CABINET
FOR HEALTH AND FAMILY SERVICES
Department for Medicaid
Services
Division of Policy and
Operations
(Amended After Comments)
907 KAR 1:046. Community mental health center primary care
services.
RELATES TO: KRS 205.520, 210.410.
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 205.6313, 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 Program’s[Services’] coverage
provisions and requirements regarding primary care services provided in a
community mental health center to Medicaid recipients.
Section 1. Definitions. (1) "Advanced
practice registered nurse" is defined by KRS 314.011(7).
(2) "Community mental health center"
or "CMHC" means a facility which meets the community mental health
center requirements established in 902 KAR 20:091.
(3) "Department" means the
Department for Medicaid Services or its designee.
(4) "Enrollee" means a
recipient who is enrolled with a managed care organization.
(5) "Federal financial participation"
is defined by 42 C.F.R. 400.203.
(6) "Injectable
drug" means an injectable, infused, or inhaled drug or biological that:
(a) Is not excluded
as a non-covered immunization or vaccine;
(b) Requires
special handling, storage, shipping, dosing, or administration; and
(c) Is a rebatable
drug.
(7) "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.
(8) "Medically necessary" means
that a covered benefit is determined to be needed in accordance with 907 KAR
3:130.
(9) "Physician assistant" is
defined by KRS 311.840(3).
(10)
"Rebatable drug" means a drug for which the drug’s manufacturer has
entered into or complied with a rebate agreement in accordance with 42 U.S.C.
1396r-8(a).
(11) "Recipient" is defined by
KRS 205.8451(9).
Section 2. General Requirements. (1) For the
department to reimburse for a primary care service provided by a community
mental health center under this administrative regulation, the:
(a) CMHC shall be currently:
1. Enrolled in the Medicaid Program in
accordance with 907 KAR 1:672;
2. Participating in the Medicaid Program
in accordance with 907 KAR 1:671; and
3. Licensed in accordance with 902 KAR
20:091; and
(b) Service shall:
1. Be medically necessary;
2. Meet the coverage and related requirements
established in this administrative regulation; and
3. Be provided by:
a. A physician;
b. An advanced practice registered nurse;
or
c. A physician assistant.
(2) In accordance with 907 KAR 17:015,
Section 3(3), a CMHC which provides a service to an enrollee shall not be
required to be currently participating in the fee-for-service Medicaid Program.
(3) A CMHC shall:
(a) Agree to provide services in compliance
with federal and state laws regardless of age, sex, race, creed, religion,
national origin, handicap, or disability; and
(b) Comply with the Americans with Disabilities
Act (42 U.S.C. 12101 et seq.) and any amendments to the Act.
Section 3. Covered Services. The physical
health services covered pursuant to 907 KAR 3:005 shall be covered:
(1) Under this administrative regulation;
and
(2) In accordance with the requirements
established in 907 KAR 3:005 except that primary care services provided in a
community mental health center shall only be provided by:
(a) A physician;
(b) An advanced practice registered
nurse; or
(c) A physician assistant.
Section 4. Service Limitations. The limitations
established in 907 KAR 3:005 for physical health services shall apply to
primary care services provided in a CMHC under this administrative regulation.
Section 5. Prior Authorization
Requirements. The prior authorization requirements
established in 907 KAR 3:005 for physical
health services shall apply to services provided in a CMHC under this
administrative regulation.
Section 6. Injectable Drugs. An injectable drug
listed on the Physician Injectable Drug List that is administered in a CMHC
shall be covered.
Section 7. No Duplication of Service. (1)
The department shall not reimburse for a primary care service provided to a
recipient by more than one (1) provider of any program in which primary care
services are covered during the same time period.
(2) For example, if a recipient is receiving
a primary care service from a rural health clinic enrolled with the Medicaid
Program, the department shall not reimburse for the same primary care service
provided to the same recipient during the same time period by a community
mental health center.
Section 8. Records Maintenance, Protection,
and Security. (1) A provider shall maintain a current health record for each
recipient.
(2) A health record shall document each
service provided to the recipient including the date of the service and the
signature of the individual who provided the service.
(3) The individual who provided the
service shall date and sign the health record on the date that the individual
provided the service.
(4)(a) Except as established in paragraph
(b) of this subsection, a provider shall maintain a health record regarding a
recipient for at least five (5) years from the date of the service or until any
audit dispute or issue is resolved beyond five (5) years.
(b) If the secretary of the United States
Department of Health and Human Services requires a longer document retention
period than the period referenced in paragraph (a) of this subsection, pursuant
to 42 C.F.R. 431.17, the period established by the secretary shall be the
required period.
(5) A provider shall comply with 45
C.F.R. Part 164.
Section 9. Medicaid Program Participation
Compliance. (1) A provider shall comply with:
(a) 907 KAR 1:671;
(b) 907 KAR 1:672; and
(c) All applicable state and federal
laws.
(2)(a) If a provider receives any
duplicate payment or overpayment from the department or a managed care
organization, regardless of reason, the provider shall return the
payment to the department or managed care organization in accordance with
907 KAR 1:671.
(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.
Section 10. Third Party Liability. A
provider shall comply with KRS 205.622.
Section 11. 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 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 12. Auditing Authority. The department
or managed care organization in which an enrollee is enrolled shall
have the authority to audit any:
(1) Claim;
(2) Health;[, medical]
record;[,] or
(3) Documentation
associated with any claim or health[medical] record.
Section 13. Federal Approval and Federal
Financial Participation. The
department’s coverage of services pursuant to 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 for the coverage.
Section 14. Appeal Rights. (1) An appeal
of an adverse action by the department regarding a service and a recipient who
is not enrolled with a managed care organization shall be in accordance with
907 KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with 907 KAR 17:010.
Section 15. Incorporation by Reference. (1)
The "Physician Injectable Drug List", February 21, 2014, is
incorporated by reference.
(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,
Monday through Friday, 8:00 a.m. to 4:30 p.m.; or
(b) Online at the department’s Web site at http://www.chfs.ky.gov/dms/incorporated.htm.907
KAR 1:046
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.
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
coverage provisions and requirements regarding community mental health center
(CMHC) primary care services covered by the Medicaid Program. Key requirements
include that the authorized primary care practitioners are physicians,
physician assistants, and advanced practice registered nurses; that any
physical health service or limit established for Medicaid-program physician’s
services (pursuant to 907 KAR 3:005) shall also apply primary care services
provided in CMHCs; and that the prior authorization requirements established in
907 KAR 3:005 shall also apply to CMHC primary care services.
(b) The necessity
of this administrative regulation: This administrative regulation is necessary
to establish the coverage provisions and requirements regarding CMHC primary
care services covered by the Medicaid Program as authorized by KRS 205.6313.
(c) How this
administrative regulation conforms to the content of the authorizing statutes:
This administrative regulation conforms to the content of the authorizing
statutes (including KRS 205.6313) by establishing the coverage provisions and
requirements regarding CMHC primary care services covered by the Medicaid Program.
(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 (including KRS 205.6313)
by establishing the coverage provisions and requirements regarding CMHC primary
care services covered by the Medicaid Program.
(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: The amendment
after comments inserts a missing word; clarifies that if a provider receives a
duplicate payment from a managed care organization (MCO) the provider is
required to return the overpayment to the MCO; clarifies that MCOs have
auditing rights to health records of Medicaid recipients enrolled with them;
and replaces the term "medical record" with "health record"
in a couple of places to ensure consistency.
(b) The necessity
of the amendment to this administrative regulation: The
amendment after comments is necessary for clarity.
(c) How the
amendment conforms to the content of the authorizing statutes: The
amendment after comments conforms to the content of the authorizing statutes by
adding clarity.
(d) How the
amendment will assist in the effective administration of the statutes: The
amendment after comments will assist in the effective administration of the
authorizing statutes by adding clarity.
(3) List the type
and number of individuals, businesses, organizations, or state and local
government affected by this administrative regulation: Community mental health
centers will be affected by this amendment as will Medicaid recipients who
receive services from CMHCs. There are fourteen (14) such centers.
(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. CMHCs that
wish to provide primary care services to Medicaid recipients will have to do so
according to the requirements such as having staff authorized to provide such
services (physicians, advanced practice registered nurses, or physician
assistants.)
(b) In complying
with this administrative regulation or amendment, how much will it cost each of
the entities identified in question (3). No additional cost is anticipated.
(c) As a result of
compliance, what benefits will accrue to the entities identified in question
(3). CMHCs that wish to provide primary care services to
Medicaid recipients will benefit by being enabled to receive reimbursement for
such services.
(5) Provide an
estimate of how much it will cost to implement this administrative regulation:
(a) Initially: Due
to the uncertainty of how many CMHCs will elect to expand their scope of
services to include primary care services and to the uncertainty of when such
CMHCs will meet the associated licensure requirements established by the Office
of Inspector General, DMS is unable to project a cost associated with this
action.
(b) On a continuing
basis: The response to (a) above also applies here.
(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
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 policies apply equally to the regulated
entities.
FEDERAL
MANDATE ANALYSIS COMPARISON
1. Federal statute
or regulation constituting the federal mandate. There is no federal mandate
that community mental health centers provide primary care services.
2. State compliance standards. KRS 205.6313
requires the Medicaid Program to reimburse for primary care services provided
by a licensed physician, advanced practice registered nurse, or physician
assistant employed by a community mental health center.
3. Minimum or
uniform standards contained in the federal mandate. There is no federal mandate
that community mental health centers provide primary care services.
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 (DMS) will be affected by the amendment.
2. Identify each state or federal statute
or federal regulation that requires or authorizes the action taken by the
administrative regulation. KRS 194A.030(2), 194A.050(1), 205.520(3), and KRS 205.6313.
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?
DMS does not anticipate additional revenues for state or local government as a
result of the amendment.
(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 response to question (a) also applies here.
(c) How much will
it cost to administer this program for the first year? Due to the uncertainty
of how many CMHCs will elect to expand their scope of services to include
primary care services and to the uncertainty of when such CMHCs will meet the
associated licensure requirements established by the Office of Inspector
General, DMS is unable to project a cost associated with this action.
(d) How much will
it cost to administer this program for subsequent years? The response in (c)
above also applies here.
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:
