Title 911 KAR — Cabinet for Health and Family Services - Office for Children with Special Healthcare Needs

title-911911 KARRegulation

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Chapter 1 Children with Special Health Care Needs Services

911 KAR 1:010 Application for Clinical Programs {#sec-911-kar-1-010 omnilex-key=us-ky-regs-official--title-911--911 KAR 1:010}

Section 1. Definitions.

(1) "Applicant" means a person in need of services offered by the Office for Children with Special Health Care Needs clinical program.

(2) "Clinical program" means an established clinical service by which OCSHCN delivers care to treat conditions listed on the OCSHCN-10g, Medical Eligibility List for Clinical and Case Management Services, through a provider:

(a) Contracted in accordance with 911 KAR 1:060; or

(b) Employed by OCSHCN as an audiologist.

(3) "Eligibility Committee" means an OCSHCN committee that is charged with:

(a) Clarifying financial eligibility questions that arise during:

  1. The application review process; and

  2. Ongoing eligibility reviews;

(b) Evaluating appeal requests for reconsideration pursuant to Section 13 of this administrative regulation;

(c) Clarifying medical eligibility questions that arise during the application review process; and

(d) Determining if a diagnosis qualifies for inclusion in the clinical program.

(4) "Income" means money received from:

(a) Statutory benefits, such as Social Security, Veterans Administration pension, black lung benefits, or railroad retirement benefits;

(b) Military housing;

(c) Clerical housing;

(d) Farm or business operations;

(e) Pensions;

(f) Wages for labor or services;

(g) Royalties;

(h) Alimony, maintenance, or child support;

(i) Miscellaneous income as defined by the Internal Revenue Service at https://www.irs.gov/forms-pubs/about-form-1099-misc;

(j) Retirement Survivors Disability Insurance;

(k) Disability benefits;

(l) Unemployment benefits;

(m) Supplemental Security Income;

(n) Workers' compensation;

(o) Annuities; or

(p) Interest and dividends.

(5) "OCSHCN" means Office for Children with Special Health Care Needs.

(6) "Responsible adult" means a person who is:

(a) Responsible for making decisions about an OCSHCN clinical program applicant or recipient of services; or

(b) Required to provide financial support for an OCSHCN clinical program applicant or recipient of services.

Section 2. Criteria for Application to an OCSHCN Clinical Program.

(1) In order to be eligible to apply to an OCSHCN clinical program, an applicant shall:

(a) Be under twenty-one (21) years of age;

(b) Live in Kentucky;

(c) Provide a Kentucky physical mailing address at which the applicant receives mail; and

(d) Declare Kentucky as permanent domicile and residency.

(2) An applicant to the OCSHCN Autism Diagnostic Service shall be referred by:

(a) A physician, licensed in accordance with KRS Chapter 311;

(b) An advanced practice registered nurse, licensed in accordance with KRS Chapter 314;

(c) A licensed behavioral analyst, licensed in accordance with KRS Chapter 319;

(d) A therapist, licensed in accordance with KRS Chapter 334A;

(e) A qualified service provider with the Kentucky Early Intervention System, as defined by KRS 200.654(13); or

(f) School personnel, based on testing results.

(3) An applicant to the OCSHCN Autism Medical Service shall be:

(a) Referred by a:

  1. Physician, licensed in accordance with KRS Chapter 311;

  2. Psychologist, licensed in accordance with KRS Chapter 319; or

  3. Speech-language pathologist, licensed in accordance with KRS Chapter 334A, if an Autism Diagnostic Observation Schedule assessment tool was used; and

(b) Diagnosed with autism.

(4) An applicant to the OCSHCN Hearing Aid Only Service shall be:

(a) Diagnosed to have a permanent childhood hearing loss; and

(b) Under the care of a licensed otorhinolaryngologist.

(5) An applicant to clinical services not established in subsections (2), (3), or (4) of this section may be referred by any person or provider.

(6) An individual shall be ineligible for application to clinical programs if a write-off balance for services is owed to OCSHCN for clinical services delivered to the individual.

(7) Any balances owed pursuant to subsection (6) of this section shall be paid in accordance with the:

(a) Individual's pay category status; and

(b) Provisions of 911 KAR 1:020.

(8) OCSHCN may consider reapplication for an applicant if the applicant has been discharged for failure to:

(a) Complete financial update in accordance with Section 12 of this administrative regulation;

(b) Cooperate with medical care;

(c) Make payments on a past due account balance;

(d) Pay OCSHCN for services received; or

(e) Reimburse OCSHCN if an insurance payment has been received by the applicant.

(9) Exceptions to subsections (7) and (8) this section shall be determined by the OCSHCN request for reconsideration process in accordance with Section 13 of this administrative regulation.

Section 3. Initial Application.

(1) If an individual who meets the criteria established in Section 2 of this administrative regulation expresses interest in submitting an application to OCSHCN's clinical program, designated staff shall provide the relevant application packet , in accordance with Section 4 of this administrative regulation:

(a) At a scheduled intake appointment with the individual;

(b) By postal mail; or

(c) Electronically.

(2) An application shall be made by:

(a) The parent or other legally appointed guardian, if the individual is:

  1. A minor who is not legally emancipated; or

  2. An adult who is in custodial care; or

(b) The individual, if the individual is:

  1. An adult; and

  2. Not in the custodial care of another person or entity.

(3) OCSHCN may require the signature of both the applicant and responsible adult if:

(a) The applicant is over the age of eighteen (18); and

(b) There is a question of the applicant's competence to make decisions regarding self-care.

Section 4. Application Forms.

(1) An applicant to an OCSHCN clinical program shall provide to the agency within thirty (30) days of application:

(a) A copy of the applicant's insurance card, or documentation of insurance, if the applicant is not receiving Medicaid or K-CHIP;

(b) OCSHCN-10b, Consent for Care Agreement;

(c) OCSHCN-10c, Guaranty of Payment Agreement;

(d) OCSHCN-10d1, Coordination of Benefits Agreement;

(e) OCSHCN-10a1, Application for Service Legal Guardian (Medicaid), if the application is made by a legal guardian on behalf of a child or adult who is:

  1. Under the age of twenty-one (21); and

  2. Not legally emancipated;

(f) OCSHCN-10a2, Application for Service Legal Guardian (private insurance), if the application is made by a legal guardian on behalf of a child or adult who is:

  1. Under the age of twenty-one (21); and

  2. Not legally emancipated;

(g) OCSHCN-10e1, Application for Service Young Adult, if the application is made by an individual who is:

  1. Not legally emancipated; or

a. Between the ages of eighteen (18) and twenty-one (21); and

b. A full-time student; and

(h) OCSHCN-10f1, Application for Service Head of Household, if the application is made by an individual who is:

  1. Under the age of eighteen (18) and legally emancipated; or

  2. Between the ages of eighteen (18) and twenty-one (21) and financially emancipated.

(2) OCSHCN may request that the applicant submit additional information or documentation concerning medical history within thirty (30) days, based on:

(a) Medical staff request; and

(b) Specific medical need.

Section 5. Limited English Proficiency.

(1) OCSHCN shall provide foreign language interpretation services to ensure that families, staff, and providers have an opportunity to communicate effectively.

(2) OCSHCN shall arrange sign language interpreter services for persons who are deaf or hard of hearing, pursuant to 920 KAR 1:070.

Section 6. Proof of Custody for Applicants.

(1) OCSHCN shall require a signed and dated legal court filing establishing custody rights of a minor if:

(a) The parents of a minor are divorced;

(b) The minor is adopted or in the legal custody of the commonwealth; or

(c) The legal guardianship of the minor is in question.

(2) OCSHCN shall require a signed and dated legal court filing establishing custody rights of an adult if the adult is said to be in custodial care of another individual.

(3) OCSHCN may require that the application be signed by the responsible adult if:

(a) The applicant is his or her own legal guardian; and

(b) There is a legitimate concern as to the applicant's ability to make decisions regarding self-care.

Section 7. Application Review Process.

(1) Upon receipt of an application for the OCSHCN clinical program, designated staff shall review the packet to ensure all materials have been completed in accordance with Sections 3 and 4 of this administrative regulation.

(2) Designated staff shall notify the applicant of:

(a) Missing information or clarification needed; and

(b) The timeframe for submitting requested information.

(3) Complete applications shall be processed in accordance with Sections 8, 9, and 10 of this administrative regulation.

(4) If an applicant fails to submit requested information to OCSHCN within the specified timeframe, the application process shall be closed.

Section 8. Medical Eligibility Determination.

(1) In order to be eligible for an OCSHCN clinical program, the applicant shall have a documented condition that is treated by OCSHCN.

(2) An application shall be eligible for expedited review if designated OCSHCN staff determine that recent medical records exist documenting that a contracted provider staffing an OCSHCN clinical program has:

(a) Diagnosed the applicant with a condition on the OCSHCN-10g, Medical Eligibility List for Clinical and Case Management Services; and

(b) Agreed to a treatment plan for the child's condition that is supported by the OCSHCN services offered.

(3) If records established in subsection (2) of this section are not available for OCSHCN review, designated OCSHCN staff shall schedule an onsite clinical evaluation:

(a) By:

  1. A contracted provider staffing an OCSHCN clinical program; or

  2. An OCSHCN clinic employee; and

(b) To obtain documentation needed to confirm medical eligibility.

(4) Upon receipt of documentation pursuant to this section, designated staff shall determine an applicant's medical eligibility for the OCSHCN clinical program.

Section 9. Financial Eligibility Determination and Pay Category Assignment.

(1) Each applicant shall undergo a financial review process upon:

(a) Application;

(b) Confirmation of medical eligibility;

(c) Change in income or household size prior to annual financial review; and

(d) Annual financial review.

(2) The OCSHCN process to determine pay category assignment shall:

(a) Be based on the household income of the responsible adult requesting services; and

(b) Include income of:

  1. The applicant, if the applicant is:

a. An adult; or

b. Not in the custodial care of another person or entity;

  1. Parents, step-parents, or legal guardians, if the applicant is:

a. A minor who is not legally emancipated; or

b. An adult who is in custodial care; and

  1. Spouse of the applicant, if the applicant is married.

(3) Designated OCSHCN staff shall establish a household size based on family composition, including:

(a) The applicant;

(b) If the applicant is a minor:

  1. Parents;

  2. Step-parents;

  3. Siblings, including:

a. Half siblings; and

b. Step-siblings; and

  1. Any other dependent child claimed by the applicant on a federal tax return; and

(c) If the applicant is an emancipated minor or adult:

  1. Spouse;

  2. Children, including:

a. Half children; and

b. Step-children; and

  1. Any other dependent child claimed by the applicant on a federal tax return.

(4) The documents required for income verification shall be the most recent:

(a) Federal tax return of the applicant or the responsible adult; and

(b) Paycheck statement with year-to-date gross earnings for each currently held job.

(5) An applicant or responsible adult without a paycheck containing the criteria established in subsection (4)(b) of this section shall provide the two (2) most recent, consecutivepay stubs or a written statement from the employer that shows:

(a) Gross amount earned; and

(b) Frequency of pay.

(6) An applicant who is covered by Kentucky Medicaid shall be:

(a) Exempt from income verification;

(b) Considered financially eligible; and

(c) Placed in the zero percent pay category.

(7) If household income suggests that an applicant is possibly Medicaid- eligible, a Medicaid application shall be completed within thirty (30) days.

(8) If a Medicaid application completed pursuant to subsection (7) of this section is denied for a reason other than being over income, the applicant shall:

(a) Be considered financially eligible;

(b) Meet medical eligibility criteria pursuant to Section 8 of this administrative regulation; and

(c) Be assigned a pay category in accordance with Section 10 of this administrative regulation.

(9) If a Medicaid application completed pursuant to subsection (7) of this section is denied for being over income, the applicant shall be:

(a) Considered financially eligible; and

(b) Assigned a pay category in accordance with Section 10 of this administrative regulation.

(10) If an application for Medicaid is not completed as requested within the specified timeframe, the application process shall be closed.

Section 10. Family Participation Scale.

(1) An eligible applicant shall be assigned a pay category, which is determined based on:

(a) Annual gross income; and

(b) Household size.

(2) OCSHCN shall:

(a) Calculate minimum and maximum annual gross income limits annually, utilizing:

  1. The federal poverty level established annually by the United States Department of Health and Human Services pursuant to 42 U.S.C. 9902(2); and

  2. Modified adjusted gross income-based methods established in 42 C.F.R. 435.603; and

(b) Post the current Family Participation Scale at https://www.chfs.ky.gov/agencies/ocshcn.

(3) Except as established in subsection (5) of this section, pay categories shall:

(a) Represent eligibility requirements at income levels for the Kentucky Children's Health Insurance program established in 907 KAR 4:030; and

(b) Be established at:

  1. Zero Percent;

  2. Twenty (20) percent;

  3. Forty (40) percent;

  4. Sixty (60) percent;

  5. Eighty (80) percent; and

  6. 100 percent.

(4) In accordance with KRS 200.470(1), an applicant who is placed in the 100 percent pay category shall be eligible for acceptance only if access to adequate care and treatment is limited as evidenced by:

(a) Service needed is not otherwise available within a fifty (50) mile radius of where the patient resides;

(b) Treatment requires a multi-disciplinary team, which may include a physician, RN care coordinator, social worker, nutritionist, and therapist;

(c) Service is needed for the purchase of hearing aids;

(d) The patient is:

  1. Uninsured; and

  2. A member of a religious sect that is exempt from the requirement to maintain minimum essential coverage as required by 26 U.S.C. 5000A ;

(e) The patient is:

  1. Uninsured;

  2. Not eligible for Medicaid or the Kentucky Children's Health Insurance Program (KCHIP); and

  3. Is exempt from the requirements to maintain minimum essential coverage as required by 26 U.S.C. 5000A; or

(f) The medical care or service ordered by an OCSHCN-contracted specialist as treatment for a qualifying condition:

  1. Is a non-covered benefit or excluded under the patient's insurance policy; and

  2. The patient would benefit from the OCSHCN negotiated rate.

(5) An exception to subsection (3) of this section shall be determined by the OCSHCN request for reconsideration process in accordance with Section 13 of this administrative regulation.

Section 11. Notice of Eligibility Determination.

(1) If an applicant is determined to be eligible in accordance with Sections 8 and 9 of this administrative regulation, designated staff shall notify the applicant in writing of the:

(a) Acceptance into the OCSHCN clinical program;

(b) Effective date of eligibility;

(c) Pay category assigned and a description of family participation fees and responsibilities;

(d) Annual review date;

(e) Name of the OCSHCN contact person assigned to:

  1. Manage medical care;

  2. Schedule appointments; and

  3. Discuss services available; and

(f) Right to request reconsideration of pay category assignment, in accordance with Section 13 of this administrative regulation.

(2) If an applicant is determined to be ineligible for acceptance into the OCSHCN clinical program, designated staff shall notify the following individuals, in writing, of the reason for denial:

(a) The applicant, enumerating a right to request reconsideration of the adverse decision; and

(b) The applicant's primary care or referring physician, if applicable.

Section 12. Continuing Eligibility and Reapplication.

(1) A responsible adult shall advise OCSHCN if there is a change in:

(a) Employment;

(b) Contact information;

(c) Insurance coverage; or

(d) Family composition.

(2) A financial recertification shall be completed annually.

(3) During the financial recertification, designated OCSHCN staff shall:

(a) Verify continued Medicaid enrollment; or

(b) If the recipient of services is not enrolled in Kentucky Medicaid, send the responsible adult written notice pursuant to Section 4 of this administrative regulation, requesting completion of:

  1. The financial portion of the application form; and

  2. The OCSHCN-10c, Guaranty of Payment Agreement form.

(4) If the forms requested pursuant to subsection (3)(b) of this section are not returned in accordance with the requested timeframe, designated staff shall follow up in writing.

(5) If the requested forms are not returned subsequent to a written follow up pursuant to subsection (4) of this section, designated staff shall:

(a) Initiate discharge of the recipient from the OCSHCN clinical program; and

(b) Notify the responsible adult or person receiving services, providing the:

  1. Date of discharge;

  2. Referral to primary care physician;

  3. Option to reapply for OCSHCN services, and contact phone number; and

  4. Courtesy copies of notifications of discharge sent to:

a. Primary care physician;

b. Dental provider, if applicable; and

c. Pharmacy provider, if applicable.

(6) Financial recertification shall occur if there is:

(a) A loss of Medicaid;

(b) Change in circumstances, such as income or household size; or

(c) Change in guardianship.

(7) Upon receipt of documentation related to this section's continuing eligibility and reapplication, designated staff shall notify the responsible adult in writing of the:

(a) Acceptance into the OCSHCN clinical program;

(b) Effective date of eligibility;

(c) Pay category assigned and a description of family participation fees and responsibilities;

(d) Annual review date;

(e) Name of OCSHCN contact person assigned to:

  1. Manage medical care;

  2. Schedule appointments; and

  3. Discuss services available; and

(f) Right to request reconsideration of pay category assignment, pursuant to Section 13 of this administrative regulation.

Section 13. Request for Reconsideration.

(1) An individual who is aggrieved by an adverse decision regarding initial eligibility, termination of services, or pay category assignment in accordance with the procedures established in Section 10 of this administrative regulation may request a reconsideration. A request for reconsideration shall be filed within thirty (30) days of receipt of the adverse decision.

(2) A request for reconsideration of pay category assignment shall be directed to the Eligibility Committee for resolution.

(3) Once a request for reconsideration of the pay category assigned is received, the applicant shall be provided with an OCSHCN-10h, Medical Expense Worksheet, which shall be completed and returned to OCSHCN within thirty (30) days.

(4) An applicant shall submit with the OCSHCN-10h, Medical Expense Worksheet, and written proof of out of pocket payment for allowable medical expenses as established in subsection (5) of this section and paid for:

(a) By the applicant or a member of the applicant's household; and

(b) Within the last twelve (12) months from the date of the letter of the pay category assignment.

(5) Allowable medical expenses shall include:

(a) Insurance premiums;

(b) Medical office or clinic visits;

(c) Medical supplies;

(d) Nutritional supplies;

(e) Prescription medications;

(f) Over the counter medications;

(g) Durable medical equipment;

(h) Hearing aids;

(i) Dental or orthodontia;

(j) Vision or Eye;

(k) Hospitalizations;

(l) Additional expenses for consideration; and

(m) OCSHCN payments in accordance with 911 KAR 1:020.

(6) Upon receipt of the OCSHCN-10h, Medical Expense Worksheet, and documentation established in subsection (4) of this section, OCSHCN staff shall:

(a) Verify expenses;

(b) Present to the OCSHCN Eligibility Committee for review; and

(c) Notify the applicant in writing of the determination.

Section 14. Request for Hearing. An individual who has received a notice of adverse action following a reconsideration may request an administrative hearing from the Office of Administrative Hearings within the Department of law in accordance with KRS 15.111(2)(g) and KRS 13B.

Section 15. Incorporation by Reference.

(1) The following material is incorporated by reference:

(a) OCSHCN-10a1, "Application for Service Legal Guardian (Medicaid) ",01/2025;

(b) OCSHCN-10a2, "Application for Service Legal Guardian (Private Insurance)", 01/2025;

(c) OCSHCN-10b, "Consent for Care Agreement", 01/2019;

(d) OCSHCN-10c, "Guaranty of Payment Agreement", 01/2019;

(e) OCSHCN-10d1, "Coordination of Benefits Agreement",01/2025;

(f) OCSHCN-10e1, "Application for Service Young Adult",01/2025;

(g) OCSHCN-10f1, "Application for Service Head of Household",01/2025;

(h) OCSHCN-10g, "Medical Eligibility List for Clinical and Case Management Services", 08/2019; and

(i) OCSHCN-10h, "Medical Expense Worksheet", 01/2019.

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Office for Children with Special Health Care Needs, 310 Whittington Parkway, Suite 200, Louisville, Kentucky 40222, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the agency's Web site at https://chfs.ky.gov/agencies/ocshcn.

History

  • RELATES TO: KRS 13B, 15.111(2)(g), 200.460, 200.470, 200.654(13), Chapters 311, 314,
  • STATUTORY AUTHORITY: KRS 194A.030(3)
  • NECESSITY, FUNCTION, AND CONFORMITY: KRS 194A.030(3) authorizes the Department for Public Health to promulgate administrative regulations to implement and administer its responsibilities, which include oversight of the Office for Children with Special Health Care Needs (OCSHCN). This administrative regulation establishes application forms used for clinical programs, procedures for application and reapplication, eligibility criteria, assignment of pay category, and processes used to determine initial and continuing eligibility for services, as well as a process for reconsideration of an adverse decision.
  • History: 911 KAR 001:010. 45 Ky.R. 2814; 3425; 46 Ky.R. 906; eff. 8-19-2019; 52 Ky.R. 1607, 50; eff. 7-20-2026.
911 KAR 1:020 Billing and fees {#sec-911-kar-1-020 omnilex-key=us-ky-regs-official--title-911--911 KAR 1:020}

Section 1. Definitions.

(1) "Eligibility Committee" or "committee" means an OCSHCN committee that is charged with:

(a) Clarifying financial eligibility questions that arise during:

  1. The application review process; and

  2. Ongoing eligibility reviews;

(b) Evaluating appeal requests for reconsideration pursuant to Section 13 of this administrative regulation;

(c) Clarifying medical eligibility questions that arise during the application review process; and

(d) Determining if a diagnosis qualifies for inclusion in the clinical program.

(2) "OCSHCN" means the Office for Children with Special Health Care Needs.

(3) "OCSHCN medical staff" means the staff who meets the requirements established in 911 KAR 1:060.

Section 2. Minimum Monthly Payment.

(1) A patient's minimum monthly payment shall be computed as the lesser of:

(a) The amount assigned as the minimum amount due, for the patient's pay category, determined in accordance with 911 KAR 1:010, Section 10; or

(b) The total current balance of the patient's account, including all amounts paid or incurred during the past thirty (30) calendar days, as established in the table in this paragraph.

(2) An individual shall also pay any unpaid portion of a previously billed amount.

Section 3. Patient Statement of Account. Designated staff shall prepare a statement of account, which shall:

(1) Be mailed to the family on or around the twentieth day of each calendar month; and

(2) Include the:

(a) Total account balance;

(b) Amount past due calculated in accordance with Section 2 of this administrative regulation;

(c) Required minimum monthly payment;

(d) Amounts paid or incurred during the past thirty (30) calendar days; and

(e) Contact information for any questions concerning billed amounts.

Section 4. Receipt of Payments. A family shall make payments to OCSHCN:

(1) Via mail;

(2) In person at any OCSHCN regional office; or

(3) By telephone using a credit card.

Section 5. OCSHCN Clinic Participation Fees.

(1) A patient shall be charged a program participation fee when services are provided at an OCSHCN-managed clinic by:

(a) OCSHCN staff; or

(b) OCSHCN medical staff.

(2) The OCSHCN clinic participation fee shall be determined as established in the table in this subsection.

(3) The OCSHCN clinic participation fee shall not be charged if the patient is enrolled in Kentucky Medicaid when service is provided.

(4) Only one (1) OCSHCN clinic participation fee shall be charged per day per person receiving services.

Section 6. OCSHCN Referral for Services Provided by Contracted Providers.

(1) If services are provided to a patient by an OCSHCN-contracted provider outside of an OCSHCN-managed clinic, the patient shall be responsible for payment for services, in accordance with the terms and conditions contained in the contractual agreement entered into by OCSHCN and the contracted provider.

(2) Prior to the delivery of services, designated staff shall:

(a) Ensure that the contracted provider is a participant under the patient's insurance plan;

(b) Issue a written referral for services to the contracted provider to identify that the patient is enrolled in an OCSHCN clinical program; and

(c) Provide demographic and insurance information to the contracted provider.

(3) A patient shall contact the contracted provider prior to the delivery of services in order to:

(a) Identify that the patient is enrolled in the OCSHCN clinical program; and

(b) Discuss payment expectations.

(4) A patient may contact the OCSHCN Payments and Provider Relations branch to confirm that the contracted provider is billing the contracted rate after any insurance payments are applied.

Section 7. Authorization of Payment for External Services.

(1) OCSHCN shall issue an authorization of payment for outpatient services to an OCSHCN-contracted provider for a patient who:

(a) Has no insurance coverage;

(b)

  1. Has private insurance; and

  2. Is in the zero percentage pay category; or

(c)

  1. Has private insurance;

  2. Is in the twenty (20) percent through 100 percent pay category; and

  3. Needs services or benefits that are not covered (excluding co-pays).

(2) Prior to submitting a bill to OCSHCN, the OCSHCN-contracted provider shall bill any third-party insurance payors.

(3) After OCSHCN has paid the contracted provider, OCSHCN shall bill the patient for the portion of the cost as established in the table in this subsection.

(4) A patient with insurance coverage in twenty (20) percent through 100 percent pay category status shall be responsible for the payment of any copays or co-insurance for outpatient or inpatient services with an OCSHCN contracted provider.

(5) OCSHCN shall authorize payments for recommended or prescribed durable medical equipment and shall bill the patient for the portion of the cost as established in the table in this subsection.

(6) OCSHCN shall authorize payment for recommended or prescribed hearing aids, earmolds, or dispensing and fitting fees, and shall bill the patient for the portion of the cost as established in the table in this subsection.

(7) OCSHCN shall authorize payment for orthodontia or dental services provided by a Medicaid-contracted provider or an in-network provider, and shall bill a patient for the portion of the cost as established in the table in this subsection.

(8) If OCSHCN authorizes payments for prescription drugs for a patient, the patient responsibility shall be:

(a) No charge for the family of a patient in the zero percent pay category;

(b) 100 percent of what OCSHCN pays the provider, for a patient in the twenty (20) percent to 100 percent pay category with private insurance under which the drug is a non-covered benefit;

(c) Payment to the provider for a patient in the twenty (20) percent to 100 percent pay category with private insurance under which the drug is a covered benefit; and

(d) As established in the table in this paragraph for an uninsured patient in the twenty (20) percent to 100 percent pay category.

(9) The schedule for making payment to OCSHCN on an account shall be as established in the table in this subsection.

Section 8. Failure to Provide Payments.

(1) If the minimum required payment, calculated in accordance with Section 2 of this administrative regulation, is not received within thirty (30) days following the first billing to the family, OCSHCN shall:

(a) Mail a second statement of account, pursuant to Section 3 of this administrative regulation; and

(b) Request that the assigned OCSHCN care coordinator contact the family to follow up with the family.

(2) If the minimum required payment, calculated in accordance with Section 2 of this administrative regulation, is not received within sixty (60) days following the first billing to the family:

(a) The account shall not be considered in good standing; and

(b) OCSHCN shall:

  1. Mail a third statement of account, pursuant to Section 3 of this administrative regulation, indicating that the patient is subject to discharge from the OCSHCN program if all required payments are not received within thirty (30) days from the date of the letter; and

  2. Discontinue eligibility for:

a. Services that require an authorization of payment for external services, in accordance with Section 7 of this administrative regulation;

b. Assistance with lodging;

c. Meal reimbursement; and

d. Assistance with transportation.

(3) If the minimum required payment calculated in accordance with Section 2 of this administrative regulation is not received within 120 days following the first billing to the family, OCSHCN shall:

(a) Discharge the patient from the OCSHCN program;

(b) Mail the family a letter, which states that:

  1. The patient has been discharged for failure to make required payments; and

  2. Reapplication may be made, but readmission to the program is contingent upon the payment of any write-off for bad debt balances for services previously delivered to the patient, based on the patient's pay category determined in accordance with 911 KAR 1:010, Section 10;

(c) Rescind any outstanding authorizations to the patient's:

  1. Medical providers; and

  2. Pharmacy providers; and

(d) Write off the balance of the account, adjusting the balance to reflect a zero dollar balance.

Section 9. Reapplication. OCSHCN shall allow no more than three (3) reapplications if the discharge reasons include failure to:

(1) Complete financial update pursuant to 911 KAR 1:010, Section 12;

(2) Cooperate with medical care;

(3) Make payments based on the patient's pay category; or

(4) Reimburse OCSHCN when insurance payments are received.

Section 10. Request for Reconsideration.

(1) An individual who is aggrieved may request a reconsideration of:

(a) Discharge due to non-payment of an account balance pursuant to Section 8 of this administrative regulation; or

(b) Dismissal of a reapplication due to reaching the maximum number of reapplications pursuant to Section 9 of this administrative regulation.

(2) An individual requesting reconsideration shall complete the OCSHCN-20a, Request for Reconsideration of Discharge. The request for reconsideration shall:

(a) Be received by OCSHCN within ten (10) business days of the date the individual received notification of discharge or dismissal in accordance with subsection (1) of this section; and

(b) Contain the:

  1. Name of the individual or legal guardian;

  2. Address;

  3. Telephone;

  4. E-mail address, if available;

  5. Justification for reconsideration;

  6. Following supporting documentation, if available:

a. Bank statements;

b. Provider statements; or

c. Original receipts showing the amount paid; and

  1. Dated signature of individual or legal guardian.

(3) OCSHCN review of the completed form and supporting documentation shall be completed:

(a) Within ten (10) business days; and

(b) By the eligibility committee.

(4) OCSHCN's review shall include consideration of:

(a) If a change in circumstances exists, including a change in:

  1. The amount of earned income;

  2. Job status; or

  3. Excessive out of pocket expenses made throughout the calendar year for medical expenses, including:

a. Co-payments;

b. Required deductions for insurance;

c. Fees;

d. Prescription costs; or

e. Any other direct costs to the individual or legal guardian for medical expenses; and

(b) The severity of the condition and the need to keep the patient enrolled for services due to:

  1. Limitation in access to care; or

  2. Costs related to medication needed to treat the patient.

(5) The eligibility committee shall vote to approve or deny the request for reconsideration.

(6) If additional information is requested:

(a) The committee shall request the information within five (5) business days of the review date;

(b) The individual or legal guardian shall return the information to the committee within thirty (30) days; and

(c) OCSHCN shall approve or deny the request for reconsideration within five (5) business days.

(7) OCSHCN shall communicate to the individual or legal guardian:

(a) If the reconsideration request was approved or denied; and

(b) A brief justification of the approval or denial.

(8) An individual who has received a notice of adverse action following a reconsideration may request an administrative hearing in accordance with KRS Chapter 13B. The request for an administrative hearing shall be received by OCSHCN within thirty (30) days of the notice of adverse action.

Section 11. Incorporation by Reference.

(1) OCSHCN-20a, "Request for Reconsideration of Discharge", 01/2019, is incorporated by reference.

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Office for Children with Special Health Care Needs, 310 Whittington Parkway, Suite 200, Louisville, Kentucky 40222, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the agency's Web site at https://chfs.ky.gov/agencies/ccshcn.

History

  • RELATES TO: KRS 194A.030(5), 200.470(2)
  • STATUTORY AUTHORITY: KRS 194A.030(5)
  • NECESSITY, FUNCTION, AND CONFORMITY: KRS 194A.030(5) authorizes the Office for Children with Special Health Care Needs to promulgate administrative regulations to implement and administer its responsibilities. This administrative regulation establishes minimum monthly payments for cost of treatment and care, commensurate with ability to pay, procedures for the preparation and transmittal of patient statement of accounts, receipt of payments, clinic participation fees, services provided by contracted providers, authorizations of payment, procedures for failure to provide payments, provisions for discharge, criteria for reapplication, as well as a process for reconsideration of an adverse decision.
  • History: 45 Ky.R. 2819, 3430; eff. 7-19-2019; Crt eff. 4-21-2026.
911 KAR 1:060 Medical staff {#sec-911-kar-1-060 omnilex-key=us-ky-regs-official--title-911--911 KAR 1:060}

Section 1. Definitions.

(1) "Advanced practice registered nurse" is defined by KRS 314.011(7).

(2) "Dentist" is defined by KRS 313.010(10).

(3) "MAC" means the Medical Advisory Committee, which is an internal OCSHCN committee that consists of thirteen (13) members and advises OCSHCN on issues pertaining to medical staff qualification, credentialing, quality, and other related issues.

(4) "OCSHCN" means Office for Children with Special Health Care Needs.

(5) "Physician" is defined by KRS 311.550(12).

(6) "Physician assistant" is defined by KRS 311.840(3).

(7) "Psychologist" is defined by KRS 319.010(9).

Section 2. Qualifications for Acceptance to OCSHCN Active Medical Staff.

(1) In order to be eligible for acceptance to the OCSHCN active medical staff, an individual shall be:

(a) Licensed to practice in Kentucky as a:

  1. Physician;

  2. Dentist;

  3. Advanced practice registered nurse;

  4. Physician assistant; or

  5. Psychologist; and

(b) Able to document:

  1. Background, experience, training, and competence;

  2. Adherence to the ethics of the individual's profession;

  3. Professionalism; and

  4. Interpersonal skills.

(2) A physician or dentist shall be:

(a)

  1. Eligible for membership in the national medical or dental society; or

  2. Enrolled as a member of the national medical or dental society; and

(b) Enrolled as a participating provider in the Kentucky Medicaid program, in accordance with 907 KAR 1:672.

(3) For specific medical specialties, for which there is a generally recognized certification by a board giving examinations in the field, the individual shall be:

(a) Eligible to sit for the examination of the board; or

(b) Board certified.

(4) - For initial appointment to the medical staff in a dental specialty area, the individual shall be licensed in the specialty area, in accordance with KRS 313.035 and 201 KAR 8:532.

Section 3. Categories of Medical Staff. The medical staff shall consist of the following categories:

(1) Temporary active status, pursuant to Section 6 of this administrative regulation;

(2) Active status, pursuant to Sections 2, 4, and 5 of this administrative regulation; and

(3) Contracted status, pursuant to Section 7 of this administrative regulation.

Section 4. Initial Application Process for Active Medical Staff.

(1) An individual seeking initial appointment to the medical staff shall submit to OCSHCN a completed application packet containing:

(a) A completed and signed:

a. OCSHCN-60a, Application for Active Medical or Dental Staff, if the individual is a dentist or physician;

b. OCSHCN-60b, Application for Active Medical APRN Staff, if the individual is an advanced practice registered nurse;

c. OCSHCN-60c, Application for Active Psychology Staff, if the individual is a psychologist; or

d. OCSHCN-60d, Application for Active Medical Physician Assistant Staff, if the individual is a physician assistant;

  1. OCSHCN-60e, Authorization, Attestation, and Release; and

  2. OCSHCN-60f, Anti-Harassment and Discrimination Acknowledgment;

  3. Two (2) OCSHCN- 60g, Peer Reference Letter Medical or Dental;

(b) A copy of the individual's current Council for Affordable Quality Healthcare (CAQH) application;

(c) A current curriculum vitae;

(d) A copy of the individual's malpractice insurance endorsement; and

(e) The applicable information required by subsections (2) through (5) of this section.

(2) If the individual is a dentist or physician, the following attachments shall be included:

(a) A copy of the individual's license to practice, issued by the Kentucky:

  1. Board of Dentistry; or

  2. Board of Medical Licensure; and

(b) If applicable, a copy of the individual's current Form DEA-223, Controlled Substance Registration Certificate issued by the United States Department of Justice, Drug Enforcement Administration.

(3) If the individual is an advanced practice registered nurse, the following attachments shall be included:

(a) A copy of a signed Collaborative Practice Agreement between the physician and the individual, as submitted to the Kentucky Board of Nursing; and

(b) A copy of the individual's current credentialing from the:

  1. American Nurses Credentialing Center (ANCC); or

  2. American Academy of Nurse Practitioners (AANP).

(4) If the individual is a psychologist, the application packet shall include a copy of the individual's license to practice, issued by the Kentucky Board of Examiners of Psychology.

(5) If the individual is a physician assistant, the following attachments shall be included:

(a) A copy of the individual's license to practice, issued by the Kentucky Board of Medical Licensure;

(b) A copy of the initial and any applicable Supplemental Application for Physician to Supervise Physician Assistant, as submitted to the Kentucky Board of Medical Licensure; and

(c) A copy of the National Commission on Certification of Physician Assistants (NCCPA) certification.

Section 5. Procedures for Application Review and Appointment.

(1) Within seven (7) working days of receipt of the application pursuant to Section 4 of this administrative regulation, designated OCSHCN staff shall request that:

(a) Individuals listed as references complete theOCSHCN 60g, Peer Reference Letter Medical or Dental; and

(b) An individual submit missing information or other required documents necessary to an evaluation of the individual's qualifications.

(2) If the documentation requested pursuant to subsection (1) of this section is not received by OCSHCN within forty-five (45) working days from the date of the request, designated OCSHCN staff shall notify the individual in writing that:

(a) The individual shall be responsible for following up to obtain missing information and ensuring receipt by OCSHCN within twenty (20) working days of written notice;

(b) Failure to submit the missing information within twenty (20) working days of written notice under paragraph (a) of this subsection shall result in the application being placed in closed status without further review;

(c) Reapplication for staff appointment shall not be considered for a period of six (6) months from the date of the notice that the application has been closed pursuant to paragraph (b) of this subsection; and

(d) Reapplication for staff appointment shall be processed as an initial application.

(3) Upon receipt of documentation requested pursuant to subsection (1) of this section, designated OCSHCN staff shall make the application and other documentation available to the MAC chair, who shall present the application at the next meeting of the MAC.

(4) The MAC shall:

(a) Ensure that all necessary documents and investigations have been validated with objectivity, fairness, and impartiality, and that recommendations are soundly based and compatible with the objectives of OCSHCN;

(b) Determine if the individual meets all necessary qualifications for the category of staff membership and clinical privileges requested;

(c) If the MAC determines that the individual meets all necessary qualifications for the category of staff membership and clinical privileges requested, recommend to designated OCSHCN staff:

  1. Appointment to the appropriate staff category; and

  2. Granting of privileges according to the specialty to which the individual shall be assigned; and

(d) If the MAC determines that the individual does not meet all necessary qualifications for the category of staff membership and clinical privileges requested:

  1. Defer consideration of the application, if clarifying information is needed; or

  2. Reject the application.

(5) Upon the MAC approving the individual, designated OCSHCN staff shall add the individual approved in accordance with this section to OCSHCN's active medical staff for a period of three (3) years.

(6) An individual aggrieved by an adverse decision pursuant to subsection (4)(d) of this section may request to address the MAC to seek reconsideration pursuant to Section 12 of this administrative regulation.

Section 6. Temporary Active Medical Staff.

(1) The executive director or designee may make a temporary active medical staff appointment if necessary to provide clinical coverage. This type of staff appointment shall be:

(a) Emergency in nature;

(b) Made based on information currently available that may reasonably be obtained as to the competence and ethical standing of the individual; and

(c) Reviewed by the MAC within six (6) months following the appointment.

(2) A temporary active medical staff appointment shall last no longer than six (6) months, at which time the appointment shall be eligible for conversion to the active medical staff pursuant to the processes established in Sections 4 and 5 of this administrative regulation.

(3) Each appointee to the temporary active medical staff shall have an assigned member of the active medical staff review performance during clinic and make recommendations to the MAC as necessary regarding conversion to the active medical staff.

(4) An appointee to temporary active medical staff status shall be compensated in accordance with Section 10 of this administrative regulation.

Section 7. Contracted Staff.

(1) In accordance with KRS Chapter 45A, OCSHCN may contract with medical or dental specialists to provide services to children outside of OCSHCN offices and clinics.

(2) OCSHCN-enrolled children may be referred to contracted staff by a member of the active OCSHCN medical staff or the OCSHCN medical director.

Section 8. Annual Review and Reappointment Process.

(1) OCSHCN shall, on an annual basis, verify for each member of the active medical staff:

(a) Current state license; and

(b) Current malpractice insurance.

(2) Each member of the active medical staff shall undergo a re-credentialing process every three (3) years. Required documents to be submitted to OCSHCN shall include:

(a) OCSHCN-60i, Renewal Application for Active Medical or Dental Staff; and

(b) All documents requested by OCSHCN-60i, Renewal Application for Active Medical or Dental Staff.

(3) The reappointment evaluation shall include:

(a) Review of required forms and documents;

(b) Timely completion and preparation of medical and other required patient records;

(c) Satisfactory evidence of compliance with ethics;

(d) Compliance with OCSHCN procedures;

(e) General cooperation and ability to work with others;

(f) Results of quality assurance audits, if conducted; and

(g) Reports of disciplinary action requested, or proceedings initiated against a provider at any institution.

(4) At each regularly scheduled meeting, the MAC shall complete a review of the active medical staff that are due for a three (3) year re-credentialing appraisal. The review shall include:

(a) OCSHCN-60i, Renewal Application for Active Medical or Dental Staff; and

(b) Any other information pertinent to continuation on the medical staff.

(5) After the review, the MAC shall make a determination to re-credential or not re-credential based on the information requested in this section.

Section 9. Duties and Responsibilities of Medical Staff.

(1) Each member of the medical staff shall assume the same responsibility for care and treatment of the staff member's assigned patients as in private practice.

(2) A resident physician or dentist in training may assist in the care of patients, if a member of the active medical staff:

(a) Remains entirely responsible for the care of each patient;

(b) Examines and, if indicated, recommends treatment for each new patient under the staff member's care;

(c) Remains present in the surgical suite at all operations and other procedures in which general anesthesia is used;

(d) Directs the examination of all patients assigned to the active staff member for discharge from the hospital and designates follow-up care; and

(e) Maintains oversight of the resident physician or dentist.

(3) Active medical staff members assigned to OCSHCN clinics shall be present to conduct an assigned clinic. If an active medical staff member cannot be present to conduct an assigned clinic, the staff member shall:

(a) Make arrangements with another member of the OCSHCN medical staff to serve in the staff member's place, if the staff member advises the assigned OCSHCN staff of this change; or

(b) Request that assigned OCSHCN staff reschedule the clinic, if the request is timely enough to allow OCSHCN staff to notify patients of the rescheduling.

(4) For a clinic with more than one (1) provider representing different specialties, if an active medical staff member cannot be present to conduct an assigned clinic, the staff member shall:

(a) Make arrangements with another member of the OCSHCN medical staff to serve in the staff member's place, if the staff member advises the assigned OCSHCN staff of this change; or

(b) Make arrangements with the other active medical staff members assigned to the clinic to reschedule the entire clinic, if the request is timely enough to allow OCSHCN staff to notify patients of the rescheduling.

(5) If an active medical staff member who has responsibility for a clinic fails to attend two (2) clinics during a twelve (12) month period and does not comply with subsection (3) or (4) of this section, the active medical staff member shall be:

(a) Removed from the active medical staff; and

(b) Advised in writing of:

  1. The removal; and

  2. Right to be heard by the MAC pursuant to Section 12 of this administrative regulation.

(6) Medical staff members participating in OCSHCN onsite clinics shall document a summary of each patient visit. Documentation shall be completed:

(a) On the day of the visit; or

(b) Within seventy-two (72) hours of the visit if it cannot be finished on the day of the visit.

(7) Medical staff members participating in OCSHCN onsite clinics shall:

(a) Not remove patient medical records from OCSHCN premises; and

(b) Authenticate their medical record entries regarding diagnosis, findings, and recommendations for treatment, by:

  1. Signature; or

  2. Initials.

(8) If a medical staff member elects to initial the medical record pursuant to subsection (7) of this section, OCSHCN shall maintain a legend for purpose of identity, which shall include the typed or printed name of the medical staff member, followed by hand signed initials.

(9) A medical staff member may see OCSHCN patients in the staff member's private office, as deemed necessary by the medical staff member. Office visit records shall be:

(a) Completed; and

(b) Forwarded to the assigned OCSHCN office within three (3) working days of the visit.

(10) To the extent possible, total care for the child shall be considered while the specific condition for which treatment is sought is being cared for. Coexistent diseases, disabilities, or anomalies shall be investigated and treated if:

(a) The referring physician or dentist, if any, approves and consents; and

(b) The services fall within the categories eligible for treatment by OCSHCN in accordance with 911 KAR 1:010.

(11) A program of total care for the child shall be developed by a team approach. There shall be discussion of all phases of the problem of each child by all medical personnel concerned with the child's care, including therapists and other professional personnel. Team care shall be provided within the context of a multidisciplinary clinic.

(12) Contracted staff shall be available for consultation and treatment if indicated. Arrangements for contracts shall be made through the assigned OCSHCN office on an individual basis.

Section 10. Compensation.

(1) A member of the medical staff shall be compensated for services provided during OCSHCN clinics in accordance with a contract agreed to pursuant to the provisions of KRS Chapter 45A.

(2) If OCSHCN staff refer patients to a member of the active medical staff for services outside of an OCSHCN clinic, information needed to bill the appropriate insurance carrier shall be included.

Section 11. Corrective Action.

(1) The following parties may request corrective action be directed toward a member of the medical staff:

(a) Any member of the medical staff;

(b) The chair of the MAC;

(c) OCSHCN staff; or

(d) A member of the family of an OCSHCN-enrolled child.

(2) The basis for a request for corrective action shall include activities or professional conduct that are considered to be:

(a) Contrary to the standards or aims of the medical staff; or

(b) Disruptive to OCSHCN operations, programs, or clinics.

(3) A request for corrective action shall be:

(a) In writing;

(b) Addressed to the executive director; and

(c) Supported by references to the specific activities or conduct that constitutes grounds for the request.

(4) Within ten (10) working days of receipt of a request for corrective action, the executive director or designee shall:

(a) Initiate an investigation of the facts and circumstances surrounding the grounds for the requested corrective action;

(b) Interview the member of the medical staff against whom the corrective action is requested;

(c) Document the interview in writing; and

(d) Submit a report and recommendation to the MAC for consideration.

(5) Within ninety (90) working days following the receipt of the recommendation by the executive director, the MAC shall make recommendations on the request.

(6) In accordance with subsection (5) of this section, the MAC may:

(a) Reject the request for corrective action;

(b) Issue a warning, letter of admonition, or letter of reprimand;

(c) Impose terms of probation or a suspension from the medical staff; or

(d) Recommend that the affected member's medical staff membership be suspended or revoked.

(7) The executive director shall have the authority to summarily suspend or dismiss a member of the medical staff if action is needed immediately in the interest of patient care. Grounds for summary suspension or dismissal from the medical staff shall include:

(a) Action by the governing Board of Medical Licensure, Board of Dentistry, Board of Nursing, or Board of Examiners of Psychology, in which a member's license is revoked or suspended;

(b) Loss of hospital privileges; or

(c) Behavior that creates a risk of harm to children or OCSHCN staff.

Section 12. Request for Reconsideration.

(1) A provider may request to appear before the MAC to advocate for reconsideration if the provider:

(a) Was denied appointment to the medical staff pursuant to Section 5 of this administrative regulation;

(b) Was removed from the active medical staff pursuant to Section 9(5) of this administrative regulation; or

(c) Has been the subject of corrective action pursuant to Section 11 of this administrative regulation.

(2) A provider who is aggrieved pursuant to subsection (1) of this section shall complete form OCSHCN-60k, Request for Reconsideration by Medical Advisory Committee, to include:

(a) Name of provider;

(b) Specialty;

(c) Address;

(d) Telephone;

(e) E-mail address, if available;

(f) Justification for reconsideration;

(g) Supporting documentation, if available, including:

  1. Verification of training or work history; and

  2. Provider statements or recommendations; and

(h) Dated signature of the provider.

(3) The MAC shall review the completed form and supporting documentation.

(4) The MAC may request additional pertinent information, as needed, within five (5) working days of the review date.

(5) The provider shall return the information requested pursuant to subsection (4) of this section within ten (10) working days.

(6) The MAC shall communicate to the provider:

(a) The date to appear before the MAC; and

(b) Within five (5) working days of the receipt of all information requested.

(7) Following the provider's appearance at the MAC, the MAC shall communicate within five (5) working days to the provider:

(a) The decision made; and

(b) A brief explanation.

Section 13. Incorporation by Reference.

(1) The following material is incorporated by reference:

(a) OCSHCN-60a, "Application for Active Medical or Dental Staff," 06/2022;

(b) OCSHCN-60b, "Application for Active Medical APRN Staff," 06/2022;

(c) OCSHCN-60c, "Application for Active Psychology Staff," 06/2022;

(d) OCSHCN-60d, "Application for Active Medical Physician Assistant Staff," 06/2022;

(e) OCSHCN-60e, "Authorization, Attestation, and Release," 01/2019;

(f) OCSHCN-60f, "Anti-Harassment and Discrimination Acknowledgment," 01/2019;

(g) OCSHCN-60g, "Peer Reference Letter Medical or Dental," 06/2022;

(h) OCSHCN-60i, "Renewal Application for Active Medical or Dental Staff," 06/2022; and

(i) OCSHCN-60k, "Request for Reconsideration by Medical Advisory Committee," 06/2022.

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Office for Children with Special Health Care Needs, 310 Whittington Parkway, Suite 200, Louisville, Kentucky 40222, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the agency's Web site at https://chfs.ky.gov/agencies/ccshcn/Pages/Incorporated.aspx.

History

  • RELATES TO: KRS 45A, 200.460, 313.035
  • STATUTORY AUTHORITY: KRS 194A.030(5)
  • NECESSITY, FUNCTION, AND CONFORMITY: KRS 194A.030(5) authorizes the Office for Children with Special Health Care Needs to promulgate administrative regulations to implement and administer its responsibilities under KRS 200.460 to 200.490. This administrative regulation establishes requirements relating to the Office for Children with Special Health Care Needs medical staff.
  • History: 45 Ky.R. 2823, 3434; eff. 7-19-2019; 49 Ky.R. 1361, 1796; eff. 3-16-2023.
911 KAR 1:085 Early Hearing Detection and Intervention Program {#sec-911-kar-1-085 omnilex-key=us-ky-regs-official--title-911--911 KAR 1:085}

Section 1. Definitions.

(1) "AAA Guidelines" means the "Clinical Guidance Document Assessment of Hearing in Infants and Young Children" published by the American Academy of Audiology.

(2) "ASHA Guidelines" means the "Guidelines for the Audiologic Assessment of Children from Birth to 5 Years of Age" published by the American Speech-Language-Hearing Association.

(3) "Audiologist" is defined by KRS 334A.025(2).

(4) "Audiology extern" means a student engaged in the clinical experience component of an audiology doctoral degree program.

(5) "Auditory brainstem response" or "ABR" means an objective electrophysiologic measurement of the brainstem's response to the ear when stimulated with a click sound or tone burst.

(6) "Automated auditory brainstem response" or "AABR" means an automatic ABR resulting in a pass/refer outcome.

(7) "Center" means Infant Audiological Assessment and Diagnostic Center.

(8) "JCIH Guidelines" means "Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs" published by the Joint Committee on Infant Hearing.

(9) "Office" or "OCSHCN" is defined by KRS 211.645(2).

(10) "Otoacoustic emissions" means an objective physiological test method for measuring responses elicited directly from the cochlea.

Section 2. Eligibility Criteria for Centers.

(1) In order to be eligible for designation as a Level 1 infant audiological assessment and diagnostic center, an entity located in Kentucky shall:

(a) Employ at least one (1) audiologist who:

  1. Is currently licensed pursuant to KRS Chapter 334A;

  2. Has experience testing children in the age range newborn to three (3) years; and

a. Performs all evaluations; or

b. Directly supervises audiology externs performing evaluations;

(b) Possess the capacity to complete the following tests:

  1. Otoscopic examination;

  2. Tympanometry;

  3. Ipsilateral acoustic reflex measurement;

  4. Contralateral acoustic reflex measurement;

  5. Ear-specific behavioral observation audiometry;

  6. Speech awareness threshold;

  7. Speech recognition or reception threshold;

  8. Play audiometry; and

  9. Either:

a. Otoacoustic emissions with diagnostic or screening capabilities; or

b. ABR screening;

(c) Annually calibrate all measuring and testing equipment; and

(d) Submit a complete application and assurance packet in accordance with Section 3 of this administrative regulation.

(2) In order to be eligible for designation as a Level 2 infant audiological Assessment and diagnostic center, an entity located in Kentucky shall:

(a) Meet the requirements specified in subsection (1) of this section; and

(b) Possess the capacity to complete:

  1. Otoacoustic emissions with diagnostic or screening capabilities;

  2. Frequency-specific ABR;

  3. Bone conduction ABR; and

  4. Real ear measures.

Section 3. Application Process.

(1) An entity seeking designation as an infant audiological assessment and diagnostic center shall submit to OCSHCN a completed application packet containing:

(a) Completed and signed form OCSHCN-E106, Potential Infant Audiological Assessment and Diagnostic Center Questionnaire;

(b) Copies of current professional licenses for audiologists performing evaluations;

(c) Copies of current calibration certificates for audiological testing equipment; and

(d) Copies of policies and procedures for tests and measures requested on the OCSHCN-E106, Potential Infant Audiological Assessment and Diagnostic Center Questionnaire.

(2) OCSHCN shall review an entity's application within thirty (30) calendar days of receiving a complete packet submitted in accordance with subsection (1) of this Section.

(3) Upon review of an entity's application packet, OCSHCN's executive director or designee shall approve the entity as a Level 1 Infant Audiological Assessment and Diagnostic Center if:

(a) The entity meets the requirements specified in Section 2(1) of this administrative regulation; and

(b) OCSHCN determines that the entity's policies and procedures conform to best practice standards as described in JCIH Guidelines and:

  1. AAA Guidelines; or

  2. ASHA Guidelines.

(4) Upon review of an entity's application packet, OCSHCN's executive director or designee shall approve the entity as a Level 2 Infant Audiological Assessment and Diagnostic Center if:

(a) The entity meets the requirements specified in Section 2(2) of this administrative regulation; and

(b) OCSHCN determines that the entity's policies and procedures conform to best practice standards as described in JCIH Guidelines and:

  1. AAA Guidelines; or

  2. ASHA Guidelines.

(5) If OCSHCN's executive director or designee determines that the entity does not meet the requirements specified in Section 2 of this administrative regulation, OCSHCN shall:

(a) Advise the entity and request clarifying information; or

(b) Deny the designation as an Infant Audiological Assessment and Diagnostic Center and notify the entity of appeal rights pursuant to Section 8 of this administrative regulation.

(6) Approvals shall expire on December 31 of odd-numbered years. All entities seeking continued approval shall re-apply by December 1 of that year in accordance with this section.

Section 4. Publication of Approved List.

(1) In accordance with KRS 211.647, OCSHCN shall maintain a current listing of all approved centers, with contact information.

(2) OCSHCN shall make the listing public through the following methods:

(a) Posting the listing on its agency Web site, https://chfs.ky.gov/agencies/ocshcn;

(b) Providing to the Cabinet for Health and Family Services, Office of Administrative and Technology Services, a listing for inclusion on the KY-CHILD electronic information system used by birthing hospitals and centers;

(c) Enclosing a listing as an attachment to correspondence with parents; and

(d) Mailing a listing to birthing hospitals and centers upon request.

Section 5. Removal from Approved List and Updates Required.

(1) OCSHCN shall remove an entity from the approved list and notify the entity of the removal if the entity requests removal.

(2) If OCSHCN receives a complaint that an entity no longer meets the requirements of Section 2 of this administrative regulation, OCSHCN shall:

(a) Advise the entity of the complaint;

(b) Request clarifying information from the entity;

(c) Review any information received; and

(d) Determine whether the entity meets the eligibility requirements of Section 2 of this administrative regulation.

(3) If OCSHCN determines that the entity no longer meets the eligibility requirements, the office shall:

(a) Notify the entity of appeal rights pursuant to Section 8 of this administrative regulation; and

(b) Remove the entity from the approved list.

(4) Following approval, a center shall provide documentation using form OCSHCN-E107, Infant Audiological Assessment and Diagnostic Center Program Modification, if any of the following changes in circumstances occur:

(a) Employment or termination of employment of an audiologist;

(b) Change in licensure status of an audiologist;

(c) Relocation of agency, name change, or addition of a location; or

(d) Modification to policy or procedure with regard to evaluations described in Section 2 of this administrative regulation.

Section 6. Reporting Requirements.

(1) Upon completion of diagnostic testing of an infant or child aged birth to three (3) years described in KRS 211.647(5), an approved center shall report the following to OCSHCN using form OCSHCN-E3:

(a) Identifying and demographic information;

(b) Results of the follow-up audiological evaluation; and

(c) Documentation of the referral required by KRS 211.647(5).

(2) An approved Infant Audiological Assessment and Diagnostic Center shall submit information specified in subsection (1) of this section electronically via the KY-CHILD electronic information system for permanent hearing loss, within forty-eight (48) hours of evaluation, in accordance with KRS 211.647, using form OCSHCN-E3.

(3) Scheduled appointments which are not kept by families shall be marked in the KY-CHILD electronic information system as no-show within four (4) calendar days if not rescheduled.

Section 7. Resource and Informational Materials. OCSHCN shall make available information provided by the Kentucky Commission on the Deaf and Hard of Hearing to families of all newborns and children ages birth to three (3) years identified as having permanent hearing loss .

Section 8. Appeal Rights. An entity denied designation as an Infant Audiological Assessment and Diagnostic Center or which has been removed from the approved list may request an administrative hearing from the Office of Administrative Hearings within the Department of Law in accordance with KRS 15.111(2)(g) and KRS 13B.

Section 9. Approved Methods of Auditory Screening for Newborn Infants and Children Ages Birth to Three (3) Years.

(1) Auditory screenings pursuant to KRS 216.2970(1) shall include at least one (1) of the following physiological tests:

(a) AABR; or

(b) Otoacoustic emissions.

(2) Auditory screening reports shall:

(a) Document the results of physiological tests conducted;

(b) Document the presence of any risk factors pursuant to KRS 211.645(5); and

(c) Be submitted via the KY-CHILD electronic information system.

Section 10. Incorporation by Reference.

(1) The following material is incorporated by reference:

(a) "Clinical Guidance Document Assessment of Hearing in Infants and Young Children", 1/2020;

(b) "OCSHCN-E106, Potential Infant Audiological Assessment and Diagnostic Center Questionnaire", 03/2025;

(c) "OCSHCN-E107, Infant Audiological Assessment and Diagnostic Center Program Modification",03/2025;

(d) "Guidelines for the Audiologic Assessment of Children From Birth to 5 Years of Age" 2004 American Speech-Language-Hearing Association;

(e) "Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs" Joint Committee on Infant Hearing; and

(f) "OCSHCN-E3 Audiology Update Form (AUF) Worksheet", 04/2026.

(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Office for Children with Special Health Care Needs, 310 Whittington Parkway, Suite 200, Louisville, Kentucky 40222, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the agency's Web site at https://chfs.ky.gov/agencies/ocshcn.

(3)

(a) The material in paragraph (a) is available online at https://www.audiology.org/practice-guideline/clinical-guidance-document-assessment-of-hearing-in-infants-and-young-children.

(b) The materials in paragraph (b), (c), (d), (e), and (f) is available online at the agency's website at https://www.chfs.ky.gov/agencies/ocshcn/Pages/Incorporated.aspx.

History

  • RELATES TO: KRS 13B.050, 15.111(2)(g), 194A.030(5), 200.460
  • STATUTORY AUTHORITY: KRS 194A.030(3), 194A.050(1), 211.647(3), 216.2970(1)
  • NECESSITY, FUNCTION, AND CONFORMITY: KRS 194A.050(1) requires the Secretary of the Cabinet for Health and Family Services to promulgate administrative regulations necessary to operate the programs and fulfill the responsibilities vested in the cabinet, to implement programs mandated by federal law, or to qualify for federal funds. KRS 194A.030(3) authorizes the Department for Public Health to promulgate administrative regulations as may be necessary to implement and administer its responsibilities under KRS 200.460 to 200.490, which include oversight of the Office for Children with Special Health Care Needs (OCSHCN). KRS 211.647(3) authorizes OCSHCN to promulgate administrative regulations establishing standards for infant audiological assessments and diagnostics centers. KRS 216.2970(1) requires the OCSHCN to promulgate administrative regulations establishing approved methods for auditory screening for all infants born in health facilities offering obstetric or midwifery services. This administrative regulation establishes standards, eligibility criteria, application processes, reporting requirements, and appeal rights for entities seeking designation as approved infant audiological assessment and diagnostic centers, and identifies approved methods for auditory screening for newborn infants in health care facilities offering obstetric or midwifery services.
  • History: 911 KAR 001:085. 27 Ky.R. 2013; Am. 2469; eff. 3-6-2001; Recodified from 902 KAR 4:085, 8-10-2001; 36 Ky.R. 698; 1228; eff. 1-4-2010; 41 Ky.R. 1226; 1658; eff. 2-5-2015; TAm eff. 8-29-2019; 49 Ky.R. 1366, 1799; eff. 3-16-2023; 52 Ky.R. 1612, 2096, 53; eff. 7-20-2026.

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