907 KAR 3:015. Supplemental payments for certain primary care and vaccines

Link to law: http://www.lrc.ky.gov/kar/907/003/015.htm
Published: 2015

      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.)
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