907 KAR 15:055.Reimbursement provisions and requirements regarding targeted case management for individuals with a mental health or substance use disorder and chronic or complex physical health issues.

RELATES TO:

KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 42 U.S.C. 1396a(a)(23)

STATUTORY AUTHORITY:

KRS 194A.030(2), 194A.050(1), 205.520(3)

NECESSITY, FUNCTION, AND CONFORMITY:

The Cabinet for Health and Family Services, Department for Medicaid Services, has a responsibility to administer the Medicaid Program. 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 to qualify for federal Medicaid funds. This administrative regulation establishes the reimbursement provisions and requirements regarding Medicaid Program targeted case management services for individuals with a mental health or substance use disorder and chronic or complex physical health issues who are not enrolled with a managed care organization.

Section 1.

General Requirements. For the department to reimburse for a service covered under this administrative regulation, the service shall be:

(1)

Medically necessary;

(2)

Provided:

(a)

To a recipient;

(b)

By a provider that meets the provider participation requirements established in 907 KAR 15:050; and

(c)

In accordance with the requirements established in 907 KAR 15:050; and

(3)

Covered in accordance with 907 KAR 15:050.

Section 2.

Reimbursement.

(1)

The department shall reimburse a monthly rate of $541 in total for all targeted case management services provided to a recipient during the month.

(2)

Except as established in subsection (3) of this section, to qualify for the reimbursement referenced in subsection (1) of this section, a targeted case management services provider shall provide services to a recipient consisting of at least five (5) targeted case management service contacts including:

(a)

At least three (3) face-to-face contacts with:

1.

The recipient; or

2.

If the recipient is at least eighteen (18) years of age but under twenty-one (21) years of age, with:

a.

The recipient; or

b.

A parent or legal guardian of the recipient; and

(b)

At least two (2) additional contacts which shall be:

1. a.

By telephone; or

b.

Face-to-face; and

2.

With the recipient or with another individual on behalf of the recipient.

(3)

For a recipient who is under the age of eighteen (18) years, the contacts that a targeted case management services provider shall have shall include at least:

(a)

1.

One (1) face-to-face contact with the recipient's parent or legal guardian and two (2) face-to-face contacts with the recipient; and

2.

Two (2) additional contacts which shall be:

a.

(i)

By telephone; or

(ii)

Face-to-face; and

b.

With the recipient or with another individual or agency on behalf of the recipient; or

(b)

1.

Two (2) face-to-face contacts with the recipient's parent or legal guardian and one (1) face-to-face contact with the recipient; and

2.

Two (2) additional contacts which shall be:

a.

(i)

By telephone; or

(ii)

Face-to-face; and

b.

With the recipient or with another individual or agency on behalf of the recipient.

Section 3.

No Duplication of Service.

(1)

The department shall not reimburse for a service provided to a recipient by more than one (1) provider of any program in which the same service is covered during the same time period.

(2)

For example, if a recipient is receiving targeted case management services from an independent behavioral health provider, the department shall not reimburse for the targeted case management services provided to the same recipient during the same time period by a behavioral health services organization.

Section 4.

Not Applicable to Managed Care Organizations. A managed care organization shall not be required to reimburse in accordance with this administrative regulation for a service covered pursuant to:

(1)

907 KAR 15:050; and

(2)

This administrative regulation.

Section 5.

Federal Approval and Federal Financial Participation. The department's reimbursement for services pursuant to this administrative regulation shall be contingent upon:

(1)

Receipt of federal financial participation for the reimbursement; and

(2)

Centers for Medicare and Medicaid Services' approval for the reimbursement.

HISTORY: (41 Ky.R. 1276; Am. 1827; 1989; eff. 4-3-2015; Cert. eff. 3-28-2022.)

907 KAR 15:055.Reimbursement provisions and requirements regarding targeted case management for individuals with a mental health or substance use disorder and chronic or complex physical health issues.

RELATES TO:

KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 42 U.S.C. 1396a(a)(23)

STATUTORY AUTHORITY:

KRS 194A.030(2), 194A.050(1), 205.520(3)

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

General Requirements. For the department to reimburse for a service covered under this administrative regulation, the service shall be:

(1)

Medically necessary;

(2)

Provided:

(a)

To a recipient;

(b)

By a provider that meets the provider participation requirements established in 907 KAR 15:050; and

(c)

In accordance with the requirements established in 907 KAR 15:050; and

(3)

Covered in accordance with 907 KAR 15:050.

Section 2.

Reimbursement.

(1)

The department shall reimburse a monthly rate of $541 in total for all targeted case management services provided to a recipient during the month.

(2)

(a)

At least three (3) face-to-face contacts with:

1.

The recipient; or

2.

If the recipient is at least eighteen (18) years of age but under twenty-one (21) years of age, with:

a.

The recipient; or

b.

A parent or legal guardian of the recipient; and

(b)

At least two (2) additional contacts which shall be:

1. a.

By telephone; or

b.

Face-to-face; and

2.

With the recipient or with another individual on behalf of the recipient.

(3)

For a recipient who is under the age of eighteen (18) years, the contacts that a targeted case management services provider shall have shall include at least:

(a)

1.

One (1) face-to-face contact with the recipient's parent or legal guardian and two (2) face-to-face contacts with the recipient; and

2.

Two (2) additional contacts which shall be:

a.

(i)

By telephone; or

(ii)

Face-to-face; and

b.

With the recipient or with another individual or agency on behalf of the recipient; or

(b)

1.

Two (2) face-to-face contacts with the recipient's parent or legal guardian and one (1) face-to-face contact with the recipient; and

2.

Two (2) additional contacts which shall be:

a.

(i)

By telephone; or

(ii)

Face-to-face; and

b.

With the recipient or with another individual or agency on behalf of the recipient.

Section 3.

No Duplication of Service.

(1)

The department shall not reimburse for a service provided to a recipient by more than one (1) provider of any program in which the same service is covered during the same time period.

(2)

Section 4.

Not Applicable to Managed Care Organizations. A managed care organization shall not be required to reimburse in accordance with this administrative regulation for a service covered pursuant to:

(1)

907 KAR 15:050; and

(2)

This administrative regulation.

Section 5.

Federal Approval and Federal Financial Participation. The department's reimbursement for services pursuant to this administrative regulation shall be contingent upon:

(1)

Receipt of federal financial participation for the reimbursement; and

(2)

Centers for Medicare and Medicaid Services' approval for the reimbursement.

HISTORY: (41 Ky.R. 1276; Am. 1827; 1989; eff. 4-3-2015; Cert. eff. 3-28-2022.)

Page Generated: 9/19/2024, 12:15:11 PM

Title 907 | Chapter 015 | Regulation 055

907 KAR 15:055.Reimbursement provisions and requirements regarding targeted case management for individuals with a mental health or substance use disorder and chronic or complex physical health issues.

RELATES TO:

STATUTORY AUTHORITY:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(a)

(b)

(c)

(3)

Section 2.

(1)

(2)

(a)

1.

2.

a.

b.

(b)

1.

a.

b.

2.

(3)

(a)

1.

2.

a.

(i)

(ii)

b.

(b)

1.

2.

a.

(i)

(ii)

b.

Section 3.

(1)

(2)

Section 4.

(1)

(2)

Section 5.

(1)

(2)

907 KAR 15:055.Reimbursement provisions and requirements regarding targeted case management for individuals with a mental health or substance use disorder and chronic or complex physical health issues.

RELATES TO:

STATUTORY AUTHORITY:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(a)

(b)

(c)

(3)

Section 2.

(1)

(2)

(a)

1.

2.

a.

b.

(b)

1.

a.

b.

2.

(3)

(a)

1.

2.

a.

(i)

(ii)