900
KAR 6:130. Certificate of Need criteria for physician exemption.
RELATES
TO: KRS 216B.010, 216B.015, 216B.020, 216B.040, 216B.095, 216B.990
STATUTORY
AUTHORITY: KRS 194A.030, 194A.050, 216B.040(2)(a)1
NECESSITY,
FUNCTION, AND CONFORMITY: KRS 216B.040(2)(a)1 requires the Cabinet for Health
and Family Services to administer Kentucky's Certificate of Need Program and to
promulgate administrative regulations as necessary for the program. This
administrative regulation establishes the requirements for physician exemption
criteria necessary for the orderly administration of the Certificate of Need
Program.
Section
1. Definitions. (1) "Ambulatory surgical center" is defined by KRS
216B.015(4).
(2)
"Entity" means any legally recognized business entity in which an
individual or group may practice its profession including a professional
limited liability company, professional service corporation, partnership, or
sole proprietor.
(3)
"Evaluation and Management codes" means those codes recognized by the
American Medical Association as procedures involving evaluation of patients and
management of patient care in the Current Procedure Terminology© references.
(4)
"Office" or "clinic" means the physical location at which
health care services are provided by a physician, dentist, advanced practice
registered nurse, licensed clinical social worker, speech therapist,
occupational therapist, physical therapist, psychologist, or other practitioner
of the healing arts.
(5)
"Owner" means a person as defined in KRS 216B.015(21) who is applying
for the Certificate of Need and will become the licensee of the proposed health
service or facility.
(6)
"Practice" means the individual, entity, or group that proposes to
provide health care services and shall include the owners and operators of an
office or clinic.
(7)
"Practitioner of the healing arts" means a person licensed by the
appropriate state agency to practice a healing art as defined in KRS
311.271(2)(a).
(8)
"Primarily" means a simple majority or something that occurs at least
fifty-one (51) percent of the time.
(9)
"Qualified academic medical center" means:
(a)
An institution of higher education which operates an accredited medical school
within the Commonwealth of Kentucky;
(b)
An institution, organization, or other entity which directly or indirectly owns
or is under common control or ownership with an accredited medical school
operated within the Commonwealth of Kentucky; or
(c)
An individual, organization, entity, or other person which is qualified under
Section 501(c)(3) of the Internal Revenue Code (26 U.S.C. 501(c)(3)) as a
result of supporting or operating in support of an institution, organization,
entity, or other person referenced in paragraph (a) or (b) of this subsection.
Section
2. Physician non-exemption due to operation of an ambulatory surgical center.
An office or clinic that is operating an ambulatory surgical center pursuant to
KRS 216B.095(7) shall not be exempt from the Certificate of Need requirements.
Section
3. Physician exemption from Certificate of Need. (1) An office or clinic that
would otherwise be required to obtain a Certificate of Need shall be exempt
from Certificate of Need pursuant to KRS 216B.020(2) if:
(a)
The practice claiming the exemption is 100 percent owned in an organizational
form recognized by the Commonwealth as one (1) in which the listed professions
can be practiced by the individual physician, dentist, advanced practice
registered nurse, licensed clinical social worker, speech therapist,
occupational therapist, physical therapist, psychologist, or other practitioner
of the healing arts or group of physicians, dentists, or advanced practice
registered nurses, licensed clinical social workers, speech therapists, occupational
therapists, physical therapists, psychologists, or other practitioners of the
healing arts (hereinafter collectively referred to as "physician")
claiming the exemption;
(b)
The practice claiming the exemption primarily provides physician services
(e.g., evaluation and management codes) rather than services or equipment
covered by the State Health Plan;
(c)
Services or equipment covered by the State Health Plan which are offered or
provided at the office or clinic shall be primarily provided to patients whose
medical conditions are being treated or managed by the practice;
(d)
A physician or physicians licensed to practice and practicing in Kentucky
within the practice and claiming the exemption are responsible for all
decisions regarding the care and treatment provided to patients;
(e)
Patients are treated on an outpatient basis and are not maintained overnight on
the premises of the office or clinic;
(f)
Services or equipment covered by the State Health Plan that are offered or
provided at the office or clinic are related to the professional services
offered to patients of the practice claiming the exemption;
(g)
Major medical equipment in excess of the limits set forth in 900 KAR 6:030 is
not being utilized without a Certificate of Need or other statutory or
regulatory exemption; and
(h)
Nothing in this section shall limit or prohibit the
continued operation of an office or clinic that was established and in
operation prior to January 31, 2006, and operating pursuant to and in accordance
with the following:
1.
Provisions of a Certificate of Need advisory opinion issued by the Office of
Health Policy specifically with respect to that office or clinic;
2.
Provisions of an Attorney General opinion issued specifically with respect to
that office or clinic; or
3.
An order issued with respect to that office or clinic by a court of competent
jurisdiction in the Commonwealth of Kentucky.
(2)
A practice owned entirely by a radiologist or group of radiologists shall
demonstrate the following:
(a)
Compliance with subsection (1)(a), (d), (e), and (f) of this section;
(b)
The radiologists shall regularly perform physician services (e.g., test
interpretations) at the location where the diagnostic tests are performed,
including interpretations by or through teleradiology; and
(c)
The billing patterns of the practice indicate that the practice is not
primarily a testing facility and that it was organized to provide the
professional services of radiology.
(3)
An office or clinic owned and operated by a Qualified Academic Medical Center
shall demonstrate the following:
(a)
The physician or physicians providing care and treatment to the patients of the
office or clinic shall be licensed to practice in Kentucky and shall be
employed by the Qualified Academic Medical Center; and
(b)1.
The office was established and in operation prior to January 31, 2006;
2.
The office does not provide any services or equipment covered by the State
Health Plan; or
3.
At the time the office began providing care and treatment to patients, it was
not located in a county designated as a Metropolitan Statistical Area as
defined by the U.S. Office of Management and Budget, and there is a documented
agreement of support or collaboration between the Qualified Academic Medical
Center and each existing hospital in the county in which the office is located.
(39 Ky.R. 365; 811; 985; eff. 11-9-2012.)