205.560 Scope of care to be designated by administrative regulations -- Reimbursements mandated or prohibited -- Assessment of health care provider credentials -- Guidelines for dentists' particip - Kentucky Statutes

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205.560 Scope of care to be designated by administrative regulations -- Reimbursements mandated or prohibited -- Assessment of health care provider
credentials -- Guidelines for dentists' participation. (1) The scope of medical care for which the Cabinet for Health and Family Services undertakes to pay shall be designated and limited by regulations promulgated by the
cabinet, pursuant to the provisions in this section. Within the limitations of any
appropriation therefor, the provision of complete upper and lower dentures to
recipients of Medical Assistance Program benefits who have their teeth removed by
a dentist resulting in the total absence of teeth shall be a mandatory class in the
scope of medical care. Payment to a dentist of any Medical Assistance Program
benefits for complete upper and lower dentures shall only be provided on the
condition of a preauthorized agreement between an authorized representative of the
Medical Assistance Program and the dentist prior to the removal of the teeth. The
selection of another class or other classes of medical care shall be recommended by
the council to the secretary for health and family services after taking into
consideration, among other things, the amount of federal and state funds available,
the most essential needs of recipients, and the meeting of such need on a basis
insuring the greatest amount of medical care as defined in KRS 205.510 consonant
with the funds available, including but not limited to the following categories,
except where the aid is for the purpose of obtaining an abortion:
(a) Hospital care, including drugs, and medical supplies and services during any period of actual hospitalization; (b) Nursing-home care, including medical supplies and services, and drugs during confinement therein on prescription of a physician, dentist, or podiatrist; (c) Drugs, nursing care, medical supplies, and services during the time when a recipient is not in a hospital but is under treatment and on the prescription of a
physician, dentist, or podiatrist. For purposes of this paragraph, drugs shall
include products for the treatment of inborn errors of metabolism or genetic
conditions, consisting of therapeutic food, formulas, supplements, or low-
protein modified food products that are medically indicated for therapeutic
treatment and are administered under the direction of a physician, and include
but are not limited to the following conditions:
1. Phenylketonuria; 2. Hyperphenylalaninemia; 3. Tyrosinemia (types I, II, and III); 4. Maple syrup urine disease; 5. A-ketoacid dehydrogenase deficiency; 6. Isovaleryl-CoA dehydrogenase deficiency; 7. 3-methylcrotonyl-CoA carboxylase deficiency; 8. 3-methylglutaconyl-CoA hydratase deficiency; 9. 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMG-CoA lyase
deficiency); 10. B-ketothiolase deficiency;
11. Homocystinuria;
12. Glutaric aciduria (types I and II);
13. Lysinuric protein intolerance;
14. Non-ketotic hyperglycinemia;
15. Propionic acidemia;
16. Gyrate atrophy;
17. Hyperornithinemia/hyperammonemia/homocitrullinuria syndrome;
18. Carbamoyl phosphate synthetase deficiency;
19. Ornithine carbamoyl transferase deficiency;
20. Citrullinemia;
21. Arginosuccinic aciduria;
22. Methylmalonic acidemia; and
23. Argininemia; (d) Physician, podiatric, and dental services;
(e) Optometric services for all age groups shall be limited to prescription services, services to frames and lenses, and diagnostic services provided by an
optometrist, to the extent the optometrist is licensed to perform the services
and to the extent the services are covered in the ophthalmologist portion of the
physician's program. Eyeglasses shall be provided only to children under age
twenty-one (21); (f) Drugs on the prescription of a physician used to prevent the rejection of transplanted organs if the patient is indigent; (g) Nonprofit neighborhood health organizations or clinics where some or all of the medical services are provided by licensed registered nurses or by advanced
medical students presently enrolled in a medical school accredited by the
Association of American Medical Colleges and where the students or licensed
registered nurses are under the direct supervision of a licensed physician who
rotates his services in this supervisory capacity between two (2) or more of the
nonprofit neighborhood health organizations or clinics specified in this
paragraph; (h) Services provided by health-care delivery networks as defined in KRS 216.900; (i) Services provided by midlevel health-care practitioners as defined in KRS 216.900; and (j) Smoking cessation treatment interventions or programs prescribed by a physician, advanced practice registered nurse, physician assistant, or dentist,
including but not limited to counseling, telephone counseling through a
quitline, recommendations to the recipient that smoking should be
discontinued, and prescription and over-the-counter medications and nicotine replacement therapy approved by the United States Food and Drug
Administration for smoking cessation. (2) Payments for hospital care, nursing-home care, and drugs or other medical, ophthalmic, podiatric, and dental supplies shall be on bases which relate the amount
of the payment to the cost of providing the services or supplies. It shall be one (1) of
the functions of the council to make recommendations to the Cabinet for Health and
Family Services with respect to the bases for payment. In determining the rates of
reimbursement for long-term-care facilities participating in the Medical Assistance
Program, the Cabinet for Health and Family Services shall, to the extent permitted
by federal law, not allow the following items to be considered as a cost to the
facility for purposes of reimbursement:
(a) Motor vehicles that are not owned by the facility, including motor vehicles that are registered or owned by the facility but used primarily by the owner or
family members thereof; (b) The cost of motor vehicles, including vans or trucks, used for facility business shall be allowed up to fifteen thousand dollars ($15,000) per facility, adjusted
annually for inflation according to the increase in the consumer price index-u
for the most recent twelve (12) month period, as determined by the United
States Department of Labor. Medically equipped motor vehicles, vans, or
trucks shall be exempt from the fifteen thousand dollar ($15,000) limitation.
Costs exceeding this limit shall not be reimbursable and shall be borne by the
facility. Costs for additional motor vehicles, not to exceed a total of three (3)
per facility, may be approved by the Cabinet for Health and Family Services if
the facility demonstrates that each additional vehicle is necessary for the
operation of the facility as required by regulations of the cabinet; (c) Salaries paid to immediate family members of the owner or administrator, or both, of a facility, to the extent that services are not actually performed and are
not a necessary function as required by regulation of the cabinet for the
operation of the facility. The facility shall keep a record of all work actually
performed by family members; (d) The cost of contracts, loans, or other payments made by the facility to owners, administrators, or both, unless the payments are for services which would
otherwise be necessary to the operation of the facility and the services are
required by regulations of the Cabinet for Health and Family Services. Any
other payments shall be deemed part of the owner's compensation in
accordance with maximum limits established by regulations of the Cabinet for
Health and Family Services. Interest paid to the facility for loans made to a
third party may be used to offset allowable interest claimed by the facility; (e) Private club memberships for owners or administrators, travel expenses for trips outside the state for owners or administrators, and other indirect
payments made to the owner, unless the payments are deemed part of the
owner's compensation in accordance with maximum limits established by
regulations of the Cabinet for Health and Family Services; and (f) Payments made to related organizations supplying the facility with goods or services shall be limited to the actual cost of the goods or services to the
related organization, unless it can be demonstrated that no relationship
between the facility and the supplier exists. A relationship shall be considered
to exist when an individual, including brothers, sisters, father, mother, aunts,
uncles, and in-laws, possesses a total of five percent (5%) or more of
ownership equity in the facility and the supplying business. An exception to
the relationship shall exist if fifty-one percent (51%) or more of the supplier's
business activity of the type carried on with the facility is transacted with
persons and organizations other than the facility and its related organizations. (3) No vendor payment shall be made unless the class and type of medical care rendered and the cost basis therefor has first been designated by regulation. (4) The rules and regulations of the Cabinet for Health and Family Services shall require that a written statement, including the required opinion of a physician, shall
accompany any claim for reimbursement for induced premature births. This
statement shall indicate the procedures used in providing the medical services. (5) The range of medical care benefit standards provided and the quality and quantity standards and the methods for determining cost formulae for vendor payments
within each category of public assistance and other recipients shall be uniform for
the entire state, and shall be designated by regulation promulgated within the
limitations established by the Social Security Act and federal regulations. It shall
not be necessary that the amount of payments for units of services be uniform for
the entire state but amounts may vary from county to county and from city to city, as
well as among hospitals, based on the prevailing cost of medical care in each locale
and other local economic and geographic conditions, except that insofar as allowed
by applicable federal law and regulation, the maximum amounts reimbursable for
similar services rendered by physicians within the same specialty of medical
practice shall not vary according to the physician's place of residence or place of
practice, as long as the place of practice is within the boundaries of the state. (6) Nothing in this section shall be deemed to deprive a woman of all appropriate medical care necessary to prevent her physical death. (7) To the extent permitted by federal law, no medical assistance recipient shall be recertified as qualifying for a level of long-term care below the recipient's current
level, unless the recertification includes a physical examination conducted by a
physician licensed pursuant to KRS Chapter 311 or by an advanced practice
registered nurse licensed pursuant to KRS Chapter 314 and acting under the
physician's supervision. (8) If payments made to community mental health centers, established pursuant to KRS Chapter 210, for services provided to the intellectually disabled exceed the actual
cost of providing the service, the balance of the payments shall be used solely for
the provision of other services to the intellectually disabled through community
mental health centers. (9) No long-term-care facility, as defined in KRS 216.510, providing inpatient care to recipients of medical assistance under Title XIX of the Social Security Act on July 15, 1986, shall deny admission of a person to a bed certified for reimbursement
under the provisions of the Medical Assistance Program solely on the basis of the
person's paying status as a Medicaid recipient. No person shall be removed or
discharged from any facility solely because they became eligible for participation in
the Medical Assistance Program, unless the facility can demonstrate the resident or
the resident's responsible party was fully notified in writing that the resident was
being admitted to a bed not certified for Medicaid reimbursement. No facility may
decertify a bed occupied by a Medicaid recipient or may decertify a bed that is
occupied by a resident who has made application for medical assistance. (10) Family-practice physicians practicing in geographic areas with no more than one (1) primary-care physician per five thousand (5,000) population, as reported by the
United States Department of Health and Human Services, shall be reimbursed one
hundred twenty-five percent (125%) of the standard reimbursement rate for
physician services. (11) The Cabinet for Health and Family Services shall make payments under the Medical Assistance program for services which are within the lawful scope of practice of a
chiropractor licensed pursuant to KRS Chapter 312, to the extent the Medical
Assistance Program pays for the same services provided by a physician. (12) The Medical Assistance Program shall use the form and guidelines established pursuant to KRS 304.17A-545(5) for assessing the credentials of those applying for
participation in the Medical Assistance Program, including those licensed and
regulated under KRS Chapters 311, 312, 314, 315, and 320, any facility required to
be licensed pursuant to KRS Chapter 216B, and any other health care practitioner or
facility as determined by the Department for Medicaid Services through an
administrative regulation promulgated under KRS Chapter 13A. (13) Dentists licensed under KRS Chapter 313 shall be excluded from the requirements of subsection (12) of this section. The Department for Medicaid Services shall
develop a specific form and establish guidelines for assessing the credentials of
dentists applying for participation in the Medical Assistance Program. Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 85, sec. 34, effective July 15, 2010; and ch. 141, sec. 12, effective July 15, 2010. -- Amended 2008 Ky. Acts ch. 119, sec. 1, effective
July 15, 2008. -- Amended 2007 Ky. Acts ch. 34, sec. 1, effective June 26, 2007; and
ch. 90, sec. 1, effective June 26, 2007. -- Amended 2005 Ky. Acts ch. 99, sec. 234,
effective June 20, 2005; ch. 144, sec. 4, effective June 20, 2005. -- Amended 2000
Ky. Acts ch. 290, sec. 1, effective July 14, 2000; and ch. 457, sec. 1, effective July
14, 2000. -- Amended 1998 Ky. Acts ch. 426, sec. 199, effective July 15, 1998. --
Amended 1996 Ky. Acts ch. 304, sec. 1, effective July 15, 1996. -- Amended 1990
Ky. Acts ch. 482, sec. 8, effective July 13, 1990. -- Amended 1986 Ky. Acts ch. 154,
sec. 1, effective July 15, 1986; ch. 306, sec. 1, effective July 15, 1986; ch. 310,
sec. 1, effective July 15, 1986; and 466, sec. 1, effective July 15, 1986. -- Amended
1982 Ky. Acts ch. 133, sec. 1, effective July 15, 1982; and ch. 248, sec. 4, effective
July 15, 1982. -- Amended 1980 Ky. Acts ch. 29, sec. 1, effective July 15, 1980; and
ch. 315, sec. 3, effective July 15, 1980. -- Amended 1978 Ky. Acts ch. 99, sec. 1,
effective June 17, 1978; and ch. 140, sec. 3, effective July 17, 1978. -- Amended
1976 Ky. Acts ch. 141, sec. 1. -- Amended 1974 Ky. Acts ch. 74, Art. VI, secs. 50
and 107(1), (14), (15) and (19); and ch. 225, sec. 3. -- Amended 1972 Ky. Acts ch. 256, sec. 16. -- Amended 1970 Ky. Acts ch. 78, sec. 3. -- Amended 1960 (1st
Extra. Sess.) Ky. Acts ch. 2, sec. 3. -- Created 1960 ch. 68, Art. VII, sec. 7. Legislative Research Commission Note (7/15/2010). This section was amended by 2010 Ky. Acts chs. 85 and 141, which do not appear to be in conflict and have been
codified together. Legislative Research Commission Note (6/20/2005). 2005 Ky. Acts chs. 11, 85, 95, 97, 98, 99, 123, and 181 instruct the Reviser of Statutes to correct statutory references to
agencies and officers whose names have been changed in 2005 legislation confirming
the reorganization of the executive branch. Such a correction has been made in this
section.