907 Ky. Admin. Regs. 9:020

Current through Register Vol. 51, No. 6, December 1, 2024

Section 907 KAR 9:020 - Reimbursement provisions and requirements regarding outpatient behavioral health services provided by Level I or Level II psychiatric residential treatment facilities

RELATES TO: KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 42 U.S.C. 1396a(a)(23)

NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has a 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 reimbursement provisions and requirements regarding Medicaid Program outpatient behavioral health services provided by Level I or Level II psychiatric residential treatment facilities to Medicaid recipients who are not enrolled with a managed care organization.

Section 1. Definitions.

(1) "Advanced practice registered nurse" or "APRN" is defined by KRS 314.011(7).

(2) "Behavioral health practitioner under supervision" means an individual who is:

(a)

1. A licensed professional counselor associate;

2. A certified social worker;

3. A marriage and family therapy associate;

4. A licensed professional art therapist associate;

5. A licensed assistant behavior analyst;

6. A physician assistant;

7. A certified alcohol and drug counselor; or

8. A licensed clinical alcohol and drug counselor associate in accordance with Section 5 of this administrative regulation; and

(b) Employed by or under contract with the same billing provider as the billing supervisor.

(3) "Billing provider" means the individual who, group of individual providers that, or organization that:

(a) Is authorized to bill the department or a managed care organization for a service; and

(b) Is eligible to be reimbursed by the department or a managed care organization for a service.

(4) "Billing supervisor" means an individual who is:

(a)

1. A physician;

2. A psychiatrist;

3. An advanced practice registered nurse;

4. A licensed psychologist;

5. A licensed clinical social worker;

6. A licensed professional clinical counselor;

7. A licensed psychological practitioner;

8. A certified psychologist with autonomous functioning;

9. A licensed marriage and family therapist;

10. A licensed professional art therapist; or

11. A licensed behavior analyst; and

(b) Employed by or under contract with the same billing provider as the behavioral health practitioner under supervision who renders services under the supervision of the billing supervisor.

(5) "Certified alcohol and drug counselor" means an individual who meets the requirements established in KRS 309.083.

(6) "Certified psychologist" means an individual who is a certified psychologist pursuant to KRS 319.056.

(7) "Certified psychologist with autonomous functioning" means an individual who is a certified psychologist with autonomous functioning pursuant to KRS 319.056.

(8) "Certified social worker" means an individual who meets the requirements established in KRS 335.080.

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

(10) "Federal financial participation" is defined by 42 C.F.R. 400.203.

(11) "Healthcare common procedure coding system" or "HCPCS" means a collection of codes acknowledged by the Centers for Medicare and Medicaid Services (CMS) that represents procedures or items.

(12) "Level I PRTF" means a psychiatric residential treatment facility that meets the criteria established in KRS 216B.450(5)(a).

(13) "Level II PRTF" means a psychiatric residential treatment facility that meets the criteria established in KRS 216B.450(5)(b).

(14) "Licensed assistant behavior analyst" is defined by KRS 319C.010(7).

(15) "Licensed behavior analyst" is defined by KRS 319C.010(6).

(16) "Licensed clinical alcohol and drug counselor" is defined by KRS 309.080(4).

(17) "Licensed clinical alcohol and drug counselor associate" is defined by KRS 309.080(5).

(18) "Licensed clinical social worker" means an individual who meets the licensed clinical social worker requirements established in KRS 335.100.

(19) "Licensed marriage and family therapist" is defined by KRS 335.300(2).

(20) "Licensed professional art therapist" is defined by KRS 309.130(2).

(21) "Licensed professional art therapist associate" is defined by KRS 309.130(3).

(22) "Licensed professional clinical counselor" is defined by KRS 335.500(3).

(23) "Licensed professional counselor associate" is defined by KRS 335.500(4).

(24) "Licensed psychological associate" means an individual who:

(a) Currently possesses a licensed psychological associate license in accordance with KRS 319.010(6); and

(b) Meets the licensed psychological associate requirements established in 201 KAR Chapter 26.

(25) "Licensed psychological practitioner" means an individual who meets the requirements established in KRS 319.053.

(26) "Licensed psychologist" means an individual who:

(a) Currently possesses a licensed psychologist license in accordance with KRS 319.010(6); and

(b) Meets the licensed psychologist requirements established in 201 KAR Chapter 26.

(27) "Managed care organization" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined in 42 C.F.R. 438.2.

(28) "Marriage and family therapy associate" is defined by KRS 335.300(3).

(29) "Physician" is defined by KRS 205.510(11).

(30) "Physician assistant" is defined by KRS 311.840(3).

(31) "Provider" is defined by KRS 205.8451(7).

Section 2. General Requirements. For the department to reimburse for a service covered under this administrative regulation, the service shall:

(1) Meet the requirements established in 907 KAR 9:015; and

(2) Be covered in accordance with 907 KAR 9:015.

Section 3. Reimbursement.

(1)

(a) A unit of service for a service listed on the Level I and Level II PRTF Non-Medicare Services Fee Schedule shall be as established on the Level I and Level II PRTF Non-Medicare Services Fee Schedule.

(b) A unit of service for a service not listed on the Level I and Level II PRTF Non-Medicare Services Fee Schedule shall be:

1. Fifteen (15) minutes in length unless a different amount is established for the service in the corresponding:

a. Current procedural terminology code; or

b. Healthcare common procedure coding system code; or

2. The unit amount established in the corresponding:

a. Current procedural terminology code; or

b. Healthcare common procedure coding system code.

(2) The rate per unit for a screening or for crisis intervention shall be:

(a) Seventy-five (75) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Physician; or

2. Psychiatrist;

(b) 63.75 percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by:

1. An advanced practice registered nurse; or

2. A licensed psychologist;

(c) Sixty (60) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Licensed professional clinical counselor;

2. Licensed clinical social worker;

3. Licensed psychological practitioner;

4. Certified psychologist with autonomous functioning;

5. Licensed marriage and family therapist;

6. Licensed professional art therapist; or

7. Licensed clinical alcohol and drug counselor in accordance with Section 5 of this administrative regulation; or

(d) Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Marriage and family therapy associate working under the supervision of a billing supervisor;

2. Licensed professional counselor associate working under the supervision of a billing supervisor;

3. Licensed psychological associate working under the supervision of a board-approved licensed psychologist;

4. Certified psychologist working under the supervision of a board-approved licensed psychologist;

5. Certified social worker working under the supervision of a billing supervisor;

6. Physician assistant working under the supervision of a billing supervisor;

7. Licensed professional art therapist associate working under the supervision of a billing supervisor;

8. Certified alcohol and drug counselor working under the supervision of a billing supervisor; or

9. Licensed clinical alcohol and drug counselor associate:

a. In accordance with Section 5 of this administrative regulation; and

b. Working under the supervision of a billing supervisor.

(3) The rate per unit for an assessment shall be:

(a) Seventy-five (75) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Physician; or

2. Psychiatrist;

(b) 63.75 percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by:

1. An advanced practice registered nurse; or

2. A licensed psychologist;

(c) Sixty (60) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Licensed professional clinical counselor;

2. Licensed clinical social worker;

3. Licensed psychological practitioner;

4. Certified psychologist with autonomous functioning;

5. Licensed marriage and family therapist;

6. Licensed professional art therapist;

7. Licensed behavior analyst; or

8. Licensed clinical alcohol and drug counselor in accordance with Section 5 of this administrative regulation; or

(d) Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Marriage and family therapy associate working under the supervision of a billing supervisor;

2. Licensed professional counselor associate working under the supervision of a billing supervisor;

3. Licensed psychological associate working under the supervision of a board-approved licensed psychologist;

4. Certified psychologist working under the supervision of a board-approved licensed psychologist;

5. Certified social worker working under the supervision of a billing supervisor;

6. Physician assistant working under the supervision of a billing supervisor;

7. Licensed professional art therapist associate working under the supervision of a billing supervisor;

8. Licensed assistant behavior analyst working under the supervision of a billing supervisor;

9. Certified alcohol and drug counselor working under the supervision of a billing supervisor; or

10. Licensed clinical alcohol and drug counselor associate:

a. In accordance with Section 5 of this administrative regulation; and

b. Working under the supervision of a billing supervisor.

(4) The rate per unit for psychological testing shall be:

(a) 63.75 percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a licensed psychologist;

(b) Sixty (60) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Licensed psychological practitioner; or

2. Certified psychologist with autonomous functioning;

(c) Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Licensed psychological associate working under the supervision of a board-approved licensed psychologist; or

2. Certified psychologist working under the supervision of a board-approved licensed psychologist.

(5) The rate per unit for individual outpatient therapy, group outpatient therapy, or collateral outpatient therapy shall be:

(a) Seventy-five (75) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Physician; or

2. Psychiatrist;

(b) 63.75 percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by:

1. An advanced practice registered nurse; or

2. A licensed psychologist;

(c) Sixty (60) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Licensed professional clinical counselor;

2. Licensed clinical social worker;

3. Licensed psychological practitioner;

4. Certified psychologist with autonomous functioning;

5. Licensed marriage and family therapist;

6. Licensed professional art therapist;

7. Licensed behavior analyst; or

8. Licensed clinical alcohol and drug counselor in accordance with Section 5 of this administrative regulation; or

(d) Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Marriage and family therapy associate working under the supervision of a billing supervisor;

2. Licensed professional counselor associate working under the supervision of a billing supervisor;

3. Licensed psychological associate working under the supervision of a board-approved licensed psychologist;

4. Certified psychologist working under the supervision of a board-approved licensed psychologist;

5. Certified social worker working under the supervision of a billing supervisor;

6. Physician assistant working under the supervision of a billing supervisor;

7. Licensed professional art therapist associate working under the supervision of a billing supervisor;

8. Licensed assistant behavior analyst working under the supervision of a billing supervisor;

9. Certified alcohol and drug counselor working under the supervision of a billing supervisor; or

10. Licensed clinical alcohol and drug counselor associate:

a. In accordance with Section 5 of this administrative regulation; and

b. Working under the supervision of a billing supervisor.

(6) The rate per unit for family outpatient therapy shall be:

(a) Seventy-five (75) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Physician; or

2. Psychiatrist;

(b) 63.75 percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by:

1. An advanced practice registered nurse; or

2. A licensed psychologist;

(c) Sixty (60) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Licensed professional clinical counselor;

2. Licensed clinical social worker;

3. Licensed psychological practitioner;

4. Certified psychologist with autonomous functioning;

5. Licensed marriage and family therapist;

6. Licensed professional art therapist; or

7. Licensed clinical alcohol and drug counselor in accordance with Section 5 of this administrative regulation; or

(d) Fifty-two and five-tenths (52.5) percent of the rate on the Kentucky-specific Medicare Physician Fee Schedule for the service if provided by a:

1. Marriage and family therapy associate working under the supervision of a billing supervisor;

2. Licensed professional counselor associate working under the supervision of a billing supervisor;

3. Licensed psychological associate working under the supervision of a board-approved licensed psychologist;

4. Certified psychologist working under the supervision of a board-approved licensed psychologist;

5. Certified social worker working under the supervision of a billing supervisor;

6. Physician assistant working under the supervision of a billing supervisor;

7. Licensed professional art therapist associate working under the supervision of a billing supervisor;

8. Certified alcohol and drug counselor working under the supervision of a billing supervisor; or

9. Licensed clinical alcohol and drug counselor associate in accordance with Section 5 of this administrative regulation.

(7) Reimbursement for the following services shall be as established on the Level I and II PRTF Non-Medicare Services Fee Schedule:

(a) Mobile crisis services;

(b) Day treatment;

(c) Peer support services;

(d) Parent or family peer support services;

(e) Intensive outpatient program services;

(f) Service planning;

(g) Screening, brief intervention, and referral to treatment;

(h) Assertive community treatment;

(i) Comprehensive community support services; or

(j) Therapeutic rehabilitation services.

(8)

(a) The department shall use the current version of the Kentucky-specific Medicare Physician Fee Schedule for reimbursement purposes.

(b) For example, if the Kentucky-specific Medicare Physician Fee Schedule currently published and used by the Centers for Medicare and Medicaid Services for the Medicare Program is:

1. An interim version, the department shall use the interim version until the final version has been published; or

2. A final version, the department shall use the final version.

(9) The department shall not reimburse for a service billed by or on behalf of an entity or individual that is not a billing provider.

Section 4. Not Applicable to Managed Care Organizations. A managed care organization shall not be required to reimburse in accordance with this administrative regulation for a service covered pursuant to:

(1)907 KAR 9:015; and

(2) This administrative regulation.

Section 5. Federal Approval and Federal Financial Participation.

(1) The department's reimbursement for services pursuant to this administrative regulation shall be contingent upon:

(a) Receipt of federal financial participation for the reimbursement; and

(b) Centers for Medicare and Medicaid Services' approval for the reimbursement.

(2) The reimbursement of services provided by a licensed clinical alcohol and drug counselor or licensed clinical alcohol and drug counselor associate shall be contingent and effective upon approval by the Centers for Medicare and Medicaid Services.

Section 6. Incorporation by Reference.

(1) "Level I and Level II PRTF Non-Medicare Services Fee Schedule", January 2015, is incorporated by reference.

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law:

(a) At the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky, Monday through Friday, 8:00 a.m. to 4:30 p.m.; or

(b) Online at the department's Web site at http://www.chfs.ky.gov/dms/incorporated.htm.

907 KAR 9:020

41 Ky.R. 2487; Am. 42 Ky.R. 738; eff. 11-16-2015; Cert. eff. 10/18/2022.

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