907 KAR 1:006. Coverage of and payment for services for persons eligible for benefits under both Title XIX and Title XVIII

Link to law: http://www.lrc.ky.gov/kar/907/001/006.htm
Published: 2015

      907 KAR 1:006. Coverage of and payment

for services for persons eligible for benefits under both Title XIX and Title

XVIII.

 

      RELATES TO: KRS 205.520, 42 U.S.C. 1396a,

1396a(n)

      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.

1396a(a)(10)(E)(iv)(II).

      (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

for:

      (a) QMB coverage; or

      (b) Both Title XVIII and Title XIX

benefits.

      (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

coinsurance.

      (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

Program; or

      (b) 907 KAR 1:026, Dental services;

      (c) 907 KAR 1:028, Other laboratory and

x-ray services;

      (d) 907 KAR 1:038, Hearing and Vision

Program services;

      (e) 907 KAR 1:044, Mental Health Center

services;

      (f) 907 KAR 1:060, Medical

transportation;

      (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

services;

      (k) 907 KAR 1:479, Durable medical

equipment covered benefits and reimbursement;

      (l) 907 KAR 3:005, Physicians' services;

or

      (m) 907 KAR 3:125, Chiropractic services

and reimbursement.

      (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

regulation.

 

      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.)
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