907 KAR 8:040. Coverage of occupational therapy, physical therapy, and speech-language pathology services providedby various entities

      Section 1. Provider Participation. To be eligible to provide and be reimbursed for services covered under this administrative regulation, a provider shall be:

      (1) Currently enrolled in the Kentucky Medicaid Program in accordance with 907 KAR 1:672;

      (2) Currently participating in the Kentucky Medicaid Program in accordance with 907 KAR 1:671; and

      (3)(a) An adult day health care program;

      (b) A multi-therapy agency;

      (c) A comprehensive outpatient rehabilitation facility;

      (d) A mobile health service;

      (e) A special health clinic; or

      (f) A rehabilitation agency.

 

      Section 2. Coverage of Services. (1) The services covered under this administrative regulation shall include:

      (a) Physical therapy;

      (b) Occupational therapy; or

      (c) Speech-language pathology services.

      (2) To be covered under this administrative regulation, a service shall be:

      (a) Provided to a recipient;

      (b) Provided by:

      1. An occupational therapist who renders services on behalf of a provider listed in Section 1(3) of this administrative regulation;

      2. A physical therapist who renders services on behalf of a provider listed in Section 1(3) of this administrative regulation;

      3. A speech-language pathologist who renders services on behalf of a provider listed in Section 1(3) of this administrative regulation;

      4. An occupational therapy assistant who renders services:

      a. Under supervision in accordance with 201 KAR 28:130; and

      b. On behalf of a provider listed in Section 1(3) of this administrative regulation;

      5. A physical therapist assistant who renders services:

      a. Under supervision in accordance with 201 KAR 22:053; and

      b. On behalf of a provider listed in Section 1(3) of this administrative regulation; or

      6. A speech-language pathology clinical fellow who renders services:

      a. Under the supervision of a speech-language pathologist; and

      b. On behalf of a provider listed in Section 1(3) of this administrative regulation;

      (c) Ordered by:

      1. A physician currently participating in the Medicaid Program in accordance with 907 KAR 1:671;

      2. An advanced practice registered nurse currently participating in the Medicaid Program in accordance with 907 KAR 1:671;

      3. A physician assistant currently participating in the Medicaid Program in accordance with 907 KAR 1:671; or

      4. A psychiatrist currently participating in the Medicaid Program in accordance with 907 KAR 1:671;

      (d) Consistent with a plan of care that shall:

      1. Be developed:

      a. By:

      (i) An occupational therapist currently participating in the Medicaid Program in accordance with 907 KAR 1:671;

      (ii) A physical therapist currently participating in the Medicaid Program in accordance with 907 KAR 1:671; or

      (iii) A speech-language pathologist currently participating in the Medicaid Program in accordance with 907 KAR 1:671; and

      b. In collaboration with:

      (i) A physician currently participating in the Medicaid Program in accordance with 907 KAR 1:671;

      (ii) An advanced practice registered nurse currently participating in the Medicaid Program in accordance with 907 KAR 1:671;

      (iii) A physician assistant currently participating in the Medicaid Program in accordance with 907 KAR 1:671; or

      (iv) A psychiatrist currently participating in the Medicaid Program in accordance with 907 KAR 1:671; and

      2. Identify a specific amount and duration;

      (e) For the:

      1. Maximum reduction of the effects of a physical or intellectual disability; or

      2. Restoration of a recipient to the recipient’s best possible functioning level; and

      (f) Medically necessary.

      (3)(a) There shall be an annual limit of twenty (20) visits for each of the following:

      1. Occupational therapy service visits per recipient per calendar year except as established in paragraph (c) of this subsection;

      2. Physical therapy service visits per recipient per calendar year except as established in paragraph (c) of this subsection; and

      3. Speech-language pathology service visits per recipient per calendar year except as established in paragraph (c) of this subsection.

      (b) For example, a recipient may receive twenty (20) occupational therapy visits, twenty (20) physical therapy visits, and twenty (20) speech-language pathology service visits per calendar year.

      (c) The limit established in paragraph (a) of this subsection may be exceeded if services in excess of the limits are determined to be medically necessary by the:

      1. Department, if the recipient is not enrolled with a managed care organization; or

      2. Managed care organization in which the enrollee is enrolled, if the recipient is an enrollee.

      (d) Medical necessity shall be determined on an individual basis per recipient based on the given recipient’s needs.

      (e) Prior authorization by the department shall be required for visits above the limit established in paragraph (a) of this subsection for a recipient who is not enrolled with a managed care organization.

 

      Section 3. Documentation, Records Maintenance, Protection, and Security. (1) A provider shall maintain a current health record for each recipient.

      (2) A health record shall:

      (a) Document the provider’s initial assessment of the recipient and any subsequent assessments;

      (b) Document each service provided to the recipient; and

      (c) Include detailed staff notes that state:

      1. Progress made toward outcomes identified according to the provider’s assessment and in the plan of care developed pursuant to Section 2(2)(d) of this administrative regulation;

      2. The date of each service;

      3. The beginning and ending time of each service; and

      4. The signature and title of the individual providing each service.

      (3) The individual who provides a service shall date and sign the health record on the date that the individual provides the service.

      (4)(a) Except as established in paragraph (b) of this subsection, a provider shall maintain a health record regarding a recipient for at least six (6) years from the date of the service or until any audit dispute or issue is resolved beyond six (6) years.

      (b) If the secretary of the United States Department of Health and Human Services requires a longer document retention period than the period referenced in paragraph (a) of this subsection, pursuant to 42 C.F.R. 431.17, the period established by the secretary shall be the required period.

      (5) A provider shall comply with 45 C.F.R. Part 164.

 

      Section 4. Medicaid Program Participation Compliance. (1) A provider shall comply with:

      (a) 907 KAR 1:671;

      (b) 907 KAR 1:672; and

      (c) All applicable state and federal laws.

      (2)(a) If a provider receives any duplicate payment or overpayment from the department, regardless of reason, the provider shall return the payment to the department in accordance with 907 KAR 1:671.

      (b) Failure to return a payment to the department in accordance with paragraph (a) of this subsection may be:

      1. Interpreted to be fraud or abuse; and

      2. Prosecuted in accordance with applicable federal or state law.

 

      Section 5. No Duplication of Service. (1) The department shall not reimburse for an occupational therapy service, physical therapy service, or speech-language pathology service provided to a recipient by more than one (1) provider of any Medicaid program in which the respective service is covered during the same time period.

      (2) For example, if a recipient is receiving an occupational therapy service from a multi-therapy agency enrolled with the Medicaid Program, the department shall not reimburse for the same occupational therapy service provided to the same recipient during the same time period via the home health program.

 

      Section 6. Third Party Liability. A provider shall comply with KRS 205.622.

 

      Section 7. Out-of-State Providers. The department shall cover a service under this administrative regulation that is provided by an out-of-state provider if the:

      (1) Service meets the coverage requirements of this administrative regulation; and

      (2) Provider:

      (a) Complies with the requirements of this administrative regulation; and

      (b) Is:

      1.a. Licensed as an adult day health care program in the state in which it is located;

      b. A comprehensive outpatient rehabilitation facility licensed in the state in which it is located;

      c. Licensed as a mobile health service in the state in which it is located;

      d. A special health clinic licensed in the state in which it is located;

      e. A rehabilitation agency licensed in the state in which it is located;

      f. An occupational therapist or occupational therapist group;

      g. A physical therapist or physical therapist group;

      h. A speech-language pathologist or speech-language pathologist group; or

      i. A multi-therapy agency;

      2. Currently enrolled in the Kentucky Medicaid Program in accordance with 907 KAR 1:672; and

      3. Currently participating in the Kentucky Medicaid Program in accordance with 907 KAR 1:671.

 

      Section 8. Use of Electronic Signatures. (1) 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.

      (2) A provider that chooses to use electronic signatures shall:

      (a) Develop and implement a written security policy that shall:

      1. Be adhered to by each of the provider's employees, officers, agents, or contractors;

      2. Identify each electronic signature for which an individual has access; and

      3. Ensure that each electronic signature is created, transmitted, and stored in a secure fashion;

      (b) Develop a consent form that shall:

      1. Be completed and executed by each individual using an electronic signature;

      2. Attest to the signature's authenticity; and

      3. Include a statement indicating that the individual has been notified of his or her responsibility in allowing the use of the electronic signature; and

      (c) Provide the department, immediately upon request, with:

      1. A copy of the provider's electronic signature policy;

      2. The signed consent form; and

      3. The original filed signature.

 

      Section 9. Auditing Authority. The department shall have the authority to audit any claim, medical record, or documentation associated with any claim or medical record.

 

      Section 10. Federal Approval and Federal Financial Participation. The department’s coverage of services pursuant to 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 for the coverage.

 

      Section 11. Appeals. (1) An appeal of an adverse action by the department regarding a service and a recipient who is not enrolled with a managed care organization shall be in accordance with 907 KAR 1:563.

      (2) An appeal of an adverse action by a managed care organization regarding a service and an enrollee shall be in accordance with 907 KAR 17:010. (42 Ky.R. 2304, 2603, 2757; eff. 6-3-2016.)

Notation

      RELATES TO: KRS 205.520

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 C.F.R. 440.130, 42 U.S.C. 1396a(a)(30)

      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 Medicaid Program coverage provisions and requirements regarding occupational therapy services, physical therapy services, and speech-language pathology services provided by adult day health care programs, rehabilitation agencies, special health clinics, mobile health services, multi-therapy agencies, and comprehensive outpatient rehabilitation facilities to Medicaid recipients.