Kan. Admin. Regs. § 129-8-10

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

Section 129-8-10 - When a state fair hearing is required

(a) Any enrollee may submit a request for a standard state fair hearing if the enrollee identifies an adverse benefit determination by the MCE or an action by the secretary to deny the enrollee's request to disenroll from the enrollee's current MCE, as the basis for the request. Any enrollee may submit a request for a state fair hearing following receipt of the MCE's notice of external review decision if the enrollee identifies the MCE's denial of an authorization for a new healthcare service that was the subject of the external review as the basis for the request.

(b) If the basis for the state fair hearing request is an adverse benefit determination by the MCE, the enrollee shall complete the appeal process with the MCE before requesting a standard state fair hearing. The enrollee shall meet the requirements stated in a state plan, an amendment to a state plan, a waiver, or a CMS-approved contract between the secretary and the MCE before the enrollee may request a state fair hearing. Failure to meet any contractual preconditions shall be grounds for dismissing the request for a state fair hearing. The enrollee shall submit the request for a state fair hearing in accordance with the timeliness requirements in 129-8-11(a)(1).

(c) Any enrollee may submit a request for an expedited state fair hearing if the enrollee has completed the appeal process with the MCE, an adverse benefit determination by an MCE is identified as the basis for the request, and the MCE determines that the expedited state fair hearing request meets one of the following conditions:

(1) The enrollee met the criteria for expedited appeal resolution, but the appeal was not resolved within the time frame for expedited resolution.

(2) The appeal was resolved within the time frame for expedited resolution, but the MCE reached a decision wholly or partially adverse to the enrollee.

(d) The enrollee's request for an expedited state fair hearing, when combined with the secretary's approval, shall constitute a mutual waiver of procedural time requirements otherwise required by law that would defeat the purpose for the expedited state fair hearing. The enrollee shall submit the request for an expedited state fair hearing in accordance with the timeliness requirements in 129-8-11(b).

(e) If the basis for the state fair hearing request is a denial of an authorization for a new healthcare service by the MCE and the denial has been reviewed by the external independent third-party reviewer, the enrollee shall first meet any requirements stated in a state plan, an amendment to a state plan, a waiver, or a CMS-approved contract between the secretary and the MCE before the enrollee may seek a state fair hearing. Failure to meet any contractual preconditions shall be grounds for dismissing the request for a state fair hearing. The enrollee shall submit the request for a state fair hearing in accordance with the timeliness requirements in 129-8-11(a)(2).

(f) If the request for a state fair hearing concerns a matter that the MCE, by the terms of the managed care contract, does not handle or make decisions upon, the MCE shall forward the request to the secretary for routing to the appropriate entity for processing the request for a state fair hearing.

(g) If the basis for the state fair hearing request is a denial of the enrollee's disenrollment request by the secretary, the enrollee shall not be required to complete the appeal process with the MCE before requesting a standard state fair hearing. The enrollee shall submit the request for a state fair hearing in accordance with the timeliness requirements in 129-8-11(a)(3).

(h) The granting of a state fair hearing shall not be required of the secretary if the sole issue is a federal or state law requiring an automatic change adversely affecting some or all enrollees.

(i) Each request for a state fair hearing received by the secretary or the MCE shall be forwarded to the secretary's designee for the state fair hearing within one business day by the secretary or the MCE. Each oral request for a state fair hearing shall be reduced to writing by the secretary or the MCE before the request is forwarded.

(j) The enrollee's right to request a state fair hearing shall not be limited or interfered with by the secretary or the MCE.

Kan. Admin. Regs. § 129-8-10

Authorized by and implementing K.S.A. 651,254 and 75-7403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.