AN ACT relating to Medicaid coverage for palliative care.

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AN ACT relating to Medicaid coverage for palliative care. 1
Be it enacted by the General Assembly of the Commonwealth of Kentucky: 2
SECTION 1. A NEW SECTION OF KRS CHAPTER 205 IS CREATED TO 3
READ AS FOLLOWS: 4
The Department for Medicaid Services and any managed care organization with which 5
the department has contracted for the delivery of Medicaid services shall provide 6
coverage for palliative care in accordance with the following: 7
(1) In order to be eligible for Medicaid -covered palliative care services, an individual 8
shall be: 9
(a) Eligible for and enrolled in the Medicaid program; 10
(b) In the professional opinion of the individual's care team, in the last two (2) 11
years of life; 12
(c) At risk for significant healthcare utilization; and 13
(d) Except as provided in subsection (2) of this section, diagnosed with one (1) 14
or more of the following qualifying conditions: 15
1. Stage IV cancer of any type; 16
2. Certain stage III cancers, as determined by the Department for 17
Medicaid Services in accordance with subsection (4) of this section; 18
3. NYHA class III or IV advanced heart failure; 19
4. Stage III or IV chronic obstructive pulmonary disease; 20
5. End-stage renal disease; 21
6. End-stage liver disease; 22
7. Advanced neurological disease; 23
8. Advanced dementia; or 24
9. Any other condition identified as a qualifying condition by the 25
Department for Medicaid Services t hrough the promulgation of an 26
administrative regulation, including conditions for pediatric patients 27
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that comply with the requirements of subsection (2)(b)2. of this 1
section. 2
(2) (a) An individual shall not be eligible for Medicaid -covered palliative care 3
services under this section if he or she has a primary diagnosis of substance 4
use disorder. 5
(b) An individual who is less than eighteen (18) years of age shall be eligible 6
for Medicaid-covered palliative care services under this section if he or she: 7
1. Meets the requirements established in subsection (1)(a), (b), and (c) of 8
this section; and 9
2. Has been diagnosed with an advanced illness or medical condition 10
that is expected to result in early mortality, complex healthcare needs, 11
or significant suffering. 12
(3) Palliative care services covered under this section shall: 13
(a) Include: 14
1. Physician oversight; 15
2. An interdisciplinary team approach; 16
3. Access to care twenty -four (24) hours a day, seven (7) days a week; 17
and 18
4. Regularly scheduled in -person visits by members of the individual's 19
care team. Telehealth may only be utilized to augment or supplement 20
in-person care visits; and 21
(b) Be provided under the scope of current licensure by organizations that hold 22
a valid and operational hospice license and by provi ders that are enrolled 23
Medicare and Medicaid providers. The Department for Medicaid Services 24
shall not require a separate license to provide palliative care services under 25
this section. 26
(4) The Department for Medicaid Services shall promulgate administrati ve 27
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regulations in accordance with KRS Chapter 13A to implement this section, 1
including: 2
(a) Establishing reimbursement rates and a payment methodology for palliative 3
care services covered under this section; 4
(b) Identifying certain stage III cancers that m ay qualify an individual for 5
palliative care services covered under this section; and 6
(c) Quality control measures and reporting requirements to be utilized by the 7
Department for Medicaid Services to evaluate the cost effectiveness of 8
palliative care services covered under this section, which shall include: 9
1. Hospitalization rates; 10
2. Emergency department utilization rates; 11
3. Transitions to hospice care; 12
4. Completion of advanced care planning by individuals receiving 13
Medicaid-covered palliative care services; and 14
5. Patient experience. 15
Section 2. If the Cab inet for Health and Family Services or the Department for 16
Medicaid Services determines that a state plan amendment, waiver, or any other form of 17
authorization or approval from any federal agency to implement Section 1 of this Act is 18
necessary to prevent th e loss of federal funds or to comply with federal law, the cabinet 19
or department: 20
(1) Shall, within 90 days after the effective date of this Act, request the necessary 21
federal authorization or approval to implement Section 1 of this Act; and 22
(2) May only d elay implementation of the provisions of Section 1 of this Act for 23
which federal authorization or approval was deemed necessary until the federal 24
authorization or approval is granted. 25
Section 3. Sections 1 and 2 of this Act shall constitute the specific authorization 26
required under KRS 205.5372(1). 27