RELATES TO:
KRS
205.560,
205.6312,
205.6485,
205.8451,
319A.010,
327.010,
334A.020,
42 C.F.R. 430.10,
431.51,
447.15,
447.20,
447.21,
447.50,
447.52,
447.54,
447.55,
447.56,
447.57,
457.224,
457.310,
457.505,
457.510,
457.515,
457.520,
457.530,
457.535,
457.570,
42 U.S.C.
1396a,
1396b,
1396c,
1396d,
1396o,
1396r-6,
1396r-8,
1396u-1,
1397aa -1397jj
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) 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 prohibits cost-sharing within
the Medicaid program, and extends the
KRS
205.6312 prohibition of cost-sharing to
providers as well as the department and managed care organizations.
Section 1. Definitions.
(1) "Copayment" means a dollar amount
representing the portion of the cost of a Medicaid benefit that a recipient is
required to pay.
(2) "Department"
means the Department for Medicaid Services or its designee.
(3) "Enrollee" means a Medicaid recipient who
is enrolled with a managed care organization.
(4) "Managed care organization" or "MCO"
means an entity for which the Department for Medicaid Services has contracted
to serve as a managed care organization as defined by
42
C.F.R.
438.2.
(5) "Recipient" is defined by
KRS
205.8451(9).
Section 2. Copayment General
Provisions and Exemptions.
(1) Pursuant to
KRS
205.6312, the department or any MCO shall not
utilize or require cost-sharing or copayments within any component of the
Medicaid program.
(2) A provider
shall not collect a copayment from an enrollee for a service or item.
Section 3. Freedom of Choice.
(1) In accordance with
42 C.F.R.
431.51, a recipient who is not an enrollee
may obtain services from any qualified provider who is willing to provide
services to that particular recipient.
(2) A managed care organization may restrict
an enrollee's choice of providers to the providers in the provider network of
the managed care organization in which the enrollee is enrolled except as
established in:
Section 4. Appeal
Rights. An appeal of a department decision regarding the Medicaid eligibility
of an individual shall be in accordance with
907
KAR 1:560.
Section
5. Federal Approval and Federal Financial Participation. The
department's copayment provisions and any coverage of services established in
this administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation; and
(2) Centers for
Medicare and Medicaid Services' approval.
Section 6. This administrative regulation was
found deficient by the Administrative Regulation Review Subcommittee on May 13,
2014.
