907 Ky. Admin. Regs. 3:310

Current through Register Vol. 51, No. 5, November 1, 2024

Section 907 KAR 3:310 - Community Health Worker services and reimbursement

RELATES TO: KRS 309.460-309.464, 369.101-369.120

NECESSITY, FUNCTION, AND CONFORMITY: KRS 194A.030(2) requires the Cabinet for Health and Family Services, Department for Medicaid Services 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. KRS 205.648 requires DMS to seek a state plan amendment and implement covered services on behalf of community health workers. This administrative regulation establishes community health worker services and reimbursement.

Section 1. Definitions.

(1) "Certified community health worker" is defined by KRS 309.460(2).

(2) "Department" means the Department for Medicaid Services or its designee.

(3) "Medical intervention":

(a) Means a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways; and

(b) Includes, but does not require the direct application of medical care.

(4) "Ordering provider" means a provider that is employed by or contracted with a sponsoring provider and who is:

(a) A physician;

(b) A physician assistant;

(c) An advanced practice registered nurse, including a certified nurse midwife;

(d) A dentist;

(e) An optometrist; or

(f) Any other clinician type included by the department.

(5) "Sponsoring provider":

(a) Means a provider listed or permitted to employ a certified community health worker pursuant to KRS 205.648(2); and

(b)

1. Includes a behavioral health multi-specialty group; or

2. Any other provider or facility that has been approved pursuant to KRS 205.648(2)(b) 10.

Section 2. Certified Community Health Worker Qualifications. In order to be eligible for reimbursement, a certified community health worker shall:

(1) Be a legal United States resident;

(2) Be employed as a certified community health worker in the state of Kentucky;

(3) Be at least eighteen (18) years of age;

(4) Meet and maintain the certification or recertification requirements of 902 KAR 21:040;

(5) Provide services as approved by an ordering provider who is associated with a sponsoring provider; and

(6) Provide services on behalf of a sponsoring provider.

Section 3. Community Health Worker Services.

(1) A community health worker service shall be related to a medical intervention that is outlined in the individual's care plan.

(2) Community health worker services shall include all services established within KRS 205.648(3)(a)-(e).

(3) Consistent with federal approval, the following services may be conducted by a certified community health worker. Any services provided shall be consistent with established or recognized healthcare standards:

(a) Health system navigation and resource coordination, which may include:

1. Helping a recipient find Medicaid providers to receive a covered service;

2. Helping a recipient make an appointment for a Medicaid covered service;

3. Arranging transportation to a medical appointment;

4. Attending an appointment with the recipient for a covered service; or

5. Helping a recipient find other relevant community resources such as support groups.

(b) Health promotion and coaching, which may include providing information or training to recipients that make positive contributions to their health status, such as:

1. Cessation of tobacco use;

2. Reduction in the misuse of alcohol or drugs;

3. Improvement in nutrition;

4. Improvement of physical fitness;

5. Family planning;

6. Control of stress; or

7. Pregnancy and infant care, including prevention of fetal alcohol syndrome.

(c) Health education and training to train or promote to recipients methods and measures that have been proven effective in avoiding illness or lessening its effects, including:

1. Immunizations;

2. Control of high blood pressure;

3. Control of sexually transmittable disease;

4. Prevention and control of diabetes;

5. Control of toxic agents;

6. Occupational safety and health; or

7. Accident prevention.

Section 4. Ordering and Delivery of Community Health Worker Services. Community health worker services shall be:

(1) Ordered or approved by an ordering provider; and

(2) Delivered according to a care plan approved by the ordering provider.

Section 5. Documentation of Community Health Worker Services. Community health worker services shall be:

(1) Signed and documented by the certified community health worker;

(2) Approved by the ordering provider of the sponsoring provider; and

(3) Recorded and kept in the patient medical record.

Section 6. Reimbursement for Community Health Worker Services. Reimbursement for community health worker services shall be via appropriate codes that comply with relevant existing rate methodologies utilized by the department and established by state and federal law. As appropriate, billing and reimbursement information shall be included in the Medicaid Physician Fee Schedule established in 907 KAR 3:010, available at: https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.

Section 7. There shall not be reimbursement under this administrative regulation available for a certified community health worker:

(1) If performing a specific service that is funded by a federal grant, and only for that specific federally grant-funded service; or

(2) That is directly employed by a managed care organization.

Section 8. A community health worker service, by itself, shall not generate a wrap payment, including wrap payments for the following provider types:

(1) Federally qualified health center (FQHC);

(2) Rural health clinic (RHC); or

(3) Certified community behavioral health clinic (CCBHC).

Section 9. Use of Electronic Signatures. The creation, transmission, storage, and other use of electronic signatures and documents shall comply with the requirements established in KRS 369.101 to 369.120.

Section 10. Auditing Authority. The department or the managed care organization in which an enrollee is enrolled may audit any:

(1) Claim;

(2) Medical record; or

(3) Documentation associated with any claim or medical record.

Section 11. Federal Approval and Federal Financial Participation. The coverage provisions and requirements established in 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 of the coverage.

Section 12. Appeal Rights. An appeal of a department decision or adverse action regarding a Medicaid recipient who is:

(1) Enrolled with a managed care organization shall be in accordance with 907 KAR 17:010; or

(2) Not enrolled with a managed care organization shall be in accordance with 907 KAR 1:563.

907 KAR 3:310

49 Ky.R. 2174; eff. 1/18/2024.

STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.648