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Benefits by State: Kentucky (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes A, C & D - $3/visit Limited to procedures safely performed in ambulatory setting, as approved by CMS Prospective cost based rate per episode of care using Medicare payment rates as ceiling or 45% of charge A, B, C & D - See state-specific FN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes A - $2/visit Mental Health Clinics not covered - see Rehab Services Fee for service A, B, C & D - See state-specific FN
Federally Qualified Health Center Services
Yes A - $2/visit Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment A, B, C & D - See state-specific FN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes A - $50/admission, C & D - $10/admission Admissions for specified procedures safely rendered on outpatient basis, elective admissions Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis Prospective payment/discharge using DRG A, B, C & D - See state-specific FN
Outpatient Hospital Services
Yes A, C & D - $3/ambulatory visit; A, B, C & D - 5% of payment for non-emergency visit in ER up to $6 Fee for service with surgical procedures grouped using Medicare methodology or cost based payment A, B, C & D - See state-specific FN
Rehabilitation Services: Mental Health and Substance Abuse
Yes Adult coverage of substance abuse services as a primary diagnosis limited to pregnant women; covered as secondary diagnosis for other adults Prospective cost based per diem A, B, C & D - See state-specific FN
Rural Health Clinic Services
Yes A - $2/visit Prospective cost based rate/visit A, B, C & D - See state-specific FN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service at 75% of physician fee A, B, C & D - See state-specific FN
Chiropractor Services
Yes A - $2/visit 26 visits/year Fee for service A, B, C & D - See state-specific FN
Dental Services
Yes A - $2/visit Specified services including periodontal scaling and root planing Adult exam and cleaning 1/year, frequency of x-rays limited by type, alveoplasty 1/quad/lifetime, coverage of gingevectomy limited by diagnosis Fee for service A, B, C & D - See state-specific FN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes A - $2/visit Fee for service A, B, C & D - See state-specific FN
Nurse Midwife Services
Yes A - $2/visit except maternity care Fee for service at 75% of physician fee A, B, C & D - See state-specific FN
Nurse Practitioner Services
Yes A - $2/visit except maternity care Fee for service at 75% of physician fee A, B, C & D - See state-specific FN
Optometrist Services
Yes A, C & D - $2/visit Limited to diagnosis and treatment of medical eye problems as permitted by law Fee for service A, B, C & D - See state-specific FN
Physician Services
Yes A, B, C & D - no copays for preventive services; A - $2/visit except maternity care; B - $2/visit for allergy testing 4 psychotherapy visits/year Fee for service A, B, C & D - See state-specific FN
Podiatrist Services
Yes A, C & D - $2/visit Specified services, orthopedic shoes and appliances not covered Fee for service with upper limits set at 65% of median billed charge for ambulatory services and at 50% of median for services in inpatient hospital setting A, B, C & D - See state-specific FN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes $1/generic Rx; $2/preferred brand Rx; B - $3/non-preferred brand Rx; A, C & D - 5% of payment up to $20 for non-preferred brand Rx; A, B, C & D - annual out-of-pocket expense capped at $225 Specified drugs, including amphetamines and over the counter products A, C & D - 4 Rx/month including up to 3 brand Rx AWP-15% for brand Rx plus $4.50 dispensing fee; AWP-14% for generic Rx plus $5.00 dispensing fee A, B, C & D - See state-specific FN
Physical Therapy and Other Services
Occupational Therapy Services
Yes A - $2/visit Yes A - 15 visits/year, C & D - 30 visits/year, B - direct payment not allowed Fee for service A, C & D - See state-specific FN
Physical Therapy Services
Yes A - $2/visit Specified services A - 15 visits/year, C & D - 30 visits/year Fee for service A, B, C & D - See state-specific FN
Services for Speech, Hearing and Language Disorders
Yes A - $1/visit Yes A - 10 visits/year, C & D - 30 visits/year; audiometric services not covered for adults Fee for service A, B, C & D - See state-specific FN
Products and Devices
Dentures
No
Eyeglasses
No
Hearing Aids
No
Medical Equipment and Supplies
Yes A, C & D - 3% of payment/per item up to $15/month Limited to items used in the home and in accordance with restrictions contained in state regulations Fee for service or invoice price plus 20% or suggested retail price minus 15-22% A, B, C & D - See state-specific FN
Prosthetic and Orthotic Devices
Yes B - $1500 maximum benefit/year Fee for service using Medicare payment ceilings A, B, C & D - See state-specific FN
Transportation Services
Ambulance Services
Yes Fee for service A, B, C & D - See state-specific FN
Non-Emergency Medical Transportation Services
Yes Yes See service-specific FN A, B, C & D - See state-specific FN
Other Services
Diagnostic, Screening and Preventive Services
Yes Limited to diagnostic services only Reasonable charge A, B, C & D - See state-specific FN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes A - $3/service Fee for service using Medicare payment ceilings A, B, C & D - See state-specific FN
Targeted Case Management
Yes Cost based payment A, B, C & D - See state-specific FN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 1, 2, 4 & 8 - See service-specific FN Dependent upon the services provided C & D - See state-specific FN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes B - 25 visits/year Fee for service A, B, C & D - See state-specific FN
Hospice Care
Yes Limited to non-institutional care, two 90-day periods and one 30-day period with additional periods as necessary Prospective rates based on Medicare methodology A, B, C & D - See state-specific FN
Personal Care Services
No
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes Leave days must be medically necessary and included in care plan Prospective cost based per diem, cost based payment for ancillary services C & D - See state-specific FN
Inpatient Psychiatric Services, under age 21
Yes Admission and at 30-day intervals Prospective cost based per diem A, B, C & D - See state-specific FN
Intermediate Care Facility Services for the Mentally Retarded
Yes 45 leave days of any type/quarter, 15 hosp leave days/hospitalization, combined hosp and therapeutic leave limited to 30 consecutive days Prospective cost based per diem, cost based payment for ancillary services C - See state-specific FN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes 14 hosp leave days/hospitalization up to 14 days/year, 10 therapeutic leave days/year Prospective per diem by resident class/acuity, ancillary services paid fee for service, leave days paid at 75% of facility's rate if occupancy 95% or more and 50% of rate if lower D - See state-specific FN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: This State was one of the first to receive approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act of 2005. Kentucky has implemented portions of its KyHealth Choices initiative that customizes beneficiaries’ benefits to meet their specific needs. There are four plans included in the initiative. Global Choices (“A” on the tables) includes the standard benefit package with more extensive cost sharing and benefit caps and does not include long-term care; it targets pregnant women and parents, caretaker relatives, recipients of cash assistance through SSI or the state’s TANF (KTAP) program, women with breast or cervical cancer, medically fragile children and children in foster care. Family Choices (“B” on the tables) is targeted to children, including those eligible for traditional Medicaid and those covered by both the Medicaid expansion and separate SCHIP (called KCHIP in Kentucky); it includes the standard benefit package with no cost sharing for the Medicaid-covered children. Optimum Choices (“C” on the tables) includes the standard benefit package as well as institutional (ICF/MR) and community-based long-term care; it targets persons with developmental disabilities, and its parameters, through a Section 1115 waiver, are still being negotiated with CMS. The fourth plan, Comprehensive Choices (“D” on the tables), targets the elderly and disabled in need of institutional or community-based long-term care; it includes the standard benefit package as well as long-term care services, and also relies on authority in a Section 1915 (c) waiver. Some cost sharing is required of beneficiaries in both the Optimum Choices and Comprehensive Choices plans. The plan’s designated letter on the tables notes distinctions in coverage; nuances applicable only to the separate KCHIP are not included. Any identified copayment requirements are applicable to beneficiaries age 18 and older and do not apply to preventive services; beneficiaries eligible for both Medicare and Medicaid are exempt from cost sharing.
 
 
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