907 KAR 4:020. Kentucky Children’s Health

Insurance Program Medicaid Expansion Title XXI of the Social Security Act.

 

      RELATES TO: KRS 205.510-205.645,

205.6481-205.6497, 42 C.F.R. 432, 433, 435, 436, 457, 42 U.S.C. 1397aa-jj

      STATUTORY AUTHORITY: KRS 194A.030(2),

194A.050(1), 205.520(3) 205.6485, 42 U.S.C. 1397aa-jj, EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO

2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services

and placed the Department for Medicaid Services and the Medicaid Program under

the Cabinet for Health and Family Services. KRS 194A.030(2) requires the

Cabinet for Health and Family Services, Department for Medicaid Services, to

administer Title XIX of the Federal Social Security Act, 42 U.S.C. 1396 to

1396v. KRS 194A.050(1) requires the secretary of the cabinet to promulgate

administrative regulations necessary to protect, develop, and maintain the

health, personal dignity, integrity, and sufficiency of the individual citizens

of the Commonwealth; to operate the programs and fulfill the responsibilities

vested in the cabinet; and to implement programs mandated by federal law or to

qualify for the receipt of federal funds. KRS 205.6485 authorizes the cabinet

to establish the Kentucky Children’s Health Insurance Program (KCHIP) to provide

health care coverage and other coordinated health care services to children of

the Commonwealth who are uninsured and otherwise not eligible for health

insurance coverage. This administrative regulation establishes the KCHIP

eligibility criteria, covered services, application requirements, grievance and

appeal rights for recipients, and the requirements for providers who wish to

participate with the Commonwealth to provide health care coverage to KCHIP

members through an expansion of the Title XIX Medicaid Program.

 

      Section 1. Definitions. (1)

"Cabinet" means the Kentucky Cabinet for Health and Family Services

or its designee.

      (2) "Child" means an individual

under age nineteen (19).

      (3) "Creditable coverage" is

defined in KRS 304.17A-005(7)(a)1-3 and 5-10.

      (4) "Department" means the

Department for Medicaid Services or its designee.

      (5) "Excepted benefits" is

defined in KRS 304.17A-005(11).

      (6) "Health insurance" is

defined in KRS 304.5-040.

      (7) "KCHIP" means the Kentucky

Children’s Health Insurance Program administered in accordance with 42 U.S.C.

1397aa to jj.

 

      Section 2. Eligibility Criteria. (1) A

child shall be eligible for KCHIP if the child:

      (a) Meets the technical and income

requirements of 907 KAR 1:011, Section 2(3)(h) and meets the following requirements:

      1. Provides to the department the

information required in Section 4 of this administrative regulation;

      2. Meets the continuing eligibility

requirement established in 907 KAR 1:605, Section 3;

      3. Meets the relative responsibility

requirements of 907 KAR 1:660; and

      4. Is not eligible for Medicaid; or

      (b) Is an optional targeted low-income

child as defined in 42 U.S.C. 1397jj(b) and meets the following requirements:

      1. Has family income which does not

exceed 150 percent of the federal poverty guidelines, updated annually in the

Federal Register by the United States Department of Health and Human Services

under authority of 42 U.S.C. 9902(2); and

      2. Does not have creditable coverage but

may be covered by excepted benefits.

      (2) Eligibility for KCHIP shall be

determined by the department. Upon receipt of eligibility information defined

in subsection (1) of this section, the department shall determine if a child is

eligible for benefits pursuant to 42 U.S.C. 1396 or 1397aa to jj.

 

      Section 3. Covered Services. (1) Health

services shall be considered medically necessary in accordance with 907 KAR

3:130 and 42 CFR 440.230.

      (2) Amount and duration of benefits

covered by KCHIP shall be as established in 907 KAR Chapters 1 and 3.

      (3) A medical service shall be covered

through KCHIP if an individual is determined eligible for KCHIP benefits in

accordance with Section 2 of this administrative regulation.

      (4) Preventive and remedial public health

services shall be provided to KCHIP members in accordance with 907 KAR 1:360.

      (5) KCHIP shall be the payor of last

resort.

 

      Section 4. KCHIP Application

Requirements. The following information shall be required from a child or

responsible party for KCHIP enrollment:

      (1) A child’s demographics which shall

include name, address, sex, date of birth, race, and Social Security number;

      (2) Monthly gross earned income, if any,

of a parent and a child for whom information is being submitted, an employer

type and address, if any, and frequency of income;

      (3) Name and address of a health

insurance provider who:

      (a) Currently provides creditable

coverage; or

      (b) Provided creditable coverage during

the six (6) months prior to the date the information in this section is

submitted to the department;

      (4) Creditable coverage policy number,

policy holder’s name, Social Security number, and individuals covered by the

plan;

      (5) Unearned income, if any, received

weekly, biweekly, bimonthly, quarterly, or annually;

      (6) Name and age of a child or disabled

adult for whom care is purchased in order for a parent or responsible person to

work; and

      (7) Signature, date, and telephone number

of a person submitting the information for a child.

 

      Section 5. Provider Participation

Requirements. A provider’s enrollment, disclosure, and documentation for

participation in KCHIP shall meet the requirements of 907 KAR 1:671, 907 KAR

1:672, and if a KenPAC provider, 907 KAR 1:320.

 

      Section 6. Grievance, Hearing, and Appeal

Rights. (1) If dissatisfied with an action taken by the department as to the

application of Sections 1 through 5 of this administrative regulation, a child,

the child's parent, or the child's guardian shall be entitled to a grievance,

hearing, or appeal with the department, to be conducted in accordance with 907

KAR 1:560, if pertaining to initial eligibility, or 907 KAR 1:563, if

pertaining to a covered service.

      (2) If a service is provided by a managed

care organization, a dispute resolution between a provider and a child, the

child's parent, or the child's guardian shall be in accordance with KRS 211.461

through 211.466 and 907 KAR 1:563.

      (3) A KCHIP-eligible child or a

responsible party shall be informed, in writing, of his rights to and

procedures for due process by the cabinet:

      (a) When information to obtain KCHIP

approval is submitted;

      (b) If there is a change in eligibility;

or

      (c) As required by federal and state

laws.

 

      Section 7. Quality Assurance and

Utilization Review. The department shall evaluate, on a continuing basis,

access, continuity of care, health outcomes, and services arranged or provided

as established in 907 KAR 1:705. (26 Ky.R. 1055; Am. 1425; eff. 1-12-2000; 29

Ky.R. 1143; 1658; eff. 12-18-02.)