Title 907 | Chapter 001 | Regulation 006
907 KAR 1:006.Coverage of and payment for services for persons eligible for benefits under both Title XIX and Title XVIII.
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 23:010, 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.HISTORY: (2 Ky.R. 100; eff. 9-10-1975; Recodified from 904 KAR 1:006, 5-6-1986; 15 Ky.R. 1960; 2156; eff. 3-15-1989; 17 Ky.R. 546; eff. 10-14-1990; 25 Ky.R. 437; 858; eff. 9-16-1998; 30 Ky.R. 105; 871; eff. 10-31-2003; 1615; 1937; eff. 2-16-2004; TAm eff. 10-6-2017; Crt eff. 12-6-2019.)
907 KAR 1:006.Coverage of and payment for services for persons eligible for benefits under both Title XIX and Title XVIII.
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 23:010, 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.HISTORY: (2 Ky.R. 100; eff. 9-10-1975; Recodified from 904 KAR 1:006, 5-6-1986; 15 Ky.R. 1960; 2156; eff. 3-15-1989; 17 Ky.R. 546; eff. 10-14-1990; 25 Ky.R. 437; 858; eff. 9-16-1998; 30 Ky.R. 105; 871; eff. 10-31-2003; 1615; 1937; eff. 2-16-2004; TAm eff. 10-6-2017; Crt eff. 12-6-2019.)