907 KAR 1:505

907 KAR 1:505. Psychiatric residential treatment facility services.

RELATES TO: KRS 205.520, 216B.450, 216B.455, 216B.459

STATUTORY AUTHORITY: KRS 194A.030, 194A.050, 42 CFR 440.160, 42 USC 1396a-d

NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health Services, Department for Medicaid Services, has responsibility to administer the Medicaid program. KRS 205.520 authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes provisions relating to coverage of psychiatric residential treatment facility services.

Section 1. Definitions.

(1) "Active treatment" means a covered psychiatric residential treatment facility (PRTF) service:

(a) Including nursing care, mental health, case coordination, psychiatric therapies, task and skills training in accordance with an individual plan of care as specified in 42 CFR 441.154;

(b) Provided by an individual employed by a PRTF including a:

1. Psychiatrist;

2. Social worker; or

3. Direct-care staff person; and

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

(3) "Medicaid payment status" means:

(a) The person:

1. Is eligible for and receiving Medicaid; and

2. Meets patient status criteria for psychiatric residential treatment facility (PRTF) services; and

(b) The facility is billing the Medicaid Program for services provided to the person.

(4) "Medically necessary" or "medical necessity" means that a covered benefit shall be:

(a) Provided in accordance with 42 CFR 440.230;

(b) Reasonable and required to identify, diagnose, treat, correct, cure, ameliorate, palliate, or prevent a disease, illness, injury, disability, or other medical condition, including pregnancy;

(c) Clinically appropriate in terms of amount, scope, and duration based on generally-accepted standards of good medical practice;

(d) Provided for medical reasons rather than primarily for the convenience of the recipient, caregiver, or the provider;

(e) Provided in the most appropriate location, with regard to generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and effectively provided;

(f) Needed, if used in reference to an emergency medical service, to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard; and

(g) Provided in accordance with early and periodic screening, diagnosis, and treatment (EPSDT) requirements established in 42 USC 1396d(r) and 42 CFR Part 441 Subpart B for Medicaid-eligible persons under twenty-one (21) years of age.

(5) "Psychiatric residential treatment facility" or "PRTF" is defined by KRS 216B.450(4).

Section 2. Provider Participation.

(1) In order to participate in the Kentucky Medicaid Program, a PRTF shall:

(a) Have a utilization review plan which complies with 907 KAR 1:016;

(b) Appoint a utilization review committee which complies with 907 KAR 1:016 to:

1. Oversee and implement the utilization review plan; and

2. Evaluate each Medicaid admission prior to the expiration of the Medicaid certification period to determine the admission's compliance with medical necessity criteria and other applicable Medicaid requirements;

(d) Be located in the state of Kentucky;

(e) Maintain accreditation by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or the Council on Accreditation of Services for Families and Children or any other accrediting body with comparable standards that is recognized by the state; and

(f) Comply with all conditions of Medicaid provider participation established in 907 KAR 1:671 and 907 KAR 1:672.

(2) A PRTF shall establish procedures and processes for review, evaluation and individual plan of care development in accordance with 907 KAR 1:016.

(3) For an elective admission of a recipient, an independent team shall, within a period not more than thirty (30) days prior to the admission, complete and sign a MAP 569, Certification of Need form in accordance with 42 CFR 441.152 and 42 CFR 441.153, and the form shall be placed in the recipient's medical record to verify compliance with this requirement.

(4) For an emergency admission of a recipient, a PRTF's interdisciplinary team shall complete a MAP-570, Medicaid Certification of Need for Inpatient Psychiatric Services for Individuals under age twenty-one (21), and the form shall be placed in the recipient's medical record.

(5) For an individual who becomes Medicaid eligible after admission, a PRTF's interdisciplinary team shall complete a MAP 570, Medicaid Certification of Need for Inpatient Psychiatric Services for Individuals under age twenty-one (21), and the form shall be placed in the recipient's medical record.

(6) For a recipient, a PRTF shall maintain medical records that shall:

(a) Be current, readily retrievable, organized, complete, legible and shall reflect sound medical recordkeeping practice, in accordance with 902 KAR 20:320, KRS 194A.060, 434.840-860, 422.317 and 42 CFR 431 Subpart F;

(b) Document the need for admission and appropriate utilization of services;

(d) Be maintained in an organized central file, including information regarding payments claimed, for a minimum of five (5) years or until an audit dispute or issue is resolved, whichever is longer; and

(e) Be made available for inspection, copying or provided to the following upon request:

1. A representative of the United States Department for Health and Human Services or its designee;

2. The United States Office of the Attorney General or its designee;

3. The Commonwealth of Kentucky, Office of the Attorney General or its designee;

4. The Commonwealth of Kentucky, Office of the Auditor of Public Accounts or its designee;

5. The Commonwealth of Kentucky, Office of the Inspector General or its designee; or

6. The department.

Section 3. Covered Admissions.

A covered admission shall be:

(1) Preauthorized;

(2) Limited to those for children age six (6) through twenty (20) years of age who meet Medicaid payment status criteria. Coverage may continue, based on medical necessity, for a recipient who is receiving active treatment in a PRTF on his 21st birthday so long as he has not reached his 22nd birthday; and

(3) Reimbursed in accordance with 907 KAR 1:510.

Section 4. Durational Limitations.

Recipient stays shall be subject to utilization review by the cabinet.

Section 5. Determining Patient Status.

(1) The department shall review and evaluate the health status and care needs of a recipient in need of inpatient psychiatric care using the same standards as established for inpatient psychiatric hospital care in 907 KAR 1:016.

(2) The care needs of a recipient shall meet PRTF patient status criteria only if:

(a) The individual meeting the patient status criteria in 907 KAR 1:016requires long-term inpatient psychiatric care or crisis stabilization more suitably provided in a PRTF rather than a psychiatric hospital; and

(b) The recipient requires PRTF services on a continuous basis as a result of a severe mental or psychiatric illness, including severe emotional disturbances.

Section 6. Reevaluation of Need for Services.

Patient status shall be reevaluated for a PRTF recipient at thirty (30) day intervals. If a reevaluation reveals the recipient no longer requires PRTF care, payment shall continue only through the last day for which the stay is certified.

Section 7. Exclusions and Limitations in Coverage.

(1) The following shall not be covered as PRTF services:

(a) Chemical dependency treatment services if the need for the services is the primary diagnosis of the recipient. However, chemical dependency treatment services shall be covered as incidental treatment if minimal chemical dependency treatment is necessary for successful treatment of the primary diagnosis;

(b) Outpatient services;

(d) Durable medical equipment, which shall be covered as a durable medical equipment benefit in accordance with 907 KAR 1:479.

(2) A PRTF shall not charge a recipient or responsible party representing a recipient any difference between private and semiprivate room charges.

(3) Services shall not be covered if appropriate alternative services are available in the community.

(4) The following shall not qualify for a PRTF service:

(a) An admission that is not medically necessary;

(b) An individual with a major medical problem or minor symptoms;

(c) An individual who might only require a psychiatric consultation rather than an admission to a psychiatric facility; or

(d) An individual who might need only adequate living accommodations, economic aid or social support services.

Section 8. Reserved Bed Days.

The department shall cover reserved bed days in accordance with the following specified upper limits and criteria:

(1) Upper limits for reserved beds shall be applied as follows:

(a) A maximum of fourteen (14) days per admission for an acute care hospital stay;

(b) A maximum of fourteen (14) days per calendar year for an admission to a mental hospital or a psychiatric bed of an acute care hospital;

(d) A maximum of thirty (30) consecutive days for hospital and other leaves of absence combined.

(2) The following criteria shall be met for reserved bed days to be covered:

(a) The recipient shall be in Medicaid payment status in the PRTF and shall have been in the facility at least overnight;

(b) The recipient shall be reasonably expected to return to PRTF level of care;

(c) Due to the demand at the facility for PRTF care, there is likelihood the bed would be occupied by some other patient, if it had not been reserved;

(d) Hospitalization shall be in a Medicaid-participating hospital with the admission appropriately approved by the department; and

(e) For a leave of absence other than for hospitalization, the recipient's physician orders, and the recipient's plan of care shall provide for, a leave, which may include a leave of absence to visit with relatives and friends.

Section 9. Appeal Rights.

(1) An appeal of a negative action regarding a Medicaid beneficiary shall be in accordance with 907 KAR 1:563.

(2) An appeal of a negative action regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

(3) An appeal of a negative action regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.

Section 10. Incorporation by Reference.

(1) The following material is incorporated by reference:

(a) MAP-569, Certification of Need by Independent Team Psychiatric Preadmission Review of Elective Admissions for Kentucky Medicaid Recipients Under Age Twenty-one (21), revised 5/90; and

(b) MAP-570, Medicaid Certification of Need for Inpatient Psychiatric Services for Individuals Under Age Twenty-one (21), revised 5/90.

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, Cabinet for Health Services, 275 East Main Street, Third Floor East, Frankfort, Kentucky, 40621, Monday through Friday, 8 a.m. to 4:30 p.m.

(18 Ky.R. 600; eff. 10-6-91; Am. 19 Ky.R. 2340; eff. 6-16-93; 22 Ky.R. 1906; eff. 6-6-96; 27 Ky.R. 2910; 3267; eff. 6-8-2001.)