DPP-1258C (R.4/2026)

Agreement Number: Number
STATE FUNDED EXTRAORDINARY MEDICAL EXPENSES
o INITIAL o RENEGOTIATION

COMMONWEALTH OF KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES
DEPARTMENT FOR COMMUNITY BASED SERVICES ADOPTION AGREEMENT FOR EXTRAORDINARY MEDICAL EXPENSES

THIS AGREEMENT, made and entered into as of the	day of	, 20	by and between the Commonwealth of Kentucky, Cabinet for Health and Family Services, Department for Community Based Services, hereinafter referred to as the Cabinet, and

Herein after called the "adoptive parents", for the purpose of facilitating the legal adoption of	, (birth and adoptive name) born on	, TWIST#  , and to aid the adoptive family in providing proper care for this special needs child.

WITNESSETH, THAT:
Whereas KRS 199.555 authorizes the payment of extraordinary medical expenses to adoptive parents of special needs children.

Whereas the children may benefit from being adopted and the payment of assistance after the adoption shall increase the likelihood of the adoption; and

Whereas the Cabinet has determined the special needs of the child exist, pursuant to 922 KAR 1:050.

PROVISIONS OF AGREEMENT

Extraordinary Medical Expenses
The Cabinet agrees to reimburse the adoptive parents for extraordinary medical expenses, related to the child's special needs, which are not otherwise reimbursed by private insurance, Medicaid, or other third party or government programs, payable upon receipt of an appropriate billing. The Cabinet will pay for only the expenses as are related to the child's special needs and which have been specifically approved by the Cabinet.

Services have eligibility criteria. Based upon household income, adoptive parents may be responsible for a co-payment. Services available through the extraordinary medical program are limited by the availability of state funds.

1.	Child Care Expenses	Yes 	No 		% monthly copayment

Approved childcare co-payments will mirror those established by the Division of Child Care in Kentucky Administrative Regulation 922 KAR 2:160. In accordance with this regulation, adjustments in reimbursable amounts can be made at any time. Child care services are paid by the adoptive parents and reimbursed only with a paid receipt. Child care reimbursements are only available for children under the age of thirteen (13);

1

or thirteen (13) years of age and older if need is established due to physical, emotional, or developmental needs of the child, and with documentation provided from a health care or qualified mental health professional.

2.	Transportation	Yes 	No 	$
Transportation can be reimbursed if mileage driven for treatment needs exceeds the yearly mileage rolled into foster care rate.

3.	Respite Care	Yes 	No 	$
Children approved for Medically Complex, Degreed Medically Complex and Care Plus Home rates may be approved for two (2) respite days per child per month. Children approved for the Specialized Medically Complex rate can be approved for three (3) respite days per child per month. Respite requires signed receipt and cannot be carried over from month to month

4.	Orthodontia	Yes 	No 	$
Co-payment is 50 percent of what the adoptive parent(s) pay. Medical or dental need exits, is medically necessary, and verification was obtained prior to the adoption finalization. 

5.	Funeral and Burial 	Yes 	No 	$________
For medically complex child who had a terminal medical diagnosis documented by a treating physician prior to an adoption being finalized, not to exceed $4,500.

6.	Tutoring	Yes 	No 	$
The rate may not exceed $25 per hour and two (2) hours per week. Co-payment may be required based on family income. The child must be in a special education classroom, grade level two (2) or more years behind chronological age or receiving specially designed instruction in the regular classroom. Documentation of need and unavailability of service is required from the school. Qualified personnel must provide tutoring services. Qualifications of the tutor must be verified. Tutoring services must be provided by someone other than an immediate family member.

7.	Mental Health	Yes 	No 	$
Counseling/expressive (art) therapy/behavioral therapy/physical therapy/occupational therapy/speech therapy may require a co-payment. Medicaid vendor must be utilized first.

8.	Medication	Yes 	No 	$
Prescribed medication, excluding over the counter medication.  Medicaid denial must be obtained. 

9.	Special Equipment	Yes 	No 	$
a)	Medicaid denial must be obtained.
b)	Please provide list of equipment that is to be covered:	.
Either party may exercise the right to terminate this agreement upon thirty (30) days written notice served upon the other party by registered mail with return receipt requested; provided, however, that the Cabinet may terminate this agreement for cause set forth in Section IV, upon written notification to the second party.
It is expressly understood that the Cabinet's care, custody, and control over the child will cease upon entry of the adoption judgment as provided by law.

THIS INSTRUMENT HAS BEEN EXAMINED AND APPROVED AS TO FORM AND LEGALITY BY THE OFFICE OF LEGAL SERVICES, CABINET FOR HEALTH AND FAMILY SERVICES.

APPROVED:

Authorized Official, Cabinet for Health and Family Services	Date

ADOPTIVE PARENTS:

Adoptive Parent	Date

Adoptive Parent	Date