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Kentucky Medicaid program changes and related fiscal provisions (HB 695/HCS1)
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Summarizes a Kentucky bill (HB 695/HCS1) that restricts Department for Medicaid Services authority to change eligibility/coverage without the General Assembly, authorizes a community engagement waiver, creates a pharmaceutical rebate fund, limits psychoeducational behavioral health service units, reinstates prior authorization requirements, and adds reporting and procurement requirements affecting DMS and MCOs.
Prior authorization and MCO scorecard requirements
Psychoeducational services limits
Kentucky Medicaid pharmaceutical rebate fund established
Community engagement waiver and related reporting/procurement requirements
Coverage, Limits, and Utilization Management
Coverage limits and utilization management
Limits and reinstatements affecting coverage and utilization management:
ALL of the following
- Psychoeducational behavioral health services are subject to an annual limit of no more than 400 units or 100 hours per member per year.
- Psychoeducational behavioral health services are subject to a daily limit of no more than four units or one hour per member per day.
- Coverage for psychoeducational behavioral health services is not eliminated by this legislation; services remain coverable within the stated limits.
ALL of the following
- The Department for Medicaid Services (DMS) must reinstate all prior authorization requirements for behavioral health services that were in effect prior to January 1, 2020.
Operational impact: prior authorization policies and related MCO processes that were active before 1/1/2020 must be restored; effect on expenditures is indeterminable.
ALL of the following
- Managed care organizations (MCOs) are required to provide coverage and reimbursement consistent with the limits and prior authorization reinstatement specified for DMS.
- MCOs will be subject to any new reporting, procurement, and contract requirements established by the legislation.
Psychoeducational Service Limits
Prior Authorization, MCO Requirements, and Provider Responsibilities
Reinstate prior authorization and follow MCO scorecards
The legislation requires reinstatement of all prior authorizations for behavioral health services that were in effect prior to January 1, 2020, and mandates that MCOs develop and publish a behavioral health services scorecard. Providers must follow the reinstated prior authorization rules when seeking coverage for behavioral health services and adhere to any MCO-specific authorization processes reflected on published scorecards.
- Reinstatement of all prior authorizations in effect prior to January 1, 2020.
- MCOs required to develop and publish a behavioral health services scorecard; providers should consult MCO scorecards for reporting and performance expectations.
Key Defined Terms
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