Section 1. Covered Services. (1) Except as established in subsection (2) of this section, an
MCO shall be responsible for the provision of a covered health service:
(a) That is established in Title 907 of the Kentucky Administrative Regulations;
(b) That shall be in the amount, duration, and scope that the services are covered for recipients pursuant to the department’s administrative regulations located in Title 907 of the Kentucky Administrative Regulations; and
(c) Beginning on the date of enrollment of a recipient into the MCO.
(2) Other than a nursing facility cost referenced in subsection (3)(i) of this section, an MCO
shall be responsible for the cost of a non-nursing facility covered service provided to an enrollee during the first thirty (30) days of a nursing facility admission in accordance with this administrative regulation.
(3) An MCO shall not be responsible for the provision or costs of the following:
(a) A service provided to a recipient in an intermediate care facility for individuals with an intellectual disability;
(b) A service provided to a recipient in a 1915(c) home and community-based waiver program;
(c) A hospice service provided to a recipient in an institution;
(d) A nonemergency medical transportation service provided in accordance with 907 KAR 3:066;
(e) Except as established in Section 5 of this administrative regulation, a school-based
health service;
(f) A service not covered by the Kentucky Medicaid Program;
(g) A health access nurturing development service pursuant to 907 KAR 3:140;
(h) An early intervention program service pursuant to 907 KAR 1:720; or
(i) A nursing facility service for an enrollee during the first thirty (30) days of a nursing facility
admission.
(4) The following covered services provided by an MCO shall be accessible to an enrollee
without a referral from the enrollee’s primary care provider:
(a) A primary care vision service;
(b) A primary dental or oral surgery service;
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(c) An evaluation by an orthodontist or a prosthodontist;
(d) A service provided by a women’s health specialist;
(e) A family planning service;
(f) An emergency service;
(g) Maternity care for an enrollee under age eighteen (18);
(h) An immunization for an enrollee under twenty-one (21);
(i) A screening, evaluation, or treatment service for a sexually transmitted disease or tuberculosis;
(j) Testing for HIV, HIV-related condition, or another communicable disease;
(k) A chiropractic service;
(l) A behavioral health service; and
(m) A substance use disorder service.
(5) An MCO shall:
(a) Not require the use of a network provider for a family planning service;
(b) In accordance with 42 C.F.R. 431.51(a)(4), reimburse for a family planning service provided within or outside of the MCO’s provider network;
(c) Cover an emergency service:
1. In accordance with 42 U.S.C. 1396u-2(b)(2)(A)(i);
2. Provided within or outside of the MCO’s provider network; and
3. If provided out-of-state, in accordance with 42 C.F.R. 431.52;
(d) Comply with 42 U.S.C. 1396u-2(b)(2)(A)(ii); and
(e) Be responsible for the provision and reimbursement of a covered service as described in
this section beginning on or after the beginning date of enrollment of a recipient with an MCO
as established in 907 KAR 17:010.
(6)(a) If an enrollee is receiving a medically necessary covered service the day before enrollment with an MCO, the MCO shall be responsible for the reimbursement of continuation of
the medically necessary covered service without prior approval and without regard to whether
services are provided within or outside the MCO’s network until the MCO can reasonably
transfer the enrollee to a network provider.
(b) An MCO shall comply with paragraph (a) of this subsection without impeding service delivery or jeopardizing the enrollee’s health.

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