902 KAR 4:035. Cost reimbursement for special food products

      Section 1. Definitions. (1) "Amino acid modified preparation" is defined at KRS 304.17A-139(4)(a)1.

      (2) "Low protein modified food" is defined at KRS 304.17A-139(4)(a)2.

      (3) "Patient" means a person with one (1) or more of the metabolic conditions listed in KRS 205.560.

      (4) "Provider" means an individual or entity authorized to fill a prescription for an amino acid modified preparation or low protein modified food product.

      (5) "Uninsured patient" means one who does not meet the criteria to receive Medicaid, K-CHIP, WIC benefits, or whose insurance coverage is exhausted.

      (6) "WIC" means the Special Nutrition Program for Women, Infants, and Children administered pursuant to 42 U.S.C. 1786 and 7 C.F.R. Part 246.

 

      Section 2. Eligibility. (1) The cost of the formula for a patient who is eligible for WIC shall be covered by the WIC Program.

      (2) The cost for food and formula for a patient covered by private health insurance shall be paid under the terms of the individual insurance policy, which shall meet or exceed the limit established in KRS 304.17A-139.

      (3) An uninsured patient may qualify for financial assistance by submitting the following information and completed forms annually, to the Department for Public Health, Division of Adult and Child Health Improvement, 275 East Main Street HS 2GW-A, Frankfort, Kentucky 40621:

      (a) Kentucky Metabolic Disease Program Physician’s Statement of Medical Necessity - Metabolic Disease Therapy form;

      (b) Kentucky Metabolic Food and Formula Provision Financial and Release of Information Form; and

      (c) Written verification that application for WIC, Medicaid, or K-CHIP was denied, and that private health insurance has been exhausted.

 

      Section 3. Cost Reimbursement. To receive reimbursement of the actual cost plus twenty (20) percent, a provider shall submit the following documents to the Department for Public Health, Division of Adult and Child Health Improvement:

      (1) A prescription for the metabolic food and formula from a licensed or certified healthcare practitioner with prescriptive authority;

      (2) A completed Division of Adult and Child Health, Authorization for Services, Form ACH 233; and

      (3) An invoice from the supplier with the service date, patient name, and cost to the provider.

 

      Section 4. Incorporation by Reference. (1) The following material is incorporated by reference:

      (a) "Kentucky Metabolic Disease Program Physician’s Statement of Medical Necessity - Metabolic Disease Therapy, 5/2001";

      (b) "Division of Adult and Child Health Authorization for Services, Form ACH 233, 10/00"; and

      (c) "Kentucky Metabolic Food and Formula Provision Financial and Release of Information Form, 12/2004".

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Public Health, Division of Adult and Child Health Improvement, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (27 Ky.R. 3477; Am. 28 Ky.R. 393; eff. 8-15-2001; 379; 890; eff. 11-16-05.)

Notation

      RELATES TO: KRS 205.560(1)(c), 213.141(2), 214.155(1), 304.17A-139, 7 C.F.R. Part 246, 42 U.S.C. 1786

      STATUTORY AUTHORITY: KRS 194A.050(1), 205.560(1)(c), 214.155(1)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 214.155(1) requires the cabinet to establish and collect fees to cover the cost of analyzing testing samples for inborn metabolic errors. KRS 213.141(2) requires the cabinet to prescribe a fee for a copy of a birth record, one (1) dollar of which shall be used by the Division of Adult and Child Health Improvement to pay for amino acid modified preparations and low-protein modified food products for the treatment of genetic and metabolic diseases. This administrative regulation establishes the application and cost reimbursement procedures.