Kan. Admin. Regs. § 129-7-4

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

Section 129-7-4 - Notices to applicants, beneficiaries, and residents; applicability

This regulation shall apply to adequate notices of action and timely notices of action sent by the secretary to applicants and beneficiaries regarding an eligibility or FFS decision, and to adequate notices of action and timely notices of action sent by a nursing facility or skilled nursing facility regarding a decision by the facility to transfer or discharge a resident.

(a) An adequate notice of action shall be sent by the secretary to an applicant for medical assistance and the applicant's authorized representative when the secretary denies an applicant's claim for eligibility or to a beneficiary of medical assistance and the beneficiary's authorized representative when the secretary takes an action, as defined in 129-7-1 . Each adequate notice of action shall include the following:

(1) The date of the adequate notice of action;

(2) the eligibility determination that the secretary has made or intends to make or the action that the secretary has taken or intends to take;

(3) the effective date of the secretary's eligibility determination or action. If no effective date is specified, the effective date shall be the date of the adequate notice of action;

(4) the reasons for the eligibility determination, the action taken, or the intended action;

(5) the statute, regulation, policy, or procedure supporting the eligibility determination or action;

(6) a statement of the applicant's or beneficiary's right to request a standard or expedited state fair hearing within 30 days of the date of the adequate notice of action. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means;

(7) the circumstances under which a state fair hearing process can be expedited and the way to request an expedited state fair hearing process;

(8) the procedures by which the applicant or beneficiary may request a standard or expedited state fair hearing and the address and contact information for submission of the request or, for an eligibility determination or action based on a change in law, the circumstances under which a state fair hearing will be granted;

(9) any change in federal or state law that requires the eligibility determination or action;

(10) a statement of the applicant's or beneficiary's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson;

(11) the time frames in which the department must make a state fair hearing decision;

(12) the circumstances under which a beneficiary may continue to receive previously authorized FFS covered services pending resolution of the state fair hearing; and

(13) any other information required by Kansas statute or regulation that involves the secretary's adequate notice of action.

(b) A timely notice of action shall be sent by the secretary to an applicant and the applicant's authorized representative no later than one business day following the date upon which the secretary takes the action that is the subject of the adequate notice of action. A timely notice of action shall be sent by the secretary to a beneficiary and the beneficiary's authorized representative within the time frames specified in paragraphs (b)(1) through (b)(4). An adequate notice of action as specified in subsection (a) shall be sent by the secretary to applicants and beneficiaries in accordance with the timeliness standards specified in this subsection.

(1) An adequate notice of action shall be sent by the secretary at least 10 days before the date upon which the action that is the subject of the notice would become effective, except as specified in paragraphs (b)(2) through (b)(4).

(A) A beneficiary's previously authorized and ongoing medical assistance or eligibility shall not be terminated, suspended, or reduced and a beneficiary's liability shall not be increased, unless the secretary issues an adequate notice of action and a timely notice of action to the beneficiary.

(B) Expiration of an approved time-limited stay as an inpatient shall not constitute a termination, suspension, or reduction of covered services.

(2) Timely notice shall not be required, but an adequate notice shall be sent by the secretary five days before the effective date if both of the following conditions are met:

(A) The secretary has facts indicating that action should be taken because of probable fraud by the beneficiary.

(B) The facts have been verified, if possible, through secondary sources.

(3) Timely notice shall not be required, but an adequate notice shall be sent by the secretary no later than the effective date of the action under any of the following conditions:

(A) The secretary has factual information confirming the death of a beneficiary.

(B) The secretary receives a clear written statement signed by a beneficiary that the beneficiary no longer wishes services or gives information that requires termination or reduction of medical assistance and indicates that the beneficiary understands that this must be the result of supplying that information.

(C) The beneficiary has been admitted or committed to an institution, and further payments for that beneficiary's care are not authorized by program regulations as long as the person resides in the institution.

(D) The beneficiary has been placed in a skilled nursing facility, an intermediate care facility, or a long-term care facility.

(E) The beneficiary's whereabouts are unknown and the post office returns department mail directed to the beneficiary indicating no known forwarding address.

(F) The secretary establishes the fact that the beneficiary has been accepted for medicaid services in a new jurisdiction.

(G) A child is removed from the home as a result of a judicial determination or has been voluntarily placed in foster care by the child's legal guardian.

(H) A change in the level of medical care is prescribed by the beneficiary's physician.

(I) A special allowance granted for a specific period is terminated, and the beneficiary was informed in writing when the allowance was granted that it would automatically terminate at the end of the specified period.

(J) The department takes action because of information that the beneficiary furnished in a status report or because the beneficiary has failed to submit a complete or a timely status report.

(K) An individual fails to participate in an assessment process.

(L) An individual threatens or endangers personal care attendants, case managers, or workers.

(M) The notice involves an adverse determination made regarding the preadmission screening requirements.

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

(4) If the secretary takes action to discontinue, terminate, suspend, or reduce medical coverage for a child who has been determined eligible for presumptive medical assistance as specified in K.A.R. 129-6-151 or K.A.R. 129-6-152, neither timely notice of action nor adequate notice of action shall be required.

(c) A skilled nursing facility or nursing facility shall send an adequate skilled nursing facility or nursing facility notice of action to each resident proposed to be transferred or discharged, which shall include a statement of the facility's determination to transfer or discharge the resident. Each adequate skilled nursing facility or nursing facility notice of action shall include the following:

(1) The date of the adequate skilled nursing facility or nursing facility notice of action;

(2) the action the skilled nursing facility or nursing facility has taken or intends to take;

(3) the effective date of the transfer or discharge;

(4) the reasons supporting the action taken or the intended action;

(5) the location to which the resident is transferred or discharged;

(6) the regulations or policy that supports, or the change in federal or state law that requires, the action;

(7) a statement of the resident's right to request a state fair hearing or, in cases of an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(8) the method by which the resident may obtain a state fair hearing, the way to obtain assistance in completing and submitting the request, and the mailing address of the presiding officer;

(9) the name, postal mailing and electronic-mail addresses, and telephone number of the Kansas office of the long-term care ombudsman;

(10) for nursing facility residents with a mental disorder, intellectual and developmental disabilities, and related disabilities, the postal mailing and electronic-mail addresses and the telephone number of the entity responsible for the protection and advocacy of these individuals;

(11) for nursing facility residents with a mental disorder or related disabilities, the postal mailing and electronic-mail addresses and the telephone number of the Kansas advocacy and protection organization;

(12) a statement that the resident may have self representation or use legal counsel, a relative, a friend, or a spokesperson; and

(13) the time frame in which the secretary shall make a state fair hearing decision.

(d) The skilled nursing facility or nursing facility shall send a timely skilled nursing facility or nursing facility notice of action to each resident proposed to be transferred or discharged in accordance with the timeliness requirements in K.A.R. 26-39-102, as in effect on February 8, 2023, which is hereby adopted by reference. The skilled nursing facility or nursing facility shall send an adequate skilled nursing facility or nursing facility notice of action as specified in subsection (c) to residents in accordance with the timeliness standards specified in this subsection.

Kan. Admin. Regs. § 129-7-4

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.