Kan. Admin. Regs. § 129-8-4

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

Section 129-8-4 - Notices to enrollees; applicability

This regulation shall apply to adequate and timely notices of adverse benefit determinations and to adequate and timely notices of appeal resolution issued by the MCE to the enrollee, the enrollee's authorized representative, and to the provider requesting an authorization for a new healthcare service on behalf of the enrollee.

(a) The MCE shall send an adequate notice of adverse benefit determination to the enrollee, the enrollee's authorized representative, and the requesting provider when the MCE makes an adverse benefit determination, as defined in 129-8-1 . Each adequate notice of adverse benefit determination shall include the following:

(1) The date of the adequate notice of adverse benefit determination;

(2) the date the adequate notice of adverse benefit determination was sent;

(3) the adverse benefit determination that the MCE has made or intends to make, including the dates, types, and amount of service requested, if the adverse benefit determination pertains to a service authorization request;

(4) the effective date of the MCE's adverse benefit determination;

(5) the reasons for the adverse benefit determination, including an explanation of the medical basis for the decision, application of policy, or accepted standard of medical practice to the enrollee's medical circumstances, if the MCE based its adverse benefit determination upon a decision that the covered service is not medically necessary;

(6) the statute, regulation, policy, or procedure supporting the adverse benefit determination;

(7) a statement of the enrollee's right to be provided, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. The information shall include medical necessity criteria and any processes, strategies, or evidentiary standards used in setting coverage limits;

(8) an explanation of the enrollee's right to request an appeal and the MCE's requirement for the enrollee to complete the MCE's appeal process before requesting a state fair hearing;

(9) the circumstances under which an appeal process can be expedited and the way to request an expedited appeal process;

(10) an explanation of the enrollee's right to request an appeal within 60 days of the date of the adequate notice of adverse benefit determination. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means;

(11) the procedures by which the enrollee may request an appeal regarding the MCE's adverse benefit determination;

(12) an explanation of the enrollee's right to request a state fair hearing within 120 days of the date of the adequate notice of appeal resolution. Three days shall be added to the 120-day response period if the adequate notice is served by U.S. mail or electronic means;

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

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

(15) any change in federal or state law that requires the adverse benefit determination;

(16) an explanation of the enrollee's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson;

(17) the circumstances under which the enrollee may continue to receive benefits pending resolution of the appeal or state fair hearing, the procedures by which the enrollee may request that benefits be continued, and the circumstances under which the enrollee may be required to pay the costs of these services;

(18) a toll-free number that the enrollee can call to request the assistance of the enrollee representative, request an appeal, or request a state fair hearing; and

(19) any other information required by Kansas statute or regulation that involves the MCE's adequate notice of adverse benefit determination.

(b) The MCE shall send a timely notice of adverse benefit determination to the enrollee, the enrollee's authorized representative, and the requesting provider within the time frames specified in paragraphs (b)(1) through (b)(4). A timely notice of adverse benefit determination shall include the contents of an adequate notice of adverse benefit determination as specified in subsection (a).

(1) The MCE shall send an adequate notice of adverse benefit determination at least 10 days before the date upon which the adverse benefit determination that is the subject of the adequate notice would become effective if the adverse benefit determination involves a termination, suspension, or reduction of covered services.

(A) The enrollee's previously authorized and ongoing covered services shall not be terminated, suspended, or reduced unless the MCE issues an adequate and timely notice of adverse benefit determination to the enrollee or the provider.

(B) If the enrollee is approved for additional or different medical assistance and a concurrent action to terminate, suspend, or reduce previously approved medical assistance that was being received immediately before the newly approved medical assistance is incorporated in the adequate notice of adverse benefit determination, a timely notice of adverse benefit determination shall be required if the newly approved medical assistance is less in quantity or quality than the previously approved medical assistance.

(C) Changes in the enrollee's plan of care due to a new assessment that terminates, suspends, or reduces previously authorized covered services being received by the enrollee in the plan of care immediately preceding the new assessment shall constitute a termination, suspension, or reduction of covered services.

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

(2) A timely notice shall not be required, but the MCE shall send an adequate notice five days before the effective date if both of the following conditions are met:

(A) The MCE has information indicating that the adverse benefit determination is necessary because of probable fraud by the enrollee in receiving previously authorized and ongoing services.

(B) The MCE's information has been verified from a secondary source, if possible.

(3) A timely notice shall not be required, but the MCE shall send an adequate notice of adverse benefit determination no later than the effective date of the adverse benefit determination if at least one of the following conditions is met:

(A) The MCE or department has factual information confirming the death of the enrollee.

(B) The MCE receives a clear written statement signed by the enrollee that the enrollee no longer wishes services or gives information that requires termination or reduction of medical assistance. The enrollee shall indicate that the enrollee understands that this shall be the result of supplying that information.

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

(D) The enrollee's whereabouts are unknown and the post office returns MCE or secretary mail directed to the enrollee indicating no known forwarding address.

(E) The MCE or secretary establishes the fact that the enrollee has been accepted for medicaid services in a new jurisdiction.

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

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

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

(4) The MCE shall send an adequate notice of adverse benefit determination when the MCE denies a service authorization request or authorizes a service in an amount, duration, or scope that is less than requested within the following time frames:

(A) For standard authorization decisions, the MCE shall make an authorization decision and send an adequate notice as expeditiously as the enrollee's condition requires and no later than 14 days after the MCE's receipt of the request for service. The MCE may extend the 14-day time period by up to 14 days if the enrollee, or the provider, requests the extension or the MCE justifies to the secretary, upon the secretary's request, a need for additional information and how the extension is in the enrollee's interest. If the resolution time frame is extended by up to 14 days, the MCE shall send an adequate notice no later than 28 days after the MCE's receipt of the request for service.

(B) If the provider indicates, or the MCE determines, that following the standard time frame could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, the MCE shall make an expedited authorization decision and send an adequate notice as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE's receipt of the request for service.

The MCE may extend the 72-hour time period by up to 14 days if the enrollee, or the provider, requests the extension or the MCE justifies to the secretary, upon the secretary's request, a need for additional information and how the extension is in the enrollee's interest. If the resolution time frame is extended by up to 14 days, the MCE shall send an adequate notice no later than 14 days after the date of the extension decision.

(c) The MCE shall send an adequate notice of appeal resolution to the enrollee, the enrollee's authorized representative, and the requesting provider when the MCE reviews a request for an appeal of an adverse benefit determination. Each adequate notice of appeal resolution shall include the following:

(1) The date of the adequate notice of appeal resolution;

(2) the date the adequate notice of appeal resolution was sent;

(3) the adverse benefit determination that is the subject of the appeal;

(4) the results of the resolution process and the date of the appeal resolution;

(5) the reasons for the appeal resolution, including an explanation of the medical basis for the resolution, application of policy, or accepted standard of medical practice to the enrollee's medical circumstances, if the resolution is based upon a determination that the service is not medically necessary;

(6) the statute, regulation, policy, or procedure supporting the appeal resolution;

(7) a statement of the enrollee's right to be provided, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's appeal resolution. This information shall include medical necessity criteria and any processes, strategies, or evidentiary standards used in setting coverage limits;

(8) a statement of the enrollee's right to request a state fair hearing within 120 days of the date of the MCE's adequate notice of appeal resolution. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means;

(9) the procedures by which the enrollee may request a state fair hearing regarding the MCE's resolution or, for an appeal resolution based on change in law, the circumstances under which a state fair hearing will be granted;

(10) the circumstances under which the enrollee may continue to receive benefits pending the decision in the state fair hearing, the procedures by which the enrollee may request that benefits be continued, and the circumstances under which the enrollee may be required to pay the costs of these services;

(11) a toll-free number that the enrollee can call to request the assistance of the enrollee representative to request a state fair hearing;

(12) a statement of the enrollee's right to have selfrepresentation or to be represented by legal counsel, a relative, a friend, or a spokesperson when requesting a state fair hearing; and

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

(d) The MCE shall send a timely notice of appeal resolution to the enrollee, the enrollee's authorized representative, and the provider within 30 days following the date of receipt of the appeal. The MCE shall send an adequate notice of appeal resolution to the enrollee and the provider as specified in subsection (c) in accordance with the timeliness standards specified in this subsection.

(e) A response by the MCE or department to an inquiry concerning a prior adverse benefit determination shall not be a new adverse benefit determination.

Kan. Admin. Regs. § 129-8-4

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.