RELATES TO:
KRS 96A.095,
205.520,
281.010,
281.605(9),
281.635(5),
281.872,
281.875,
42 C.F.R.
431.53,
440.170,
42 U.S.C.
1396n(b)
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 establishes the coverage and
payment requirements for nonemergency medical transportation services,
excluding ambulance stretcher services, provided pursuant to
42 U.S.C.
1396n(b) and approved by the
Centers for Medicare and Medicaid Services to waive Medicaid requirements
related to nonemergency medical transportation of Medicaid requirements.
Section 1. Definitions.
(1) "Capitated rate" means one (1) amount
paid each month:
(a) For each Medicaid
recipient covered under authority of the waiver; and
(b) That is:
1. Not a statewide rate; and
2. Set individually for each human service
transportation delivery region as established in
603 KAR 7:080.
(2) "Department" means
the Department for Medicaid Services or its designee.
(3) "Human service transportation" means
provision of mass transportation and taxi services to transport an individual
who is eligible to receive Medicaid transportation services.
(4) "Nonemergency medical transportation" or
"NEMT" means medical transportation not of an emergency nature, excluding
ambulance stretcher services, provided to an eligible Medicaid recipient by the
Transportation Cabinet pursuant to an agreement between the Transportation
Cabinet and the department.
(5)
"Waiver authority" means the provisions contained in
42 U.S.C.
1396n(b).
Section 2. Interagency Agreement. Pursuant to
waiver authority granted by the Centers for Medicare and Medicaid Services, the
Department for Medicaid Services may enter into an agreement with the
Transportation Cabinet for the provision of nonemergency medical transportation
to a Medicaid recipient.
Section 3.
Coverage.
(1) The coverage provisions
established in
603 KAR 7:080 shall comply with
this administrative regulation.
(2)
(a) A Medicaid-eligible recipient may receive
nonemergency medical transportation services if the recipient meets the
following conditions:
1. The recipient is
traveling to or from a Medicaid-covered service;
2. The service is determined to be of medical
necessity; and
3.
a. The recipient does not own a vehicle;
or
b. The recipient owns a vehicle,
but a clinician, employer, school, mechanic, or transportation authority issues
a note that is submitted by the recipient that states the vehicle is not:
(i) Operable; or
(ii) Usable for the recipient.
(b) A
recipient who is under the age of eighteen (18) shall have the same vehicle
ownership status as the custodial parent or legal guardian.
(c) A parent or guardian may request a two
(2) week exemption to paragraph (b) of this subsection in order to allow a
child recipient to attend medically necessary services.
(3)
(a) A
transportation provider shall not self-refer or solicit a recipient or a
recipient's parent or guardian to use NEMT if the recipient or recipient's
parent or guardian owns or has access to appropriate transportation pursuant to
this section.
(b) A transportation
provider that self-refers or solicits a recipient or a recipient's parent or
guardian pursuant to paragraph (a) of this subsection may be excluded from
offering NEMT on a permanent or temporary basis.
Section 4. Reimbursement.
(1) The Transportation Cabinet shall be
reimbursed at a monthly capitated rate set by the department for each Medicaid
recipient receiving services pursuant to this administrative
regulation.
(2) The capitated rate
shall not exceed the Medicaid Program's usual aggregate cost on a projected
statewide basis of providing nonemergency medical transportation services to
the covered group of recipients.
Section 5. Appeal Rights.
(1) An appeal of a negative action regarding
a Medicaid recipient shall be in accordance with
907 KAR 1:563.
(2) An appeal of a negative action regarding
Medicaid eligibility of an individual shall be in accordance with
907 KAR 1:560.
(3) An appeal of a negative action regarding
a Medicaid provider shall be in accordance with
907 KAR 1:671.
Section 6. Implementation. The provisions of
this administrative regulation shall be applicable for nonemergency
transportation waiver services provided in accordance with KRS Chapter 45A and
Section 2 of this administrative regulation.
Section 7. Federal Approval and Federal
Financial Participation. The department's coverage and reimbursement of
services pursuant to this administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage and reimbursement; and
(2) Centers for Medicare and Medicaid
Services' approval of the coverage and reimbursement, as relevant.
