RELATES TO:
KRS 205.5605(2), 34 C.F.R.
Subtitle B, Chapter III, 42
C.F.R. 441.300- 310, 29 U.S.C. Chapter 16,
42 U.S.C.
1396a, b, d, n
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health
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 for the provision of
medical assistance to Kentucky's indigent citizenry. This administrative
regulation establishes the payment provisions relating to home - and community
-based waiver services provided to an individual with an acquired brain injury
as an alternative to nursing facility services for the purpose of
rehabilitation and retraining for reentry into the community with existing
resources.
Section 1. Definitions.
(1) "ABI" means an acquired brain
injury.
(2) "ABI provider" means an
entity that meets the provider criteria established in
907 KAR 3:090, Section
2.
(3) "ABI recipient" means an
individual who meets the ABI recipient criteria established in
907 KAR 3:090, Section
3.
(4) "Acquired brain injury
waiver service" or "ABI waiver service" means a home and community based waiver
service provided to a Medicaid eligible individual who has acquired a brain
injury.
(5) "Consumer" is defined
by KRS 205.5605(2).
(6) "Consumer directed option" or "CDO" means
an option established by
KRS 205.5606 within the home and community based
services waiver that allows recipients to:
(a)
Assist with the design of their programs;
(b) Choose their providers of services;
and
(c) Direct the delivery of
services to meet their needs.
(7) "Department" means the Department for
Medicaid Services or its designated agent.
(8) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
Section 2. Coverage. The department shall
reimburse a participating provider for an ABI waiver service if the service is:
(1) Provided to an ABI recipient;
(2) Prior authorized;
(3) Included in the recipient's plan of
care;
(4) Medically necessary;
and
(5) Essential for the
rehabilitation and retraining of the recipient.
Section 3. Exclusions to Acquired Brain
Injury Waiver Program. Under the ABI waiver program, the department shall not
reimburse a provider for a service provided:
(1) To an individual who has a condition
identified in
907 KAR 3:090, Section 5;
or
(2) Which has not been prior
authorized as a part of the recipient's plan of care.
Section 4. Payment Amounts.
(1) A participating ABI waiver service
provider shall be reimbursed a fixed rate for reasonable and medically
necessary services for a prior-authorized unit of service provided to a
recipient.
(2) A participating ABI
waiver service provider certified in accordance with
907 KAR
3:090 shall be reimbursed
at the lesser of:
(a) The provider's usual and
customary charge; or
(b) The
Medicaid per unit of service as established in Section 5 of this administrative
regulation.
Section
5. Base Payment Rate Table and Reimbursement Requirements.
(1) The rates established in the following
table shall establish the base payment rate for ABI waiver services:
|
Service
|
Unit
|
Base Rate Effective January 1, 2025
|
|
Adult Day Training
|
15-minute
|
$4.88
|
|
Assessment & Reassessment
|
Per assessment
|
$121.00
|
|
Behavior Programming
|
15-minute
|
$40.67
|
|
Case Management
|
Per month
|
$525.14
|
|
Companion
|
15-minute
|
$6.73
|
|
Companion - PDS
|
15-minute
|
$6.73
|
|
Counseling, Individual
|
15-minute
|
$28.85
|
|
Counseling, Group
|
15-minute
|
$6.96
|
|
Environmental or Minor Home
Adaptation
|
Per year
|
Up to $2,420.00
|
|
Financial Management Services
|
Per month
|
$121.00
|
|
Occupational Therapy
|
15-minute
|
$31.34
|
|
Personal Care
|
15-minute
|
$6.73
|
|
Personal Care - PDS
|
15-minute
|
$6.73
|
|
Respite
|
15-minute
|
$5.92
|
|
Respite - PDS
|
15-minute
|
$5.92
|
|
Speech Therapy
|
15-minute
|
$34.38
|
|
Supervised Residential Care - Level I
|
Per day
|
$300.00
|
|
Supervised Residential Care - Level
II
|
Per day
|
$225.00
|
|
Supervised Residential Care - Level
III
|
Per day
|
$112.50
|
|
Supported Employment
|
15-minute
|
$10.54
|
|
Supported Employment - PDS
|
15-minute
|
$10.54
|
(2)
Specialized medical equipment and supplies shall be reimbursed on a per-item
basis based on a reasonable cost as negotiated by the department if the
equipment or supply is:
(a) Not covered
through the Medicaid durable medical equipment program established in
907 KAR 1:479; and
(b) Provided to an individual participating
in the ABI waiver program.
(3) Respite care may exceed 336 hours in a
twelve (12) month period if an individual's normal caregiver is unable to
provide care due to a death in the family, serious illness, or
hospitalization.
(4) If an ABI
recipient is placed in a nursing facility to receive respite care, the
department shall pay the nursing facility its per diem rate for that
individual.
(5) If supported
employment services are provided at a work site in which persons without
disabilities are employed, payment shall:
(a)
Be made only for the supervision and training required as the result of the ABI
recipient's disabilities; and
(b)
Not include payment for supervisory activities normally rendered.
(6)
(a) The department shall only pay for
supported employment services for an individual if supported employment
services are unavailable under a program funded by either the Rehabilitation
Act of 1973 (29 U.S.C. Chapter
16) or Pub.L.
94-142 (
34 C.F.R. Subtitle B,
Chapter III).
(b) For an individual
receiving supported employment services, documentation shall be maintained in
his or her record demonstrating that the services are not otherwise available
under a program funded by either the Rehabilitation Act of 1973 (29 U.S.C.
Chapter
16) or Pub.L.
94-142 (
34 C.F.R. Subtitle B, Chapter III).
Section 6. Payment
Exclusions. Payment shall not include:
(1) The
cost of room and board, unless provided as part of respite care in a Medicaid
certified nursing facility;
(2) The
cost of maintenance, upkeep, an improvement, or an environmental modification
to a group home or other licensed facility;
(3) Excluding an environmental modification,
the cost of maintenance, upkeep, or an improvement to a recipient's place of
residence;
(4) The cost of a
service that is not listed in the recipient's approved plan of care;
or
(5) A service provided by a
family member.
Section 7.
Records Maintenance. A participating provider shall:
(1) Maintain fiscal and service records for
at least six (6) years;
(2)
Provide, as requested by the department, a copy of, and access to, each record
of the ABI waiver program retained by the provider pursuant to:
(a) Subsection (1) of this section;
or
(3) Upon request, make available
service and financial records to a representative or designee of:
(a) The Commonwealth of Kentucky, Cabinet for
Health and Family Services;
(b) The
United States Department for Health and Human Services, Comptroller
General;
(c) The United States
Department for Health and Human Services, the Centers for Medicare and Medicaid
Services (CMS);
(d) The General
Accounting Office;
(e) The
Commonwealth of Kentucky, Office of the Auditor of Public Accounts;
or
(f) The Commonwealth of
Kentucky, Office of the Attorney General.
Section 8. Appeal Rights. An ABI waiver
provider may appeal department decisions as to the application of this
administrative regulation as it impacts the provider's reimbursement in
accordance with
907 KAR 1:671, Sections 8 and
9.
Section 9. Federal Approval and
Federal Financial Participation. The department's coverage of services pursuant
to this administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
