RELATES TO:
42 C.F.R.
441.300- 310,
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 fixed
upper payment limit per unit of service as established in Section 5 of this
administrative regulation.
Section 5. Fixed Upper Payment Limits.
(1) Except as provided by subsection (2) of
this section, the following respective rates shall be the fixed upper payment
limits for the corresponding respective ABI waiver services in conjunction with
the corresponding units of service and unit of service limits:
|
Service
|
Unit of Service
|
Unit of Service Limit
|
Upper Payment Limit
|
|
Case management
|
1 month
|
1 unit per ABI recipient per month
|
$434.00 per month
|
|
Personal care
|
15 minutes
|
80 units per week
|
$5.56 per unit
|
|
Respite care
|
15 minutes
|
1,344 units per 12-month period
|
$4.00 per unit
|
|
Companion
|
15 minutes
|
200 units per week
|
$5.56 per unit
|
|
Adult day training
|
15 minutes
|
160 units, alone or in combination with supported
employment, per calendar week
|
$4.03 per unit
|
|
Supported employment
|
15 minutes
|
160 units, alone or in combination with adult day
training, per calendar week
|
$7.98 per unit
|
|
Behavior programming
|
15 minutes
|
16 units per day
|
$33.61
|
|
Counseling - group
|
15 minutes
|
2 - 8 people in a group setting and 48 units per ABI
recipient per calendar month
|
$5.75 per unit
|
|
Counseling - individual
|
15 minutes
|
16 units per day
|
$23.84 per unit
|
|
Occupational therapy
|
15 minutes
|
16 units per day
|
$25.90 per unit
|
|
Speech, hearing and Language services
|
15 minutes
|
16 units per day
|
$28.41 per unit
|
|
Specialized medical equipment and supplies (see
subsection (2) of this section)
|
Per item
|
As negotiated by the department
|
As negotiated by the department
|
|
Environmental modification
|
Per modification
|
Actual cost not to exceed $2,000.00 per 12-month
period
|
Actual cost not to exceed $2,000.00 per 12-month
period
|
|
Supervised residential care level I
|
1 calendar day
|
1 unit per ABI recipient per calendar day
|
$200.00 per unit
|
|
Supervised residential care level II
|
1 calendar day
|
1 unit per ABI recipient per calendar day
|
$150.00 per unit
|
|
Supervised residential care level III
|
1 calendar day
|
1 unit per ABI recipient per calendar day
|
$75.00 per unit
|
|
Assessment
|
The entire assessment equals 1 unit
|
1 unit per ABI recipient
|
$100.00 per unit
|
|
Reassessment
|
The entire reassessment equals 1 unit
|
1 unit per ABI recipient
|
$100.00 per unit
|
|
CDO home and community supports
|
not applicable
|
not applicable
|
Service limited by prior authorized dollar amount
based on the consumer's budget approved by the department
|
|
CDO community day supports
|
not applicable
|
not applicable
|
Service limited by prior authorized dollar amount
based on the consumer's budget approved by the department
|
|
CDO goods and services
|
not applicable
|
not applicable
|
Service limited by prior authorized dollar amount
based on the consumer's budget approved by the department
|
|
Support broker
|
1 calendar month
|
1 unit per ABI recipient per calendar month
|
$375.00
|
|
Financial management
|
15 minutes
|
8 units or $100.00 per month
|
$12.50 per unit
|
(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 care giver 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 wavier
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.
