Kan. Admin. Regs. § 129-7-5

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

Section 129-7-5 - Continuation of covered services for FFS beneficiaries; applicability

This regulation shall apply to maintaining or reinstating FFS covered services when a beneficiary requests a state fair hearing involving an action by the secretary.

(a) Medical assistance shall be maintained by the secretary if an adequate and timely notice is sent by the secretary as required in 129-7-4 and the beneficiary requests a state fair hearing before the effective date of the action. Medical assistance shall not be terminated or reduced by the secretary until a decision is rendered after the state fair hearing unless one of the following conditions is met:

(1) The request for a state fair hearing concerns a discontinued program or service.

(2) The presiding officer determines at the state fair hearing that the sole issue is one of federal or state law, regulation, or policy, or change in federal or state law, regulation, or policy and not one of incorrect application of policy.

(3) The beneficiary is promptly informed in writing by the secretary that covered services will be terminated or reduced pending the state fair hearing decision.

(4) A change affecting the beneficiary's medical assistance occurs while the state fair hearing decision is pending and the beneficiary fails to request a state fair hearing after notification of the change.

(5) The beneficiary's redetermination or reenrollment period expires.

(6) A change affecting the eligibility or basis of issuance of multiple beneficiaries within one or more coverage groups specified in K.A.R. 129-6-34 or in article 14 of the division's regulations affects the beneficiary's eligibility or basis of issuance while the state fair hearing decision is pending.

(7) The beneficiary has reached the maximum benefit for the coverage time period.

(b) If any of the exceptions noted in subsection (a) apply to the case being heard by the presiding officer and the secretary seeks to terminate, suspend, or reduce a beneficiary's medical assistance, including previously authorized and ongoing FFS covered services, before the issuance of an initial order, the beneficiary shall be informed in writing by the secretary. For the purposes of this subsection, an adequate and timely notice of action shall not be required by the secretary to inform the beneficiary of the secretary's decision to seek the termination, suspension, or reduction of medical assistance, including previously authorized FFS covered services, before the issuance of an initial order.

(c) If the secretary's action is sustained by the state fair hearing decision, recovery procedures may be instituted by the secretary against the beneficiary to recover the cost of any FFS covered services furnished the beneficiary, to the extent the covered services were furnished solely by reason of subsection (a).

(d) Medical assistance shall be reinstated by the secretary and continued until a decision is rendered after a state fair hearing if all of the following conditions are met:

(1) A beneficiary's medical assistance, including previously authorized and ongoing FFS covered services, was terminated, suspended, or reduced without adequate and timely notice of action by the secretary as required in 129-7-4.

(2) The beneficiary requests a state fair hearing within 10 days from the date that the beneficiary receives the adequate notice of action. The date on which the adequate notice of action is received shall be considered to be five days after the date of the adequate notice of action, unless the beneficiary shows that the beneficiary did not receive the adequate notice of action within the five-day period.

(3) The action was determined by the secretary to have resulted from other than the application of federal or state law, regulation, or policy or a change in federal or state law, regulation, or policy.

(e) If a beneficiary's whereabouts are unknown, as indicated by the return of mail directed to the beneficiary by the secretary that cannot be forwarded, all discontinued medical assistance shall be reinstated if the beneficiary's whereabouts become known while the beneficiary is eligible for medical assistance.

Kan. Admin. Regs. § 129-7-5

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.