RELATES TO:
KRS
205.520,
42 U.S.C.
1396a,
1396a(n)
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
July 9, 2004, reorganized the Cabinet for Health Services and placed the
Department for Medicaid Services and the Medicaid Program under the Cabinet for
Health and Family Services. The Cabinet for Health and Family Services,
Department for Medicaid Services has responsibility to administer the Medicaid
Program in accordance with Title XIX of the Social Security Act.
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 for the provision of medical
assistance to Kentucky's indigent citizenry. This administrative regulation
establishes the provisions for coverage of and payment for services for
categorically needy and medically needy individuals eligible for benefits under
both Title XIX (42 U.S.C.
1396 to
1396v)
and Title XVIII (42 U.S.C.
1395 to
1395gg
g).
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:
(b)907 KAR
1:026, Dental services;
(d)907 KAR
1:038, Hearing
and Vision Program services;
(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;
(k)
907
KAR 1:479, Durable medical equipment covered benefits
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.
