907 KAR 1:005 - Nonduplication of payments

RELATES TO: KRS 205.624, 205.6312, 42 U.S.C. 1396a, 42 U.S.C. 1396k, 42 C.F.R. Parts 431, 433, 447

NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid program. KRS 205.520(3) empowers 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 Medicaid program policies relating to nonduplication of payment and treatment of third-party liability.

Section 1. Nonduplication of Payment.

(1) In accordance with 42 C.F.R. 447.15, a payment to a provider for a service provided to a recipient shall be payment in full to the provider for the service.

(2)

(a) A provider shall not seek payment from a recipient for a covered service provided to the recipient.

(b) A recipient shall not be financially liable to a provider for a covered service provided by the provider to the recipient.

Section 2. Third-party Liability.

(1) The department shall comply with 42 C.F.R. Part 433 , Subpart D, and consider any third-party liability as a resource.

(2) A recipient shall cooperate with the department for third-party liability purposes in accordance with 42 U.S.C. 1396k, 42 C.F.R. 433.138, and 42 C.F.R. 433.145.

(3) If payment for a covered service is due and payable from a third-party source such as Medicare, an insurance plan, or some other third-party with a legal obligation to pay, the amount payable by the cabinet shall be reduced by the amount of the third-party obligation.

Notes

907 KAR 1:005

2 Ky.R. 100; 9-10-1975; Recodified from 904 KAR 1:005, 5-2-1986; 17 Ky.R. 148; eff. 9-13-1990; 45 Ky.R. 1439; eff. 2-1-2019; 48 Ky.R. 1409; eff. 3-10-2022.

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.622