907 KAR 8:015. Independent occupational 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
occupational therapy services provided by an independent occupational therapist,
or an occupational therapy assistant working under the direct supervision of an
independent occupational therapist, to Medicaid recipients who are not enrolled
with a managed care organization.
Section 1. General Requirements. For the
department to reimburse for an occupational therapy service under this
administrative regulation, the:
(1) Occupational therapist shall meet the
provider requirements established in 907 KAR 8:010; and
(2) Service shall meet the coverage and
related requirements established in 907 KAR 8:010.
Section 2. Reimbursement. (1) The department
shall reimburse for an occupational therapy service provided by an:
(a) Occupational therapist, in accordance
with 907 KAR 8:010 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) Occupational therapy assistant
working for an occupational therapist, in accordance with 907 KAR 8:010 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 an occupational
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 8:010; 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. 2043; 2547; 2766; eff. 7-7-2014.)