907 KAR 17:010 - Managed care organization requirements and policies relating to enrollees
RELATES TO: KRS Chapter 13B, 194A.025(3), 205.624, 311.621-311.643, 387.500-387.800, 42 U.S.C. 1396a, 1396n, 1396u-2, 42 C.F.R. 422.112, 422.113, 431.51, 431.200-431.250, 433.138, Part 438, 45 C.F.R. 233.100
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 a requirement that may be imposed or opportunity presented by federal law to qualify for federal Medicaid funds. 42 U.S.C. 1396n(b) and 42 C.F.R. Part 438 require specific standards relating to managed care. This administrative regulation establishes the managed care organization requirements and policies relating to individuals enrolled with a Medicaid managed care organization.
Section 1. Enrollment of
Medicaid or KCHIP Recipients into Managed Care.
(1) Except as established in subsection (3)
of this section, enrollment into a managed care organization shall be mandatory
for a Medicaid or KCHIP recipient.
(2) The provisions in this administrative
regulation shall be applicable to a:
(a)
Medicaid recipient; or
(b) KCHIP
recipient.
(3) The
following recipients shall not be required to enroll, and shall not enroll,
into a managed care organization:
(a) A
recipient who resides in:
1. A nursing
facility for more than thirty (30) calendar days; or
2. An intermediate care facility for
individuals with an intellectual disability; or
(b) A recipient who is:
1. Determined to be eligible for Medicaid
benefits due to a nursing facility admission;
2. Receiving:
a. Services through the breast and cervical
cancer program pursuant to
907
KAR 20:055;
b. Medicaid benefits in accordance with the
spend-down policies established in
907
KAR 20:020;
c. Services through a 1915(c) home and
community based services waiver program; or
d. Hospice services in a nursing facility or
intermediate care facility for individuals with an intellectual
disability;
3. A
Qualified Medicare beneficiary who is not otherwise eligible for Medicaid
benefits;
4. A specified low-income
Medicare beneficiary who is not otherwise eligible for Medicaid
benefits;
5. A Medicare qualified
individual group 1 (QI-1) individual;
6. A qualified disabled and working
individual;
7. A qualified alien
eligible for Medicaid benefits for a limited period of time; or
8. A nonqualified alien eligible for Medicaid
benefits for a limited period of time.
(4)
(a) The
department shall assign a recipient to an MCO based upon an algorithm that
considers:
1. Continuity of care;
and
2. Enrollee preference of an
MCO provider.
(b) An
assignment shall focus on a need of a child or an individual with a special
health care need.
(5)
(a) A newly eligible recipient or a recipient
who has had a break in eligibility of greater than two (2) months shall have an
opportunity to choose an MCO during the eligibility application
process.
(b) If a recipient does
not choose an MCO during the eligibility application process, the department
shall assign the recipient to an MCO in accordance with subsections (4) and (6)
of this section.
(6)
Each member of a household shall be assigned to the same MCO.
(7) The effective date of enrollment for a
recipient established in subsection (5) of this section shall be the date of
Medicaid eligibility.
(8) A
recipient shall be given a choice of MCOs.
(9) A recipient enrolled with an MCO who
loses Medicaid eligibility for less than two (2) months shall be automatically
reenrolled with the same MCO upon redetermination of Medicaid
eligibility.
(10) A newborn who has
been deemed eligible for Medicaid shall be automatically enrolled with the
newborn's mother's MCO as an individual enrollee for up to sixty (60) calendar
days.
(11)
(a) An enrollee may change an MCO for any
reason, regardless of whether the MCO was selected by the enrollee or assigned
by the department:
1. Within ninety (90)
calendar days of the effective date of enrollment;
2. Annually during an open enrollment
period;
3. Upon automatic
enrollment under subsection (9) of this section, if a temporary loss of
Medicaid eligibility caused the recipient to miss the annual opportunity in
subparagraph 2. of this paragraph; or
4. If the Commonwealth of Kentucky imposes an
intermediate sanction established in
42 C.F.R.
438.702(a)(3).
(b) An MCO shall accept an
enrollee who changes MCOs under this section.
(12) Only the department may enroll a
Medicaid recipient with an MCO in accordance with this section.
(13) Upon enrollment with an MCO, an enrollee
shall receive an identification card issued by the MCO.
(14)
(a)
Within five (5) business days after receipt of notification of a new enrollee,
an MCO shall send, by a method that shall not take more than three (3) calendar
days to reach the enrollee, a confirmation letter to an enrollee.
(b) The confirmation letter shall include at
least:
1. The effective date of
enrollment;
2. The name, location,
and contact information of the PCP;
3. How to obtain a referral;
4. Care coordination;
5. The benefits of preventive health
care;
6. The enrollee
identification card;
7. A member
handbook; and
8. A list of covered
services.
(15) Enrollment with an MCO shall be without
restriction.
(16) An MCO shall:
(a) Have continuous open enrollment for new
enrollees; and
(b) Accept enrollees
regardless of overall enrollment.
(17)
(a)
Except as established in paragraphs (b) through (e) of this subsection, a
recipient eligible to enroll with an MCO shall be enrolled beginning with the
first day of the month that the enrollee applied for Medicaid.
(b) A newborn shall be enrolled beginning
with the newborn's date of birth.
(c) An unemployed parent shall be enrolled
beginning with the date the unemployed parent met the definition of
unemployment in accordance with
45 C.F.R.
233.100.
(d)
1.
Except as established in paragraph (e) of this subsection, if an enrollee is
retroactively determined eligible for Medicaid, the retroactive eligibility
shall be for a period up to three (3) months prior to the month that the
enrollee applied for Medicaid.
2.
An MCO shall be responsible for reimbursing for covered services provided to a
retroactively determined eligible individual established in subparagraph 1. of
this paragraph during the individual's retroactive eligibility
period.
(e) If an
enrollee is retroactively determined eligible for Medicaid as a result of being
determined retroactively eligible for SSI benefits:
1. The individual's enrollment date with an
MCO shall be the first of the month following the month in which the department
is notified of the individual's retroactive eligibility for SSI benefits;
and
2. The department shall be
responsible for reimbursing for any services provided during the retroactive
eligibility period for an individual determined to be retroactively eligible
for SSI benefits.
(18) For an enrollee whose eligibility
resulted from a successful appeal of a denial of eligibility, the enrollment
period shall begin on the first day of the month of:
(a) The original application for eligibility;
or
(b) Retroactive eligibility as
referenced in subsection (17)(d) or (e) of this section, if
applicable.
(19) A
provider shall be responsible for verifying an individual's eligibility for
Medicaid and enrollment in a managed care organization when providing a
service.
Section 2.
Disenrollment.
(1) The policies established in
42 C.F.R.
438.56 shall apply to an MCO.
(2) Only the department may disenroll a
recipient from an MCO.
(3) A
disenrollment of a recipient from an MCO shall occur:
(a) If the enrollee:
1. Becomes incarcerated or deceased;
or
2. Is exempt from managed care
enrollment in accordance with Section 1(3) of this administrative regulation;
or
(b) In accordance
with
42 C.F.R.
438.56.
(4) An MCO may recommend to the department
that an enrollee be disenrolled if the enrollee:
(a) Is found guilty of fraud in a court of
law or administratively determined to have committed fraud related to the
Medicaid Program;
(b) Is abusive or
threatening but not for uncooperative or disruptive behavior resulting from his
or her special needs (except if his or her continued enrollment in the MCO
seriously impairs the entity's ability to provide services to either this
particular enrollee or other enrollees) pursuant to
42 C.F.R.
438.56(b)(2); or
(c) Becomes deceased.
(5) An enrollee shall not be disenrolled by
the department, nor shall the managed care organization recommend disenrollment
of an enrollee, due to an adverse change in the enrollee's health.
(6)
(a) An
approved disenrollment shall be effective no later than the first day of the
second month following the month the enrollee or the MCO files a request in
accordance with
42 C.F.R.
438.56(e)(1).
(b) If the department fails to make a
determination within the timeframe established in paragraph (a) of this
subsection, the disenrollment shall be considered approved in accordance with
42 C.F.R.
438.56(e)(2).
(7) If an enrollee is disenrolled
from an MCO, the:
(a) Enrollee shall be
enrolled with a new MCO if the enrollee is:
1.
Eligible for Medicaid; and
2. Not
excluded from managed care participation; and
(b) MCO shall:
1. Assist in the selection of a new primary
care provider, if requested;
2.
Cooperate with the new primary care provider in transitioning the enrollee's
care; and
3. Make the enrollee's
medical record available to the new primary care provider in accordance with
state and federal law.
(8) An MCO shall notify the department or
Social Security Administration in an enrollee's county of residence within five
(5) working days of receiving notice of the death of an enrollee.
Section 3. Enrollee Rights and
Responsibilities. An MCO shall have written policies and procedures to protect
the rights of an enrollee that meets the information requirements established
in
42 C.F.R.
438.10.
Section 4. MCO Internal Appeal Process.
(1) An enrollee may file a grievance orally
or in writing with the MCO at any time.
(a)
Within five (5) working days of receipt of a grievance, an MCO shall provide
the enrollee with written notice that the grievance has been received and the
expected date of its resolution.
(b) An investigation and final resolution of
a grievance shall:
1. Be completed within
thirty (30) calendar days of the date the grievance is received by the MCO;
and
2. Include a resolution letter
to the enrollee that shall include:
a. All
information considered in investigating the grievance;
b. Findings and conclusions based on the
investigation; and
c. The
disposition of the grievance.
(2) An MCO shall have an internal appeal
process in place that allows an enrollee to challenge a denial of coverage of,
or payment for, a service in accordance with
42 C.F.R.
438.400 through
438.424
and 42 U.S.C. 1396u-2(b)(4).
(3)
(a) A provider shall not be an authorized
representative of an enrollee without the enrollee's written consent for the
specific action that is being appealed or that is the subject of a state fair
hearing.
(b)
1. For authorized representative purposes,
written consent unique to an appeal or state fair hearing shall be required for
the appeal or state fair hearing.
2. A single written consent shall not qualify
as written consent for more than one (1):
a.
Hospital admission;
b. Physician or
other provider visit; or
c.
Treatment plan.
(4) A legal guardian of an enrollee who is a
minor or an incapacitated adult or an authorized representative of an enrollee
in accordance with subsection (3) of this section may file an appeal on behalf
of the enrollee.
(5) An enrollee
shall have sixty (60) calendar days from the date of receiving a notice of
adverse action from an MCO to file an appeal either orally or in writing with
the MCO.
(6) Except as established
in subsection 10 of this section, an MCO shall resolve an appeal within thirty
(30) calendar days from the date the initial oral or written appeal is received
by the MCO.
(7) An MCO shall have a
process in place that ensures that an oral or written inquiry from an enrollee
seeking to appeal an adverse action shall be treated as an appeal to establish
the earliest possible filing date for the appeal.
(8) An oral appeal shall be followed by a
written appeal that is signed by the enrollee or an individual listed in
subsection (4) of this section within ten (10) calendar days.
(9)
(a)
Within five (5) working days of receipt of an appeal, an MCO shall provide the
enrollee with written notice that the appeal has been received and the expected
date of its resolution. A copy of this information shall also be sent to an
individual listed in subsection (4) of this section, if applicable.
(b) An MCO shall confirm in writing receipt
of an oral appeal unless an expedited resolution has been requested.
(10) An MCO shall extend the
thirty (30) day timeframe for resolution of an appeal established in subsection
(6) of this section by fourteen (14) calendar days if:
(a) The enrollee requests the extension;
or
(b)
1. The MCO demonstrates to the department
that there is need for additional information; and
2. The extension is in the enrollee's
interest.
(11) For an extension requested by an MCO,
the MCO shall give the enrollee written notice of the extension and the reason
for the extension within two (2) working days of the decision to
extend.
(12)
(a) For an appeal, an MCO shall provide
written notice of its decision within thirty (30) calendar days to an enrollee
or a provider, if the provider filed the appeal.
(b) The provider shall:
1. Give a copy of the notice to the enrollee;
or
2. Inform the enrollee of the
provisions of the notice.
(13) An MCO shall:
(a) Continue to provide benefits to an
enrollee, if the enrollee requested a continuation of benefits, until one (1)
of the following occurs:
1. The enrollee
withdraws the appeal;
2. Fourteen
(14) calendar days have passed since the date of the resolution letter, if the
resolution of the appeal was against the enrollee and the enrollee has not
requested a state fair hearing or taken any further action; or
3. A state fair hearing decision adverse to
the enrollee has been issued;
(b) Have an expedited review process for
appeals if the MCO determines that allowing the time for a standard resolution
could seriously jeopardize an enrollee's life or health or ability to attain,
maintain, or regain maximum function;
(c) Except as established in paragraph (d) of
this subsection, resolve an expedited appeal within three (3) working days of
receipt of the request; and
(d)
Extend the timeframe for an expedited appeal established in paragraph (c) of
this subsection by up to fourteen (14) calendar days if:
1. The enrollee requests the extension;
or
2.
a. The MCO demonstrates to the department
that there is need for additional information; and
b. The extension is in the enrollee's
interest.
(14) For an extension requested by an MCO,
the MCO shall give the enrollee written notice of the reason for the
extension.
(15) If an MCO denies a
request for an expedited resolution of an appeal, the MCO shall:
(a) Transfer the appeal to the thirty (30)
day timeframe for a standard resolution, in which the thirty (30) day period
shall begin on the date the MCO received the original request for
appeal;
(b) Give prompt oral notice
of the denial; and
(c) Follow up
with a written notice within two (2) calendar days of the denial.
(16) An MCO shall document in
writing an oral request for an expedited resolution and shall maintain the
documentation in the enrollee case file.
(17) If an MCO takes adverse action at the
conclusion of an internal appeal process, the MCO shall issue an adverse action
letter to the enrollee that complies with
KRS 13B.050(3)(d)
and (e).
(18)
(a) The
requirements and policies established in this section regarding an MCO appeal
shall apply to an MCO.
(b) If a
requirement or policy regarding an appeal or an MCO appeal stated in another
Kentucky administrative regulation within Title 907 of the Kentucky
Administrative Regulations contradicts a requirement or policy regarding an MCO
appeal that is established in this section, the requirement stated in the other
administrative regulation shall not apply to an MCO.
Section 5. Department's State Fair
Hearing for an Enrollee.
(1) An enrollee may
have a state fair hearing administered by the department in accordance with KRS
Chapter 13B only after exhausting an MCO's internal appeal process.
(2) The department shall provide an enrollee
with a hearing process that shall adhere to
907
KAR 1:563; 42 C.F.R. 438, Subpart F (438.400-438.424);
and 42 C.F.R. 431, Subpart E (431.200-431.250).
(3)
(a) An
enrollee or authorized representative may request a state fair hearing by
filing a written request with the department.
(b) If an enrollee or authorized
representative requests a hearing, the request shall:
1. Be in writing and specify the reason for
the request;
2. Indicate the date
of service or the type of service denied; and
3. Be postmarked or filed within 120 calendar
days from the date of the MCO adverse action letter issued at the conclusion of
the MCO internal appeal process.
(4) A document supporting an MCO's adverse
action shall be:
(a) Received by the
department no later than five (5) calendar days from the date the MCO receives
a notice from the department that a request for a state fair hearing has been
filed by an enrollee; and
(b) Made
available to an enrollee upon request by either the enrollee or the enrollee's
legal counsel.
(5) An
automatic ruling shall be made by the department in favor of an enrollee if an
MCO fails to:
(a) Comply with the requirements
of:
1. Section 4 of this administrative
regulation; or
2. Subsection (4) of
this section; or
(b)
Participate in and present evidence at the state fair hearing.
Section 6. Enrollee
Selection of Primary Care Provider.
(1) Except
for an enrollee established in subsection (2) of this section, an MCO shall
have a process for enrollee selection and assignment of a primary care
provider.
(2) The following shall
not be required to have, but may request, a primary care provider:
(a) A dual eligible;
(b) A child in foster care;
(c) A child under the age of eighteen (18)
years who is disabled;
(d) A
pregnant woman who is presumptively eligible pursuant to
907 KAR
20:050; or
(e) An adult for whom the state is appointed
a guardian.
(3)
(a) For an enrollee who is not receiving
supplemental security income benefits:
1. An
MCO shall notify the enrollee within ten (10) calendar days of notification of
enrollment by the department of the procedure for choosing a primary care
provider; and
2. If the enrollee
does not choose a primary care provider, an MCO shall assign to the enrollee a
primary care provider who:
a. Has
historically provided services to the enrollee; and
b. Meets the requirements of subsection (6)
of this section.
(b) If there is not a primary care provider
that meets the requirements of paragraph (a)2. of this subsection, an MCO shall
assign the enrollee to a primary care provider who is within:
1. Thirty (30) miles or thirty (30) minutes
from the enrollee's residence if the enrollee is in an urban area; or
2. Forty-five (45) miles or forty-five (45)
minutes from the enrollee's residence if the enrollee is in a rural
area.
(4)
(a) For an enrollee who is receiving
supplemental security income benefits and is not a dual eligible, an MCO shall
notify the enrollee of the procedure for choosing a primary care
provider.
(b) If an enrollee has
not chosen a primary care provider within thirty (30) calendar days, an MCO
shall send a second notice to the enrollee.
(c) If an enrollee has not chosen a primary
care provider within thirty (30) calendar days of the second notice, the MCO
shall send a third notice to the enrollee.
(d) If an enrollee has not chosen a primary
care provider within thirty (30) calendar days after the third notice, the MCO
shall assign a primary care provider.
(e) Except for an enrollee who was previously
enrolled with the MCO, an MCO shall not automatically assign a primary care
provider within ninety (90) calendar days of the enrollee's initial
enrollment.
(5)
(a) An enrollee may select from at least two
(2) primary care providers within an MCO's provider network.
(b) At least one (1) of the two (2) primary
care providers established in paragraph (a) of this subsection shall be a
physician.
(6) A primary
care provider shall:
(a) Be a licensed or
certified health care practitioner who functions within the provider's scope of
licensure or certification, including:
1. A
physician;
2. An advanced practice
registered nurse;
3. A physician
assistant; or
4. A clinic,
including a primary care center, federally qualified health center, federally
qualified health center look-alike, or rural health clinic;
(b) Have admitting privileges at a
hospital or a formal referral agreement with a provider possessing admitting
privileges;
(c) Agree to provide
twenty-four (24) hours a day, seven (7) days a week primary health care
services to enrollees; and
(d) For
an enrollee who has a gynecological or obstetrical health care need, a
disability, or chronic illness, be a specialist who agrees to provide or
arrange for primary and preventive care.
(7) Upon enrollment in an MCO, an enrollee
may change primary care providers:
(a) Within
the first ninety (90) calendar days of assignment;
(b) Once a year regardless of
reason;
(c) At any time for a
reason approved by the MCO;
(d) If,
during a temporary loss of eligibility, an enrollee loses the opportunity
provided by paragraph (b) of this subsection;
(e) If Medicare or Medicaid imposes a
sanction on the PCP;
(f) If the PCP
is no longer in the MCO provider network; or
(g) At any time with cause, which shall
include the enrollee:
1. Receiving poor
quality of care;
2. Lacking access
to providers qualified to treat the enrollee's medical condition; or
3. Being denied access to needed medical
services.
(8)
A PCP shall not request the reassignment of an enrollee to a different PCP for
the following reasons:
(a) A change in the
enrollee's health status or treatment needs;
(b) An enrollee's utilization of health
services;
(c) An enrollee's
diminished mental capacity; or
(d)
Disruptive behavior of an enrollee due to the enrollee's special health care
needs unless the behavior impairs the PCP's ability to provide services to the
enrollee or others.
(9)
A PCP change request shall not be based on race, color, national origin,
disability, age, or gender.
(10) An
MCO may approve or deny a primary care provider change.
(11) An enrollee shall be able to obtain the
following services outside of an MCO's provider network:
(a) A family planning service in accordance
with
42 C.F.R.
431.51;
(b) An emergency service in accordance with
42 C.F.R.
438.114;
(d) An out-of-network service
that an MCO is unable to provide within its network to meet the medical need of
the enrollee in accordance with
42 C.F.R.
438.206(b)(4) subject to any
prior authorization requirements of the MCO.
(12) An MCO shall:
(a) Notify an enrollee within:
1. Thirty (30) calendar days of the effective
date of a voluntary termination of the enrollee's primary care provider;
or
2. Fifteen (15) calendar days of
an involuntary termination of the enrollee's primary care provider;
and
(b) Assist the
enrollee in selecting a new primary care provider.
Section 7. Member Handbook. An MCO
shall send a member handbook to an enrollee as required by
42 C.F.R.
438.10.
Section 8. Enrollee Non-Liability and
Liability for Payment.
(1)
(a) Except as established in Section 9 of
this administrative regulation, an enrollee shall not be required to pay for a
medically necessary covered service provided by the enrollee's MCO.
(2) An MCO shall not impose cost
sharing on an enrollee greater than the limits established by the department in
907
KAR 1:604.
Section 9. Recoupment of Payment from an
Enrollee for Fraud, Waste, or Abuse.
(1) If an
enrollee is determined to be ineligible for Medicaid through an administrative
hearing or adjudication of fraud by the CHFS OIG, the department shall recoup a
capitation payment it has made to an MCO on behalf of the enrollee.
(2) An MCO shall request a refund from the
enrollee established in subsection (1) of this section of a payment the MCO has
made to a provider for the service provided to the enrollee.
(3) If an MCO has been unable to collect a
refund established in subsection (2) of this section within six (6) months, the
commonwealth may recover the refund from the enrollee.
Section 10. Third Party Liability and
Coordination of Benefits.
(1) Medicaid shall
be the payer of last resort for a service provided to an enrollee.
(2) An MCO shall:
(a) Exhaust a payment by a third party prior
to payment for a service provided to an enrollee;
(b) Be responsible for determining a legal
liability of a third party to pay for a service provided to an
enrollee;
(c) Actively seek and
identify a third party liability resource to pay for a service provided to an
enrollee in accordance with
42 C.F.R.
433.138; and
(d) Assure that Medicaid shall be the payer
of last resort for a service provided to an enrollee.
(3) In accordance with
907
KAR 20:005 and
KRS
205.624, an enrollee shall:
(a) Assign, in writing, to the MCO the
enrollee's rights to a medical support or payment from a third party for a
medical service paid for by the MCO; and
(b) Cooperate with an MCO in identifying and
providing information to assist the MCO in pursuing a third party that may be
liable for care or services.
(4) If an MCO becomes aware of a third party
liability resource after payment for a service provided to an enrollee, the MCO
shall seek recovery from the third party resource.
Section 11. Legal Guardians.
(1) A parent, custodial parent, person
exercising custodial control or supervision, or an agency with a legal
responsibility for a child by virtue of a voluntary commitment or of an
emergency or temporary custody order may act on behalf of an enrollee who is
under the age of eighteen (18) years, a potential enrollee, or a former
enrollee for the purpose of:
(a) Selecting a
primary care provider;
(b) Filing a
grievance or appeal; or
(c) Taking
an action on behalf of the child regarding an interaction with an
MCO.
(2)
(a) A legal guardian who has been appointed
pursuant to
KRS
387.500 through
387.800 may act on behalf
of an enrollee who is a ward of the commonwealth.
(b) A person authorized to make a health care
decision pursuant to
KRS
311.621 through
311.643
may act on behalf of an enrollee, potential enrollee, or former enrollee in
making the health care decisions.
(c) An enrollee may:
1. Represent the enrollee; or
2. Use legal counsel, a relative, a friend,
or other spokesperson.
Section 12. Enrollees with Special Health
Care Needs.
(1)
(a) In accordance with
42 C.F.R.
438.208, the following shall be considered an
individual with a special health care need:
1. A child in or receiving foster care or
state-funded adoption assistance;
2. A homeless individual;
3. An individual with a chronic physical or
behavioral illness;
4. A blind or
disabled child;
5. An individual
who is eligible for SSI benefits; or
6. An adult who is a ward of the Commonwealth
in accordance with 910 KAR Chapter 2.
(b) In accordance with
42 C.F.R.
438.208, an MCO shall:
1. Have a process to target enrollees for the
purpose of screening and identifying those with special health care
needs;
2. Assess each enrollee
identified by the department as having a special health care need to determine
if the enrollee needs case management or regular care monitoring;
3. Include the use of appropriate health care
professionals to perform an assessment; and
4. Have a treatment plan for an enrollee with
a special health care need who has been determined, through an assessment, to
need a course of treatment or regular care monitoring.
(c)
1. An
enrollee who is a child in foster care shall be enrolled with an MCO through a
service plan that shall be completed for the enrollee by DCBS prior to being
enrolled with the MCO.
2.
a. The service plan referenced in
subparagraph 1. of this paragraph shall be used by DCBS and the MCO to
determine the enrollee's medical needs and to identify if there is a need for
case management.
b. The MCO shall
be available to meet with DCBS at least quarterly to discuss the health care
needs of the child as identified in the service plan. The child's caretaker may
attend each meeting held to discuss the health care needs of that
child.
c. If a service plan
identifies the need for case management or DCBS requests case management for an
enrollee, the foster parent of the child or DCBS shall work with the MCO to
develop a case management plan of care.
d. The MCO shall consult with DCBS prior to
developing or modifying a case management plan of care.
e. If the service plan accomplishes a
requirement established in paragraph (b) of this subsection, the requirement
shall be considered to have been met.
(2) A treatment plan established
in subsection (1)(b)4. of this section shall be developed:
(a) With participation from the enrollee or
the enrollee's legal guardian as referenced in Section 11 of this
administrative regulation; and
(b)
By the enrollee's primary care provider, if the enrollee has a primary care
provider.
(3) An MCO
shall:
(a)
1. Develop materials specific to the needs of
an enrollee with a special health care need; and
2. Provide the materials established in
subparagraph 1. of this paragraph to the enrollee, caregiver, parent, or legal
guardian;
(b) Have a
mechanism to allow an enrollee identified as having a special health care need
to directly access a specialist, as appropriate, for the enrollee's condition
and identified need; and
(c) Be
responsible for the ongoing care coordination for an enrollee with a special
health care need.
(4)
The information established in subsection (3)(a) of this section shall include
health educational material to assist the enrollee with a special health care
need or the enrollee's caregiver, parent, or legal guardian in understanding
the enrollee's special need.
(5)
(a) An enrollee who is a ward of the
commonwealth shall be enrolled with an MCO through a service plan that shall be
completed for the enrollee by DAIL prior to being enrolled with the
MCO.
(b) If the service plan
established in paragraph (a) of this subsection identifies the need for case
management, the MCO shall work with DAIL or the enrollee to develop a case
management plan of care.
Section 13. Second Opinion. An enrollee may
get a second opinion within the MCO's provider network for a surgical procedure
or diagnosis and treatment of a complex or chronic condition.
Section 14. Managed Care Requirements.
(1) All aspects of managed care shall be
governed and controlled by the applicable federal and state laws, including 42
C.F.R. Part 438, 42 U.S.C. 1396n, and
42 U.S.C.
1396u-2, and the negotiated terms of the
contract between a managed care organization and the department.
(2) The current MCO contracts shall be posted
on the department's Web site at
https://chfs.ky.gov/agencies/dms/dpqo/Pages/mco-contracts.aspx.
Section 15. Centers for Medicare
and Medicaid Services Approval and Federal Financial Participation. A policy
established in this administrative regulation shall be null and void if the
Centers for Medicare and Medicaid Services:
(1) Denies or does not provide federal
financial participation for the policy; or
(2) Disapproves the policy.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.