907 KAR 3:015. Supplemental payments for
certain primary care and vaccines.
RELATES TO: KRS 205.520, 205.560
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 205.560(1), 42 U.S.C. 1395l, 42 U.S.C.
1395w-4(c)(2)(B), 42 C.F.R. 447.400, 42 C.F.R. 447.405, 42 C.F.R. 447.410, 42 C.F.R.
447.415
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) 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 policies and
requirements regarding Medicaid program supplemental payments for certain
primary care services and vaccines in accordance with Title V, Subtitle F,
Section 5501 of the Affordable Care Act (42 U.S.C. 1395l and 42 U.S.C.
1395w-4(c)(2)(B)), 42 C.F.R. 447.405, 42 C.F.R. 447.410, and 42 C.F.R. 447.415.
Section 1. Definitions. (1) "Advanced
practice registered nurse" is defined by KRS 314.011(7).
(2) "CPT code" means a code
used for reporting procedures and services performed by medical practitioners
and published annually by the American Medical Association in Current
Procedural Terminology.
(3) "Department" means the
Department for Medicaid Services or its designee.
(4) "Eligible evaluation and
management service" means a service:
(a) Which qualifies for supplemental
reimbursement in accordance with Section 3(1)(a), (b), and (c)1. of this
administrative regulation; and
(b) For which there is a corresponding paid
claim.
(5) "Eligible provider" means a
provider who qualifies for supplemental reimbursement in accordance with
Section 2 of this administrative regulation.
(6) "Eligible vaccine" means a vaccine:
(a) Which qualifies for supplemental
reimbursement in accordance with Section 3(1)(a), (b) and (c)2. of this administrative
regulation; and
(b) For which there is a corresponding paid
claim.
(7) "Federal financial participation"
is defined by 42 C.F.R. 400.203.
(8) "Managed care organization"
or "MCO" 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.
(9) "Medically necessary" or
"medical necessity" means that a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.
(10) "Medicaid program" means Kentucky’s
program of services and benefits covered by the Department for Medicaid
Services or managed care organizations.
(11) "Personal supervision"
means being professionally responsible for the services rendered by an advanced
practice registered nurse or a physician assistant.
(12) "Physician" is defined by
KRS 311.550(12).
(13) "Physician assistant" is
defined by KRS 311.840(3).
(14) "Provider" is defined by
KRS 205.8451(7).
(15) "Recipient" is defined in
KRS 205.8451(9).
Section 2. Conditions to Qualify for Supplemental
Reimbursement for Primary Care Services and Vaccines. (1) To qualify for a
supplemental payment, a provider shall:
(a) Be currently enrolled with the
Medicaid program in accordance with 907 KAR 1:672;
(b)1. Be currently participating in the
Medicaid program in accordance with 907 KAR 1:671; and
2. Comply with 907 KAR 1:671;
(c) Be a primary care physician practicing
in one (1) of the following areas:
1. Family medicine;
2. General internal medicine; or
3. Pediatric medicine; and
(d) Attest to being a primary care
physician and to one (1) of the following:
1. Currently having board certification
as a primary care physician by the:
a. American Board of Medical Specialties;
b. American Board of Physician
Specialties; or
c. American Osteopathic Association;
2. Unless a newly eligible physician or
physician without a prior billing history, having provided the following
evaluation and management services or vaccines in an amount that equals at
least sixty (60) percent of Medicaid codes billed to the Medicaid program
during the most recently completed calendar year:
a. Evaluation and management CPT codes:
(i) Within the range of 99201 through
99499; and
(ii) That are covered by the department
in accordance with 907 KAR 3:010; or
b. Vaccine codes which are covered by the
department in accordance with 907 KAR 1:680 (regardless of the age of the recipient)
or 907 KAR 3:010;
3. If a newly eligible physician, having
provided the services or vaccines referenced in subparagraph 2a or 2b of this
paragraph in an amount that equals at least sixty (60) percent of Medicaid
codes billed to the Medicaid program during the prior month; or
4. Being an eligible primary care
physician:
a. Without a billing history; and
b. For whom sixty (60) percent of total
Medicaid billings shall be of codes referenced in subparagraph 2a or 2b of this
paragraph.
(2) Services or vaccines which meet the
qualifying criteria in Section 3 of this administrative regulation and which
are provided by a physician assistant or advanced practice registered nurse working
under the personal supervision of a qualifying primary care physician shall
qualify for the supplemental reimbursement.
Section 3. Supplemental Reimbursement for
Primary Care Services and Vaccines. (1) Supplemental reimbursement shall be
made, as established in subsections (2) and (3) of this section, for providing a
service or vaccine:
(a) On a day on or after January 1, 2013
until midnight December 31, 2014:
1. To a recipient; and
2. By a:
a. Provider who qualifies for the supplemental
reimbursement pursuant to Section 2 of this administrative regulation; or
b. An APRN or a physician assistant
working under the personal supervision of a primary care physician who
qualifies for the supplemental reimbursement pursuant to Section 2 of this
administrative regulation;
(b) That is medically necessary for the
given recipient; and
(c) That is:
1. An evaluation and management service
which:
a. Corresponds to a CPT code within the
range of 99201 through 99499; and
b. Is currently covered by the department
in accordance with 907 KAR 3:010; or
2. Billed using a vaccine code which is
covered by the department in accordance with 907 KAR 1:680 (regardless of the
age of the recipient) or 907 KAR 3:010.
(2)(a) For a given quarter of paid claims
associated with eligible evaluation and management services provided by an
eligible provider to recipients who were not enrolled in a managed care organization
and for which:
1. DMS had an established rate as of July
1, 2009, the department shall make a lump sum payment that represents the
difference between:
a. The DMS established rates as of July
1, 2009 for the claims in aggregate for the quarter; and
b. What the provider would have received
for the same paid claims in aggregate for the same quarter if the provider’s
reimbursement for the claims had been the amount established in 42 C.F.R.
447.405(a); or
2. DMS did not have an established rate
as of July 1, 2009, but established a rate prior to January 1, 2013, the
department shall make a lump sum payment that represents the difference
between:
a. The DMS established rates as of
December 31, 2012 for the claims in aggregate for the quarter; and
b. What the provider would have received
for the same paid claims in aggregate for the same quarter if the provider’s
reimbursement for the claims had been the amount established in 42 C.F.R.
447.405(a).
(b) For a given quarter of paid claims
associated with eligible vaccines provided by an eligible provider to
recipients who were not enrolled in a managed care organization and for which:
1. DMS had an established rate as of July
1, 2009, the department shall make a lump sum payment that represents the
difference between:
a. The DMS established rates as of July
1, 2009 for the claims in aggregate for the quarter; and
b. What the provider would have received
for the same paid claims in aggregate for the same quarter if the provider’s
reimbursement for the claims had been the amount established in 42 C.F.R.
447.405(b); or
2. DMS did not have an established rate
as of July 1, 2009, but established a rate prior to January 1, 2013, the
department shall make a lump sum payment that represents the difference
between:
a. The DMS established rates as of
December 31, 2012 for the claims in aggregate for the quarter; and
b. What the provider would have received
for the same paid claims in aggregate for the same quarter if the provider’s
reimbursement for the claims had been the amount established in 42 C.F.R.
447.405(b).
(3)(a) For a given quarter of paid claims
associated with eligible evaluation and management services provided by all
eligible providers to recipients who were enrolled in a given managed care
organization, the:
1. Department shall send funds to the
managed care organization representing the aggregate supplemental reimbursement
amount for the paid claims; and
2. Managed care organization shall:
a. Within fifteen (15) business days of
receiving the funds referenced in subparagraph 1. of this paragraph, supplement
reimbursement to each eligible provider in an amount determined using the
methodology described in subsection (2)(a) of this section; and
b. Submit documentation to the department
demonstrating that the supplemental reimbursement referenced in subparagraph 1
of this paragraph was made to all eligible providers for the corresponding
quarter.
(b) For a given quarter of paid claims
associated with eligible vaccines provided by all eligible providers to
recipients who were enrolled in a given managed care organization, the:
1. Department shall send funds to the
managed care organization representing the aggregate supplemental reimbursement
amount for the paid claims; and
2. Managed care organization shall:
a. Within fifteen (15) business days of
receiving the funds referenced in subparagraph 1 of this paragraph, supplement
reimbursement to each eligible provider in an amount determined using the
methodology described in subsection (2)(b) of this section; and
b. Submit documentation to the department
demonstrating that the supplemental reimbursement referenced in subparagraph 1
of this paragraph was made to all eligible providers for the corresponding
quarter.
Section 4. Applicability. (1) The
policies and requirements established in this administrative regulation shall govern
supplemental payments for certain primary care services and vaccines in accordance
with Title V, Subtitle F, Section 5501 of the Affordable Care Act (42 U.S.C.
1395l and 42 U.S.C. 1395w-4(c)(2)(B)), 42 C.F.R. 447.400, 42 C.F.R. 447.405, 42
C.F.R. 447.410, and 42 C.F.R. 447.415.
(2) Any policy or requirement regarding
payments for physician or primary care services or vaccines established in any
other administrative regulation within Title 907 of the Kentucky Administrative
Regulations shall not apply to the supplemental payments referenced in subsection
(1) of this section.
Section 5. Auditing. (1) A provider shall
be subject to departmental review or audit.
(2) The department shall be authorized to
take action regarding fraud or abuse in accordance with:
(a) 907 KAR 1:671; or
(b) KRS 205.8453.
Section 6. 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. (39 Ky.R.
2284; 40 Ky.R. 19; eff. 8-2-2013.)
