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AN ACT relating to coverage for the care of children. 1
Be it enacted by the General Assembly of the Commonwealth of Kentucky: 2
Section 1. KRS 304.17A-258 is amended to read as follows: 3
(1) As used in[For purposes of] this section: 4
(a) "Therapeutic food, formulas, and supplements" means products intended for 5
the dietary treatment of inborn errors of metabolism or genetic conditions, 6
including but not limited to eosinophilic disorders, food protein allergies, food 7
protein-induced enterocolitis syndrome, mitochondrial disease, and short 8
bowel disorders, under the direction of a physician, and includes amino acid-9
based elemental formula and the use of vitamin and nutritional supplements 10
such as coenzyme Q10, vitamin E, vitamin C, vitamin B1, vitamin B2, 11
vitamin K1, and L-carnitine; 12
(b) "Low-protein modified food" means a product formulated to have less than 13
one (1) gram of protein per serving and intended for the dietary treatment of 14
inborn errors of metabolism or genetic conditions under the direction of a 15
physician; and 16
(c) "Amino acid-based elemental formula" means a product intended for the 17
diagnosis and dietary treatment of eosinophilic disorders, food protein 18
allergies, food protein-induced enterocolitis, and short bowel[-bowel] 19
syndrome under the direction of a physician. 20
(2) (a) A health benefit plan that provides prescription drug coverage shall include in 21
that coverage therapeutic food, formulas, supplements, and low-protein 22
modified food products for the treatment of inborn errors of metabolism or 23
genetic conditions, including those that are compounded, if the therapeutic 24
food, formulas, supplements, and low-protein modified food products are 25
obtained for the therapeutic treatment of inborn errors of metabolism or 26
genetic conditions, including but not limited to mitochondrial disease, under 27 UNOFFICIAL COPY 23 RS BR 160
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the direction of a physician. 1
(b) Except as provided in subsection (4) of this section, coverage under this 2
subsection may be subject, for each plan year, to a cap of twenty-five thousand 3
dollars ($25,000) for therapeutic food, formulas, and supplements and a 4
separate cap for each plan year of four thousand dollars ($4,000) for[on] low-5
protein modified foods.[ Each cap shall be subject to annual inflation 6
adjustments based on the consumer price index.] 7
(c) Coverage under this subsection[section] shall not be denied because two (2) 8
or more supplements are compounded. 9
(3) (a) To the extent that coverage is not provided under subsection (2) of this 10
section or KRS 304.17A-139, a health benefit plan shall provide coverage 11
for enteral infant and baby formulas prescribed by a physician in a written 12
order, which states that the formula: 13
1. Is medically necessary; and 14
2. Has been proven effective as a disease-specific treatment regimen[The 15
requirements of this section shall apply to all health benefit plans issued 16
or renewed on and after January 1, 2017]. 17
(b) Except as provided in subsection (4) of this section, coverage under this 18
subsection may be subject to, for each plan year, a cap of three thousand 19
dollars ($3,000). 20
(4) Any cap imposed on the coverages required under subsections (2) and (3) of this 21
section shall be subject to annual inflation adjustments based on the 22
nonseasonally adjusted annual average Consumer Price Index for All Urban 23
Consumers (CPI-U), U.S. City Average, All Items, as published by the United 24
States Bureau of Labor Statistics.[Nothing in this section or KRS 205.560, 25
213.141, or 214.155 shall be construed to require a health benefit plan to provide 26
coverage for therapeutic foods, formulas, supplements, or low-protein modified 27 UNOFFICIAL COPY 23 RS BR 160
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food for the treatment of lactose intolerance, protein intolerance, food allergy, food 1
sensitivity, or any other condition or disease that is not an inborn error of 2
metabolism or genetic condition.] 3
SECTION 2. A NEW SECTION OF SUBTITLE 17A OF KRS CHAPTER 304 4
IS CREATED TO READ AS FOLLOWS: 5
(1) (a) A health benefit plan shall provide, in conjunction with each birth, 6
coverage for: 7
1. Renting or purchasing breastfeeding equipment; and 8
2. Comprehensive lactation support and counseling by a trained health 9
care professional during pregnancy and in the postpartum period. 10
(b) A health benefit plan shall not require a prescription or order from a health 11
care provider in order for a covered person to be entitled to the coverage 12
provided under this section. 13
(2) The coverage required under this section shall not be subject to any cost-sharing 14
requirement, including any copayment, coinsurance, or deductible. 15
Section 3. KRS 205.522 (Effective January 1, 2023) is amended to read as 16
follows: 17
(1) The Department for Medicaid Services and any managed care organization 18
contracted to provide Medicaid benefits pursuant to this chapter shall comply with 19
the provisions of Sections 1 and 2 of this Act and KRS 304.17A-163, 304.17A-20
1631, 304.17A-167, 304.17A-235, 304.17A-257, 304.17A-259, 304.17A-515, 21
304.17A-580, 304.17A-600, 304.17A-603, 304.17A-607, and 304.17A-740 to 22
304.17A-743, as applicable. 23
(2) A managed care organization contracted to provide Medicaid benefits pursuant to 24
this chapter shall comply with the reporting requirements of KRS 304.17A-732. 25
Section 4. KRS 205.6485 (Effective January 1, 2023) is amended to read as 26
follows: 27 UNOFFICIAL COPY 23 RS BR 160
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(1) The Cabinet for Health and Family Services shall prepare a state child health plan 1
meeting the requirements of Title XXI of the Federal Social Security Act, for 2
submission to the Secretary of the United States Department of Health and Human 3
Services within such time as will permit the state to receive the maximum amounts 4
of federal matching funds available under Title XXI. The cabinet shall, by 5
administrative regulation promulgated in accordance with KRS Chapter 13A, 6
establish the following: 7
(a) The eligibility criteria for children covered by the Kentucky Children's Health 8
Insurance Program. However, no person eligible for services under Title XIX 9
of the Social Security Act, 42 U.S.C. secs. 1396 to 1396v, as amended, shall 10
be eligible for services under the Kentucky Children's Health Insurance 11
Program except to the extent that Title XIX coverage is expanded by KRS 12
205.6481 to 205.6495 and KRS 304.17A-340; 13
(b) The schedule of benefits to be covered by the Kentucky Children's Health 14
Insurance Program, which shall include preventive services, vision services 15
including glasses, and dental services including at least sealants, extractions, 16
and fillings, and which shall be at least equivalent to one (1) of the following: 17
1. The standard Blue Cross/Blue Shield preferred provider option under the 18
Federal Employees Health Benefit Plan established by 5 U.S.C. sec. 19
8903(1); 20
2. A mid-range health benefit coverage plan that is offered and generally 21
available to state employees; or 22
3. Health insurance coverage offered by a health maintenance organization 23
that has the largest insured commercial, non-Medicaid enrollment of 24
covered lives in the state; 25
(c) The premium contribution per family of health insurance coverage available 26
under the Kentucky Children's Health Insurance Program with provisions for 27 UNOFFICIAL COPY 23 RS BR 160
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the payment of premium contributions by families of children eligible for 1
coverage by the program based upon a sliding scale relating to family income. 2
Premium contributions shall be based on a six (6) month period not to exceed: 3
1. Ten dollars ($10), to be paid by a family with income between one 4
hundred percent (100%) to one hundred thirty-three percent (133%) of 5
the federal poverty level; 6
2. Twenty dollars ($20), to be paid by a family with income between one 7
hundred thirty-four percent (134%) to one hundred forty-nine percent 8
(149%) of the federal poverty level; and 9
3. One hundred twenty dollars ($120), to be paid by a family with income 10
between one hundred fifty percent (150%) to two hundred percent 11
(200%) of the federal poverty level, and which may be made on a partial 12
payment plan of twenty dollars ($20) per month or sixty dollars ($60) 13
per quarter; 14
(d) There shall be no copayments for services provided under the Kentucky 15
Children's Health Insurance Program; and 16
(e) The criteria for health services providers and insurers wishing to contract with 17
the Commonwealth to provide the children's health insurance coverage. 18
However, the cabinet shall provide, in any contracting process for the 19
preventive health insurance program, the opportunity for a public health 20
department to bid on preventive health services to eligible children within the 21
public health department's service area. A public health department shall not 22
be disqualified from bidding because the department does not currently offer 23
all the services required by paragraph (b) of this subsection. The criteria shall 24
be set forth in administrative regulations under KRS Chapter 13A and shall 25
maximize competition among the providers and insurers. The Cabinet for 26
Finance and Administration shall provide oversight over contracting policies 27 UNOFFICIAL COPY 23 RS BR 160
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and procedures to assure that the number of applicants for contracts is 1
maximized. 2
(2) Within twelve (12) months of federal approval of the state's Title XXI child health 3
plan, the Cabinet for Health and Family Services shall assure that a KCHIP program 4
is available to all eligible children in all regions of the state. If necessary, in order to 5
meet this assurance, the cabinet shall institute its own program. 6
(3) KCHIP recipients shall have direct access without a referral from any gatekeeper 7
primary care provider to dentists for covered primary dental services and to 8
optometrists and ophthalmologists for covered primary eye and vision services. 9
(4) The Kentucky Children's Health Insurance Program[Plan] shall comply with: 10
(a) Sections 1 and 2 of this Act; and 11
(b) KRS 304.17A-163 and 304.17A-1631. 12
Section 5. KRS 164.2871 (Effective January 1, 2023) is amended to read as 13
follows: 14
(1) The governing board of each state postsecondary educational institution is 15
authorized to purchase liability insurance for the protection of the individual 16
members of the governing board, faculty, and staff of such institutions from liability 17
for acts and omissions committed in the course and scope of the individual's 18
employment or service. Each institution may purchase the type and amount of 19
liability coverage deemed to best serve the interest of such institution. 20
(2) All retirement annuity allowances accrued or accruing to any employee of a state 21
postsecondary educational institution through a retirement program sponsored by 22
the state postsecondary educational institution are hereby exempt from any state, 23
county, or municipal tax, and shall not be subject to execution, attachment, 24
garnishment, or any other process whatsoever, nor shall any assignment thereof be 25
enforceable in any court. Except retirement benefits accrued or accruing to any 26
employee of a state postsecondary educational institution through a retirement 27 UNOFFICIAL COPY 23 RS BR 160
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program sponsored by the state postsecondary educational institution on or after 1
January 1, 1998, shall be subject to the tax imposed by KRS 141.020, to the extent 2
provided in KRS 141.010 and 141.0215. 3
(3) Except as provided in KRS Chapter 44, the purchase of liability insurance for 4
members of governing boards, faculty and staff of institutions of higher education in 5
this state shall not be construed to be a waiver of sovereign immunity or any other 6
immunity or privilege. 7
(4) The governing board of each state postsecondary education institution is authorized 8
to provide a self-insured employer group health plan to its employees, which plan 9
shall: 10
(a) Conform to the requirements of Subtitle 32 of KRS Chapter 304; and 11
(b) Except as provided in subsection (5) of this section, be exempt from 12
conformity with Subtitle 17A of KRS Chapter 304. 13
(5) A self-insured employer group health plan provided by the governing board of a 14
state postsecondary education institution to its employees shall comply with: 15
(a) Sections 1 and 2 of this Act; and 16
(b) KRS 304.17A-163 and 304.17A-1631. 17
Section 6. KRS 18A.225 (Effective January 1, 2023) is amended to read as 18
follows: 19
(1) (a) The term "employee" for purposes of this section means: 20
1. Any person, including an elected public official, who is regularly 21
employed by any department, office, board, agency, or branch of state 22
government; or by a public postsecondary educational institution; or by 23
any city, urban-county, charter county, county, or consolidated local 24
government, whose legislative body has opted to participate in the state-25
sponsored health insurance program pursuant to KRS 79.080; and who 26
is either a contributing member to any one (1) of the retirement systems 27 UNOFFICIAL COPY 23 RS BR 160
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administered by the state, including but not limited to the Kentucky 1
Retirement Systems, County Employees Retirement System, Kentucky 2
Teachers' Retirement System, the Legislators' Retirement Plan, or the 3
Judicial Retirement Plan; or is receiving a contractual contribution from 4
the state toward a retirement plan; or, in the case of a public 5
postsecondary education institution, is an individual participating in an 6
optional retirement plan authorized by KRS 161.567; or is eligible to 7
participate in a retirement plan established by an employer who ceases 8
participating in the Kentucky Employees Retirement System pursuant to 9
KRS 61.522 whose employees participated in the health insurance plans 10
administered by the Personnel Cabinet prior to the employer's effective 11
cessation date in the Kentucky Employees Retirement System; 12
2. Any certified or classified employee of a local board of education or a 13
public charter school as defined in KRS 160.1590; 14
3. Any elected member of a local board of education; 15
4. Any person who is a present or future recipient of a retirement 16
allowance from the Kentucky Retirement Systems, County Employees 17
Retirement System, Kentucky Teachers' Retirement System, the 18
Legislators' Retirement Plan, the Judicial Retirement Plan, or the 19
Kentucky Community and Technical College System's optional 20
retirement plan authorized by KRS 161.567, except that a person who is 21
receiving a retirement allowance and who is age sixty-five (65) or older 22
shall not be included, with the exception of persons covered under KRS 23
61.702(2)(b)3. and 78.5536(2)(b)3., unless he or she is actively 24
employed pursuant to subparagraph 1. of this paragraph; and 25
5. Any eligible dependents and beneficiaries of participating employees 26
and retirees who are entitled to participate in the state-sponsored health 27 UNOFFICIAL COPY 23 RS BR 160
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insurance program; 1
(b) The term "health benefit plan" for the purposes of this section means a health 2
benefit plan as defined in KRS 304.17A-005; 3
(c) The term "insurer" for the purposes of this section means an insurer as defined 4
in KRS 304.17A-005; and 5
(d) The term "managed care plan" for the purposes of this section means a 6
managed care plan as defined in KRS 304.17A-500. 7
(2) (a) The secretary of the Finance and Administration Cabinet, upon the 8
recommendation of the secretary of the Personnel Cabinet, shall procure, in 9
compliance with the provisions of KRS 45A.080, 45A.085, and 45A.090, 10
from one (1) or more insurers authorized to do business in this state, a group 11
health benefit plan that may include but not be limited to health maintenance 12
organization (HMO), preferred provider organization (PPO), point of service 13
(POS), and exclusive provider organization (EPO) benefit plans encompassing 14
all or any class or classes of employees. With the exception of employers 15
governed by the provisions of KRS Chapters 16, 18A, and 151B, all 16
employers of any class of employees or former employees shall enter into a 17
contract with the Personnel Cabinet prior to including that group in the state 18
health insurance group. The contracts shall include but not be limited to 19
designating the entity responsible for filing any federal forms, adoption of 20
policies required for proper plan administration, acceptance of the contractual 21
provisions with health insurance carriers or third-party administrators, and 22
adoption of the payment and reimbursement methods necessary for efficient 23
administration of the health insurance program. Health insurance coverage 24
provided to state employees under this section shall, at a minimum, contain 25
the same benefits as provided under Kentucky Kare Standard as of January 1, 26
1994, and shall include a mail-order drug option as provided in subsection 27 UNOFFICIAL COPY 23 RS BR 160
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(13) of this section. All employees and other persons for whom the health care 1
coverage is provided or made available shall annually be given an option to 2
elect health care coverage through a self-funded plan offered by the 3
Commonwealth or, if a self-funded plan is not available, from a list of 4
coverage options determined by the competitive bid process under the 5
provisions of KRS 45A.080, 45A.085, and 45A.090 and made available 6
during annual open enrollment. 7
(b) The policy or policies shall be approved by the commissioner of insurance and 8
may contain the provisions the commissioner of insurance approves, whether 9
or not otherwise permitted by the insurance laws. 10
(c) Any carrier bidding to offer health care coverage to employees shall agree to 11
provide coverage to all members of the state group, including active 12
employees and retirees and their eligible covered dependents and 13
beneficiaries, within the county or counties specified in its bid. Except as 14
provided in subsection (19)[(20)] of this section, any carrier bidding to offer 15
health care coverage to employees shall also agree to rate all employees as a 16
single entity, except for those retirees whose former employers insure their 17
active employees outside the state-sponsored health insurance program and as 18
otherwise provided in KRS 61.702(2)(b)3.b. and 78.5536(2)(b)3.b. 19
(d) Any carrier bidding to offer health care coverage to employees shall agree to 20
provide enrollment, claims, and utilization data to the Commonwealth in a 21
format specified by the Personnel Cabinet with the understanding that the data 22
shall be owned by the Commonwealth; to provide data in an electronic form 23
and within a time frame specified by the Personnel Cabinet; and to be subject 24
to penalties for noncompliance with data reporting requirements as specified 25
by the Personnel Cabinet. The Personnel Cabinet shall take strict precautions 26
to protect the confidentiality of each individual employee; however, 27 UNOFFICIAL COPY 23 RS BR 160
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confidentiality assertions shall not relieve a carrier from the requirement of 1
providing stipulated data to the Commonwealth. 2
(e) The Personnel Cabinet shall develop the necessary techniques and capabilities 3
for timely analysis of data received from carriers and, to the extent possible, 4
provide in the request-for-proposal specifics relating to data requirements, 5
electronic reporting, and penalties for noncompliance. The Commonwealth 6
shall own the enrollment, claims, and utilization data provided by each carrier 7
and shall develop methods to protect the confidentiality of the individual. The 8
Personnel Cabinet shall include in the October annual report submitted 9
pursuant to the provisions of KRS 18A.226 to the Governor, the General 10
Assembly, and the Chief Justice of the Supreme Court, an analysis of the 11
financial stability of the program, which shall include but not be limited to 12
loss ratios, methods of risk adjustment, measurements of carrier quality of 13
service, prescription coverage and cost management, and statutorily required 14
mandates. If state self-insurance was available as a carrier option, the report 15
also shall provide a detailed financial analysis of the self-insurance fund 16
including but not limited to loss ratios, reserves, and reinsurance agreements. 17
(f) If any agency participating in the state-sponsored employee health insurance 18
program for its active employees terminates participation and there is a state 19
appropriation for the employer's contribution for active employees' health 20
insurance coverage, then neither the agency nor the employees shall receive 21
the state-funded contribution after termination from the state-sponsored 22
employee health insurance program. 23
(g) Any funds in flexible spending accounts that remain after all reimbursements 24
have been processed shall be transferred to the credit of the state-sponsored 25
health insurance plan's appropriation account. 26
(h) Each entity participating in the state-sponsored health insurance program shall 27 UNOFFICIAL COPY 23 RS BR 160
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provide an amount at least equal to the state contribution rate for the employer 1
portion of the health insurance premium. For any participating entity that used 2
the state payroll system, the employer contribution amount shall be equal to 3
but not greater than the state contribution rate. 4
(3) The premiums may be paid by the policyholder: 5
(a) Wholly from funds contributed by the employee, by payroll deduction or 6
otherwise; 7
(b) Wholly from funds contributed by any department, board, agency, public 8
postsecondary education institution, or branch of state, city, urban-county, 9
charter county, county, or consolidated local government; or 10
(c) Partly from each, except that any premium due for health care coverage or 11
dental coverage, if any, in excess of the premium amount contributed by any 12
department, board, agency, postsecondary education institution, or branch of 13
state, city, urban-county, charter county, county, or consolidated local 14
government for any other health care coverage shall be paid by the employee. 15
(4) If an employee moves his or her place of residence or employment out of the service 16
area of an insurer offering a managed health care plan, under which he or she has 17
elected coverage, into either the service area of another managed health care plan or 18
into an area of the Commonwealth not within a managed health care plan service 19
area, the employee shall be given an option, at the time of the move or transfer, to 20
change his or her coverage to another health benefit plan. 21
(5) No payment of premium by any department, board, agency, public postsecondary 22
educational institution, or branch of state, city, urban-county, charter county, 23
county, or consolidated local government shall constitute compensation to an 24
insured employee for the purposes of any statute fixing or limiting the 25
compensation of such an employee. Any premium or other expense incurred by any 26
department, board, agency, public postsecondary educational institution, or branch 27 UNOFFICIAL COPY 23 RS BR 160
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of state, city, urban-county, charter county, county, or consolidated local 1
government shall be considered a proper cost of administration. 2
(6) The policy or policies may contain the provisions with respect to the class or classes 3
of employees covered, amounts of insurance or coverage for designated classes or 4
groups of employees, policy options, terms of eligibility, and continuation of 5
insurance or coverage after retirement. 6
(7) Group rates under this section shall be made available to the disabled child of an 7
employee regardless of the child's age if the entire premium for the disabled child's 8
coverage is paid by the state employee. A child shall be considered disabled if he or 9
she has been determined to be eligible for federal Social Security disability benefits. 10
(8) The health care contract or contracts for employees shall be entered into for a period 11
of not less than one (1) year. 12
(9) The secretary shall appoint thirty-two (32) persons to an Advisory Committee of 13
State Health Insurance Subscribers to advise the secretary or the secretary's designee 14
regarding the state-sponsored health insurance program for employees. The 15
secretary shall appoint, from a list of names submitted by appointing authorities, 16
members representing school districts from each of the seven (7) Supreme Court 17
districts, members representing state government from each of the seven (7) 18
Supreme Court districts, two (2) members representing retirees under age sixty-five 19
(65), one (1) member representing local health departments, two (2) members 20
representing the Kentucky Teachers' Retirement System, and three (3) members at 21
large. The secretary shall also appoint two (2) members from a list of five (5) names 22
submitted by the Kentucky Education Association, two (2) members from a list of 23
five (5) names submitted by the largest state employee organization of nonschool 24
state employees, two (2) members from a list of five (5) names submitted by the 25
Kentucky Association of Counties, two (2) members from a list of five (5) names 26
submitted by the Kentucky League of Cities, and two (2) members from a list of 27 UNOFFICIAL COPY 23 RS BR 160
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names consisting of five (5) names submitted by each state employee organization 1
that has two thousand (2,000) or more members on state payroll deduction. The 2
advisory committee shall be appointed in January of each year and shall meet 3
quarterly. 4
(10) Notwithstanding any other provision of law to the contrary, the policy or policies 5
provided to employees pursuant to this section shall not provide coverage for 6
obtaining or performing an abortion, nor shall any state funds be used for the 7
purpose of obtaining or performing an abortion on behalf of employees or their 8
dependents. 9
(11) Interruption of an established treatment regime with maintenance drugs shall be 10
grounds for an insured to appeal a formulary change through the established appeal 11
procedures approved by the Department of Insurance, if the physician supervising 12
the treatment certifies that the change is not in the best interests of the patient. 13
(12) Any employee who is eligible for and elects to participate in the state health 14
insurance program as a retiree, or the spouse or beneficiary of a retiree, under any 15
one (1) of the state-sponsored retirement systems shall not be eligible to receive the 16
state health insurance contribution toward health care coverage as a result of any 17
other employment for which there is a public employer contribution. This does not 18
preclude a retiree and an active employee spouse from using both contributions to 19
the extent needed for purchase of one (1) state sponsored health insurance policy for 20
that plan year. 21
(13) (a) The policies of health insurance coverage procured under subsection (2) of 22
this section shall include a mail-order drug option for maintenance drugs for 23
state employees. Maintenance drugs may be dispensed by mail order in 24
accordance with Kentucky law. 25
(b) A health insurer shall not discriminate against any retail pharmacy located 26
within the geographic coverage area of the health benefit plan and that meets 27 UNOFFICIAL COPY 23 RS BR 160
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the terms and conditions for participation established by the insurer, including 1
price, dispensing fee, and copay requirements of a mail-order option. The 2
retail pharmacy shall not be required to dispense by mail. 3
(c) The mail-order option shall not permit the dispensing of a controlled 4
substance classified in Schedule II. 5
(14) The policy or policies provided to state employees or their dependents pursuant to 6
this section shall provide coverage for obtaining a hearing aid and acquiring hearing 7
aid-related services for insured individuals under eighteen (18) years of age, subject 8
to a cap of one thousand four hundred dollars ($1,400) every thirty-six (36) months 9
pursuant to KRS 304.17A-132. 10
(15) Any policy provided to state employees or their dependents pursuant to this section 11
shall provide coverage for the diagnosis and treatment of autism spectrum disorders 12
consistent with KRS 304.17A-142. 13
(16)[ Any policy provided to state employees or their dependents pursuant to this section 14
shall provide coverage for obtaining amino acid-based elemental formula pursuant 15
to KRS 304.17A-258. 16
(17)] If a state employee's residence and place of employment are in the same county, and 17
if the hospital located within that county does not offer surgical services, intensive 18
care services, obstetrical services, level II neonatal services, diagnostic cardiac 19
catheterization services, and magnetic resonance imaging services, the employee 20
may select a plan available in a contiguous county that does provide those services, 21
and the state contribution for the plan shall be the amount available in the county 22
where the plan selected is located. 23
(17)[(18)] If a state employee's residence and place of employment are each located in 24
counties in which the hospitals do not offer surgical services, intensive care 25
services, obstetrical services, level II neonatal services, diagnostic cardiac 26
catheterization services, and magnetic resonance imaging services, the employee 27 UNOFFICIAL COPY 23 RS BR 160
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may select a plan available in a county contiguous to the county of residence that 1
does provide those services, and the state contribution for the plan shall be the 2
amount available in the county where the plan selected is located. 3
(18)[(19)] The Personnel Cabinet is encouraged to study whether it is fair and reasonable 4
and in the best interests of the state group to allow any carrier bidding to offer 5
health care coverage under this section to submit bids that may vary county by 6
county or by larger geographic areas. 7
(19)[(20)] Notwithstanding any other provision of this section, the bid for proposals for 8
health insurance coverage for calendar year 2004 shall include a bid scenario that 9
reflects the statewide rating structure provided in calendar year 2003 and a bid 10
scenario that allows for a regional rating structure that allows carriers to submit bids 11
that may vary by region for a given product offering as described in this subsection: 12
(a) The regional rating bid scenario shall not include a request for bid on a 13
statewide option; 14
(b) The Personnel Cabinet shall divide the state into geographical regions which 15
shall be the same as the partnership regions designated by the Department for 16
Medicaid Services for purposes of the Kentucky Health Care Partnership 17
Program established pursuant to 907 KAR 1:705; 18
(c) The request for proposal shall require a carrier's bid to include every county 19
within the region or regions for which the bid is submitted and include but not 20
be restricted to a preferred provider organization (PPO) option; 21
(d) If the Personnel Cabinet accepts a carrier's bid, the cabinet shall award the 22
carrier all of the counties included in its bid within the region. If the Personnel 23
Cabinet deems the bids submitted in accordance with this subsection to be in 24
the best interests of state employees in a region, the cabinet may award the 25
contract for that region to no more than two (2) carriers; and 26
(e) Nothing in this subsection shall prohibit the Personnel Cabinet from including 27 UNOFFICIAL COPY 23 RS BR 160
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other requirements or criteria in the request for proposal. 1
(20)[(21)] Any fully insured health benefit plan or self-insured plan issued or renewed on 2
or after July 12, 2006, to public employees pursuant to this section which provides 3
coverage for services rendered by a physician or osteopath duly licensed under KRS 4
Chapter 311 that are within the scope of practice of an optometrist duly licensed 5
under the provisions of KRS Chapter 320 shall provide the same payment of 6
coverage to optometrists as allowed for those services rendered by physicians or 7
osteopaths. 8
(21)[(22)] Any fully insured health benefit plan or self-insured plan issued or renewed to 9
public employees pursuant to this section shall comply with: 10
(a) KRS 304.12-237; 11
(b) KRS 304.17A-270 and 304.17A-525; 12
(c) KRS 304.17A-600 to 304.17A-633; 13
(d) KRS 205.593; 14
(e) KRS 304.17A-700 to 304.17A-730; 15
(f) KRS 304.14-135; 16
(g) KRS 304.17A-580 and 304.17A-641; 17
(h) KRS 304.99-123; 18
(i) KRS 304.17A-138; 19
(j) KRS 304.17A-148; 20
(k) KRS 304.17A-163 and 304.17A-1631;[ and] 21
(l) Sections 1 and 2 of this Act; and 22
(m) Administrative regulations promulgated pursuant to statutes listed in this 23
subsection. 24
Section 7. KRS 205.560 is amended to read as follows: 25
(1) The scope of medical care for which the Cabinet for Health and Family Services 26
undertakes to pay shall be designated and limited by regulations promulgated by the 27 UNOFFICIAL COPY 23 RS BR 160
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cabinet, pursuant to the provisions in this section. Within the limitations of any 1
appropriation therefor, the provision of complete upper and lower dentures to 2
recipients of Medical Assistance Program benefits who have their teeth removed by 3
a dentist resulting in the total absence of teeth shall be a mandatory class in the 4
scope of medical care. Payment to a dentist of any Medical Assistance Program 5
benefits for complete upper and lower dentures shall only be provided on the 6
condition of a preauthorized agreement between an authorized representative of the 7
Medical Assistance Program and the dentist prior to the removal of the teeth. The 8
selection of another class or other classes of medical care shall be recommended by 9
the council to the secretary for health and family services after taking into 10
consideration, among other things, the amount of federal and state funds available, 11
the most essential needs of recipients, and the meeting of such need on a basis 12
insuring the greatest amount of medical care as defined in KRS 205.510 consonant 13
with the funds available, including but not limited to the following categories, 14
except where the aid is for the purpose of obtaining an abortion: 15
(a) Hospital care, including drugs, and medical supplies and services during any 16
period of actual hospitalization; 17
(b) Nursing-home care, including medical supplies and services, and drugs during 18
confinement therein on prescription of a physician, dentist, or podiatrist; 19
(c) Drugs, nursing care, medical supplies, and services during the time when a 20
recipient is not in a hospital but is under treatment and on the prescription of a 21
physician, dentist, or podiatrist. For purposes of this paragraph, drugs shall 22
include those products covered under Section 1 of this Act[for the treatment 23
of inborn errors of metabolism or genetic, gastrointestinal, and food allergic 24
conditions, consisting of therapeutic food, formulas, supplements, amino acid-25
based elemental formula, or low-protein modified food products that are 26
medically indicated for therapeutic treatment and are administered under the 27 UNOFFICIAL COPY 23 RS BR 160
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direction of a physician,] and include but [are ]not be limited to products for 1
the following conditions: 2
1. Phenylketonuria; 3
2. Hyperphenylalaninemia; 4
3. Tyrosinemia (types I, II, and III); 5
4. Maple syrup urine disease; 6
5. A-ketoacid dehydrogenase deficiency; 7
6. Isovaleryl-CoA dehydrogenase deficiency; 8
7. 3-methylcrotonyl-CoA carboxylase deficiency; 9
8. 3-methylglutaconyl-CoA hydratase deficiency; 10
9. 3-hydroxy-3-methylglutaryl-CoA lyase deficiency (HMG-CoA lyase 11
deficiency); 12
10. B-ketothiolase deficiency; 13
11. Homocystinuria; 14
12. Glutaric aciduria (types I and II); 15
13. Lysinuric protein intolerance; 16
14. Non-ketotic hyperglycinemia; 17
15. Propionic acidemia; 18
16. Gyrate atrophy; 19
17. Hyperornithinemia/hyperammonemia/homocitrullinuria syndrome; 20
18. Carbamoyl phosphate synthetase deficiency; 21
19. Ornithine carbamoyl transferase deficiency; 22
20. Citrullinemia; 23
21. Arginosuccinic aciduria; 24
22. Methylmalonic acidemia; 25
23. Argininemia; 26
24. Food protein allergies; 27 UNOFFICIAL COPY 23 RS BR 160
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25. Food protein-induced enterocolitis syndrome; 1
26. Eosinophilic disorders; and 2
27. Short bowel syndrome; 3
(d) Physician, podiatric, and dental services; 4
(e) Optometric services for all age groups shall be limited to prescription services, 5
services to frames and lenses, and diagnostic services provided by an 6
optometrist, to the extent the optometrist is licensed to perform the services 7
and to the extent the services are covered in the ophthalmologist portion of the 8
physician's program. Eyeglasses shall be provided only to children under age 9
twenty-one (21); 10
(f) Drugs on the prescription of a physician used to prevent the rejection of 11
transplanted organs if the patient is indigent; and 12
(g) Nonprofit neighborhood health organizations or clinics where some or all of 13
the medical services are provided by licensed registered nurses or by advanced 14
medical students presently enrolled in a medical school accredited by the 15
Association of American Medical Colleges and where the students or licensed 16
registered nurses are under the direct supervision of a licensed physician who 17
rotates his services in this supervisory capacity between two (2) or more of the 18
nonprofit neighborhood health organizations or clinics specified in this 19
paragraph. 20
(2) Payments for hospital care, nursing-home care, and drugs or other medical, 21
ophthalmic, podiatric, and dental supplies shall be on bases which relate the amount 22
of the payment to the cost of providing the services or supplies. It shall be one (1) of 23
the functions of the council to make recommendations to the Cabinet for Health and 24
Family Services with respect to the bases for payment. In determining the rates of 25
reimbursement for long-term-care facilities participating in the Medical Assistance 26
Program, the Cabinet for Health and Family Services shall, to the extent permitted 27 UNOFFICIAL COPY 23 RS BR 160
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by federal law, not allow the following items to be considered as a cost to the 1
facility for purposes of reimbursement: 2
(a) Motor vehicles that are not owned by the facility, including motor vehicles 3
that are registered or owned by the facility but used primarily by the owner or 4
family members thereof; 5
(b) The cost of motor vehicles, including vans or trucks, used for facility business 6
shall be allowed up to fifteen thousand dollars ($15,000) per facility, adjusted 7
annually for inflation according to the increase in the consumer price index-u 8
for the most recent twelve (12) month period, as determined by the United 9
States Department of Labor. Medically equipped motor vehicles, vans, or 10
trucks shall be exempt from the fifteen thousand dollar ($15,000) limitation. 11
Costs exceeding this limit shall not be reimbursable and shall be borne by the 12
facility. Costs for additional motor vehicles, not to exceed a total of three (3) 13
per facility, may be approved by the Cabinet for Health and Family Services if 14
the facility demonstrates that each additional vehicle is necessary for the 15
operation of the facility as required by regulations of the cabinet; 16
(c) Salaries paid to immediate family members of the owner or administrator, or 17
both, of a facility, to the extent that services are not actually performed and are 18
not a necessary function as required by regulation of the cabinet for the 19
operation of the facility. The facility shall keep a record of all work actually 20
performed by family members; 21
(d) The cost of contracts, loans, or other payments made by the facility to owners, 22
administrators, or both, unless the payments are for services which would 23
otherwise be necessary to the operation of the facility and the services are 24
required by regulations of the Cabinet for Health and Family Services. Any 25
other payments shall be deemed part of the owner's compensation in 26
accordance with maximum limits established by regulations of the Cabinet for 27 UNOFFICIAL COPY 23 RS BR 160
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Health and Family Services. Interest paid to the facility for loans made to a 1
third party may be used to offset allowable interest claimed by the facility; 2
(e) Private club memberships for owners or administrators, travel expenses for 3
trips outside the state for owners or administrators, and other indirect 4
payments made to the owner, unless the payments are deemed part of the 5
owner's compensation in accordance with maximum limits established by 6
regulations of the Cabinet for Health and Family Services; and 7
(f) Payments made to related organizations supplying the facility with goods or 8
services shall be limited to the actual cost of the goods or services to the 9
related organization, unless it can be demonstrated that no relationship 10
between the facility and the supplier exists. A relationship shall be considered 11
to exist when an individual, including brothers, sisters, father, mother, aunts, 12
uncles, and in-laws, possesses a total of five percent (5%) or more of 13
ownership equity in the facility and the supplying business. An exception to 14
the relationship shall exist if fifty-one percent (51%) or more of the supplier's 15
business activity of the type carried on with the facility is transacted with 16
persons and organizations other than the facility and its related organizations. 17
(3) No vendor payment shall be made unless the class and type of medical care 18
rendered and the cost basis therefor has first been designated by regulation. 19
(4) The rules and regulations of the Cabinet for Health and Family Services shall 20
require that a written statement, including the required opinion of a physician, shall 21
accompany any claim for reimbursement for induced premature births. This 22
statement shall indicate the procedures used in providing the medical services. 23
(5) The range of medical care benefit standards provided and the quality and quantity 24
standards and the methods for determining cost formulae for vendor payments 25
within each category of public assistance and other recipients shall be uniform for 26
the entire state, and shall be designated by regulation promulgated within the 27 UNOFFICIAL COPY 23 RS BR 160
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limitations established by the Social Security Act and federal regulations. It shall 1
not be necessary that the amount of payments for units of services be uniform for 2
the entire state but amounts may vary from county to county and from city to city, as 3
well as among hospitals, based on the prevailing cost of medical care in each locale 4
and other local economic and geographic conditions, except that insofar as allowed 5
by applicable federal law and regulation, the maximum amounts reimbursable for 6
similar services rendered by physicians within the same specialty of medical 7
practice shall not vary according to the physician's place of residence or place of 8
practice, as long as the place of practice is within the boundaries of the state. 9
(6) Nothing in this section shall be deemed to deprive a woman of all appropriate 10
medical care necessary to prevent her physical death. 11
(7) To the extent permitted by federal law, no medical assistance recipient shall be 12
recertified as qualifying for a level of long-term care below the recipient's current 13
level, unless the recertification includes a physical examination conducted by a 14
physician licensed pursuant to KRS Chapter 311 or by an advanced practice 15
registered nurse licensed pursuant to KRS Chapter 314 and acting under the 16
physician's supervision. 17
(8) If payments made to community mental health centers, established pursuant to KRS 18
Chapter 210, for services provided to the intellectually disabled exceed the actual 19
cost of providing the service, the balance of the payments shall be used solely for 20
the provision of other services to the intellectually disabled through community 21
mental health centers. 22
(9) No long-term-care facility, as defined in KRS 216.510, providing inpatient care to 23
recipients of medical assistance under Title XIX of the Social Security Act on July 24
15, 1986, shall deny admission of a person to a bed certified for reimbursement 25
under the provisions of the Medical Assistance Program solely on the basis of the 26
person's paying status as a Medicaid recipient. No person shall be removed or 27 UNOFFICIAL COPY 23 RS BR 160
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discharged from any facility solely because they became eligible for participation in 1
the Medical Assistance Program, unless the facility can demonstrate the resident or 2
the resident's responsible party was fully notified in writing that the resident was 3
being admitted to a bed not certified for Medicaid reimbursement. No facility may 4
decertify a bed occupied by a Medicaid recipient or may decertify a bed that is 5
occupied by a resident who has made application for medical assistance. 6
(10) Family-practice physicians practicing in geographic areas with no more than one (1) 7
primary-care physician per five thousand (5,000) population, as reported by the 8
United States Department of Health and Human Services, shall be reimbursed one 9
hundred twenty-five percent (125%) of the standard reimbursement rate for 10
physician services. 11
(11) The Cabinet for Health and Family Services shall make payments under the Medical 12
Assistance program for services which are within the lawful scope of practice of a 13
chiropractor licensed pursuant to KRS Chapter 312, to the extent the Medical 14
Assistance Program pays for the same services provided by a physician. 15
(12) (a) The Medical Assistance Program shall use the appropriate form and 16
guidelines for enrolling those providers applying for participation in the 17
Medical Assistance Program, including those licensed and regulated under 18
KRS Chapters 311, 312, 314, 315, and 320, any facility required to be 19
licensed pursuant to KRS Chapter 216B, and any other health care practitioner 20
or facility as determined by the Department for Medicaid Services through an 21
administrative regulation promulgated under KRS Chapter 13A. A Medicaid 22
managed care organization shall use the forms and guidelines established 23
under KRS 304.17A-545(5) to credential a provider. For any provider who 24
contracts with and is credentialed by a Medicaid managed care organization 25
prior to enrollment, the cabinet shall complete the enrollment process and 26
deny, or approve and issue a Provider Identification Number (PID) within 27 UNOFFICIAL COPY 23 RS BR 160
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fifteen (15) business days from the time all necessary completed enrollment 1
forms have been submitted and all outstanding accounts receivable have been 2
satisfied. 3
(b) Within forty-five (45) days of receiving a correct and complete provider 4
application, the Department for Medicaid Services shall complete the 5
enrollment process by either denying or approving and issuing a Provider 6
Identification Number (PID) for a behavioral health provider who provides 7
substance use disorder services, unless the department notifies the provider 8
that additional time is needed to render a decision for resolution of an issue or 9
dispute. 10
(c) Within forty-five (45) days of receipt of a correct and complete application for 11
credentialing by a behavioral health provider providing substance use disorder 12
services, a Medicaid managed care organization shall complete its contracting 13
and credentialing process, unless the Medicaid managed care organization 14
notifies the provider that additional time is needed to render a decision. If 15
additional time is needed, the Medicaid managed care organization shall not 16
take any longer than ninety (90) days from receipt of the credentialing 17
application to deny or approve and contract with the provider. 18
(d) A Medicaid managed care organization shall adjudicate any clean claims 19
submitted for a substance use disorder service from an enrolled and 20
credentialed behavioral health provider who provides substance use disorder 21
services in accordance with KRS 304.17A-700 to 304.17A-730. 22
(e) The Department of Insurance may impose a civil penalty of one hundred 23
dollars ($100) per violation when a Medicaid managed care organization fails 24
to comply with this section. Each day that a Medicaid managed care 25
organization fails to pay a claim may count as a separate violation. 26
(13) Dentists licensed under KRS Chapter 313 shall be excluded from the requirements 27 UNOFFICIAL COPY 23 RS BR 160
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of subsection (12) of this section. The Department for Medicaid Services shall 1
develop a specific form and establish guidelines for assessing the credentials of 2
dentists applying for participation in the Medical Assistance Program. 3
Section 8. Sections 1 and 2 of this Act apply to health benefit plans issued or 4
renewed on or after January 1, 2024. 5
Section 9. If the Cabinet for Health and Family Services determines that a 6
waiver or any other authorization from a federal agency is necessary to implement 7
Section 3, 4, 6, or 7 of this Act for any reason, including the loss of federal funds, the 8
cabinet shall, within 90 days after the effective date of this section, request the waiver or 9
authorization, and may only delay implementation of those provisions for which a waiver 10
or authorization was deemed necessary until the waiver or authorization is granted. 11
Section 10. Sections 1 to 8 of this Act take effect January 1, 2024. 12