RELATES TO: KRS 205.560, 205.6312, 205.6485, 205.8451, 319A.010, 327.010, 334A.020, 42 C.F.R. 430.10, 431.51, 447.15, 447.20, 447.21, 447.50, 447.52, 447.54, 447.55, 447.56, 447.57, 457.224, 457.310, 457.505, 457.510, 457.515, 457.520, 457.530, 457.535, 457.570, 42 U.S.C. 1396a, 1396b, 1396c, 1396d, 1396o, 1396r-6, 1396r-8, 1396u-1, 1397aa -1397jj
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 prohibits cost-sharing within the Medicaid program, and extends the KRS 205.6312 prohibition of cost-sharing to providers as well as the department and managed care organizations.
Section 1. Definitions. (1) "Copayment" means a dollar amount representing the portion of the cost of a Medicaid benefit that a recipient is required to pay.(2) "Department" means the Department for Medicaid Services or its designee.(3) "Enrollee" means a Medicaid recipient who is enrolled with a managed care organization.(4) "Managed care organization" or "MCO" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined by 42 C.F.R. 438.2.(5) "Recipient" is defined by KRS 205.8451(9).Section 2. Copayment General Provisions and Exemptions. (1) Pursuant to KRS 205.6312, the department or any MCO shall not utilize or require cost-sharing or copayments within any component of the Medicaid program.(2) A provider shall not collect a copayment from an enrollee for a service or item.Section 3. Freedom of Choice. (1) In accordance with 42 C.F.R. 431.51, a recipient who is not an enrollee may obtain services from any qualified provider who is willing to provide services to that particular recipient.(2) A managed care organization may restrict an enrollee's choice of providers to the providers in the provider network of the managed care organization in which the enrollee is enrolled except as established in:Section 4. Appeal Rights. An appeal of a department decision regarding the Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.Section 5. Federal Approval and Federal Financial Participation. The department's copayment provisions and any coverage of services established in this administrative regulation shall be contingent upon: (1) Receipt of federal financial participation; and(2) Centers for Medicare and Medicaid Services' approval.Section 6. This administrative regulation was found deficient by the Administrative Regulation Review Subcommittee on May 13, 2014.29 Ky.R. 1458; 2201; 2478; eff. 4-11-2003; 30 Ky.R. 1117; 1533; eff. 2-16-2004; 32 Ky.R. 417; 925; 1111; eff. 1-6-2006; 33 Ky.R. 607; 1386; 1568; eff. 1-5-2007; 34 Ky.R. 1840; 2117; eff. 4-4-2008; TAm eff. 7-16-2013; TAm eff. 8-7-2013; TAm eff. 9-30-2013; 40 Ky.R. 1991; 2524; 2749; eff. 7-7-2014; TAm eff. 10-6-2017; 46 Ky.R. 512, 937; eff. 10-4-2019; 47 Ky.R. 350; 729; eff. 11-19-2020; 48 Ky.R. 1414; eff. 1/13/2022.STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3),, 205.6485(1), 42 C.F.R. 431.51, 447.15, 447.50-447.90, 457.535, 457.560, 42 U.S.C. 1396r-6(b)(5)