907 KAR 1:006. Coverage of and payment
for services for persons eligible for benefits under both Title XIX and Title
RELATES TO: KRS 205.520, 42 U.S.C. 1396a,
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 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. The Cabinet for Health and Family
Services, Department for Medicaid Services has responsibility to administer the
Medicaid Program in accordance with Title XIX of the Social Security Act. 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 for
the provision of medical assistance to Kentucky's indigent citizenry. This
administrative regulation establishes the provisions for coverage of and
payment for services for categorically needy and medically needy individuals
eligible for benefits under both Title XIX (42 U.S.C. 1396 to 1396v) and Title
XVIII (42 U.S.C. 1395 to 1395ggg).
Section 1. Definitions. (1)
"Coinsurance" means that portion of each bill a Medicare-eligible
person pays for a covered benefit, including copayments.
(2) "Deductible" means an
amount paid by a Medicare-eligible person before Medicare begins paying its
portion of a medical bill.
(3) "Department" means the
Department for Medicaid Services or its designee.
(4) "Medicare Part A" means
federal health insurance that covers:
(a) Inpatient hospital or skilled nursing
facility services, including blood;
(b) Hospice services; and
(c) Home health services.
(5) "Medicare Part B" means
federal health insurance that covers:
(a) Physician services;
(b) Outpatient hospital services;
(c) Durable medical equipment; and
(d) Other services not covered under
Medicare Part A.
(6) "Premium" means a monthly
amount paid for coverage of Medicare Part A or Part B.
(7) "Qualified disabled and working
individual" or "QDWI" means an individual who meets the
requirements in 42 U.S.C. 1396d(s).
(8) "Qualified individual one"
or "QI-1" means an individual who meets the requirements in 42 U.S.C.
(9) "Qualified Medicare
beneficiary" or "QMB" means an individual who meets the
requirements in 42 U.S.C. 1396d(p)(1).
(10) "Specified low-income Medicare
beneficiary" or "SLMB" means an individual who meets the
requirements in 42 U.S.C. 1396a(a)(10)(E)(iii).
Section 2. Medicare Buy-in. The
department shall purchase through the Social Security Administration:
(1) Medicare Part B for a recipient
eligible for Medicare who is receiving a money payment under the state program
of optional or mandatory supplementation;
(2) Medicare Part A and Medicare Part B
for a recipient determined eligible as a QMB;
(3) Medicare Part B for a recipient
determined eligible as a SLMB;
(4) Medicare Part A for a recipient
determined eligible as a QDWI; and
(5) Medicare Part B for a recipient
determined eligible as a QI-1.
Section 3. Payment of Deductibles and
Coinsurance. (1) The department shall pay the deductible and coinsurance for a
benefit covered under Medicare Part A or Medicare Part B for an individual eligible
(a) QMB coverage; or
(b) Both Title XVIII and Title XIX
(2) The amount of deductible and
coinsurance paid by the department to a provider for a benefit covered under
Medicare Part A shall be the lesser of:
(a) The Medicaid-allowed amount minus the
Medicare payment; or
(b) The Medicare coinsurance and
deductible, up to the Medicaid-allowed amount.
(3) With the exception of services
identified in subsection (4)(a) through (m) of this section, the amount of
coinsurance and deductible paid by the department to a provider for a benefit
covered under Medicare Part B shall be the full amount of the deductible and
(4) The amount of deductible and
coinsurance paid by the department for a service provided in accordance with
one (1) of the following administrative regulations and covered under Medicare
Part B shall be the lesser of the Medicaid-allowed amount minus the Medicare payment
or the Medicare coinsurance and deductible up to the Medicaid-allowed amount:
(a) 907 KAR 1:019, Outpatient Pharmacy
(b) 907 KAR 1:026, Dental services;
(c) 907 KAR 1:028, Other laboratory and
(d) 907 KAR 1:038, Hearing and Vision
(e) 907 KAR 1:044, Mental Health Center
(f) 907 KAR 1:060, Medical
(g) Ancillary services pursuant to 907
KAR 1:065, Payments for Price-based Nursing Facility Services;
(h) Ancillary services pursuant to 907
KAR 1:025, Payment for services provided by an intermediate care facility for
the mentally retarded and developmentally disabled, a dually-licensed pediatric
facility, an institution for mental diseases, and a nursing facility with an
all-inclusive rate unit;
(i) 907 KAR 1:102, Advanced registered
nurse practitioner services;
(j) 907 KAR 1:270, Podiatry Program
(k) 907 KAR 1:479, Durable medical
equipment covered benefits and reimbursement;
(l) 907 KAR 3:005, Physicians' services;
(m) 907 KAR 3:125, Chiropractic services
(5) A payment made by the department under
this section of this administrative regulation shall be considered as payment
in full for a benefit provided under Medicare Part A or B.
Section 4. Obligation for a QMB Enrolled
in a Medicare Managed Care Organization. (1) The department shall be responsible
for payment of Part A and Part B premiums, deductibles and coinsurance,
copayments, and enrollment premiums for a QMB recipient enrolled in a Medicare
managed care organization.
(2) The department shall reimburse
deductibles and coinsurance in accordance with Section 3 of this administrative
Section 5. Special Provisions. An
individual determined eligible as a QI-1, shall:
(1) Be limited by a block grant with
eligibility established on a first-come first-serve basis;
(2) In calendar years following the year
of initial approval, be given preference over another individual who may apply
who was not eligible the previous year; and
(3) Have eligibility terminated when the
block grant authorized under 42 U.S.C. 1396u-3(c)(1) is no longer available
from federal Medicaid funds. (Recodified from 904 KAR 1:006, 5-6-86; Am. 15
Ky.R. 1960; 2156; eff. 3-15-89; 17 Ky.R. 546; eff. 10-14-90; 25 Ky.R. 437; 858;
eff. 9-16-98; 30 Ky.R. 105; 871; eff. 10-31-2003; 1615; 1937; eff. 2-16-04.)