Kan. Admin. Regs. § 30-5-70 - Payment of medical expenses for eligible recipients
(a) Payment for
covered services shall be made only to those providers participating in the
program pursuant to K.A.R. 30-5-59. The only exceptions shall be pursuant to
K.A.R. 30-5-65.
(b) Each program
recipient shall be eligible for the payment of specific medical expenses as
follows:
(1) Payment of Medicare (title
XVIII) premiums and deductibles and co-insurance amounts for services covered
in the medicaid program. Recipients who are ineligible for program coverage
because they have a spenddown shall be eligible for the payment of the Medicare
(title XVIII) premium expense. For cash recipients, including SSI recipients,
who are age 65 or older, payment of the Medicare (title XVIII) premium shall
begin with the month of approval for medicaid, excluding any months of prior
eligibility. For recipients under age 65 who are eligible for Medicare after
receiving retirement and survivor's disability insurance for 24 consecutive
months, payment of the Medicare (title XVIII) premium shall begin with the 25th
month. For all other recipients, payment of the Medicare (title XVIII) premium
shall begin with the second month following the month of approval for medicaid,
excluding any months of prior eligibility;
(2) payment of premiums of health maintenance
organizations that are approved by the agency or premiums of group health plans
offered by the recipient's employer if the agency has determined that this plan
is cost-effective;
(3) payment of
other allowable medical expenses incurred in the current eligibility base
period in excess of any co-pay or spenddown requirements;
(4) payment for services rendered to a person
who is mandated to receive inpatient treatment for tuberculosis and who is not
otherwise eligible for participation in the program. Coverage shall be limited
to services related to the treatment for tuberculosis;
(5) payment for services in excess of
medicaid/medikan program limitations for foster care and adoption support
recipients, when approved by the agency; and
(6) payment for covered medical services
provided to an individual participating in the KanWork program. A monthly
cost-sharing amount for medical services shall be paid by each individual
participating in the KanWork program when required.
(c) The scope of services provided to
recipients and the payment for those services shall be as set forth in articles
5 and 10 of this chapter, subject to the following limitations.
(1) Payment for a particular medical expense
shall be denied if it is determined that any one of these conditions is met:
(A) The recipient failed to utilize medical
care available through other community resources, including public
institutions, veterans administration benefits, and those laboratory services
that are available at no charge through the state department of health and
environment.
(B) A third party
liability for the medical expense has been established and is available.
(C) The recipient fails to make a
good faith effort to establish a third party liability for the medical expense
or fails to cooperate with the agency in establishing the liability. Payment of
a medical expense may be delayed pending the outcome of a determination
concerning third party liability.
(D) The expense is not covered or is only
partially covered by an insurance policy because of an insurance program
limitation or exclusion.
(E) The
recipient failed to notify the provider of services of the recipient's
eligibility for the program.
(F)
The service is cosmetic, pioneering, or experimental, or is a result of
complications related to these procedures.
(G) The service is related to transplant
procedures that are not covered by the medicaid/medikan program.
(H) The service was provided by a provider
not designated as a lock-in provider for any recipient who is locked into
designated providers due to abuse, unless the provider has a written referral
from a designated provider or unless the service was an emergency service.
(I) The service was provided by a
provider not designated as the primary care case manager for any recipient who
is enrolled in the primary care case manager program, unless the provider has a
written referral from the designated provider or unless the service was an
emergency service.
(J) The service
was covered in a health maintenance organization plan for any recipient
enrolled in a health maintenance organization.
(K) The service was provided by an
unlicensed, unregistered, or noncertified provider when licensure,
registration, or certification is a requirement to participate in the
medicaid/medikan program.
(L) The
service exceeds the limitations defined by the program policies.
(2) Payment for out-of-state
services shall be limited to the following:
(A) Payment on behalf of recipients if
medical services are normally provided by medical vendors that are located in
the bordering state and within 50 miles of the state border, except for
community mental health center services, alcohol and drug abuse services, or
partial hospitalization services;
(B) emergency services rendered outside the
state;
(C) nonemergency services
for which prior approval by the agency has been given. Authorization from the
agency shall be obtained before making arrangements for the individual to
obtain the out-of-state services;
(D) services provided by independent
laboratories; and
(E) medical
services provided to foster care recipients and medical services in excess of
the limitations of the state of residence, when approved by the Kansas
department of social and rehabilitation services and within the scope of the
adoption agreement for those for whom Kansas has initiated adoption support
agreements.
(d) Payment for medical services
shall be made, at the discretion of the secretary, when it has been determined
that an agency administrative error has been made.
(e) This regulation shall take effect on and
after October 1, 1998.
Notes
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