection

(3)(d) or (e) of this section.

      (3)(a) Rate group one (1) criteria shall

be for a recipient who:

      1. Is twelve (12) years of age or

younger; and

      2.[Is male or female; and

      3.]a. Is sexually reactive;

or

      b.(i) Has a severe and persistent

aggressive behavior;

      (ii) Does not have an intellectual or a

developmental disability; and

      (iii) Has an intelligence quotient higher

than seventy (70).

      (b) Rate group two (2) criteria shall be

for a recipient who:

      1. Is twelve (12) years of age or

younger; and

      2.[Is male or female; and

      3.]a. Is sexually reactive;

and

      b.(i) Has a severe and persistent

aggressive behavior;

      (ii) Does not have an intellectual or a

developmental disability; and

      (iii) Has an intelligence quotient higher

than seventy (70).

      (c) Rate group three (3) criteria shall

be for a recipient who:

      1. Is thirteen (13) years of age or

older; and

      2.[Is male or female; and

      3.]a. Is sexually reactive;

or

      b.(i) Has a severe and persistent

aggressive behavior;

      (ii) Does not have an intellectual or a

developmental disability; and

      (iii) Has an intelligence quotient higher

than seventy (70).

      (d) Rate group four (4) criteria shall be

for a recipient who:

      1. Is thirteen (13) years of age or

older; and

      2.[Is male or female; and

      3.]a. Is sexually reactive;

and

      b.(i) Has a severe and persistent

aggressive behavior;

      (ii) Does not have an intellectual or a

developmental disability; and

      (iii) Has an intelligence quotient higher

than seventy (70).

      (e) Rate group four (4) criteria shall be

for a recipient who:

      1. Is under twenty-two (22) years of age;

and

      2.[Is male or female; and

      3.]a. Is sexually reactive;

or

      b.(i) Has a severe and persistent

aggressive behavior;

      (ii) Has an intellectual or a

developmental disability; and

      (iii) Has an intelligence quotient lower

than seventy (70).

      (4) The per diem rates referenced in

subsection (2) of this section, or the usual and customary charge if less than

the per diem rate, shall represent the total Medicaid reimbursement for Level

II PRTF services and costs:

      (a) Including all care and treatment

costs;

      (b) Including costs for all ancillary

services;

      (c) Including capital costs;

      (d) Including room and board costs; and

      (e) Excluding the costs of drugs as drugs

shall be:

      1. Covered in accordance with 907 KAR

1:019; and

      2. Reimbursed via the department’s

pharmacy program in accordance with 907 KAR 1:018.

      (5)(a) The department shall annually

evaluate each per diem rate for Level II PRTF services and costs by reviewing

the most recent, reliable claims data and cost report data to analyze treatment

patterns, technology, and other factors that may alter the cost of efficiently

providing Level II PRTF services.

      (b) The department shall use the

evaluation, review, and analysis referenced in paragraph (a) of this subsection

to determine if an adjustment to the Level II PRTF reimbursement would be

appropriate.

 

      Section 4. Cost Reports and Audits.

(1)(a) A Level I or II PRTF shall annually submit to the department, within

ninety (90) days of the closing date of the facility’s fiscal year end, a

legible and completed Form CMS 2552-96.

      (b) The department shall grant a thirty

(30) day extension for submitting a legible and completed Form CMS 2552-96 to

the department if an extension is requested by a Level I or II PRTF.

      (2)(a) A Form CMS 2552-96 shall be

subject to review and audit by the department.

      (b) The review and audit referenced in

paragraph (a) of this subsection shall be to determine if the information

provided is accurate.

 

      Section 5. Access to Level I and II PRTF

Fiscal and Services Records. A Level I or II PRTF shall provide, upon request,

all fiscal and service records relating to services provided to a Kentucky recipient,

to the:

      (1) Department;

      (2) Cabinet for Health and Family

Services, Office of Inspector General;

      (3) Commonwealth of Kentucky, Office of

the Attorney General;

      (4) Commonwealth of Kentucky, Auditor of

Public Accounts;

      (5) Secretary of the United States

Department of Health and Human Services; or

      (6) United States Office of the Attorney

General.

 

      Section 6. Bed Reserve and Therapeutic

Pass Reimbursement. (1) The department’s reimbursement for a bed reserve day

which qualifies as a bed reserve day pursuant to 907 KAR 9:005 for a recipient

not enrolled in a managed care organization shall be:

      (a) Seventy-five (75) percent of the rate

established in Section 2 or 3 of this administrative regulation if the Level I

or II PRTF’s occupancy percent is at least eighty-five (85) percent; or

      (b) Fifty (50) percent of the rate

established in Section 2 or 3 of this administrative regulation if the Level I

or II PRTF’s occupancy percent is less than eighty-five (85) percent.

      (2) The department’s reimbursement for a

therapeutic pass day which qualifies as a therapeutic pass day pursuant to 907

KAR 9:005 for a recipient not enrolled in a managed care organization shall be:

      (a) 100 percent[%] of the

rate established in Section 2 or 3 of this administrative regulation if the

Level I or II PRTF’s occupancy percent is at least fifty (50) percent; or

      (b) Fifty (50) percent of the rate

established in Section 2 or 3 of this administrative regulation if the Level I

or II PRTF’s occupancy percent is below fifty (50) percent.

      (3)(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 7. Outpatient Services

Reimbursement Established in 907 KAR 9:020. The department’s reimbursement

provisions and requirements regarding outpatient behavioral health services provided

by a Level I or II PRTF shall be as established in 907 KAR 9:020.

 

      Section 8. Federal Financial

Participation. The department’s reimbursement for services pursuant to this

administrative regulation shall be contingent upon[A policy established

in this administrative regulation shall be null and void if the Centers for

Medicare and Medicaid Services]:

      (1) Receipt of[Denies or does

not provide] federal financial participation for the reimbursement[policy];

and[or]

      (2) Centers for Medicare and Medicaid

Services’ approval for the reimbursement[Disapproves the policy].

 

      Section 9.[8.] Appeals. A

provider may appeal a decision by the department regarding the application of

this administrative regulation in accordance with 907 KAR 1:671.

 

      Section 10.[9.] Not

Applicable to Managed Care Organizations. [(1)] A managed care

organization[may elect to reimburse for Level I or II psychiatric

residential treatment facility services in accordance with this administrative

regulation.

      (2) The reimbursement policies

established in this administrative regulation] shall not be required to

reimburse in accordance with this administrative regulation for a service

covered pursuant to:

      (1) This administrative regulation; or

      (2)[apply to a managed care

organization, except the requirement that a Level I or II PRTF service shall be

in accordance with] 907 KAR 9:005[in order to be reimbursable under the

Medicaid Program].

 

      Section 11.[10.]

Incorporation by Reference. (1) "Form CMS 2552-96", August 2010

edition, is incorporated by reference.

      (2) This material may be inspected,

copied, or obtained, subject to applicable copyright law, at the Department for

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

through Friday, 8:00 a.m. to 4:30 p.m.

 

 

LISA LEE, Commissioner

AUDREY TAYSE HAYNES, Secretary

      APPROVED BY AGENCY: April 9, 2015

      FILED WITH LRC: April 9, 2015 at 4 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.