Kan. Admin. Regs. § 129-7-1

Current through Register Vol. 44, No. 2, January 9, 2025

Section 129-7-1 - Applicability; definitions

(a) Applicability. This article of the division's regulations shall apply to grievances and state fair hearings involving medical assistance eligibility and fee-for-service covered services.

(b) Definitions. For purposes of this article of the division's regulations, each of the following terms shall have the meaning specified in this regulation:

(1)

(A) "Action" and "adverse action" mean any of the following department decisions:

(i) A denial or limited authorization of a requested non-covered service or FFS covered service;

(ii) a change in the amount or type of FFS covered services;

(iii) a termination of, suspension of, or reduction in FFS covered services;

(iv) a denial of, termination of, suspension of, or reduction in medicaid eligibility; or

(v) a determination of the amount or an increase in applicant or beneficiary liability, including a determination that an applicant or beneficiary shall incur a greater amount of medical expenses in order to establish income eligibility or shall be subject to an increase in premiums or cost-sharing charges.

(B) This term shall include the following:

(i) A determination by a skilled nursing facility or a nursing facility to transfer or discharge a resident, even though the secretary is not the respondent;

(ii) a determination by KMAP with regard to the preadmission screening and resident review that a beneficiary does not require the level of services provided by a nursing facility or that a beneficiary does or does not require specialized services; and

(iii) a denial by the secretary of the enrollee's request to disenroll from the enrollee's MCE outside of the annual open enrollment period.

(2) "Adequate notice of action" means a written document that is sent to an applicant or beneficiary by the secretary as specified in 129-7-4.

(3) "Adequate notice of approval" means a written document that is sent by the secretary to the applicant or beneficiary at the time the secretary approves eligibility or a covered service authorization request and that meets the requirements specified in 129-7-8.

(4) "Adequate skilled nursing facility or nursing facility notice of action" means a written document that is sent to a resident by a skilled nursing facility or nursing facility as specified in 129-7-4.

(5) "Date of action" means the intended date on which a termination, suspension, reduction, transfer, or discharge becomes effective. This term shall include the date of the finding made by the department with regard to the preadmission screening and annual resident review.

(6) "Days" means calendar days, unless otherwise specified.

(7) "Grievance" means either of the following:

(A) The expression of dissatisfaction by a KMAP applicant or beneficiary about any eligibility matter other than an action involving eligibility. An applicant or beneficiary submitting an eligibility grievance shall not have state fair hearing rights; or

(B) the expression of dissatisfaction by a KMAP beneficiary who is not enrolled with an MCE about any FFS matter including actions involving FFS covered services. An FFS beneficiary submitting an FFS grievance shall have state fair hearing rights if the matter involves an action.

(8) "Grievance and appeal system" means the grievance and state fair hearing processes that are available to applicants and beneficiaries for expressions of dissatisfaction and for contesting actions regarding eligibility, covered services, and non-covered services, as well as the process to collect and track information about them.

(9) "Lock-in" means the restriction of a beneficiary's access to covered services because of abuse that is accomplished through limitation of the use of the KMAP medical identification card to designated medical providers.

(10) "Preadmission screening and annual resident review" and "PASRR" mean a federally required evaluation to help ensure that beneficiaries are not inappropriately placed in nursing homes for long-term care.

(11) "Timely notice of action" means an adequate notice of action that is sent to a beneficiary by the secretary within the time frames specified in 129-7-4.

(12) "Timely notice of approval" means an adequate notice of approval that is sent by the secretary to the applicant or beneficiary within the time frames specified in 129-7-8.

(13) "Timely skilled nursing facility or nursing facility notice of action" means a written document that is sent to a resident by a skilled nursing facility or nursing facility within the time frames specified in 129-7-4.

Kan. Admin. Regs. § 129-7-1

Authorized by and implementing K.S.A. 65-1,254 and 75-7403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.