K.A.R. Agency 129 | Kan. Admin. Regs. Agency 129 — Department of Health and Environment—Division of Health Care Finance

Article 1 Definitions

Kan. Admin. Regs. § 129-1-1 Definitions

Each of the following terms, when used in the division's regulations, shall have the meaning specified in this regulation, unless the context clearly indicates otherwise:

(a) "Acknowledgement and order" means the initial documentation from the presiding officer that acknowledges the filing of an administrative hearing case and that includes an order from the presiding officer requiring the department to submit a department summary by the designated due date.

(b) "Activities of daily living" and "ADL" mean basic daily activities involving bathing, dressing, eating, ambulating, toileting, and personal hygiene.

(c) "Affordable care act" and "ACA" mean the patient protection and affordable care act of 2010, public law 111-148, as amended by the health care and education reconciliation act of 2010, public law 111-152, and any subsequent amendments.

(d) "Appellant" means an applicant, a beneficiary, an enrollee, or a provider who has received an adverse benefit determination or adverse action, the real party in interest as defined in K.S.A. 60-217 and amendments thereto, or the department if the department is the losing party of an external independent third-party review and requests a state fair hearing.

(e) "Applicant" means any individual who is seeking an eligibility determination for that individual through the submission of an application for medical assistance.

(f) "Beneficiary" means an individual who is eligible to receive covered services. This term shall include a recipient or consumer who is eligible to receive covered services. This term shall include a beneficiary's authorized representative.

(g) "Business day" means any day that is not a Saturday, Sunday, or legal holiday. "Legal holiday" shall include any day designated as a holiday by any Kansas statute or regulation. If a department is inaccessible on the last day of any period of time prescribed by the division's regulations, the time period shall be extended until the next business day on which the department is open for business.

(h) "CMS" means the centers for medicare and medicaid services, a division within the U.S. department of health and human services.

(i) "Computing period of time" means that, in computing any period of time prescribed by K.S.A. 77-503, the day from which the designated period of time begins to run shall not be included.

(j) "Continuation of benefits" and "continuation of services" means the continuation of previously authorized covered services.

(k) "Covered services" means medical services or other care for which reimbursement will be made, directly or indirectly, by KMAP. Coverage may be limited by the secretary through prior authorization requirements.

(l) "Department" means Kansas department of health and environment and its designees authorized to administer the medicaid program and kancare-CHIP.

(m) "Division" means division of health care finance in the Kansas department of health and environment.

(n) "Durable medical equipment" and "DME" mean equipment that meets the following conditions:

(1) Withstands repeated use;

(2) is not generally useful to a person in the absence of an illness or injury;

(3) is primarily and customarily used to serve a medical purpose;

(4) is appropriate for use in the home; and

(5) is rented or purchased as determined by the secretary or the secretary's designee.

(o) "Effective date of action" means the date on which the action, as defined in K.A.R. 129-7-1, becomes effective.

(p) "Election statement" means the revocable statement signed by a beneficiary that is filed with a particular hospice and that consists of the following:

(1) Identification of the hospice selected to provide care;

(2) acknowledgement that the beneficiary has been given a full explanation of hospice care;

(3) acknowledgement by the beneficiary that other medicaid services are waived;

(4) the effective date of the election period; and

(5) the beneficiary's signature or the signature of the beneficiary's legal representative.

(q) "Eligibility" means qualification for or access to medical assistance.

(r) "Emergency services" means medical care provided promptly after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(1) Serious jeopardy to the patient's health;

(2) serious impairment to bodily functions; or

(3) serious dysfunction of any bodily organ or part.

(s) "Enrollee" means an individual who has been assigned to and has enrolled with a KanCare MCE and is entitled to receive covered services provided by a KanCare MCE. This term shall include a recipient, consumer, or beneficiary who is entitled to receive covered services provided by a KanCare MCE and who has been assigned to and enrolled with a KanCare MCE. This term shall include an enrollee's authorized representative.

(t) "Evidentiary standard" means the responsibility to establish a proposition in a state fair hearing by a preponderance of the evidence.

(u) "Federally facilitated exchange" and "FFE" mean an insurance exchange operated by the federal government as established under the patient protection and affordable care act, public law 111-148.

(v) "Fee-for-service" and "FFS" mean a system of health insurance payment in which a doctor or other health care provider is paid a fee for each service rendered.

(w) "Final administrative action" as used in 42 C.F.R. 431.244 means a decision rendered by a presiding officer pursuant to K.S.A. 77-526(b), and amendments thereto, that determines the legal rights, duties, privileges, immunities, or other legal interest of one or more specific persons. For the purpose of interpreting 42 C.F.R. 431.244, an initial order shall be a final administrative action. This term shall include a proposed default order that has become effective.

(x) "Final order" means an initial order decision by a presiding officer that becomes a final order pursuant to KAPA, and amendments thereto, an initial order reviewed by the secretary or the state appeals committee pursuant to K.S.A. 77-527, and amendments thereto, or a final order reconsidered by the secretary pursuant to K.S.A. 77-529, and amendments thereto.

(y) "Home- and community-based services" and "HCBS" mean a program of covered services operated under the authority of section 1915(c) of the social security act that permits a state to waive certain medicaid requirements in order to furnish an array of home- and community-based services that promote community living for medicaid beneficiaries to avoid institutionalization. Waiver-based covered services complement and supplement the covered services that are available through the medicaid state plan or other federal, state, and local public programs, as well as the supports that families and communities provide to individuals.

(z) "Initial order" means a decision rendered by a presiding officer pursuant to K.S.A. 77-526(b), and amendments thereto, that determines the legal rights, duties, privileges, immunities, or other legal interest of one or more specific persons. This term shall include a proposed default order that has become effective. For the purpose of interpreting 42 C.F.R. 431.244, an initial order shall be a final administrative action.

(aa) "Instrumental activities of daily living" and "IADL" mean activities involving shopping, housekeeping, paying bills, food preparation, medicine regimens, communication, transportation, and resting.

(bb) "Kan be healthy program participant" means an individual under the age of 21 who is eligible for medicaid and who has undergone a kan be healthy medical screening in accordance with a specified screening schedule. The medical screening shall be performed for the following purposes:

(1) To ascertain physical and mental defects; and

(2) to provide treatment that corrects or ameliorates defects and chronic conditions that are found.

(cc) "Kancare-CHIP" means the health insurance program for children administered by the department and authorized under title XXI of the social security act.

(dd) "KAPA" means the Kansas administrative procedure act, K.S.A. 77-501 et seq. and amendments thereto.

(ee) "KDHE" means the Kansas department of health and environment, which is the single state medicaid agency.

(ff) "KJRA" means the Kansas judicial review act, K.S.A. 77-601 et seq. and amendments thereto.

(gg) "KMAP" means the Kansas medical assistance program.

(hh) "Local evidentiary hearing" as used in 42 C.F.R. 431.201 means a hearing held on the local or county level serving a specified portion of the state. Local evidentiary hearings are not available in Kansas.

(ii) "Long-term services and supports" and "LTSS" mean covered services and supports provided to beneficiaries of all ages with functional limitations or chronic illnesses that have the primary purpose of supporting the ability of the beneficiary to live or work in the setting of the individual's choice, which may include the individual's home, a worksite, a provider-owned or provider-controlled residential setting, a nursing facility, or other institutional setting.

(jj) "Managed care" means a system of managing and financing health care delivery to ensure that covered services provided to managed care plan members are necessary, efficiently provided, and appropriately priced.

(kk) "MCE" means a managed care entity, including an MCO, a PAHP, or a PIHP.

(ll) "MCO" means a managed care organization that has a comprehensive risk contract with the Kansas medical assistance program to provide covered services to enrollees of the MCO. The contract shall have the approval of the U.S. department of health and human services or its designee. An MCO shall provide a grievance, appeal, and state fair hearing process to its enrollees.

(mm) "Medicaid" means the federal medical assistance program authorized under title XIX of the social security act.

(nn) "Medical assistance" means assistance that covers all or part of the cost of medical care for eligible persons paid through joint federal and state funding, federal-only funding, and state-only funding, including Kansas medicaid, kancare-CHIP, and medikan. This assistance is administered under KMAP.

(oo) (1) "Medical necessity" means that a health intervention is an otherwise covered category of service, is not specifically excluded from coverage, and is medically necessary, according to all of the following criteria:

(A) Authority. The health intervention is recommended by the treating physician and is determined to be necessary by the secretary or the secretary's designee.

(B) Purpose. The health intervention has the purpose of treating a medical condition.

(C) Scope. The health intervention provides the most appropriate supply or level of service, considering potential benefits and harms to the patient.

(D) Evidence. The health intervention is known to be effective in improving health outcomes.

(i) For new interventions, effectiveness shall be determined by scientific evidence as described in paragraph (oo)(3).

(ii) For existing interventions, effectiveness shall be determined by scientific evidence as described in paragraph (oo)(4).

(E) Value. The health intervention is cost-effective for this condition compared to alternative interventions, including no intervention. Cost-effective shall not necessarily be construed to mean lowest-priced. An intervention may be medically indicated and yet not be a covered service or benefit or meet the definition of medical necessity in this subsection. Interventions that do not meet this regulation's definition of medical necessity may be covered at the discretion of the secretary or the secretary's designee. An intervention shall be considered cost-effective if the benefits and harms relative to the costs represent an economically efficient use of resources for patients with this condition. In the application of this criterion to an individual case, the condition of the individual patient shall be determinative.

(2) The following definitions shall apply to these terms only as they are used in this subsection:

(A) "Effective," when used to describe an intervention, means that the intervention can be reasonably expected to produce the intended results and to have expected benefits that outweigh potential harmful effects.

(B) "Health intervention" means an item or covered service delivered or undertaken primarily to treat a medical condition or to maintain or restore functional ability. For the definition of medical necessity in this subsection, a health intervention shall be determined not only by the intervention itself, but also by the medical condition and patient indications for which the health intervention is being applied.

(C) "Health outcomes" means treatment results that affect health status as measured by the length or quality of a person's life.

(D) "Medical condition" means a disease, illness, injury, genetic or congenital defect, pregnancy, or biological or psychological condition that lies outside the range of normal, age-appropriate human variation.

(E) "New intervention" means an intervention that is not yet in widespread use for the medical condition and patient indications under consideration.

(F) "Scientific evidence" means controlled clinical trials that either directly or indirectly demonstrate the effect of the intervention on health outcomes. However, if controlled clinical trials are not available, observational studies that demonstrate a causal relationship between the intervention and health outcomes may be used. Partially controlled observational studies and uncontrolled clinical series may be considered to be suggestive, but shall not by themselves be considered to demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or by potential experimental biases.

(G) "Secretary's designee" means a person or persons designated by the secretary to assist in the medical necessity decision-making process.

(H) "Treat" means to prevent, diagnose, detect, or palliate a medical condition.

(I) "Treating physician" means a physician who has personally evaluated the patient.

(3) Each new intervention for which clinical trials have not been conducted because of epidemiological reasons, including rare or new diseases or orphan populations, shall be evaluated on the basis of professional standards of care or expert opinion as described in paragraph (oo)(4).

(4) The scientific evidence for each existing intervention shall be considered first and, to the greatest extent possible, shall be the basis for determinations of medical necessity. If no scientific evidence is available, professional standards of care shall be considered. If professional standards of care do not exist or are outdated or contradictory, decisions about existing interventions shall be based on expert opinion. Coverage of existing interventions shall not be denied solely on the basis that there is an absence of conclusive scientific evidence. Existing interventions may be deemed to meet the definition of medical necessity in this subsection in the absence of scientific evidence if there is a strong consensus of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or, in the absence of those standards, convincing expert opinion.

(pp) "Medical necessity in psychiatric situations" means that there is medical documentation indicating either of the following:

(1) The person could be harmful to that individual or others if not under psychiatric treatment.

(2) The person is disoriented in time, place, or person.

(qq) "Medikan" means a totally state-funded program covering all or part of the cost of medical care for disabled individuals who do not qualify for medicaid but who are eligible for covered services and benefits under K.A.R. 129-6-95.

(rr) "Non-covered services" means services for which KMAP will not provide direct or indirect reimbursement, including services that have been denied due to the lack of medical necessity.

(ss) "PACE" means a program of all-inclusive care for the elderly under K.A.R. 129-6-34.

(tt) "Plan of care" and "POC" mean a plan prepared and authorized by the secretary or the secretary's designee that identifies the following:

(1) The medical and LTSS needs of a KMAP beneficiary or enrollee for a specified period of time;

(2) the treatment and covered services, including LTSS, to be used in meeting the needs of the KMAP beneficiary or enrollee during that time period;

(3) the expected result of the treatment and covered services, including LTSS;

(4) the provider or providers of the treatment and covered services, including LTSS; and

(5) the cost of the treatment and covered services, including LTSS.

(uu) "Prepaid ambulatory health plan" and "PAHP" mean an entity that meets the following conditions:

(1) Provides covered services to enrollees under contract with the state and on the basis of capitation payments or other payment arrangements that do not use state plan payment rates;

(2) does not provide or arrange for, and is not otherwise responsible for the provision of, any inpatient hospital or institutional services for its enrollees; and

(3) does not have a comprehensive risk contract.

(vv) "Prepaid inpatient health plan" and "PIHP" mean an entity that meets the following conditions:

(1) Provides covered services to enrollees under contract with the state and on the basis of capitation payments or other payment arrangements that do not use state plan payment rates;

(2) provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and

(3) does not have a comprehensive risk contract.

(ww) "Preponderance of the evidence" means a standard of evidence in which the evidence presented demonstrates a fact to be more likely true than not true.

(xx) "Presiding officer" means the secretary, one or more members of the department, or an administrative law judge assigned by the secretary's state fair hearing designee for the purposes of conducting an initial adjudicative hearing.

(yy) "Primary care" means all health care and laboratory services customarily furnished through a general medical practitioner, family physician, internal medicine physician, obstetrician, gynecologist, or pediatrician.

(zz) "Primary diagnosis" means the most significant diagnosis related to the medical care rendered.

(aaa) "Prior authorization" means a KMAP beneficiary's or a managed care enrollee's request for the provision of a covered service before the covered service is rendered. This term is also known as a covered service authorization.

(bbb) "Provider" means a person or entity who provides covered services to eligible beneficiaries and enrollees and receives payment, directly or indirectly, from KMAP. This term shall include a provider's authorized representative.

(ccc) "Recipient" means any individual who has been determined eligible and is receiving medical assistance. This term shall include a consumer who has been determined eligible and is receiving medical assistance.

(ddd) "Respondent" means the department, which appears at the state fair hearing;

the skilled nursing facility or nursing facility in a discharge or transfer of a resident;

the real party in interest as defined in K.S.A. 60-217, and amendments thereto; or

a provider, if the provider was the winning party of the external independent third-party review and the department requests a state fair hearing.

(eee) "Secretary" means secretary of the Kansas department of health and environment. This term shall include the secretary's designee.

(fff) "Secretary's designee" means a designee of the secretary, whether an individual or an entity, who has been delegated authority as specified in a contract between the secretary and the individual or entity.

(ggg) "Secretary's reconsideration" means a response by the secretary to a petition for reconsideration of the orders pursuant to K.S.A. 77-529, and amendments thereto.

(hhh) "Send" or "Sent" means deliver by mail, facsimile, or in electronic format.

(iii) "Service of order or notice" means the delivery of the order or the notice by U.S. mail or in electronic format. Delivery of a copy of an order or notice means handing the order or notice to the person or leaving the order or notice at the person's principal place of business or residence with a person of suitable age and discretion who works or resides there. Service of order or notice by mail shall be complete upon mailing. Service of order or notice by electronic means shall be complete upon transmission. Service includes delivery of a copy of an order or notice to the person's authorized representative.

(jjj) "Single state agency" and "single state medicaid agency" mean the Kansas executive agency that has been designated as the agency responsible for the overall administration and supervision of the medicaid program in Kansas. The single state agency may delegate part of the administration of the Kansas medicaid program to another state, a local agency, or a contractor. The overall authority of the single state agency for the Kansas medicaid program shall not be impaired.

(kkk) "State appeals committee" and "SAC" mean the committee appointed by the secretary as the secretary's designee to respond to petitions for review of the initial orders pursuant to K.S.A. 77-527, and amendments thereto.

(lll) "State fair hearing" means a proceeding during which evidence is presented to the secretary or the secretary's designee by an appellant and a respondent. This term is also known as a fair hearing, an evidentiary hearing, or an administrative hearing under KAPA.

(mmm) "State medicaid agency" means the single state agency for the medicaid program pursuant to K.S.A. 75-7409.

(nnn) "State plan" means the agreement between Kansas and federal authorities allowing Kansas to participate in certain federal programs.

(ooo) "Swing bed" means a hospital bed that can be used interchangeably as a hospital, skilled nursing facility, or intermediate care facility bed, with reimbursement based on the specific type of care provided.

(ppp) "Targeted case management services" means a set of covered services that will assist an enrollee in gaining access to medical, social, educational, or other needed covered services. This term shall include the following:

(1) Assessment of an enrollee to determine covered service needs;

(2) development of a specific care plan;

(3) referral and related activities; and

(4) monitoring and follow-up activities.

(qqq) "Waiver" means an amendment to the state plan in which some part of federal medicaid requirements are no longer applied to a specific applicant or enrollee seeking medical assistance. A waiver shall require agreement between KDHE and federal medicaid authorities before the waiver can be effective for KMAP. HCBS programs shall be established by waivers.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014; amended Dec. 27, 2024.)

Article 2 General

Kan. Admin. Regs. § 129-2-1 Uniformity of interpretation

The contracted staff of the department shall follow the interpretation provided by manuals, other policy materials, and official releases or communications from the secretary or the secretary's designee.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-2-2 Fees for providing copies

(a) Except as specified in subsection (b), the following fees may be charged for providing copies of department documents and records:

(1)(A) For copies, a fee of $.25 per single-sided page; and

(B) an additional fee not exceeding the actual cost of furnishing copies, including the cost of staff time required to make the information available; and

(2) for electronic records in department data systems, a fee equal to the cost of any computer services, including staff time.

(b) No fee shall be charged if the request for documents or records meets any of the following conditions:

(1) Is in the administration of a department program;

(2) is in relationship to a fair hearing;

(3) is for medical diagnosis or treatment;

(4) is from a state department; or

(5) is pursuant to a regulation authorizing the release of the document or record without charging a fee.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective Feb. 28, 2014.)

Article 5 Provider Participation, Scope of Services, and Reimbursements for the Medicaid (Medical Assistance) Program

Kan. Admin. Regs. § 129-5-1 Prior authorization

(a) Any medical service may be placed by the Kansas department of health and environment, division of health care finance on the published list of services requiring prior authorization or precertification for any of the following reasons:

(1) To ensure that provision of the service is medically necessary;

(2) to ensure that services that could be subject to overuse are monitored for appropriateness in each case; and

(3) to ensure that services are delivered in a cost-effective manner.

(b) Administration of covered pharmaceuticals in the following classes shall require prior authorization. A cross-reference of generic and brand names shall be made available upon request:

(1) Ace inhibitors:

(A) Quinapril;

(B) moexipril;

(D) ramipril; and

(E) trandolopril;

(2) retinoids:

(A) Tretinoin;

(B) alitretinoin; and

(3) adjunct antiepileptic drugs:

(A) Gabitril;

(B) zonegran;

(D) lacosamide;

(E) rufinamide;

(F) eslicarbazepine;

(G) perampanel;

(H) ezogabine;

(I) oxcarbazepine; and

(J) vigabatrin;

(4) angiotensin II receptor antagonists:

(A) Candesartan;

(B) candesartan-HCTZ;

(D) eprosartan-HCTZ;

(E) olmesartan;

(F) olmesartan-HCTZ;

(G) azilsartan;

(H) irbesartan;

(I) irbesartan-HCTZ;

(J) telmisartan; and

(K) telmisartan-HCTZ;

(5) antibiotics:

(A) Telithromycin; and

(B) rifaximin;

(6) anticholinergic urinary incontinence drugs:

(A) Flavoxate;

(B) oxybutynin XL;

(D) trospium chloride;

(E) darifenacin;

(F) oxybutynin, topical;

(G) tolterodine; and

(H) tolterodine ER;

(7) antiemetics:

(A) Nabilone;

(B) doxylamine succinate-pyridoxine hydrochloride; and

(8) antipsoriatics:

(A) Alefacept; and

(B) ustekinumab;

(9) antiretroviral drugs:

(A) Enfuvirtide; and

(B) maraviroc;

(10) antirheumatics:

(A) Leflunomide;

(B) infliximab;

(D) adalimumab;

(E) etonercept;

(F) abatacept;

(G) rituximab;

(H) golimumab;

(I) certolizumab;

(J) tocilizumab;

(K) tofacitinib; and

(L) apremilast;

(11) cervical dystonias:

(A) Onabotulinum toxin A;

(B) abobotulinum toxin A;

(D) incobotulinum toxin A;

(12) drugs for the treatment of osteoporosis: teriparatide;

(13) antituberculosis products:

(A) Aminosalicylate sodium;

(B) capreomycin;

(D) ethionamide;

(E) isoniazid;

(F) pyrazinamide; and

(G) rifampin and rifampin-isoniazid combinations;

(14) all decubitus and wound care products;

(15) all intravenous and oral dietary and nutritional products, including the following:

(A) Amino acids, injectable;

(B) 1-cysteine;

(D) sodium phenylbutyrate;

(16) beta-blockers:

(A) Betaxolol;

(B) bisoprolol;

(D) penbutolol;

(E) propranolol XL; and

(F) nebivolol;

(17) short-acting, inhaled beta 2 agonists:

(A) Metaproterenol inhaler;

(B) levalbuterol solution;

(D) levalbuterol inhaler; and

(E) pirbuterol inhaler;

(18) calcium channel blockers:

(A) Diltiazem extended release, with the following brand names:

(i) Cardizen SR®;

(ii) Cardizem CD®;

(iii) Cartia XT®;

(iv) Dilacor XR®;

(v) Taztia XT®; and

(vi) Cardizem LA®;

(B) verapamil sustained release, with the following brand names:

(i) Covera HS®; and

(ii) Verelan PM®;

(i) Nifedical XL®; and

(ii) Procardia XL® and all generic equivalents;

(D) nisoldipine;

(E) felodipine;

(F) isradipine;

(G) nicardipine SR; and

(H) nifedipine immediate release, with the following brand names:

(i) Adalat® and all generic equivalents; and

(ii) Procardia® and all generic equivalents;

(19) fibric acid derivatives:

(A) Antara®;

(B) Lofibra®;

(D) Tricor®;

(E) Triglide®; and

(F) Trilipix®;

(20) all growth hormones and growth hormone stimulating factor, including the following:

(A) Somatrem;

(B) somatropin;

(D) mecasermin rinfabate;

(21) intranasal corticosteroids:

(A) Flunisolide;

(B) beclomethasone;

(D) triamcinolone; and

(E) budesonide;

(22) inhaled corticosteroids:

(A) Flunisolide-menthol;

(B) flunisolide; and

(23) proton pump inhibitors:

(A) Esomeprazole;

(B) omeprazole;

(D) lansoprazole;

(E) pantoprazole;

(F) rabeprazole;

(G) omeprazole NaHCO3; and

(H) dexlansoprazole;

(24) monoclonal antibody for respiratory syncitial virus (RSV), including palivizumab;

(25) muscle relaxants:

(A) Tizanidine;

(B) orphenadrine;

(D) carisoprodol-aspirin;

(E) carisoprodol-aspirin-caffeine;

(F) cyclobenzaprine;

(G) metaxolone;

(H) dantrolene; and

(I) orphenadrine-aspirin-caffeine;

(26) narcotics:

(A) Buprenorphine-naloxone;

(B) buprenorphine;

(D) hydromorphone HCL ER;

(E) morphine sulfate ER;

(F) tapentadol;

(G) oxymorphone;

(H) tramadol ER; and

(I) hydrocodone bitartrate ER;

(27) nonsteroidal, anti-inflammatory drugs:

(A) Nabumetone;

(B) diclofenac patches;

(D) ketorolac, intranasal;

(28) drugs for the treatment of obesity:

(A) Orlistat;

(B) phentermine;

(D) phentermine-topirimate ER; and

(E) naltrexone-bupropion;

(29) oxazolidinones, including linezolid;

(30) HMG-CoA reductase inhibitors:

(A) Pravastatin;

(B) fluvastatin;

(D) pitavastatin; and

(E) rosuvastatin;

(31) nonsedating antihistamines:

(A) Desloratidine;

(B) fexofenadine;

(D) loratadine;

(32) H2 antagonists: nizatidine;

(33) triptans:

(A) Zolmitriptan;

(B) frovatriptan;

(D) Alsuma®;

(E) Sumavel®;

(F) rizatriptan;

(G) sumatriptan pens, vials, cartridges, and nasal sprays; and

(H) naratriptan;

(34) antidiabetic drugs:

(A) Glipizide XL;

(B) glipizide-metformin;

(D) acarbose;

(E) Glucophage XR®;

(F) Fortamet®;

(G) Glumetza®;

(H) exenatide;

(I) pramlintide acetate;

(J) liraglutide;

(K) canagliflozin;

(L) dapagliflozin;

(M) empagliflozin; and

(N) dulaglutide;

(35) the following types of syringes, penfills, and cartridges of insulin:

(A) Humalog®;

(B) Humalog Mix®;

(D) Humulin N®;

(E) Humulin 70/30®;

(F) Novolog®;

(G) Novolog Mix®

(H) Novolin R®

(I) Novolin N®

(J) Novolin 70/30®

(K) Velosulin BR®

(L) insulin determir;

(36) hypnotics:

(A) Zaleplon;

(B) zolpidem;

(D) eszopiclone; and

(E) tasimelteon;

(37) serotonin 5-HT3 receptor antagonist antiemetics:

(A) Granisetron;

(B) dolasetron; and

(38) influenza vaccines: Flumist®;

(39) monoclonal antibody for asthma: omalizumab;

(40) bisphosphonates:

(A) Risedronate; and

(B) risedronate-calcium;

(41) combination products for hypertension:

(A) Enalapriol maleate-felodipine;

(B) trandolapril-verapamil; and

(42) ophthalmic prostaglandin analogues:

(A) Bimatoprost; and

(B) unoprostone;

(43) topical immunomodulators:

(A) Protpic®(topical formulation);

(B) Elidel®; and

(44) narcotic analgesics: any transmucosal form of fentanyl;

(45) tramadol and all opioids, opioid combinations, and skeletal muscle relaxants, at any dose greater than the maximum recommended dose in a 31-day period;

(46) progestin for preterm labor: Makena®;

(47) aromatase inhibitors:

(A) Letrozole;

(B) anastrozole; and

(48) long-acting, inhaled beta 2 agonists:

(A) Salmeterol;

(B) formoterol;

(D) indacaterol;

(49) miscellaneous biologic agents;

(A) Canakinumab;

(B) natalizumab;

(D) rilonacept;

(50) hematopoietic agents:

(A) Eltrombopag;

(B) filgrastim;

(D) pegfilgrastim;

(E) plerixafor;

(F) romiplostim; and

(G) sargramostim;

(51) antidotes: methylnaltrexone;

(52) complement inhibitors:

(A) C1 esterase inhibitor;

(B) ecallantide;

(D) eculizumab;

(53) anti-hepatitis C virus agents:

(A) Boceprevir;

(B) telaprevir;

(D) sofosbuvir;

(E) ledipasvir-sofosbuvir; and

(F) ombitasvir-paritaprevir-ritonavir-dasabuvir;

(54) cystic fibrosis agents: ivacaftor;

(55) agents for gout:

(A) Febuxostat; and

(B) pegloticase;

(56) phenylketonurics: sapropterin;

(57) topical anesthetics: lidocaine;

(58) long-acting, inhaled beta 2 agonists and anticholinergic products: umeclidinium-vilanterol;

(59) anti-malarials: quinine;

(60) hormone analog for precocious puberty: histrelin acetate;

(61) agents for chorea associated with Huntington's disease: tetrabenazine;

(62) enzyme preparations: collegenase clostridium histolyticum;

(63) agents for cataplexy: sodium oxybate;

(64) topical acne agents:

(A) Adapalene;

(B) adapalene-benzyl peroxide;

(D) dapsone;

(E) tazarotene; and

(F) tretinoin-clindamycin;

(65) interferons:

(A) Interferon alfacon-1;

(B) interferon alfa-2b;

(D) interferon beta-1b;

(E) peginterferon alfa-2a; and

(F) peginterferon alfa-2b;

(66) pulmonary arterial hypertension agents:

(A) Ambrisentan;

(B) bosentan;

(D) iloprost;

(E) macitentan;

(F) riociguat;

(G) sildenafil;

(H) tadalafil; and

(I) treprostinil;

(67) testosterone agents:

(A) Androderm Transdermal®;

(B) AndroGel®;

(D) Delatestryl®;

(E) Fortesta Gel®;

(F) Striant Buccal®;

(G) Testim Gel®; and

(H) Testopel Pellets®;

(I) Vogelxo®;

(J) Natesto®; and

(K) testosterone powder;

(68) antineoplastic agents:

(A) Afatinib;

(B) dabrafenib;

(D) methotrexate;

(E) sipuleucel-T;

(F) trametinib; and

(G) trastuzumab;

(69) multiple sclerosis agents:

(A) Dalfampridine;

(B) dimethyl fumarate;

(D) glatiramer;

(E) teriflunomide; and

(F) alemtuzumab;

(70) immunosuppressive agents: belimumab;

(71) long-acting, inhaled beta 2 agonists and corticosteroid products:

(A) Budesonide-formoterol; and

(B) fluticasone-vilanterol;

(72) ammonia detoxicants:

(A) Glycerol phenylbutyrate; and

(B) sodium phenylbutyrate;

(73) heavy metal antagonists:

(A) Deferasirox;

(B) deferiprone; and

(74) pituitary corticotropin: H.P. Acthar® Gel;

(75) ocular agents:

(A) Ocriplasmin; and

(B) ranibizumab;

(76) miscellaneous anti-lipemic agents:

(A) Lomitapide; and

(B) mipomersen;

(77) miscellaneous analgesics: ziconotide intrathecal infusion;

(78) miscellaneous central nervous system agents: riluzole;

(79) calcimimetics: cinacalcet;

(80) radioactive agents: radium Ra 223 dichloride;

(81) dipeptidyl peptidase IV inhibitors:

(A) Alogliptin; and

(B) linagliptin;

(82) antimuscarinics-antispasmodics: aclidinium bromide;

(83) ophthalmic antihistamine-mast cell stabilizer combinations:

(A) Bepotastine;

(B) epinastine;

(D) azelastine;

(84) inhaled tobramycin products: Tobi Podhaler®;

(85) oral mesalamine products:

(A) Mesalamine DR; and

(B) mesalamine ER;

(86) pancreatic enzyme replacements: pancrelipase;

(87) alpha-1 proteinase inhibitors:

(A) Aralast NP®;

(B) Glassia®;

(D) Zemaira®;

(88) enzyme replacement therapy:

(A) Eliglustat;

(B) imiglucerase;

(D) velaglucerase alfa;

(89) cholesterol absorption inhibitor: ezetimibe;

(90) gonadotropin-releasing hormone agonist: leuprolide;

(91) constipation agents:

(A) Linaclotide; and

(B) lubiprostone; and

(92) idiopathic pulmonary fibrosis agents:

(A) Nintedanib; and

(B) pirfenidone.

(c) Failure to obtain prior authorization, if required, shall negate reimbursement for the service and any other service resulting from the unauthorized or noncertified treatment. The prior authorization shall affect reimbursement to all providers associated with the service.

(d) The only exceptions to prior authorization shall be the following:

(1) Emergencies. If certain surgeries and procedures that require prior authorization are performed in an emergency situation, the request for authorization shall be made within two working days after the service is provided.

(2) Situations in which services requiring prior authorization are provided and retroactive eligibility is later established. When an emergency occurs or when retroactive eligibility is established, prior authorization for that service shall be waived, and if medical necessity is documented, payment shall be made.

(e) Services requiring prior authorization shall be considered covered services within the scope of the program, unless the request for prior authorization is denied.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2014 Supp. 39-7,120, K.S.A. 75-5625; implementing K.S.A. 2014 Supp. 39-7,120 and K.S.A. 2014 Supp. 39-7,121a; effective Oct. 28, 2005; amended June 2, 2006; amended Aug. 11, 2006; amended Nov. 17, 2006; amended March 16, 2007; amended Oct. 19, 2007; amended May 23, 2008; amended Feb. 17, 2012; amended Oct. 19, 2012; amended Aug. 1, 2014; amended, T-129-1-23-15, Jan. 23, 2015; amended May 1, 2015.)

Kan. Admin. Regs. § 129-5-10 Definitions

Each of the following terms, when used in K.A.R. 129-5-10 through 129-5-21, shall have the meaning specified in this regulation:

(a) "Act" means kancare prompt payment act, K.S.A. 2014 Supp. 39-709f and amendments thereto.

(b) "Allowed amount" means any claim or portion of a claim that the provider and the managed care organization agree in good faith is correct and should be paid under the participating provider agreement with the managed care organization and under kancare program policies.

(1) A bill for services;

(2) a line item of service; or

(3) all services for one beneficiary within a bill.

(d) "Clean claim" means any claim that can be processed without obtaining additional information from the provider of the service or from a third party. This term shall include any claim with errors originating in the state's claims system. This term shall not include any claim from a provider who is under investigation for fraud or abuse and any claim under review for medical necessity.

(e) "Day" means calendar day. If the 30th calendar day or the 90th calendar day falls on a weekend or a holiday, then the 30th calendar or 90th calendar day shall be deemed to occur on the following business day.

(f) "Managed care organization" means an entity that has contracted with the Kansas medical assistance program for the provision of managed care services to medicaid beneficiaries in Kansas.

(g) "Provider" means a health care provider that has entered into a participating provider agreement with a managed care organization.

(h) "Unpaid claim" means any claim that has not been paid by a managed care organization and meets one of the following conditions:

(1) Is not subject to a bona fide dispute as specified in K.A.R. 129-5-15; or

(2) has not yet been processed and denied by a managed care organization.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-11 Applicability

The act shall apply only to each claim with a date of service on or after the effective date of the act, which was July 1, 2014.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-12 Electronic and paper claims

The act shall apply to each claim submitted under kancare to a managed care organization, whether the claim is submitted in electronic or paper format.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-13 Date claim is deemed to be received

If a provider submits a claim to a managed care organization by mail, the managed care organization shall be deemed to have received the claim no more than three business days after the claim was mailed, unless proven otherwise. If the provider submits the claim electronically, the managed care organization shall be deemed to have received the claim no more than 24 hours after the claim was submitted, unless proven otherwise.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-14 Notice of denial or need for additional information; processing additional information; suspension of time periods

(a) If a claim is not a clean claim and cannot be either paid or processed and denied within 30 days after the managed care organization's receipt of the claim, the managed care organization shall send a written or electronic notice acknowledging receipt and indicating the status of the claim. The notice shall include the date on which the claim was received by the managed care organization and shall state one of the following:

(1) The managed care organization refuses to pay all or part of the claim, with specification of each reason for denial.

(2) Additional information is necessary to determine whether all or any part of the claim shall be paid, with specification of what information is necessary. This notice shall constitute the managed care organization's request for additional information from the provider.

Each notice shall also identify the code for each reason for denial or for requesting additional information, if any, and shall include any other information necessary to inform the provider of the specific issues related to each claim.

(b)(1) The 90-day period for payment or for processing and denial of claims other than clean claims shall not include the days between the managed care organization's first request for additional information and the managed care organization's receipt of the provider's initial response to the request. The time period for payment of claims shall not be suspended following the submission by the managed care organization of a second or subsequent request for additional information to a provider on any single claim.

(2) After receipt of all requested additional information, the managed care organization shall perform one of the following:

(A) Pay the claim in accordance with the 90-day time period specified in the act; or

(B) issue a notice to the provider stating that the managed care organization refuses to pay all or part of the claim and specifying each reason for denial.

(c) Failure to comply with this regulation shall subject the managed care organization to a direct cause of action by the provider for interest on the unpaid portion of the claim as specified in the act.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-15 Claims subject to bona fide dispute

An unpaid claim that is subject to a bona fide dispute, including any claim that a managed care organization has reason to believe is fraudulent and any claim undergoing a review for medical necessity, shall not be subject to the interest requirements of the act.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-16 Partially paid claims

If a managed care organization pays a portion of a claim within the time limits specified in the act, then only the unpaid portion of that claim shall be subject to the interest provisions of the act.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-17 Resubmitted claims

For each corrected claim resubmitted by a provider due to a provider error on the initial submission of the claim, the applicable 30-day or 90-day time limit for processing and full payment of the allowed amount or for processing and denial shall begin on receipt of the corrected claim by the managed care organization.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-18 Date claim is deemed to be paid

Each claim shall be deemed paid on one of the following dates:

(a) The date on which the managed care organization issued a check for payment and any corresponding explanation of benefits to the provider; or

(b) the date on which the managed care organization electronically transmitted a notice of payment to the provider.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-19 Interest on unpaid claims

(a) The principal amount due on which the interest payment shall be calculated shall be the allowed amount due but unpaid at the contracted rate for the service. All interest due under the act shall be applied only to the principal amount due as specified in this subsection and not to any unpaid interest. Interest calculated under the act shall not be compounded.

(b) Each managed care organization shall keep accurate and sufficient records for each interest payment and its corresponding claim documentation and shall provide a detailed report to the state upon request.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-20 Retroactive rate, program, and policy changes and clarifications

A claim shall not be deemed to be an unpaid claim if a retroactive rate, program, or policy change creates an unpaid balance on a claim that the managed care organization has previously paid.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-21 Retroactive eligibility

If a provider submits a request for payment to a managed care organization before the patient is determined by the state to be eligible for medicaid, then the request shall not be deemed a claim under the act until the date on which the managed care organization is notified by the state that the patient was medicaid-eligible on the date of service.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Kan. Admin. Regs. § 129-5-65 Filing limitations for medical claims

(a) Each provider shall submit all medical claims to the Kansas medical assistance program within 12 months from the date of service.

(b) Any provider may resubmit a denied claim for payment to the Kansas medical assistance program if the resubmission meets the following requirements:

(1) Is within 24 months from the date of service; and

(2) is in conformance with all billing requirements of the medicaid/medikan program.

(c) The Kansas medical assistance program shall reimburse only claims that are submitted in accordance with subsection (a) or with subsections (a) and (b).

(d) Each of the following claims shall be an exception to subsections (a) and (b) and shall be payable by the Kansas medical assistance program:

(1) Any claim that is submitted to medicare within 12 months from the date of service, is paid or denied for payment by medicare, and is subsequently received by the Kansas medical assistance program within 30 days from the date of medicare's payment or denial of payment;

(2) any claim determined by the Kansas health policy authority to be payable by reason of administrative appeals, court action, or agency error;

(3) any claim for emergency services rendered by an out-of-state provider who is not already enrolled as a program provider;

(4) any claim for services provided to a recipient that is submitted to the Kansas medical assistance program within 12 months from the date on which the agency issues a notice of action under K.A.R. 129-6-38; and

(5) any claim specified in paragraph (d) (1), (2), (3), or (4) that is not payable under that paragraph but that the Kansas health policy authority determines is the result of extraordinary circumstances.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2006 Supp. 75-7403 and 75-7412; implementing K.S.A. 2006 Supp. 75-7405 and 75-7408; effective July 13, 2007.)

Kan. Admin. Regs. § 129-5-78 Scope of and reimbursement for home- and community-based services for persons with traumatic brain injury

(a) The scope of allowable home- and community-based services (HCBS) for persons with traumatic brain injury shall consist of those services authorized by the applicable federally approved waiver to the Kansas medicaid state plan. Recipients of services provided pursuant to this waiver shall be required to show the capacity to make progress in their rehabilitation and independent living skills.

(b) The need for HCBS shall be determined by an individualized assessment of the prospective recipient by a provider enrolled in the program. HCBS shall be provided only in accordance with a plan of care written by a case manager.

(c) HCBS, which shall require prior authorization by the Kansas medicaid HCBS program manager, may include one or more of the following:

(1) Rehabilitation therapies, which may consist of any of the following:

(A) Occupational therapy;

(B) physical therapy;

(D) cognitive rehabilitation; or

(E) behavioral therapy;

(2) personal services;

(3) medical equipment, supplies, and home modification not otherwise covered under the Kansas medicaid state plan;

(4) sleep-cycle support services;

(5) a personal emergency response system and its installation; or

(6) provision of or education on transitional living skills.

(d) Case management services up to a maximum of 160 hours each calendar year, which may be exceeded only with prior authorization by the Kansas medicaid HCBS program manager, shall be provided to all HCBS recipients under the traumatic brain injury program.

(e) The fee allowed for home- and community-based services for persons with traumatic brain injury shall be the provider's usual and customary charges, except that no fee shall be paid in excess of the waiver's range maximum.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2008 Supp. 75-7403 and 75-7412; implementing K.S.A. 2008 Supp. 75-7405 and 75-7408; effective July 18, 2008; amended Oct. 16, 2009.)

Kan. Admin. Regs. § 129-5-88 Scope of physician services

(a) Except as specified in subsection (b), the program shall cover medically necessary services recognized under Kansas law provided to program recipients by physicians who are licensed to practice medicine and surgery in the jurisdiction in which the service is provided.

(b) The following services shall be excluded from coverage under the program:

(1) Visits. The following types of visits shall be excluded:

(A) Office visits when the only service provided is an injection or some other service for which a charge is not usually made;

(B) psychotherapy services when provided concurrently by the same provider with both targeted case management services and partial hospitalization services;

(C) psychotherapy services exceeding an average of 32 hours of individual therapy or 32 hours of group therapy or any combination of these in a calendar year for each recipient, unless the recipient is a Kan Be Healthy program participant and either of these conditions is met:

(i) Psychotherapy services do not exceed 40 hours in a calendar year for each Kan Be Healthy program participant; or

(ii) psychotherapy services are being rendered pursuant to a plan approved by the agency. The provider of psychotherapy services shall obtain prior authorization for the plan. The plan shall not exceed a two-year period and shall be subject to a reimbursement limit established by the agency. Quarterly progress reports shall be submitted to the division of medical programs;

(D) inpatient hospital visits in excess of those allowable days for which the hospital is paid or would be paid if there were no spend-down requirements; and

(E) nursing home visits in excess of one each month, unless the service provider documents medical necessity.

(2) Consultations. The following types of consultations shall be excluded:

(A) Consultations for which there is no written report;

(B) inpatient hospital consultations in excess of one for each condition in a 10-day period, unless written documentation confirming medical necessity is attached to the claim; and

(C) consultations in excess of one for each condition in a 60-day period, unless written documentation confirming medical necessity is attached to the claim.

(3) Surgical procedures. The following types of surgical procedures and services shall be excluded:

(A) Procedures that are experimental, pioneering, cosmetic, or designated as noncovered;

(B) all transplant surgery, except for the following:

(i) Liver transplants, which shall be performed only at a hospital designated by the agency, unless the medical staff of that hospital recommends another location; and

(ii) corneal, heart, kidney, pancreas, and bone marrow transplants and related services;

(C) the services of a surgical assistant if the surgeon determines that an assistant is not required for a particular surgery; and

(D) elective surgery, except for sterilization operations or for Kan Be Healthy beneficiaries.

(4) Miscellaneous procedures. The following types of miscellaneous procedures shall be excluded:

(A) Diagnostic radiological and laboratory services, unless the services are medically necessary to diagnose or treat injury, illness, or disease;

(B) physical therapy, unless the following conditions are met:

(i) The therapy is performed by a physician or registered physical therapist under the direction of a physician; and

(ii) the therapy is prescribed by the attending physician;

(D) inpatient services that were provided on any day during a hospital stay and that are determined to not be medically necessary.

(5) Family planning services and materials.

(A) Family planning services and materials shall be excluded, unless all of the following conditions are met:

(i) The services are provided by a physician, family planning clinic, or county health department.

(ii) Written informed consent from the consumer is obtained as required by federal law and regulation.

(iii) The scope of services provided is in compliance with applicable federal and state statutes and regulations.

(B) Reverse sterilizations shall be excluded.

(6) Concurrent care shall be excluded, unless both of the following conditions are met:

(A) The patient has two or more diagnoses involving two or more systems.

(B) The special skills of two or more physicians are essential in rendering quality medical care. The occasional participation of two or more physicians in the performance of one procedure shall be recognized. Each physician involved shall submit that physician's usual charge for only that portion of the procedure for which the physician is actually responsible.

(7) Psychological services for an individual entitled to receive these services as a part of care or treatment from a facility already being reimbursed by the program or by a third-party payor shall be excluded.

(c) The services provided by mid-level practitioners, including advanced registered nurse practitioners and physician assistants, shall be covered.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by L. 2005, Ch. 187, § 45 and K.S.A. 2005 Supp. 75-7403; implementing L. 2005, Ch. 187, § 41; effective Jan. 12, 2007.)

Kan. Admin. Regs. § 129-5-108 Scope of services for durable medical equipment, medical supplies, orthotics, and prosthetics

(a) Selected durable medical equipment (DME) shall be available to each beneficiary, with the following limitations:

(1) The DME shall be the most economical to meet the beneficiary's need.

(2) The least expensive and most appropriate method of delivery shall be used. If round-trip delivery is over 100 miles, prior authorization shall be required.

(3) Used equipment with a warranty specified by the agency shall be used if available.

(4) Certain DME designated by the agency shall be the property of the agency.

(5) Educational, environmental control, and convenience items shall not be covered.

(6) DME shall be covered for only the following types of beneficiaries:

(A) Participants in the Kan Be Healthy program;

(B) beneficiaries who require the DME for life support;

(D) beneficiaries who would require more expensive care if the DME was not provided.

(7) DME services provided for the parenteral administration of total nutritional replacements and intravenous medication in the beneficiary's home shall require the provision of services by a local home health agency, physician, advanced registered nurse practitioner, physician assistant, or pharmacist.

(b) Selected medical supplies shall be available to each beneficiary for use in the beneficiary's home.

(c) Selected DME and medical supplies shall be considered for coverage only in cases in which exceptional hardship or medical need has been justified by documentation of medical necessity or by the granting of prior authorization.

(d) Orthotics and prosthetics shall be available to program beneficiaries from orthotic and prosthetic dealers enrolled under K.A.R. 30-5-59.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Nov. 17, 2006; amended Sept. 19, 2008.)

Kan. Admin. Regs. § 129-5-118 Scope of federally qualified health center services

For purposes of this regulation, a federally qualified health center shall mean a community health center, federally qualified health center (FQHC) look-alike, or an urban Indian organization receiving funds under the Indian health care improvement act that is accepted by the centers for medicare and medicaid to furnish federally qualified health center services for participation under medicare and medicaid. An FQHC look-alike shall mean an organization that meets all of the eligibility requirements of an organization that receives a public health service (PHS) section 330 grant but does not receive grant funding. (a) The services provided by the following health care professionals shall be billable as federally qualified health center services:

(1) Physician and physician assistant pursuant to K.A.R. 129-5-88;

(2) advanced registered nurse practitioner pursuant to K.A.R. 30-5-113;

(3) dentist and dental hygienist pursuant to K.A.R. 30-5-100;

(4) licensed mental health practitioner pursuant to K.A.R. 30-5-104;

(5) clinical social worker pursuant to K.A.R. 30-5-86;

(6) visiting nurse pursuant to K.A.R. 30-5-89; and

(7) for kan be healthy nursing assessments only, registered nurse pursuant to K.A.R. 30-5-87.

(b) Covered services of federally qualified health centers shall include the following:

(1) The services and supplies furnished as an incident to the professional services provided by the health care professionals specified in subsection (a); and

(2) other ambulatory services covered under the medicaid state plan, if provided by the federally qualified health center.

(A) Physician;

(B) nurse practitioner;

(D) nurse midwife;

(E) licensed mental health practitioner;

(F) clinical social worker; or

(G) either a member of the center's health care staff who is an employee of the center or a physician under arrangements with the center.

(2) Preventive primary services shall include only drugs and biologicals that cannot be self-administered, unless §1861(s) of the social security act provides for coverage of the drug regardless of whether the drug is self-administered.

(d) The following preventive primary services may be covered when provided by federally qualified health centers to medicaid beneficiaries:

(1) Medical social services;

(2) nutritional assessment and referral;

(3) preventive health education;

(4) children's eye and ear examinations;

(5) prenatal and postpartum care;

(6) prenatal services;

(7) well child care, including periodic screening;

(8) providing immunizations, including tetanus-diphtheria booster and influenza vaccine;

(9) voluntary family planning services;

(10) taking patient history;

(11) blood pressure measurement;

(12) weight measurement;

(13) physical examination targeted to risk;

(14) visual acuity screening;

(15) hearing screening;

(16) cholesterol screening;

(17) stool testing for occult blood;

(18) dipstick urinalysis;

(19) risk assessment and initial counseling regarding risks; and

(20) the following services, for women only:

(A) Clinical breast exam;

(B) referral for mammography; and

(3) Preventive primary services shall not include group or mass information programs, health education classes, and group education activities, which may include media productions and publication and services for eyeglasses and hearing aids.

(e) "Visiting nurse" shall include a registered nurse or licensed practical nurse who provides part-time or intermittent nursing care to a patient at the beneficiary's place of residence under a written plan of treatment prepared by a physician. The place of residence shall not include a hospital or long-term care facility. This nursing care shall be covered only if there is no home health agency in the area.

(f) Federally qualified health center services provided at a location other than a federally qualified health center shall meet the following conditions:

(1) No services are provided at an inpatient hospital, outpatient hospital, or hospital emergency room.

(2) The services provided are listed in subsection (b).

(3) The services are provided to a patient of a federally qualified health center.

(4) The health professional providing the services is an employee of a federally qualified health center or under contract with a federally qualified health center and is required to seek compensation for that person's services from the federally qualified health center.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2008 Supp. 75-7403 and 75-7412; implementing K.S.A. 2008 Supp. 75-7405 and 75-7408; effective June 2, 2006; amended March 19, 2010.)

Kan. Admin. Regs. § 129-5-118a Reimbursement for federally qualified health center services

Reimbursement shall not exceed the reasonable cost of federally qualified health center services and other ambulatory services covered under the Kansas medical assistance program. "Reasonable cost" shall consist of the necessary and proper cost incurred by the provider in furnishing covered services to program beneficiaries, subject to the cost principles and limits specified in K.A.R. 129-5-118a (c)(1) and K.A.R. 129-5-118b. (a) Reimbursement method. An interim per visit rate shall be paid to each federally qualified health center provider, with a retroactive cost settlement for each facility fiscal year.

(1) Interim reimbursement rate. The source and the method of determination of interim rate shall depend on whether the federally qualified health center is a new enrollee of the Kansas medical assistance program or is a previously enrolled provider. Under special circumstances, the interim rate may be negotiated between the agency and the provider.

(A) Newly enrolled facility. If the facility is an already-established federally qualified health center with an available medicare cost report, an all-inclusive rate derived from the cost report may be used for setting the initial medicaid interim payment rate. If the facility is an already-established federally qualified health center opening a new service location, then the rate from the already-established federally qualified health center shall be used for the new service location. If the facility converted from a rural health clinic to a federally qualified health center, then the rate from the rural health clinic shall be used for the new federally qualified health center. For all other circumstances, the initial payment rate shall be based on the average of the current reimbursement rates for previously enrolled federally qualified health center providers.

(B) Previously enrolled facility. After the facility submits a federally qualified health center cost report, the agency shall determine the maximum allowable medicaid rate per visit as specified in subsection (c). If a significant change of scope of services or a significant capital project has been implemented, the federally qualified health center shall submit an interim cost report if the center wants a change to the existing rate. The agency and the federally qualified health center shall use the interim cost report to negotiate a new interim rate.

(2) Visit. A "visit" shall mean face-to-face encounter between a center patient and a center health care professional as defined in K.A.R. 129-5-118. Encounters with more than one health professional or multiple encounters with the same health professional that take place on the same day shall constitute a single visit, except under either of the following circumstances:

(A) The patient suffers an illness or injury requiring additional diagnosis or treatment after the first encounter.

(B) The patient has a different type of visit on the same day, which may consist of a dental, medical, or mental health visit.

(3) Retroactive cost settlement. For each reporting period, the agency shall compare the total maximum allowable medicaid cost with the total payments to determine the program overpayment or underpayment. Total payments shall include interim payments, third-party liability, and any other payments for covered federally qualified health center services. The cost report and supplemental data submitted by the provider, the medicare cost report, and the medicaid-paid claims data obtained from the program's fiscal agent shall be used for these calculations.

(b) Cost reporting. Each federally qualified health center shall submit a completed cost report. The form used for cost reporting shall be the most current version of the medicare financial and statistical report form for independent rural health clinics and freestanding federally qualified health centers with adjustments made, as necessary, to report the cost and number of visits for medicaid-covered services pursuant to K.A.R. 129-5-118.

(1) Filing requirements. Each provider shall be required to file annual cost reports on a fiscal year basis.

(A) Cost reports shall be received no later than five months after the end of the facility's fiscal year. An extension in due date may be granted by the agency upon request, if necessary due to circumstances beyond the control of the federally qualified health center.

(B) Each provider filing a cost report after the due date without a preapproved extension shall be subject to the following penalties:

(i) If the cost report has not been received by the agency by the close of business on the due date, all further payments to the provider may be withheld and suspended until the complete financial and statistical report has been received.

(ii) Failure to submit the completed financial and statistical report within one year after the end of the cost report period may be cause for termination from the Kansas medical assistance program.

(2) Fiscal and statistical data. The preparation of the cost report shall be based upon the financial and statistical records of the facility and shall use the accrual basis of accounting. The reported data shall be accurate and adequately supported to facilitate verification and analysis for the determination of allowable costs.

(3) Supplemental data. The following additional information shall be submitted to support reported data and to facilitate cost report review, verifications, and other analysis.

(A) A working trial balance. This balance shall contain account numbers, descriptions of the accounts, the amount of each account, the cost report expense line on which the account was reported, and fiscal year-end adjusting entries to facilitate reconciliation between the working trial balance and the cost report. The facility shall bear the burden of proof that the reported data accurately represents the cost and revenue as recorded in the accounting records. All unexplained differences shall be used to reduce the allowable cost.

(B) Financial statements and management letter. These documents shall be prepared by the facility's independent auditors and shall reconcile with the cost report.

(D) Other data. Data deemed necessary by the agency for verification and rate determination shall also be submitted.

(1) Allowable facility costs. This term shall mean costs derived from reported expenses after making adjustments resulting from cost report review and application of the cost reimbursement principles specified in K.A.R. 129-5-118b.

(2) Allocation of overhead costs.

(A) Total allowable administrative and facility costs shall be distributed to the following cost centers:

(i) Federally qualified health center costs;

(ii) non-federally qualified health center costs; and

(iii) nonreimbursable costs, excluding bad debt.

(B) Accumulated direct cost in each cost center shall be used as the basis for the overhead cost allocation.

(3) Average allowable cost per visit. The total allowable facility costs shall be divided by the total number of visits.

(4) Reimbursable medicaid rate. The reimbursable medicaid rate per visit shall not be more than 100 percent of the reasonable and related cost of furnishing federally qualified health center services covered in K.A.R. 129-5-118b.

(d) Fiscal and statistical records and audits.

(1) Recordkeeping. Each provider shall maintain sufficient financial records and statistical data for accurate determination of reasonable costs. Standardized definitions and reporting practices widely accepted among federally qualified health centers and related fields shall be followed, except to the extent that these definitions and practices may conflict with or be superseded by state or federal medicaid requirements.

(2) Audits and reviews.

(A) Each provider shall furnish any information to the agency that may be necessary to meet the following criteria:

(i) Ensure proper payment by the program pursuant to this regulation and K.A.R. 129-5-118b; and

(ii) substantiate claims for program payments.

(B) Each provider shall permit the agency to examine any records and documents necessary to ascertain information for determination of the accurate amount of program payments. These records shall include the following:

(i) Matters of the facility ownership, organization, and operation;

(ii) fiscal, statistical, medical, and other recordkeeping systems;

(iii) federal and state income tax returns and all supporting documents;

(iv) documentation of asset acquisition, lease, sale, or other transaction;

(v) management arrangements;

(vi) matters pertaining to the cost of operation; and

(vii) health center financial statements.

(C)Other records and documents shall be made available to the agency as requested.

(D)All records and documents shall be available in Kansas.

(E)Each provider shall furnish to the agency, upon request, copies of patient service charge schedules and any subsequent changes to these schedules.

(F)The agency shall suspend program payments if it is determined that a provider does not maintain adequate records for the determination of reasonable and adequate rates under the program or if the provider fails to furnish requested records and documents to the agency.

(G)Thirty days before suspending payment to the provider, written notice shall be sent by the agency to the provider of the agency's intent to suspend payment. The notice shall explain the basis for the agency's determination and identify the provider's recordkeeping deficiencies.

(H)All provider records that support reported costs, charges, revenue, and patient statistics shall be subject to audits by the agency, the United States department of health and human services, and the United States general accounting office. These records shall be retained for at least five years after the date of filing the cost report with the agency.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2008 Supp. 75-7403 and 75-7412; implementing K.S.A. 2008 Supp. 75-7405 and 75-7408; effective March 19, 2010.)

Kan. Admin. Regs. § 129-5-118b Cost reimbursement principles for federally qualified health center services and other ambulatory services

The medicare cost reimbursement principles contained in subparts A and G in 42 C.F.R. part 413, as revised on October 1, 2009 and hereby adopted by reference, and the cost principles specified in this regulation and in K.A.R. 129-5-118a shall be applicable to the financial and statistical data reported by the federally qualified health center for the determination of reasonable cost of providing covered services. (a) Nonreimbursable costs. Each cost that is not related to patient care and is not necessary for the efficient delivery of covered federally qualified health center services and other ambulatory services shall be excluded from the medicaid rate determination. In addition, the following expenses shall be considered nonreimbursable:

(1) Salaries and fees paid to nonworking directors and officers;

(2) uncollectible debts;

(3) donations and contributions;

(4) fund-raising expenses;

(5) taxes including the following:

(A) Those from which the provider is entitled to obtain exemption;

(B) those on property not used in providing covered services; and

(6) life insurance premiums for directors, officers, and owners;

(7) the imputed value of in-kind services rendered by nonpaid workers and volunteers;

(8) the cost of social, fraternal, civic, and other organizations associated with activities unrelated to patient care;

(9) all expenses related to vending machines;

(10) board of director costs;

(11) the cost of advertising for promoting the services offered by the facility to attract more patients;

(12) public relations and public information expenses;

(13) penalties, fines, and late charges, including interest paid on state and federal payroll taxes;

(14) the cost of items or services provided only to non-Kansas medical assistance program patients and reimbursed by third-party payers;

(15) all expenses associated with the ownership, lease, or charter of airplanes;

(16) bank overdraft charges and other penalties;

(17) the cost associated with group health education classes, activities, and mass information programs including media productions, brochures, and other publications;

(18) expense items without indication of their nature or purpose including "other" and "miscellaneous," without proper documentation when requested;

(19) non-arm's-length transactions;

(20) legal and other costs associated with litigation between a provider and state or federal agencies, unless litigation is decided in the provider's favor; and

(21) legal expenses not related to patient care.

(b) Costs allowed with limitations and conditions.

(1) Loan acquisition fees and standby fees. These fees shall be amortized over the life of the loan and shall be allowed only if the loan is related to patient care.

(2) Taxes associated with financing the operations. These taxes shall be allowed only as amortized cost.

(3) Special assessments on land for capital improvements. These assessments shall be amortized over the estimated useful life of the improvements and allowed only if related to patient care.

(4) Start-up costs of a new facility.

(A) Start-up costs may include the following:

(i) Staff salaries and consultation fees;

(ii) utilities;

(iii) taxes;

(iv) insurance;

(v) mortgage interest;

(vi) employee training; and

(vii) any other allowable cost incidental to the operation of the facility.

(B) A start-up cost shall be recognized only if it meets the following criteria:

(i) Is incurred before the opening of the facility;

(ii) is related to developing the facility's ability to provide covered services;

(iii) is amortized over a period of 60 months or more; and

(iv) is identified in the cost report as a start-up cost.

(5) Expenses. Each cost that can be identified as an organization expense or capitalized as a construction expense shall be appropriately classified and excluded from start-up costs.

(6) Payments made to related parties for services, facilities, and supplies. These payments shall be allowed at the lower of the actual cost to the related party and the market price.

(7) Premium payments. If a provider chooses to pay in excess of the market price for supplies or services, the agency shall use the market price to determine the allowable cost in the absence of a clear justification for the premium.

(8) Job-related training. The cost of this training shall be the actual amount minus any reimbursement or discount received by the provider.

(9) Lease payments. These payments shall be allowed only if reported in accordance with the generally accepted accounting principles appropriate to the reporting period.

(1) The interest expense shall be allowed only if it is established with either of the following:

(A) Any lender or lending organization not related to the borrower, or

(B) the central office and other related parties under the following conditions:

(i) The terms and conditions of payment of the loans are on arm's-length basis with a recognized lending institution;

(ii) the provider demonstrates, to the satisfaction of the agency, a primary business purpose for the loan other than increasing the rate of reimbursement; and

(iii) the transaction is recognized and reported by all parties for federal income tax purposes.

(2) Interest expense shall be reduced by investment income from both restricted and unrestricted idle funds and funded reserve accounts, except when the income is from restricted or unrestricted gifts, grants, and endowments held in separate accounts with no commingling with other funds. Income from the provider's qualified pension fund shall not be used to reduce interest expense.

(3) Interest earned on restricted and unrestricted industrial revenue bond reserve accounts and sinking fund accounts shall be offset against interest expense up to and including the amount of the related interest expense.

(4) The interest expense on that portion of the facility acquisition loan attributable to an excess over historic cost or other cost basis recognized for program purposes shall not be considered a reasonable cost.

(d) Central office cost. This subsection shall be applicable in situations in which the federally qualified health center is one of several programs or departments administered by a central office or organization and the total administrative cost incurred by the central office is allocated to all components.

(1) Allocation of the central office cost shall use a logical and equitable basis and shall conform to generally accepted accounting procedures.

(2) The central office cost allocated to the federally qualified health center shall be allowed only if the amount is reasonable and if the central office provided a service normally available in similar facilities enrolled in the program.

(3) The provider shall bear the burden of furnishing sufficient evidence to establish the reasonability of the level of allocated cost and the nature of services provided by the central office.

(4) All costs incurred by the central office shall be allocated to all components as a central cost pool, and no portion of the central office cost shall be directed to individual facilities operated by the provider or reported on any line of the cost report other than the appropriate line of the central office cost on any other line of the cost report outside of the central office cost allocation plan.

(5) Only patient-related central office costs shall be recognized, which shall include the following:

(A) Cost of ownership or arm's-length rent or lease expense for office space;

(B) utilities, maintenance, housekeeping, property tax, insurance, and other facility costs;

(D) office supplies and printing;

(E) management consultant fees;

(F) telephone and other means of communication;

(G) travel and vehicle expenses;

(H) allowable advertising;

(I) licenses and dues;

(J) legal costs;

(K) accounting and data processing; and

(L) interest expense.

(6) The cost principles and limits specified in this regulation shall also apply to central office costs.

(7) Estimates of central office costs shall not be allowed.

(e)Revenue offsets. Revenue items shall be deducted from the appropriate expense item or cost center in accordance with this subsection.

(1) Revenue with insufficient explanation of its nature or purpose shall be offset against operating costs.

(2) Expense recoveries credited to expense accounts shall not be reclassified as revenue.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2008 Supp. 75-7403 and 75-7412; implementing K.S.A. 2008 Supp. 75-7405 and 75-7408; effective June 2, 2006; amended March 19, 2010.)

Article 6 Medical Assistance Program—Clients' Eligibility for Participation

Kan. Admin. Regs. § 129-6-30 Implementation of provisions specific to the ACA

The definitions in K.A.R. 129-6-34 and the provisions of K.A.R. 129-6-41, 129-6-42, 129-6-53, 129-6-54, 129-6-103, 129-6-106(e), 129-6-110(a) and (b), 129-6-111(a) and (b), 129-6-112, and 129-6-113 shall apply to all eligibility determinations completed on and after November 1, 2013.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-34 Definitions; covered groups

(a) The terms defined in K.A.R. 129-1-1 shall be applicable to this article. In addition and for purposes of this article, each of the following terms shall have the meaning specified in this regulation, unless the context clearly indicates otherwise:

(1) "Buy-in process" means the process by which the medicaid program pays a recipient's medicare premiums to establish medicare coverage.

(2) "Caretaker" means the person who is assigned the primary responsibility for the care and control of the child and who is any of the following persons:

(A) Guardian, conservator, legal custodian, or person claiming the child as a tax dependent;

(B) parent, including parent of an unborn child;

(D) nephew;

(E) niece;

(F) aunt;

(G) uncle;

(H) person of a preceding generation who is denoted by a term that includes any of the following prefixes: "grand," "great-," "great-great-," or "great-great-great-";

(I) stepfather, stepmother, stepbrother, or stepsister;

(J) legally adoptive parent or another relative of an adoptive parent as listed in paragraph (a)(1); and

(K) spouse of any person listed in paragraph (a)(1) or former spouse of any of these persons, if marriage is terminated by death or divorce.

(3) "Child" means a natural or biological child, adopted child, or stepchild.

(4) "Earned income" means income, in cash or in kind, that an applicant or recipient currently earns, through the receipt of wages, salary, or profit, from activities in which the individual engages as an employer or as an employee with responsibilities that necessitate continuing activity on the individual's part.

(5) "Eligible caretaker" means a caretaker who is considered in the assistance plan with the child.

(6) "Family group" means the applicant or recipient and all individuals living together in which there is a relationship of legal responsibility or a caretaker relationship.

(7) "HCBS" means home- and community-based services. Home- and community-based services are medical and nonmedical services provided to a medicaid recipient in the recipient's home that prevent the recipient from being placed in a nursing facility, hospital, or intermediate care facility.

(8) "Household size" means the number of persons counted as members of an individual's tax household in accordance with K.A.R. 129-6-41 and 129-6-53. For each pregnant woman in the household, the household size shall include the woman and the number of children she is expected to deliver.

(9) "Independent living" means any living arrangement in which ongoing medical care or treatment is not routinely provided, including living in one's own home, renting, living with other family members or friends, living in a room-and-board arrangement, and living in certain specialized living arrangements, including homeless shelters, shelters for battered women, and alcohol and drug abuse facilities.

(10) "Legally responsible relative" means the person who has the legal responsibility to provide support for the person in the assistance plan.

(11) "Long-term care" means care that is received in a nursing facility or other institutional arrangement, a homeand community-based services arrangement, or a program of all-inclusive care for the elderly (PACE) arrangement and whose duration is expected to exceed the month the arrangement begins and the following two months.

(12) "Modified adjusted gross income" and "MAGI" mean income as defined in 26 U.S.C. 36B(d).

(13) "PACE" means program of all-inclusive care for the elderly. The program of all-inclusive care for the elderly provides medical services to frail elderly medicaid recipients in institutional settings and non-institutional settings.

(14) "Parent" means natural or biological parent, adoptive parent, or stepparent.

(15) "Protected income level" means the amount of monthly income that is not considered available for the payment of medical expenses. The protected income level is based on the number of persons in the assistance plan in accordance with K.A.R. 129-6-42 and the number of legally responsible relatives.

(16) "Sibling" means natural or biological sibling, adopted sibling, half sibling or stepsibling.

(17) "Supplemental security income" and "SSI" mean the low-income assistance program administered by the social security administration in accordance with 42 U.S.C. 1381 et seq., which provides monthly benefits to elderly and disabled persons.

(18) "Tax dependent" means a dependent under 26 U.S.C. 152 for whom another individual claims a deduction for a personal exemption under 26 U.S.C. 151 for a taxable year.

(19) "Title IV-E" means the adoption assistance and child welfare act of 1980, which provides federal funding for foster care, adoption assistance, and other permanency and placement programs for children.

(20) "Unearned income" means all income that is not earned income.

(b) The medical assistance program shall include applicants and recipients classified as automatic eligibles and as determined eligibles.

(1) MAGI-based coverage groups whose eligibility is based on the application of MAGI methodologies as specified in K.A.R. 129-6-41 and 129-6-53, including the following:

(A) Caretaker relatives and children under K.A.R. 129-6-70;

(B) newborn children who meet the provisions of K.A.R. 129-6-65(e);

(D) poverty-level children under K.A.R. 129-6-72;

(E) determined-eligible pregnant women under K.A.R. 129-6-73; and

(F) determined-eligible children under K.A.R. 129-6-74; and

(2) MAGI-excepted coverage groups whose eligibility is not based on the application of MAGI methodologies in accordance with K.A.R. 129-6-42 and 129-6-54, including the following:

(A) Children receiving title IV-E or non-title IV-E foster care payments under K.A.R. 129-6-65(f) or 129-6-80;

(B) children for whom an adoption support agreement under title IV-E is in effect under K.A.R. 129-6-65(g);

(D) children receiving title IV-E guardianship care payments under K.A.R. 129-6-65(i);

(E) former foster care children under the age of 26 under K.A.R. 129-6-91;

(F) persons receiving supplemental security income (SSI) benefits in accordance with K.A.R. 129-6-65(a);

(G) persons receiving state supplemental payments in accordance with K.A.R. 129-6-65(b);

(H) persons deemed to be receiving SSI in accordance with K.A.R. 129-6-65(c);

(I) children under the age of 21 in an institutional arrangement in accordance with K.A.R. 129-6-81;

(J) aged, blind, or disabled persons under K.A.R. 129-6-85, including persons 65 years of age or older, persons whose eligibility is based on being blind or disabled under social security administration criteria, and persons whose eligibility is determined on the basis of the need for long-term care including nursing facility or institutional services, home- and community-based services, and PACE services;

(K) poverty-level and low-income medicare beneficiaries under K.A.R. 129-6-86;

(L) poverty-level working disabled individuals under K.A.R. 129-6-87;

(M) disabled individuals with earned income under K.A.R. 129-6-88;

(N) individuals with breast or cervical cancer under K.A.R. 129-6-89;

(O) persons living in nursing facilities for mental health under K.A.R. 129-6-94; and

(P) determined-eligible medikan beneficiaries under K.A.R. 129-6-95.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-35 Application process

(a)(1) An application for medical assistance shall be submitted by an applicant, an adult who is in the applicant's household or family, or another person authorized to act on the applicant's behalf.

(2) Each application on behalf of a deceased applicant shall be submitted by one of the following individuals:

(A) A parent of the decedent if the decedent is a minor;

(B) the surviving spouse of the decedent;

(D) an adult in the decedent's tax household; or

(E) an executor or administrator, including temporary, of the decedent's estate.

(b)(1) An application for medical assistance shall be submitted using a department-approved form. The applicant or person authorized to act on behalf of the applicant shall sign the application. Electronic signatures, including telephonically recorded signatures, and handwritten signatures transmitted by any other means of electronic transmission shall be acceptable. If any person signs by mark, the names and addresses of two witnesses shall be required. Each application on behalf of a deceased person shall be made within three months of the month of the person's death.

(2) Whenever assistance is requested for a family member following approval of assistance for other family members, the month of application for that family member shall be the month of the request, if all other eligibility requirements are met.

(3) Each application shall be submitted electronically on the state's application web site or the federally facilitated exchange web site, by telephone, in person, by mail, by electronic mail, or by fax.

(c)(1) For each application submitted online, the date of receipt of the application shall be the date the application is received from the state's application web site or the date the application is transmitted from the federally facilitated exchange web site.

(2) If the department denies an application within 90 days of the department's receipt of a signed application for medical assistance that is dependent upon a finding of disability and the applicant reapplies or provides required information within this 90-day period, the application shall be reactivated. If the department denies any other signed application within 45 days of the department's receipt of the application and the applicant reapplies or provides required information within this 45-day period, the application shall be reactivated.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014; amended July 14, 2023.)

Kan. Admin. Regs. § 129-6-36 Redetermination of eligibility process

(a) Each recipient shall provide the department with information on the recipient's current situation and have an opportunity to review the eligibility factors so that the department can redetermine the recipient's continuing eligibility for medical assistance.

(b) Each recipient shall complete the redetermination process by either of the following:

(1) Reviewing and, if necessary, responding to information provided from the department's records, including information obtained through electronic data matching with other state or federal agencies; or

(2) completing and returning information on the individual's current situation requested by the department.

(c) Each recipient's eligibility for medical assistance shall be redetermined as often as a need for review is indicated. Redetermination shall occur at least once each 12 months.

(d) If a recipient fails to respond to a required redetermination request or to provide necessary information, the recipient and the members of the recipient's assistance plan shall be ineligible for assistance in accordance with K.A.R. 129-6-56. If the recipient responds to the request or provides information within 90 days of termination of assistance, the redetermination shall be completed without requiring a new application.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-38 Revoked

Publisher status: INEFFECTIVE (not currently effective).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2005 Supp. 75-7412; implementing K.S.A. 2005 Supp. 75-7412 and 75-7413, as amended by L. 2006, ch. 4, § 2; effective Aug. 11, 2006; revoked, T-129-10-31-13, Nov. 1, 2013; revoked Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-39 Responsibilities of applicants and recipients

Each applicant or recipient shall perform the following:

(a) Submit an application for medical assistance on a department-approved form. Any applicant may withdraw the application between the date the application is submitted and the date of the notice of the department's decision;

(b) supply information essential to the establishment of eligibility, to the extent that the applicant or recipient is able to do so;

(d) report any change in circumstances within 10 calendar days of the change or as otherwise required by the program. Changes to be reported shall include changes to income, living arrangement, household size, family group members, residency, alienage status, health insurance coverage, and employment;

(e) meet that individual's own medical needs to the extent that the individual is capable of doing so;

(f) take all necessary actions to obtain income or resources due the person or any other person for whom the individual is applying or who is receiving medical assistance; and

(g) except for persons for whom a determination under presumptive medical assistance as defined in K.A.R. 129-6-151 has been made, request a fair hearing in writing if the individual is dissatisfied with any department decision or lack of action in regard to the application for or the receipt of assistance.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-41 Assistance planning for MAGI-based coverage groups

(a) The assistance plan for the groups described in K.A.R. 129-6-34(c)(1) shall consist of those persons in the household as determined in subsections (b) through (f).

(b) For each person who is not claimed as a tax dependent by any other taxpayer and is expected to file a tax return, the household shall consist of the person and all of the person's tax dependents, except as noted in subsection (e). If a taxpayer cannot reasonably establish that another individual is a tax dependent of the taxpayer for the tax year in which assistance is determined, the inclusion of the individual in the household of the taxpayer shall be determined in accordance with subsections (d) and (e).

(c) For each person claimed as a tax dependent by another taxpayer, the household shall consist of that taxpayer and the taxpayer's dependents, except as noted in subsection (e).

(d) For each person who neither files a tax return nor is claimed as a tax dependent, the household shall consist of the person and, if living with the person, the following:

(1) The person's spouse;

(2) the person's natural children, adopted children, and stepchildren under the age of 21;

(3) the person's natural parents, adoptive parents, and stepparents, if the person is under the age of 21; and

(4) the person's natural siblings, adopted siblings, and stepsiblings under the age of 21, if the person is under the age of 21.

(e) For each person who is claimed as a tax dependent by another taxpayer, the household shall be determined in accordance with subsection (d) if the person meets one of the following conditions:

(1) Is not a spouse of the taxpayer and is not a biological child, an adopted child, or stepchild of the taxpayer;

(2) is claimed by one parent as a tax dependent and is living with both parents who do not expect to file a joint tax return; or

(3) is under the age of 21 and expected to be claimed as a tax dependent by a noncustodial parent.

(f) For any married couple living together, each spouse shall be included in the household of the other spouse, whether both spouses expect to file a joint tax return under 26 U.S.C. 6013 or whether one spouse expects to be claimed as a tax dependent by the other spouse.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-42 Assistance planning for MAGI-excepted coverage groups

(a) In independent living arrangements for the groups described in K.A.R. 129-6-34(c)(2), the following requirements shall apply:

(1) For any child who is not blind or disabled, the assistance plan shall consist of all children in the family group and the legally responsible relatives of the children, if living together.

(2) For any child who is not living with a legally responsible relative, a separate assistance plan shall be applicable and shall include the siblings of the child if in the family group.

(3) For SSI recipients, a separate assistance plan shall be applicable and shall include only the SSI recipient.

(4) For all other persons, the assistance plan shall consist of those members of the family group for whom assistance is requested and eligibility is determined.

(5) For any deceased person for whom an application is made, the assistance plan shall be determined as if the person were living.

(b) In long-term care arrangements for the groups described in K.A.R. 129-6-34(c)(2), each person shall have a separate assistance plan, unless one of the following exceptions applies:

(1) The person's protected income level is being computed as if the person were maintaining an independent living arrangement.

(2) The person's income and resources are considered available to both members of a couple, as specified in K.A.R. 129-6-106(f).

(3) A couple is residing in the same long-term care institutional arrangement, and only one spouse has income.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-50 Determined eligibles; general eligibility factors

The general eligibility requirements in K.A.R. 129-6-51 through 129-6-60 and in K.A.R. 129-6-63 shall be eligibility factors applicable to determined eligibles, except as specified in those regulations. Certain eligibility requirements may be waived by the secretary and additional eligibility requirements may be adopted by the secretary for all, or designated areas, of the state for the purpose of utilizing special project funds or grants or for the purpose of conducting special demonstration or research projects.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-51 General eligibility requirements

(a) Eligibility process. The determination of eligibility shall be based upon information provided by the applicant or recipient, or on behalf of the applicant or recipient, as well as electronic data matches with other state and federal databases, including the social security administration, department of homeland security, department of labor, and the department's office of vital statistics. If the information is unclear, incomplete, conflicting, or questionable, a further review, including contact with third parties, may be required.

(b) Eligibility for medical assistance. Each applicant or recipient shall be eligible for medical assistance only if all applicable eligibility requirements have been met.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-52 Act on own behalf

(a) For purposes of this regulation, each of the following terms shall have the meaning specified in this subsection:

(1) "Emancipated minor" means either of the following:

(A) A person who is aged 16 or 17 and who is or has been married; or

(B) a person who is under the age of 18 and who has been given or has acquired the rights of majority through court action.

(2) "Medical facilitator" means a person authorized to help complete the application or reenrollment process on behalf of an applicant or recipient under written authorization made by the applicant or recipient. The medical facilitator may help with completing and submitting the application or reenrollment form, providing necessary information and verifications, and receiving copies of notices or other official communications from the department to the applicant or recipient. A medical facilitator shall not be authorized to apply for medical assistance on behalf of another person.

(3) "Medical representative" means a person who is authorized to act on behalf of an applicant or recipient under a written authorization made by the applicant or recipient and who is knowledgeable of the applicant's or recipient's financial holdings and circumstances.

(b) Each applicant or recipient shall be legally capable of acting on that individual's behalf and shall also have the right to designate a representative to assist or act on behalf of the applicant or recipient.

(1) A legally incapacitated adult who is not capable of acting in that individual's own behalf shall not be eligible for medical assistance, unless a legal guardian, conservator, medical representative, or representative payee for social security benefits applies for assistance on the adult's behalf.

(2) Each emancipated minor shall be eligible to receive medical assistance on that individual's own behalf.

(3) An unemancipated minor shall not be deemed capable of acting on that individual's own behalf and shall not be eligible to apply for or receive medical assistance on that individual's own behalf, except as specified in this paragraph. An unemancipated minor shall not be eligible unless a caretaker, representative payee for social security benefits, or other nonrelated responsible adult who resides with the child and is approved by the parent or legal guardian applies for assistance on the minor's behalf. However, an unemancipated minor may apply for or receive medical assistance on that individual's own behalf if one of the following conditions exists:

(A) The parents of the minor are institutionalized.

(B) The minor has no parent who is living or whose whereabouts are known, and there is no other caretaker who is willing to assume parental control of the minor.

(C) The health and safety of the minor has been or would be jeopardized by remaining in the household with the minor's parents or other caretakers.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-53 Financial eligibility for MAGI-based coverage groups

This regulation shall apply to all groups described in K.A.R. 129-6-34(c)(1).

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this regulation.

(1) "Household income" means the sum of the MAGI-based income of every individual included in the individual's household minus an amount equivalent to five percentage points of the federal poverty level for the applicable family size, for purposes of determining the individual's eligibility under the highest income standard for which the individual is eligible.

(2) "MAGI-based income" means income calculated using the same financial methodologies used to determine MAGI as defined in 26 U.S.C. 36B(d), with the following exceptions:

(A) An amount received as a lump sum shall be counted as income only in the month received;

(B) scholarships, awards, or fellowship grants used for education purposes and not for living expenses shall be excluded from income; and

(i) Distributions from Alaska native corporations and settlement trusts;

(ii) distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation or otherwise under the supervision of the secretary of the interior;

(iii) distributions and payments from rents, leases, rights-of-way, royalties, usage rights, or natural resource extraction and harvest from rights of ownership or possession in any lands described in this paragraph or federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources;

(iv) distributions either resulting from real property ownership interests related to natural resources and improvement located on or near a reservation or within the most recent boundaries of a prior federal reservation or resulting from the exercise of federally protected rights relating to these real property ownership interests;

(v) payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom; and

(vi) student financial assistance provided under the bureau of Indian affairs education programs.

(b) Exceptions to household income. Financial eligibility for families and children shall be based on household income, except for the following:

(1) The MAGI-based income of an individual who is included in the household of the individual's natural parent, adoptive parent, or stepparent and is not expected to be required to file a tax return under 26 U.S.C. 6012(a) for the taxable year in which eligibility is being determined shall not be included in household income whether or not the individual files a tax return.

(2) The MAGI-based income of a tax dependent described in K.A.R. 129-6-41(e)(1) who is not expected to be required to file a tax return under 26 U.S.C. 6012(a) for the taxable year in which eligibility is being determined shall not be included in household income whether or not the tax dependent files a tax return.

(d) Financial eligibility.

(1) Financial eligibility shall be based on the current monthly income and family size of the household, unless a change in circumstances is expected. In this case, financial eligibility shall be based on the projected monthly income and family size of the household.

(2) For children and pregnant women determined eligible based on K.A.R. 129-6-73 and K.A.R. 129-6-74, the provisions of K.A.R. 129-6-54(a), (b), (c), and (e) regarding base periods and spenddown determinations shall be applicable.

(e) Exclusion of resources. The value of the household's resources shall not be taken into consideration in determining financial eligibility.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-54 Financial eligibility for MAGI-excepted coverage groups

This regulation shall apply to all groups described in K.A.R. 129-6-34(c)(2), except that subsections (c) and (d) of this regulation shall not apply to any medicare beneficiary who meets the requirements of K.A.R. 129-6-86 or to any working disabled individual who meets the requirements of K.A.R. 129-6-87.

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this regulation:

(1) "Client obligation" means the amount that the individual is required to pay towards the cost of care that the individual receives in a long-term care arrangement. Client obligation shall be based on the amount of applicable income that exceeds the income standard in the eligibility base period.

(2) "Eligibility base period" means the length of time used in the determination of financial eligibility. The length of the eligibility base period varies from one month to six months as specified in subsection (b).

(3) "Spenddown" means the amount of applicable income that exceeds the protected income level in the eligibility base period and that is available to meet medical costs.

(b) Eligibility base period.

(1) The base period shall be determined according to the following:

(A) For prior eligibility, the base period shall be the three months immediately preceding the month of application.

(B) Except for persons determined eligible under K.A.R. 129-6-85, the base period shall be one month for current eligibility.

(C) For persons determined eligible under K.A.R. 129-6-85, the base period shall be one month for persons in long-term care and six months for persons in independent living for current eligibility. A six-month base period shall be shortened in certain instances including when the recipient begins long-term care, becomes eligible for cash assistance, or dies.

(2) The base period shall begin on the first day of the month in which the application was received. Subsequent eligibility base periods for recipients shall begin on the first day of the month following the expiration of the previous base period. Each reapplication received outside of a previously established eligibility base period shall be treated as a new application without regard to any previous eligibility base period. However, if the reapplication includes a request for prior eligibility, the base period of prior eligibility shall not extend into a previously established eligibility base period.

(1) The total of all applicable income in the eligibility base period, as determined in accordance with K.A.R. 129-6-111, shall be compared to the income standard, as specified in K.A.R. 129-6-103, for the base period. If the total applicable income is less than the income standard and the individual owns property that has value within the allowable limits, the individual shall be financially eligible for medical assistance. If the total applicable income exceeds the income standard, the individual shall be ineligible for medical assistance except for persons determined eligible under K.A.R. 129-6-73, 129-6-74, and 129-6-85.

(2) For determined eligibles under K.A.R. 129-6-73, 129-6-74, and 129-6-85, if the total applicable income exceeds the income standard and the individual owns property that has value within the allowable limits, the excess applicable income shall be the spenddown.

(A) Each applicant or recipient shall incur allowable medical expenses in an amount at least equal to the spenddown before becoming eligible for assistance. Medical expenses paid either voluntarily or involuntarily by third parties shall not be utilized to meet the spenddown, except for medical expenses paid by a public program of the state other than medicaid.

(B) A previously unconsidered increase in total applicable income during the current eligibility base period that results in an additional spenddown shall not alter the base period. The individual shall meet the additional spenddown during the eligibility base period before the individual becomes eligible or regains eligibility for medical assistance. A payment made through the program within the current eligibility base period shall not be considered an overpayment if a previously eligible individual fails to meet the additional spenddown within the current eligibility base period.

(d) Financial eligibility for persons in long-term care arrangements.

(1) Total gross income shall not exceed 300 percent of the payment standard for one person in the supplemental security income program as specified in K.A.R. 129-6-103(a)(13).

(2)(A) If the person is eligible in accordance with paragraph (d)(1), the total of all applicable income in the eligibility base period, as determined in accordance with K.A.R. 129-6-111, shall be compared to the income standard, as specified in K.A.R. 129-6-103(b) for institutional arrangements and K.A.R. 129-6-103(c) for HCBS arrangements, for the base period. If the total applicable income is less than the income standard and the individual owns property that has value within the allowable limits, the individual shall be financially eligible for medical assistance. If the total applicable income exceeds the income standard and the individual owns property that has value within the allowable limits, the excess applicable income shall be the client obligation.

(B) If the person is not eligible in accordance with paragraph (d)(1), financial eligibility shall first be determined in accordance with subsection (c). If allowable medical expenses, including the cost of the long-term arrangement, are in an amount that is at least equal to the spenddown, a final determination of financial eligibility shall then be determined in accordance with paragraph (d)(2)(A), including application of the appropriate institutional or HCBS income standard as specified in K.A.R. 129-6-103(b) or (c). If allowable medical expenses are not in an amount that is at least equal to the spenddown, financial eligibility shall be determined in accordance with subsection (c).

(3) Each applicant or recipient shall incur allowable medical expenses in an amount at least equal to the client obligation before becoming eligible for assistance. Medical expenses paid either voluntarily or involuntarily by third parties shall not be utilized to meet this obligation, except for medical expenses paid by a public program of the state other than medicaid.

(4) Any increase in total applicable income during the current eligibility base period may result in financial ineligibility or in additional obligation, but this increase shall not alter the base period. A payment made through the program within the current eligibility base period shall not be considered an overpayment if a previously eligible individual becomes ineligible because of an increase in total applicable income or fails to meet any additional obligation within the current eligibility base period.

(e)Allowable expenses. The following expenses shall be applied to a spenddown or client obligation if the individual provides evidence that the individual has incurred or reasonably expects to incur the expenses within the appropriate eligibility base period, or has incurred and is still obligated for expenses outside of the appropriate eligibility base period that have not been previously applied to a spenddown or obligation:

(1) Co-pay requirements;

(2) the pro rata portion of medical insurance premiums for the number of months covered in the eligibility base period regardless of the actual date of payment, past or future;

(3) any medicare premiums that are not covered by the department through the buy-in process. Premiums that are subject to the buy-in process shall not be allowable before completion of the buy-in process, even if the individual pays the premiums or the premiums are withheld;

(4) if medically necessary and recognized under Kansas law, all expenses for medical services incurred by the individual or a legally responsible family group member. Expenses for social services designated as medical services under the HCBS program shall be allowable under this paragraph for persons in the HCBS program. Expenses for routine supplies, as defined in K.A.R. 129-10-15a, and for institutional care if the individual does not meet nursing facility criteria through the level-of-care evaluation or reevaluation process as defined in K.A.R. 30-10-7, shall not be allowable under this paragraph; and

(5) the cost of necessary transportation by appropriate mode to obtain medical services specified in paragraph (e)(4).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2013 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-55 Residence, citizenship, and alienage

(a) Residence. Each applicant or recipient shall be a resident of Kansas. Temporary absence from a state with subsequent return to the state, or intent to return when the purposes of the absence have been accomplished, shall not be considered to interrupt continuity of residence. Residence shall be considered to be retained until abandoned or established in another state. Residency shall be established as specified in this subsection.

(1) Individuals aged 21 and over.

(A) For each individual not residing in an institution, the individual shall choose the state of residence, based on one of the following:

(i) The state in which the individual is living and intends to reside, including without a permanent address;

(ii) the state that the individual has entered with a job commitment or for seeking employment, whether or not the individual is currently employed; or

(iii) the state in which the individual is living, if the individual is not capable of stating intent.

(B) For each individual who is residing in an institution, the state of residence shall be any of the following, whether or not the individual is capable of stating intent:

(i) The state in which the parent or permanent guardian resides, if the individual became incapable of stating intent before the age of 21;

(ii) the state in which the individual is living if the individual became capable of stating intent on or after the age of 21;

(iii) the state that placed the individual in an out-of-state institution; or

(iv) for any other institutionalized individual, the state in which the individual is living and intends to reside.

(2) Individuals under the age of 21.

(A) For each individual who is not residing in an institution and is not eligible for title IV-E foster care or adoption support assistance, the individual shall choose the state of residence, based on one of the following:

(i) The state in which the individual meets the conditions of paragraph (a)(1)(A)(i) or (ii), if the individual is capable of stating intent and either is emancipated from the individual's parents or is married;

(ii) the state in which individual resides, including without a permanent address, if the individual does not meet the conditions of paragraph (a)(2)(A)(i); or

(iii) the state in which the individual's parent or caretaker resides, if the individual lives with the parent or caretaker and does not meet the conditions of paragraph (a)(2)(A)(i).

(B) For each individual residing in an institution, the state of residence shall be the state in which the individual's parent or guardian is residing, whether or not the individual is capable of stating intent, unless the individual has been placed in an out-of-state institution. If the individual has been placed in an out-of-state institution, the state of residence shall be the state making the placement.

(b) Citizenship and alienage. Each applicant or recipient shall be a citizen of the United States or shall be a noncitizen who meets the conditions in paragraph (b)(1) or (2).

(1) The individual entered the United States before August 22, 1996 and meets one of the following conditions:

(A) Is a refugee as specified in 8 U.S.C. 1101, including any person who is a Cuban or Haitian entrant as defined in public law 96-422 or is admitted as an Amerasian immigrant as defined in public law 100-202;

(B) is granted asylum pursuant to 8 U.S.C. 1158;

(D) is a lawful, permanent resident;

(E) is an honorably discharged veteran or is on active duty in the armed forces or is the spouse or unmarried dependent child of the veteran or the person on active duty;

(F) has been paroled into the United States for at least one year under 8 U.S.C. 1182(d)(5);

(G) has been granted conditional entry under 8 U.S.C. 1157;

(H) has been battered or subjected to extreme cruelty by a U.S. citizen or lawful permanent spouse or parent and has a pending or approved violence against women act (VAWA) case or petition before the department of homeland security pursuant to 8 U.S.C. 1641(c); or

(I) is a certified victim of severe forms of trafficking, as defined in 22 U.S.C. 7105.

(2) The individual entered the United States on or after August 22, 1996 and meets one of the following conditions:

(A) Is a refugee, as specified in 8 U.S.C. 1101, including any person who is a Cuban or Haitian entrant as defined in public law 96-422 or is admitted as an Amerasian immigrant as defined in public law 100-202;

(B) is granted asylum pursuant to 8 U.S.C. 1158;

(D) is an honorably discharged veteran or is on active duty in the armed forces or is the spouse or unmarried dependent child of the veteran or the person on active duty;

(E) is an Iraqi or Afghani special immigrant under the 2006 national defense authorization act, public law 109-163;

(F) is a certified victim of severe forms of trafficking, as defined in 22 U.S.C. 7105;

(G) is a lawful, permanent resident who has resided in the United States for at least five years;

(H) has been paroled into the United States under 8 U.S.C. 1182(d)(5) for at least one year and has resided in the United States for at least five years;

(I) has been granted conditional entry under 8 U.S.C. 1157 and has resided in the United States for at least five years; or

(J) has been battered or subjected to extreme cruelty by a U.S. citizen or lawful permanent spouse or parent, has a pending or approved violence against women act (VAWA) case or petition before the department of homeland security pursuant to 8 U.S.C. 1641(c), and has resided in the United States for at least five years.

(3) Each applicant or recipient declaring to be a citizen or national of the United States shall present evidence of citizenship or nationality in accordance with "KDHE-DHCF policy no. 2013-10-01," as adopted by reference in K.A.R. 129-14-27. This requirement shall not apply to any of the following:

(A) Newborn children who meet the provisions of K.A.R. 129-6-65(e);

(B) individuals receiving SSI benefits;

(D) individuals receiving disability insurance benefits under section 223 of the social security act or monthly benefits under section 202 of the social security act, based on the individual's disability; or

(E) individuals who are in foster care and who are assisted under title IV-B of the social security act as amended by public law 109-288 and individuals who are recipients of foster care maintenance or adoption assistance payments under title IV-E.

(4) Each individual declaring to be a noncitizen shall present evidence of that individual's status in accordance with "KDHE-DHCF policy no. 2013-10-01," as adopted by reference in K.A.R. 129-14-27. Each noncitizen who has provided evidence of qualified noncitizen status that has been verified with the department of homeland security shall be eligible for medical assistance.

(5)Each applicant or recipient shall have 90 days from the date the application is approved to provide the evidence described in paragraph (b)(3) or (4).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2013 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-56 Cooperation

(a) Establishment of eligibility. Each applicant or recipient shall cooperate with the department in the establishment of the applicant's or recipient's eligibility by providing all information necessary to determine eligibility as specified in K.A.R. 129-6-39. Failure to provide all information necessary shall render members of the assistance plan, as defined in K.A.R. 129-6-41 or 129-6-42, ineligible for medical assistance.

(b) Potential resources. Each adult applicant or recipient shall cooperate with the department by obtaining any resources, including income, due the adult or any other person for whom assistance is claimed. In applicable situations, this cooperation shall include claiming an inheritance due the applicant or recipient and taking a share of an estate due the applicant or recipient as a surviving spouse. Failure to cooperate without good cause shall render the adult ineligible for medical assistance. Good cause shall include failure to pursue a potential resource when the cost of legal action would be greater than the value of the resource and, for pregnant women, failure to pursue unemployment benefits.

(c) Social security number. Except as noted in this subsection, each applicant or recipient shall cooperate by providing the department with the applicant's or recipient's social security number. Failure to provide the number, or failure to apply for a number if the applicant or recipient has not previously been issued a social security number, shall render the applicant or recipient ineligible for medical assistance. The following individuals shall be exempt from this requirement:

(1) Any individual who is not eligible to receive a social security number;

(2) any individual who does not have a social security number and can be issued a number only for a valid non-work reason; and

(3) any individual who refuses to obtain a social security number because of well-established religious objections.

(d) Paternity and support. Except for pregnant women, each applicant or recipient shall cooperate with the department by establishing the paternity of any child born out of wedlock for whom medical assistance is claimed and in obtaining medical support payments for the applicant or recipient and for any child for whom medical assistance is claimed. Failure to cooperate shall render the applicant or recipient ineligible for medical assistance, unless the individual demonstrates good cause for refusing to cooperate. Cooperation shall include the following actions:

(1) Appearing at the local child support enforcement office, as necessary, to provide information or documentation needed to establish the paternity of a child born out of wedlock, to identify and locate the absent parent, and to obtain support payments;

(2) appearing as a witness at court or at other proceedings as necessary to achieve the child support enforcement objectives;

(3) forwarding to the child support enforcement unit any support payments received from the absent parent that are covered by the support assignment; and

(4) providing information, or attesting to the lack of information, under penalty of perjury.

Good cause shall include pending legal proceedings for adoption of the child and threat of domestic violence as a result of cooperation.

(e) Third-party resources. Each applicant or recipient shall cooperate with the department by identifying and providing information to assist the department in pursuing any third party who could be liable to pay for medical services under the medical assistance program. Failure to cooperate without good cause shall render the applicant or recipient ineligible for medical assistance. Good cause shall include the unknown whereabouts of a liable third party and no legal standing to pursue a third party.

(f) Group health plan enrollment. Each applicant or recipient who is eligible to enroll in a group health plan offered by the applicant's or recipient's employer shall cooperate with the department by enrolling in that group health plan if the department has determined that the plan is cost-effective. To be cost-effective, the amount paid for premiums, coinsurance, deductibles, other cost-sharing obligations under the group health plan, and any additional administrative costs shall be less than the amount paid by the department for an equivalent set of medicaid services. Failure to cooperate without good cause shall render the applicant or recipient ineligible for medical assistance. Good cause shall include lack of reasonable geographic access to care such that the applicant or recipient has to routinely travel more than 50 miles to reach providers participating in the plan.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-57 Transfer of assets

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this regulation:

(1) "Assets" means all income and resources of the individual and the individual's spouse, including any income or resources that the individual or the individual's spouse is entitled to but does not receive because of action by any of the following:

(A) The individual or the individual's spouse;

(B) a person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual's spouse; or

(C) any person, including any court or administrative body, acting at the direction or upon the request of the individual or the individual's spouse.

(2) "Compensation" means all money, real or personal property, food, shelter, or service received by the individual or spouse at or after the time of transfer in exchange for the asset in question. A service received shall be considered compensation only if the service is provided under the terms of a legally enforceable agreement to provide the service in exchange for the assets in question and if the terms are established before delivery of the service. Payment or assumption of a legal debt owned by the individual or spouse in exchange for the asset shall be deemed compensation.

(3) "Fair market value" means the market value of an asset at the earlier of the time of the transfer or the contract of sale. Current market value shall be determined in accordance with K.A.R. 129-6-106(b).

(4) "Institutionalized individual" means an applicant or recipient who meets any of the following conditions:

(A) Is residing in a nursing facility;

(B) is residing in a medical institution that is providing the individual with a level of care equivalent to the care provided by a nursing facility;

(D) is participating in PACE.

(5) "Transfer of assets" means any transfer or assignment of any legal or equitable interest in any asset that partially or totally passes the use, control, or ownership of the asset of an applicant or recipient, or the spouse of an applicant or recipient, to another person or corporation, including any of the following:

(A) Giving away an interest in an asset;

(B) placing an interest in an asset in a trust that is not available to the grantor;

(D) disclaiming an inheritance of any property, interest, or right;

(E) failing to take a share of an estate as a surviving spouse; or

(F) transferring or disclaiming the right to income not yet received.

(6) "Uncompensated value" means the fair market value of an asset less the amount of any compensation received by the individual or spouse in exchange for the asset.

(b) Ineligibility for payment of services. If an individual or spouse has transferred or disposed of assets for less than fair market value on or after the specified look-back date as determined by the date of transfer, the individual shall not be eligible for payment of services for any institutionalized individual as specified in paragraphs (a)(4)(A) through (D).

(c) Exempted transfers. An individual shall not be ineligible for payment of services due to a transfer of assets in any of the following circumstances:

(1) The fair market value of the assets transferred has been received.

(2) A written request to transfer the assets has been submitted by the individual and approved by the secretary before the date of the transfer.

(3) The transfer has been executed pursuant to the division of assets provisions of K.A.R. 129-6-106.

(4) A transfer of an interest in the individual's home has been made to any of the following, as determined by the interest conveyed:

(A) The spouse of the individual;

(B) a child of the individual who is under the age of 21 or who meets the blindness or disability criteria of K.A.R. 129-6-85;

(C) a sibling of the individual who has an equity interest in the home and who was residing in the home for at least one year immediately before the date the individual entered an institutional or HCBS arrangement; or

(D) a child of the individual, other than the child described in paragraph (c)(4)(B), who was residing in the home for at least two years immediately before the date the individual entered an institutional or HCBS arrangement and who provided care to the individual that permitted the individual to reside at home.

(5) The assets have been transferred to any of the following:

(A) The individual's spouse or to another individual for the sole benefit of the individual's spouse;

(B) the institutionalized individual's child who meets the blindness or disability criteria of K.A.R. 129-6-85 or a trust established solely for the benefit of the child; or

(C) a trust established solely for the benefit of an individual under 65 years of age who meets the blindness or disability criteria of K.A.R. 129-6-85.

(6) A transfer of assets has been made, and a satisfactory showing that the individual intended to dispose of the assets at fair market value, for other valuable consideration, or exclusively for a purpose other than to qualify for medicaid has been established. The following criteria shall be used to establish a satisfactory showing:

(A) A record of the facts, in chronological order, related to each transfer of assets within the applicable look-back period shall be assembled; and

(B) a transfer of assets for less than fair market value shall be presumed to have been for the purpose of establishing or maintaining medicaid eligibility, unless the individual presents clear and convincing evidence that the transfer was exclusively for some other purpose. The burden shall be on the individual to rebut this presumption by furnishing clear and convincing evidence that the asset was transferred exclusively for some other purpose. A signed statement by the individual shall not be, by itself, clear and convincing evidence. Each transfer shall be considered in the light of the circumstances at the time the transfer was made. The total amount of the transfer shall be considered in proportion to the length of the interval between the date of the transfer and the date of the application for medical assistance. In addition, the following factors shall be taken into account:

(i) Whether the transfer was ordered by the court and neither the individual, the spouse, the conservator, the guardian, the beneficiary of the transfer, nor anyone else acting in their legal authority or direction took action to effectuate the transfer; and

(ii) whether the individual could not have anticipated the need for medical assistance at the time of transfer due to an unexpected event occurring after the transfer that resulted in the traumatic onset of disability or blindness, the diagnosis of a previously undetected disability, or the loss of other income or resources, completely outside of the control of the individual or spouse, that would have otherwise precluded medical eligibility.

(7) The transferred asset has been returned to the individual or has been made available for use by the individual or spouse.

(d) Look-back date. The look-back date shall mean the earliest date on which a penalty for transferring assets for less than fair market value can be assessed, as specified in this subsection. A penalty shall be assessed for all transfers by the individual or the individual's spouse that take place on or after the look-back date. A penalty shall not be assessed for any transfers that take place before the look-back date.

(1) For transfers of assets before February 8, 2006, multiple transfers that occur within a single month shall be treated as a single transfer. The look-back date shall be either of the following:

(A) 60 months before the date the individual received or was otherwise eligible to receive institutional care or HCBS and has applied for medical assistance in the case of payment from a trust or portions of a trust that are treated as assets disposed of by the individual as specified in K.A.R. 129-6-109(c)(1) and (2); or

(B) 36 months before the date the individual received or was otherwise eligible to receive institutional care or HCBS and has applied for medical assistance in the case of all other transfers of assets.

(2) For transfers of assets on and after February 8, 2006, multiple transfers that occur within a single month shall be treated as a single transfer. The look-back date shall be the date that is 60 months before the date the individual received or was otherwise eligible to receive institutional care or HCBS and has applied for medical assistance.

(e) Transfer period of ineligibility. If the individual or spouse has transferred assets for less than fair market value, the individual shall not be eligible for the services specified in paragraphs (a)(4)(A) through (D), as follows:

(1) For transfers before February 8, 2006, the penalty period shall be equal to the number of months calculated by taking the total cumulative uncompensated value of the assets transferred by the individual or spouse on or after the look-back date, divided by $4,000.

(2) For transfers on and after February 8, 2006, the penalty period shall be equal to the number of days calculated by taking the total cumulative uncompensated value of the assets transferred by the individual or spouse on or after the look-back date, divided by the average daily private-pay cost of nursing facilities in the state in effect on the date the penalty begins. The average daily private-pay cost shall be determined at least annually based on the rates reported by the nursing facilities and compiled by department for aging and disability services.

(f) Penalty start date.

(1) The date on which the penalty period begins shall be determined by the date of the transfer, as follows:

(A) For transfers before February 8, 2006, the penalty start date shall be the first day of the month in which the transfer occurred for applicants and no later than the second month following the month of transfer for recipients giving timely and adequate notice as defined in K.A.R. 129-7-65.

(B) For transfers on and after February 8, 2006, the penalty start date shall be the later of the following:

(i) For applicants, the later of the following: the first day of the month in which the transfer occurred or the first day on which the individual is eligible for medical assistance based on an application for medical assistance and is receiving institutional care or would be receiving HCBS but for the application of the penalty period; and

(ii) for recipients giving timely and adequate notice as defined in K.A.R. 129-7-65, no later than the second month following the month of transfer.

(2) Separately established penalty periods shall be served consecutively. Once the penalty period is imposed, the period shall not be interrupted or suspended even if the individual no longer receives institutional care or HCBS.

(3) If the spouse of the individual transfers an asset that results in a penalty period and that spouse is subsequently institutionalized and is determined otherwise eligible for medical assistance, the remaining penalty period shall be divided between the spouses.

(g) Hardship waiver.

(1) A penalty period shall be initially waived or suspended if the imposition of the penalty period would cause an undue hardship on the individual. To cause an "undue hardship" on the individual shall mean to deprive the individual of either of the following:

(A) Medical care to the extent that the individual's health or life would be endangered; or

(B) food, clothing, shelter, or other necessities of life to the extent that the individual would be at risk of serious harm.

(2) Undue hardship shall not exist if the application of a penalty period merely causes an individual or any individual's family members inconvenience or restricts their lifestyle. Undue hardship shall not exist if the individual transferred the assets to the spouse and the spouse refuses to cooperate in making the resources available to the individual.

(3)(A) Any individual claiming undue hardship may submit a written request to the department at any time during the penalty period. The request shall include a description of the undue hardship along with evidence to support the claim.

(B) The facility in which the individual resides shall obtain written consent from the individual or the individual's personal representative in order to assert a claim of undue hardship on behalf of the individual and provide supporting information on behalf of the individual.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-60 Public institutions

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this subsection:

(1) "Institution" means an establishment that furnishes food, shelter, and some form of treatment or services to four or more persons who are unrelated to the proprietor.

(2) "Public institution" means any institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

(b) Living arrangement. Each applicant or recipient who lives in a public institution shall be ineligible for medical assistance, unless the applicant or recipient meets one of the following conditions:

(1) Lives in a state institution and is under the age of 21 or at least aged 65;

(2) is blind or disabled, as defined by the social security administration, and is living in a state institution that has been approved as a medicaid intermediate care facility;

(3) is under the age of 21, under the age of 22 if receiving inpatient psychiatric care on the person's 21st birthday, or at least aged 65 and is receiving inpatient care in either of the following:

(A) A state institution that has been approved as a medicaid-accredited psychiatric hospital; or

(B) a nursing facility for mental health that has been approved for medicaid coverage of inpatient services;

(4) is receiving inpatient care in a psychiatric residential treatment facility, as defined in K.A.R. 28-4-1200, and is under the age of 21 or, if receiving inpatient treatment on the person's 21st birthday, under the age of 22; or

(5) meets the provisions of subsection (c) regarding persons who are residing in a jail or prison or under the care, custody, and control of the criminal justice system.

(c)Residing in a correctional facility.

(1) For purposes of this subsection, an inmate shall mean a person serving time for a criminal offense or confined involuntarily in a state correctional facility. Inmates in other correctional facilities, including county or city correctional facilities, shall not be eligible under this paragraph. The following requirements shall apply:

(A) The inmate shall otherwise qualify for medicaid and meet all general and financial eligibility criteria for the appropriate medical program. No inmate shall be eligible for medical assistance under K.A.R. 129-6-86.

(B) Each inmate shall be covered for inpatient services received outside of the correctional facility. No coverage shall be provided for outpatient care outside of the correctional facility or for medical services provided on the premises of the facility.

(C) For budgeting purposes, each inmate shall be treated as a household of one, except for pregnant women. Each pregnant woman shall be treated as a household of two or more, based on the number of children the woman is expected to deliver. Neither the income nor resources of the parent or the spouse of the inmate shall be included in the eligibility determination.

(2) The following provisions shall apply to each individual in a correctional facility:

(A) Except as noted in paragraph (c)(2)(B), there shall be no eligibility for medicaid for each person who meets any of the following conditions:

(i) Is physically residing in a correctional facility;

(ii) is an accused person or convicted criminal under the custody of the juvenile or adult criminal justice system. A person may receive medical assistance if there is no indication of custody or if the person has been pardoned or released on the person's own recognizance, is on probation, parole, bail, or bond, or is participating in a prison diversion program operated by a privately supported facility; or

(iii) is placed in a detention facility.

(B) Any inmate of a correctional facility administered by the department of corrections may be eligible for medical assistance to cover inpatient hospital services.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-63 Assignment of rights to support or other third-party payments

Each applicant or recipient shall assign to the secretary any accrued, present, or future rights to the following:

(a) Medical support payments received for any individual for whom medical assistance is claimed; and

(b) third-party payments for medical care that the individual could receive on the individual's own behalf or on behalf of any other family member who is or would be in the individual's assistance plan.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-65 Automatic eligibles

Each of the following individuals shall be automatically eligible for medical assistance without meeting any additional requirements, except that the individual shall meet the general eligibility requirements of K.A.R. 129-6-50 and 129-6-109(c)(2):

(a) A person who is legally entitled to and receiving supplemental security income (SSI) benefits and who is in compliance with the residence requirements of K.A.R. 129-6-55;

(b) a person who is legally entitled to and receiving state supplemental payments from Kansas related to SSI;

(c) a person who is determined by the social security administration to retain recipient status, although the person is not currently receiving an SSI benefit;

(d) a person who is mandated to receive inpatient treatment for tuberculosis;

(e) a child born to a mother who is eligible for and receiving medicaid at the time of birth, including receiving medical assistance under K.A.R. 129-6-97, for up to one year, if the mother remains eligible for medicaid or would be eligible for medicaid if still pregnant. Eligibility for the child shall continue, unless the child dies or is no longer a resident of the state or action is taken to voluntarily terminate coverage;

(f) a child receiving foster care payments in an out-of-home placement, regardless of the state making the payments;

(g) a child for whom an adoption assistance agreement under title IV-E is in effect, even if adoption assistance payments are not being made or the adoption assistance agreement was entered into with another state. Eligibility shall begin when the child is placed for adoption, even if an interlocutory decree of adoption or a judicial decree of adoption has not been issued;

(h) a child for whom a non-title IV-E adoption assistance agreement is in effect between the state and the adoptive parents and who cannot be placed without medical assistance because the child has special needs for medical or rehabilitative care; and

(i) a child receiving title IV-E guardianship care payments.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-70 Medicaid determined eligibles; eligibility factors specific to qualifying families

(a) Each applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-50 and the specific eligibility requirements in this regulation.

(b) Each family shall include a caretaker and the children of the caretaker who are under 19 years of age. Any family may also include a pregnant woman and her unborn child or children.

(c) Household income as determined under K.A.R. 129-6-53 shall not exceed the income standard specified in K.A.R. 129-6-103(a)(3).

(d) Eligibility for medical assistance under this regulation shall continue for each person who receives medical assistance under this regulation for at least three of the six months immediately before the month in which the person became ineligible for medical assistance under this regulation as a result, in whole or in part, of collection or increased collection of spousal support. Eligibility for medical assistance shall continue for the four months immediately after the last month in which the person was eligible and legally entitled to receive medical assistance under this regulation if the person remains ineligible for medical assistance under this regulation due to collection or increased collection of spousal support.

(e) Eligibility for medical assistance under this regulation shall continue for each person who is included in the assistance plan of a family that has received medical assistance under this regulation in three of the six months immediately before the first month in which the family has lost eligibility for medical assistance under this regulation due solely to increased earned income or hours of employment of the caretaker, including an increase in the amount paid for hours of work.

Assistance shall be provided for a period not to exceed 12 months. Eligibility shall end for any individual who leaves the family and for any child who no longer meets the age requirements of subsection (b).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-71 Medicaid determined eligibles; poverty-level pregnant women

(a) Each applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-50 and the specific eligibility requirements in this regulation.

(b) Each eligible woman shall be pregnant. Assistance under this regulation shall continue for two calendar months following the month in which the pregnancy terminates.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-72 Medicaid determined eligibles; poverty-level children

(a) Each applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-50 and the specific eligibility requirements in this regulation.

(b) For infants, each eligible infant shall be under one year of age. Medical assistance under this regulation shall continue according to either of the following:

(1) Through the month in which the child reaches the age of one; or

(2) if receiving inpatient services in the month in which the child reaches the age of one, according to the earlier of the following:

(A) Through the calendar month in which the inpatient care ends; or

(B) through the calendar month following the month in which the inpatient care begins. If the inpatient care will exceed this time period, eligibility for the child under this regulation shall end on the last day of the calendar month in which the child reaches the age of one.

(c) For young children, each eligible child shall be at least one year of age, but no older than five years of age. Medical assistance under this regulation shall continue according to either of the following:

(1) Through the month in which the child reaches the age of six; or

(2) if receiving inpatient services in the month in which the child reaches the age of six, according to the earlier of the following:

(A) Through the calendar month in which the inpatient care ends; or

(d) For older children, each eligible child shall be at least six years of age but under the age of 19. A child who meets the poverty income guidelines of K.A.R. 129-6-103(a)(6) shall not currently be covered under a "group health plan" or under "health insurance coverage" as defined in 42 U.S.B. 300gg-91. The child shall not be considered covered if the child does not have reasonable geographic access to care under that plan or coverage. Reasonable geographic access to care shall mean that the child routinely does not have to travel more than 50 miles to reach providers participating in the plan or coverage. Medical assistance under this regulation shall continue according to any of the following:

(1) Through the month in which the child reaches the age of 19; or

(2) if receiving inpatient services in the month in which the child reaches the age of 19, according to the earlier of the following:

(A) Through the calendar month in which the inpatient care ends; or

(3) through the calendar month the child who meets the poverty-level income guidelines of K.A.R. 129-6-103(a)(6) becomes covered under a group health plan or under health insurance coverage in accordance with this subsection.

(e) A percentage of the federal poverty-level income guidelines as established in K.A.R. 129-6-103(a)(4) for infants, K.A.R. 129-6-103(a)(5) for young children, and K.A.R. 129-6-103(a)(6) for older children shall be used as the income standard for the number of persons in the assistance plan in accordance with K.A.R. 129-6-41. The total applicable income to be considered in the eligibility base period shall be compared against the poverty level for the base period. To be eligible under this regulation, the total applicable income shall not exceed the poverty level established for the base period.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 64-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-73 Medicaid determined eligibles; eligibility factors specific to pregnant women

(a) Each pregnant applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-50. In addition, the applicant or recipient shall not be eligible for medical assistance under K.A.R. 129-6-71.

(b) Financial eligibility under this regulation shall be determined for each month as if the unborn child were already born and living with the applicant or recipient and shall be based on the number of children that the applicant or recipient is expected to deliver.

(c) Assistance under this regulation shall continue for the two calendar months following the month in which the pregnancy terminates.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-74 Medicaid determined eligibles; eligibility factors specific to children

Each child shall meet the applicable general eligibility requirements of K.A.R. 129-6-50 and the following requirements:

(a) The child shall be under 19 years of age.

(b) The child shall not be eligible for medical assistance under K.A.R. 129-6-72.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-77 Revoked

Publisher status: INEFFECTIVE (not currently effective).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2005 Supp. 75-7412; effective June 30, 2006; revoked, T-129-10-31-13, Nov. 1, 2013; revoked Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-80 Medicaid determined eligibles; eligibility factors specific to children in foster care

To be eligible for participation in the medical assistance program related to foster care, each child shall meet the following requirements:

(a) Meet the general eligibility requirements of K.A.R. 129-6-50;

(b) be under the age of 18 or be a full-time elementary or secondary school student who is qualified to receive foster care maintenance payments under title IV-E of the social security act, 42 U.S.C. 670 et seq.;

(c) be placed in a living arrangement approved by the secretary, including a foster family home, a private nonprofit child care facility, a medicaid-approved medical facility, a medicaid-accredited psychiatric hospital, or an intermediate care facility; and

(d) have a written order issued by a court giving care, custody, and control of the child to one of the following:

(1) The secretary of the department for children and families;

(2) in the case of an Indian child as defined by the federal Indian child welfare act, the four tribes social services child-placing agency; or

(3) the secretary of the department of corrections.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-81 Medicaid determined eligibles; eligibility factors specific to children living in medicaid-accredited psychiatric hospitals, intermediate care facilities, or residential treatment facilities

To be eligible for participation in the medical assistance program under this regulation, each child shall meet the following requirements:

(a) Meet the general eligibility requirements of K.A.R. 129-6-50; and

(b) be under the age of 21 or, if receiving inpatient psychiatric care on the person's 21st birthday and currently receiving inpatient care in either of the following, be under the age of 22:

(1) A state institution that has been approved as a medicaid-accredited psychiatric hospital or intermediate care facility; or

(2) a psychiatric residential treatment facility as defined in K.A.R. 28-4-1200.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-82 Medicaid determined eligibles; eligibility factors specific to HCBS

(a) To be eligible for participation in the medical assistance program under this regulation, each person shall meet the following requirements:

(1) Meet the general eligibility requirements of K.A.R. 129-6-50;

(2) be assessed as in need of long-term care services in an institutional setting pursuant to K.S.A. 39-968, and amendments thereto, and choose to receive HCBS if these services are available; and

(3) be in an approved waiver under 42 U.S.C. 1315 or 1396n, or both.

(b) Each person transitioning from a nursing facility or an intermediate care facility for people with intellectual disability to the community shall be provided HCBS if the person meets the following requirements:

(1)(A) Is 65 years of age or older in accordance with K.A.R. 129-6-85(a);

(B) is physically disabled in accordance with K.A.R. 129-6-85(c) and is 16 through 64 years of age;

(C) is five years of age or older, has an intellectual disability, and meets the level of care for an intermediate care facility for people with intellectual disability; or

(D) is between the ages of 16 and 65 and has a traumatically acquired head injury requiring care in a rehabilitation facility as determined by screening; and

(2) has been in the facility for at least 90 days and received medicaid for at least 30 days.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-83 Medicaid determined eligibles; eligibility factors specific to PACE

(a) To be eligible for participation in the medical assistance program under this regulation, each person shall meet the following requirements:

(1) Meet the general eligibility requirements of K.A.R. 129-6-50;

(2) be assessed as in need of long-term care services in an institutional setting;

(3) be 55 years of age or older and residing in a PACE service area as authorized by the secretary; and

(4) meet the disability criteria of K.A.R. 129-6-85(b) or (c) if aged 55 through 64.

(b) Financial eligibility shall be determined based on the living arrangement of the individual. If services are provided in a noninstitutional living arrangement, eligibility shall be determined in accordance with the regulations applicable to the home- and community-based services program. If services are provided in an institutional living arrangement, eligibility shall be determined in accordance with the regulations applicable to persons receiving long-term care in an institutional arrangement.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-84 Medicaid determined eligibles; eligibility factors specific to work opportunities reward Kansans (WORK)

(a) To be eligible for participation in the medical assistance program under this regulation, each person shall meet the following requirements:

(1) Meet the general eligibility requirements of K.A.R. 129-6-50;

(2) be eligible for and receiving assistance under K.A.R. 129-6-88;

(3) be employed in a competitive, integrated work setting in which work is performed in the competitive labor market on a full-time or part-time basis for which individuals are compensated at or above minimum wage, but not less than the customary wage and level of benefits paid to a nondisabled individual for the same or similar work. The work shall be performed in a setting typically found in the community in which individuals with the most severe disabilities interact with nondisabled individuals according to the duties and responsibilities of the position; and

(4) be determined by an assessor authorized by the secretary to need WORK services in order to live and work in the community.

(b) The financial eligibility and premium requirements of K.A.R. 129-6-88 shall be applicable.

(c) Each individual's participation in WORK shall be based on the individual's voluntary acceptance of and agreement with the regulatory and policy requirements of the program in accordance with a participation agreement. An individual's refusal or failure to comply with the regulatory and policy requirements of the program shall be the basis for termination of the individual's participation in the program.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-85 Medicaid determined eligibles; eligibility factors specific to the aged, blind, or disabled (ABD)

Each applicant or recipient shall meet general eligibility requirements of K.A.R. 129-6-50 and one of the following specific eligibility requirements to be eligible for participation in the medical assistance program related to ABD:

(a) Age. Each individual shall have attained the age of 65 before or within the month for which eligibility is being determined.

(b) Blindness. Each individual shall be blind, based on social security administration criteria.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-86 Poverty-level, low-income, and expanded low-income medicare beneficiaries; determined eligibles

(a) Each applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-50 and the following specific eligibility requirements:

(1) Medicare part A beneficiary. Each individual shall be entitled to medicare part A benefits.

(2) Financial eligibility. A percentage of the official federal poverty-level income guidelines as established in K.A.R. 129-6-103 shall be used as the income standard for the number of persons in the assistance plan and any other persons whose income is considered. The total applicable income to be considered in the eligibility base period shall be compared against the poverty level for the base period. However, the amount of an annual social security cost-of-living adjustment shall be disregarded in determining eligibility during the first quarter of the year for which the adjustment is provided.

For an individual to be eligible, the total applicable income shall not exceed the poverty level established for the base period. The individual also shall not own nonexempt real or personal property with a resource value in excess of the allowable amounts specified in K.A.R. 129-6-107(b)(1) for the number of persons whose nonexempt resources are considered available to the individual.

(b) Medical assistance provided. Medical assistance under this regulation for each poverty-level medicare beneficiary meeting the poverty-level income guidelines of K.A.R. 129-6-103(a)(7) shall be limited to the payment of allowable medicare premiums, deductibles, and coinsurance. Medical assistance for each low-income medicare beneficiary meeting the poverty-level income guidelines of K.A.R. 129-6-103(a)(9) shall be limited to the payment of medicare part B premiums only. Medical assistance for each expanded low-income medicare beneficiary meeting the poverty-level income guidelines of K.A.R. 129-6-103(a)(10) shall be limited to the payment of medicare part B premiums only, and the person shall not seek coverage under any other type of medical assistance.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-87 Poverty-level working disabled individuals; determined eligibles

(a) Each applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-50 and the following specific eligibility requirements:

(1) Medicare part A beneficiary. Each individual shall be entitled to medicare part A benefits under 42 U.S.C. 1395i-2a.

(2) Financial eligibility. A percentage of the official federal poverty income guidelines as specified in K.A.R. 129-6-103(a)(8) shall be used as the income standard for the number of persons in the assistance plan and any other persons whose income is considered. The total applicable income to be considered in the eligibility base period shall be compared against the poverty level for the base period. To be eligible under this regulation, the total applicable income shall not exceed the poverty level established for the base period. The individual shall also not own nonexempt real or personal property with a resource value in excess of twice the allowable amount specified in K.A.R. 129-6-107 for the number of persons whose nonexempt resources are considered available to the individual.

(b) Assistance provided. Assistance under this regulation shall be limited to the payment of medicare part A premiums.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-88 Disabled individuals with earned income; determined eligibles

(a) Each applicant and each recipient shall meet the general eligibility requirements of K.A.R. 129-6-50 and the following specific eligibility requirements:

(1) Each individual shall be at least 16 years old but less than 65 years old.

(2) Each individual shall meet the blindness or disability requirements of K.A.R. 129-6-85.

(3) Each individual shall have earned income that is subject to federal insurance contributions act (FICA) taxes.

(b) Financial eligibility shall be based on a percentage of the official federal poverty-level income guidelines as specified in K.A.R. 129-6-103(a)(11), which shall be used as the income standard for the number of persons in the assistance plan and any other persons whose income is considered. Monthly applicable income to be considered in the eligibility base period shall be compared against the poverty level for the base period. For an individual to be eligible under this regulation, the monthly applicable income shall not exceed the poverty level established for the base period. If the individual also owns nonexempt real or personal property with a resource value in excess of $15,000, which shall include any nonexempt resources of all family group members, that individual shall not be eligible under this regulation.

(c) For each individual whose monthly applicable income is at least 226 percent but not greater than 300 percent of the official federal poverty-level income guidelines for the applicable family size, a monthly premium amount shall be assessed. This premium amount shall not exceed 7.5 percent of the monthly applicable income based on the official federal poverty-level income indicated for the applicable family size. Failure to pay the premium shall result in ineligibility.

(d) Each individual who is temporarily unemployed but intends to return to work shall continue to be eligible for coverage for not more than four months if all other eligibility factors are met.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014; amended June 16, 2023.)

Kan. Admin. Regs. § 129-6-89 Individuals with breast or cervical cancer; determined eligibles

(a) Each applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-55 and the following specific eligibility requirements:

(1) Each individual shall be screened for breast or cervical cancer under the breast and cervical cancer early detection program established under title XV of the public health service act, 42 U.S.C. 300k et seq., by the centers for disease control and prevention and shall be found to need treatment for either breast or cervical cancer.

(2) Each individual shall be uninsured and not be otherwise eligible for medical assistance under this article.

(3) Each individual shall be under the age of 65.

(b) Eligibility for coverage under this regulation shall end when the course of treatment is completed or if the individual no longer meets the eligibility requirements. There shall be no financial eligibility requirements.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-91 Youth formerly in foster care; determined eligibles

Each applicant or recipient shall meet the general eligibility requirements of K.A.R. 129-6-50 and the following conditions:

(a) In the month of the individual's 18th birthday, be in the custody of the department for children and families or the department of corrections and be in an out-of-home placement; and

(b) be at least 18 years old but under the age of 26.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-94 Non-medicaid determined eligibles; eligibility factors specific to persons living in nursing facilities for mental health

(a) To be eligible for participation in the medical assistance program under this regulation, each individual shall meet the following conditions:

(1) Meet the general eligibility requirements of K.A.R. 129-6-50;

(2) be aged 21 or older and under the age of 65;

(3) have a "severe and persistent mental illness," as defined in K.A.R. 30-10-1a;

(4) be otherwise eligible for medicaid; and

(5) not meet the requirements of K.A.R. 129-6-60(b) or 129-6-81(b).

(b) Eligibility shall be determined based on the financial eligibility standards and methodologies applicable to persons in institutional arrangements as specified in K.A.R. 129-6-42(c), 129-6-54(d), and 129-6-103(b).

(c) Whether an individual has a severe and persistent mental illness shall be determined by a qualified mental health professional employed by a participating mental health center, as defined in K.S.A. 59-2946 and amendments thereto.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-95 Non-medicaid determined eligibles; eligibility factors specific to the medikan program

(a) To be eligible for participation in the medical assistance program under this regulation, each individual shall meet the following conditions:

(1) Not be otherwise eligible for medicaid and not be rendered ineligible for medicaid by either deliberate or voluntary actions on the part of the individual;

(2) meet the general eligibility requirements of K.A.R. 129-6-50;

(3) be aged 18 or older and under the age of 65; and

(4) have a severe impairment that significantly limits physical or mental ability to do basic work activity and is expected to last at least 12 months or result in death.

(b) Each individual shall apply for social security disability benefits and cooperate in that process, to remain eligible. Each person who qualifies for social security disability benefits shall no longer be eligible for assistance under the medikan program.

(c) If the individual is married, the individual and the individual's spouse shall both qualify for medikan to be eligible for assistance.

(d) Assistance under this regulation shall be limited to 12 months in a lifetime.

(e) Temporary coverage under this regulation shall be provided to any person discharged from a medicaid-approved psychiatric hospital, from the Larned correctional mental health facility central unit, or from the Larned state security program. Medical assistance shall be provided at the time of discharge and may continue for not more than two additional months to facilitate the person's discharge plan.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-96 Continuous eligibility for children and certain adult eligibles

(a) Children. Except for children determined eligible for presumptive medical assistance as specified in K.A.R. 129-6-151, each child under the age of 19 who becomes eligible for medicaid under any category of medical assistance shall continue to be eligible for medical assistance for 12 months beginning with the month in which eligibility is determined or redetermined regardless of any changes in circumstances, except for any of the following:

(1) The child reaches the age of 19.

(2) Medical assistance for the child is voluntarily terminated.

(3) The child no longer resides in Kansas.

(4) The secretary determines that eligibility was granted erroneously because of fraud or department error.

(5) The child dies.

(b) Adults. Each nonpregnant adult who becomes eligible for medicaid under K.A.R. 129-6-70 shall continue to be eligible for medical assistance for 12 months beginning with the month eligibility is determined or redetermined regardless of any change in income, except for any of the following:

(1) Medical assistance for the adult is voluntarily terminated.

(2) The adult no longer resides in the state.

(3) The secretary determines that eligibility was granted erroneously because of fraud or department error.

(4) The adult dies.

(5) The adult enters a correctional or detention facility.

(6) The adult becomes eligible for coverage of nursing facility care or HCBS.

(7) The adult becomes eligible for supplemental security income.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-97 Emergency medical services for certain noncitizens

(a) Each noncitizen who does not meet the requirements of K.A.R. 129-6-55(b) but who is otherwise eligible for medicaid shall receive coverage as specified in subsection (b) of this regulation. The general requirements of K.A.R. 129-6-50, except for K.A.R. 129-6-55(b) and 129-6-56(c), shall be applicable.

(b)(1) Eligibility shall be limited to coverage of an emergency medical condition, as approved by the secretary, that requires emergency medical treatment after the sudden onset of a condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, so that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(A) Serious jeopardy to the patient's health;

(B) serious impairment of bodily functions; or

(2) Coverage shall be limited only to treatment of the emergency condition.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-103 Determined eligibles; income standards.

Kansas Administrative Regulations

Department of Health and Environment—Division of Health Care Finance

Article 6.—Medical Assistance Program—Clients' Eligibility for Participation

129-6-103. Determined eligibles; income standards.

(a) Independent living arrangements.

(1) The income standard for each person in an independent living arrangement shall be based on the total number of persons in the assistance plan as defined in K.A.R. 129-6-41 or 129-6-42.

(2) The income standards for independent living may also be used if an applicant or recipient meets either of the following conditions:

(A) Enters a medicaid-approved facility, except that this paragraph shall not apply if only one spouse in a married couple enters an institutional living arrangement; or

(B) is absent from the home for medical care for a period not to exceed the month in which the person left the home and the two months following to allow for maintaining the applicant's or recipient's independent living arrangements.

(3) Except as specified in paragraphs (a)(4) through (13), in determining eligibility for persons in an independent living arrangement, the income standard shall be 100 percent of federal supplemental security income.

(4) In determining eligibility for pregnant women under K.A.R. 129-6-71 and for infants under K.A.R. 129-6-72(b), the income standard shall be 166 percent of the official federal poverty-level income guidelines.

(5) In determining eligibility for young children under K.A.R. 129-6-72(c), the income standard shall be 149 percent of the official federal poverty-level income guidelines.

(6) In determining eligibility for older children under K.A.R. 129-6-72(d), the income standard shall be 133 percent of the official federal poverty-level income guidelines.

(7) In determining eligibility for poverty-level medicare beneficiaries under K.A.R. 129-6-86, the income standard shall be 100 percent of the official federal poverty-level income guidelines.

(8) In determining eligibility for working disabled individuals under K.A.R. 129-6-87, the income standard shall be 200 percent of the official federal poverty-level income guidelines.

(9) In determining eligibility for low-income medicare beneficiaries under K.A.R. 129-6-86, the income standard shall be 120 percent of the official federal poverty-level income guidelines.

(10) In determining eligibility for expanded low-income medicare beneficiaries under K.A.R. 129-6-86, the income standard shall be 120 to 135 percent of the official federal poverty-level income guidelines, subject to available federal funding.

(11) In determining eligibility for disabled individuals with earned income under K.A.R. 129-6-88, the income standard shall be 300 percent of the official federal poverty-level income guidelines.

(12) In determining eligibility for persons in the medikan program under K.A.R. 129-6-95, the income standard shall be $250 for a single individual and $325 for a married couple.

(13) In determining eligibility for persons in long-term care arrangements in accordance with K.A.R. 129-6-54(d)(1), the income standard shall be 300 percent of the payment standard for one person in the SSI program. For calendar year 2013, the income standard shall be $2,130, and this amount shall be increased at the beginning of each calendar year by any cost-of-living adjustment made to the SSI payment standard.

(b) Institutional living arrangements. For each person residing in an institutional setting, the monthly income standard for purposes of determining the client obligation shall be $62, except as specified in paragraph (a)(2).

(c) Home- and community-based services arrangements. For each person in the HCBS program, including any person in the PACE program who is in a noninstitutional living arrangement in accordance with K.A.R. 129-6-83(b), the monthly income standard for purposes of determining the client obligation shall be 300 percent of the payment standard for one person in the SSI program.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014; amended Jan. 1, 2021; amended July 15, 2022; amended Sept. 18, 2026.)

Kan. Admin. Regs. § 129-6-106 General requirements for consideration of resources, including real property, personal property, and income

(a) For purposes of determining eligibility for medical assistance, legal title shall determine ownership. In the absence of legal title, possession shall determine ownership.

(b) Each resource shall be of a nature that the value can be defined and measured, according to the following:

(1) Real property. The value of real property shall be initially determined by the latest uniform statewide appraisal value of the property, which shall be adjusted to reflect current market value. If the property has not been appraised or if the market value determined is not satisfactory to the applicant, recipient, or department, an estimate or appraisal of the value of the property shall be obtained from an impartial real estate broker. The cost of obtaining an estimate or appraisal shall be paid by the department.

(2) Personal property. The market value of personal property shall be initially determined using a reputable trade publication. If such a publication is not available or if there is a difference of opinion between the department and the individual regarding the value of the property, an estimate from a reputable dealer shall be used. The cost of obtaining an estimate or appraisal shall be paid by the department.

(c)(1) Resources shall be considered available if the resources are actually available and the applicant or recipient has the legal ability to make the resources available. A resource shall be considered unavailable if there is a legal impediment that precludes the disposal of the resource. The applicant or recipient shall pursue reasonable steps to overcome the legal impediment, unless it is determined that the cost of pursuing legal action would exceed the resource value of the property or it is unlikely the applicant or recipient would succeed in the legal action. This paragraph shall also apply to the spouse of the applicant or recipient.

(2) Real property shall be considered unavailable if the property cannot be sold for one of the following reasons:

(A) The property is jointly owned, and its sale would cause undue hardship because of the loss of housing for the other owner or owners.

(B) The owner's reasonable efforts to sell the property have been unsuccessful.

(d) The resource value of property shall be the value of the applicant's or recipient's equity in the property. Unless otherwise established, the proportionate share of jointly owned real property and the full value of jointly owned personal property shall be considered available to the applicant or recipient. Resources held jointly with a non-legally responsible person may be excluded from consideration if the applicant or recipient demonstrates that all of the following conditions exist:

(1) The applicant or recipient has no ownership interest in the resource.

(2) The applicant or recipient has not contributed to the resource.

(3) Any access to the resource by the applicant or recipient is limited to those duties performed while the applicant or recipient is acting as an agent for the other person.

(e) Except for persons described in K.A.R. 129-6-34(c)(1) and 129-6-34(c)(2)(A) through (I), the nonexempt resources of all persons in the assistance plan shall be considered in determining eligibility. Exempted resources as defined in K.A.R. 129-6-108(d) and 129-6-109(e) that are put in a trust that meets the requirements of K.A.R. 129-6-109(c)(1) or (c)(2)(A) shall be regarded as nonexempt, unless paragraphs (k)(4) and (6) of this regulation are applicable.

(f)(1) The combined resources of husband and wife, if they are living together, shall be considered in determining the eligibility of either individual or both individuals for the medical assistance program, except as noted in subsection (e) or unless otherwise prohibited by law.

(2) A husband and wife shall be considered to be living together if they are regularly residing in the same household. Temporary absences of either the husband or the wife for education, training, working, securing medical treatment, or visiting shall not interrupt the period of time during which the couple is considered to be living together.

(3) A husband and wife shall not be considered to be living together if they are physically separated and not maintaining a common life or if one or both enter into an institutional living arrangement, including either a medicaid-approved or non-medicaid-approved medical facility or an HCBS care arrangement.

(A) If only one spouse enters an institutional living arrangement, subsection (k) shall apply.

(B) If both spouses enter an institutional living arrangement, the combined resources of the husband and wife shall be considered available to both individuals for the month in which the institutional arrangement begins.

(g) Except as noted in subsection (e), the resources of an ineligible parent shall be considered in determining the eligibility of a minor child for the medical assistance program if the parent and child are living together. However, these resources shall not be considered for any child in an institutional arrangement or an HCBS arrangement beginning with the month following the month in which the arrangement begins.

(h) Despite subsections (e), (f), and (g), the resources of an SSI beneficiary shall not be considered in the determination of eligibility for medical assistance of any other person.

(i) The conversion of real property and personal property from one form of resource to another shall not be considered to be income to the applicant or recipient, except for the proceeds from a contract for the sale of property.

(j) Income shall not be considered to be both income and property in the same month.

(k) If one spouse enters an institutional living arrangement, the other spouse remains in the community, and an application for medical assistance is made on behalf of the institutionalized spouse, an income determination according to the following requirements shall be applied first in determining eligibility:

(1) The separate income of each spouse shall not be considered to be available to the other spouse beginning in the month in which the institutional arrangement begins. One-half of the income that is paid in the names of both spouses shall be considered available to each spouse, unless it is otherwise established that less or more than this amount is available. Income that is paid in the name of either spouse, or in the name of both spouses and the name of another person or persons, shall be considered available to each spouse in proportion to the spouse's interest, unless it is otherwise established that less or more than this amount is available.

(2)(A) A monthly income allowance for the community spouse shall be deducted from the income of the institutionalized spouse in determining the amount of patient liability for each person in an institutional living arrangement or in a spenddown status for each person in an HCBS arrangement.

(B) The income allowance for the community spouse, when added to the income already available to that spouse, shall not exceed 150 percent of the official federal poverty-level income guideline for two persons plus the amount of any excess shelter allowance. "Excess shelter allowance" shall mean the amount by which the community spouse's expenses for rent or mortgage payments, taxes and insurance for the community spouse's principal residence, and the supplemental nutrition assistance program (SNAP) standard utility allowance, 7 U.S.C. 2014(e), exceed 30 percent of 150 percent of the federal poverty-level income guideline amount specified in this paragraph.

(C) The maximum monthly income allowance that may be provided under paragraph (k)(2) shall be $1,500. The $1,500 limitation shall be increased at the beginning of each calendar year by the same percentage as the percentage increase in the consumer price index for all urban consumers between September 1988 and the September before the applicable calendar year.

(D) If a greater income allowance is provided under a court order of support or through the Kansas administrative hearing process, that amount shall be used in place of the limits specified in paragraph (k)(2)(C).

(3) A monthly income allowance for each dependent family member shall be deducted from the income of the institutionalized spouse in determining the 300 percent income limit as specified in K.A.R. 129-6-54(d)(1) and the amount of client obligation for each person in an institutional living arrangement or in an HCBS arrangement.

(A) "Dependent family member" shall mean a person who is a minor or dependent child, dependent parent, or dependent sibling of either spouse and who lives with the community spouse.

(B) The allowance for each member shall be equal to one-third of 150 percent of the official federal poverty-level income guideline for two persons.

(C) An allowance for a dependent family member shall not be provided if the family member's gross income exceeds 150 percent of the federal poverty-level income guideline for two persons.

(4) If the spouse is institutionalized on or after September 30, 1989, the nonexempt real property and personal property of both spouses shall be considered in determining the eligibility of the institutionalized spouse, based on the amount of property in excess of the community spouse property allowance specified in paragraph (k)(6), whether or not this allowance will be made.

(A) If the excess property is within the allowable resource standards of K.A.R. 129-6-107, the institutionalized spouse shall be eligible.

(B) In the month following the first month of eligibility for the institutionalized spouse, only the property of the institutionalized spouse shall be considered available in determining continuing eligibility, except for property to be transferred in accordance with paragraph (k)(6).

(5) If the spouse was institutionalized before September 30, 1989, the real property and personal property of each spouse shall be considered available to the other spouse in the month in which the institutional arrangement began. Thereafter, the property of each spouse shall not be considered available to the other spouse.

(6) The institutionalized spouse may make available to the community spouse a property allowance that, when added to the property already available to the community spouse, would be equal to one-half of the total value of the property owned by both spouses at the beginning of the first period of continuous institutionalization beginning on or after September 30, 1989.

(A) This property allowance shall not exceed $60,000 and shall be at least $12,000. Both the $12,000 and the $60,000 limits shall be increased at the beginning of each calendar year by the same percentage as the percentage increase in the consumer price index for all urban consumers between September 1988 and the September before the applicable calendar year.

(B) If a greater property allowance is provided under a court order of support or through the Kansas administrative hearing process, that amount shall be used in place of the limits specified in paragraph (k)(6)(A). If a greater property allowance is required to increase the community spouse's income to the amount allowed under paragraphs (k)(2)(B) and (C), a fair hearing officer shall take into account the income-generating value of the current property allowance as well as the additional property allowance requested. The property provided shall be invested so that income is maximized, including through a single-premium annuity, and based on the salable or market value of the property.

(7) The amount of property received by the community spouse as a result of the property allowance determined in paragraph (k)(6) shall not be considered in determining the eligibility of the institutionalized spouse, except as provided in paragraph (k)(4). If the institutionalized spouse will be eligible based upon transferring sufficient property to the community spouse to equal the amount of the property allowance, the institutionalized spouse shall be given not more than 90 days from the date of application to transfer the property. Additional time may be allowed for good cause. Pending disposition of the property, the institutionalized spouse shall be eligible during this period if all other eligibility factors are met.

(l) The resources of a noncitizen's sponsor and the sponsor's spouse shall be considered in determining eligibility for the sponsored noncitizen.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2013 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-107 Property exemption

(a) Ownership of otherwise nonexempt real property or personal property shall not affect eligibility if the aggregate resource value is not in excess of $2,000 for one person or $3,000 for two or more persons, including the number of persons whose nonexempt resources are considered available to a person in the assistance plan.

(b) Ownership of property with a resource value in excess of the amounts specified in subsection (a) shall render the applicant or recipient and the members of the applicant's or recipient's assistance plan ineligible for medical assistance, except for the following:

(1) For medicare beneficiaries who meet the requirements of K.A.R. 129-6-86, the resource value shall be in excess of the following standards before the applicant or recipient and the members of the applicant's or recipient's family group shall be rendered ineligible:

(A) For calendar year 2006, $6,000 for one person or $9,000 for a couple; and

(B) for subsequent years, the amounts established in paragraph (b)(1)(A) increased by the annual percentage increase in the consumer price index for all items based on the United States city average as established in September of the previous year.

(2) For working disabled individuals who meet the requirements of K.A.R. 129-6-87, the resource value shall be over twice the amounts specified in subsection (a) before the applicant or recipient and the members of the applicant's or recipient's assistance plan shall be rendered ineligible.

(3) For disabled individuals with earned income who meet the requirements of K.A.R. 129-6-88, the resource value shall be over $15,000 before the applicant or recipient and the members of the applicant's or recipient's assistance plan shall be rendered ineligible. If the applicant or recipient is making a bona fide and documented effort to dispose of the excess property at a reasonable market value, medical assistance for not more than nine months shall be provided.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-108 Real property

(a) Definitions.

(1) "Home" shall mean the house or shelter in which the applicant or recipient is living, as well as the tract of land and contiguous tracts of land upon which the house and other improvements essential to the use or enjoyment of the home are located. Tracts of land shall be considered to be contiguous if lying side by side, except for streets, alleys, and other easements. Pieces of property that touch only at the corners shall not be considered to be contiguous.

(2) "Other real property" shall mean real property other than a home, including land and buildings.

(b) Treatment of real property. The equity value of nonexempt real property shall be deemed a resource. If a specific and discrete property interest of less than 100 percent is designated for real property, the full value shall be considered in the determination of eligibility, regardless of the exemptions specified in subsection (d).

(c) Substantial home equity. Each person who applies for long-term care on or after January 1, 2006 and has an equity interest in a home in excess of $500,000 shall be ineligible for payment of care for a nursing facility or other institutional arrangement, HCBS arrangement, or PACE arrangement, unless one of the following persons continues to reside in the home:

(1) The person's spouse;

(2) the person's child, if the child meets the criteria of K.A.R. 129-6-85(b) or (c); or

(3) the person's child, if the child is under the age of 21.

The $500,000 limit shall be increased beginning in calendar year 2011 from year to year based on the percentage increase in the consumer price index for all urban consumers based on all items and the United States city average, rounded to the nearest $1,000.

(d) Exempted real property. The equity value of the following classifications of real property shall be exempt, except as noted in subsections (b) and (c):

(1) The home, except either of the following:

(A) A home from which an applicant or recipient has been absent and does not intend to return; or

(B) a home from which a person who enters an institutional living situation has been absent for at least three months, unless the absence is determined to be temporary or a spouse, dependent child, or another dependent relative remains in the home;

(2) other real property that is essential for employment or self-employment;

(3) income-producing other real property that is used in an individual's trade or business or that produces income consistent with its fair market value;

(4) restricted or allotted land held by an enrolled member of an Indian tribe that cannot be sold or transferred without permission of other members of the tribe or a federal agency; and

(5) real property that is directly related to the maintenance or use of a vehicle that is used primarily for producing income or is necessary to transport a physically disabled household member.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-109 Personal property

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this regulation:

(1) "Cash assets" means the following resources:

(A) Cash surrender or loan values of life insurance policies;

(B) investments;

(D) similar items from which a determinate amount of money can be realized; and

(E) trust funds.

(2) "Other personal property" means the following:

(A) Contracts from the sale of property;

(B) equipment;

(D) household equipment and furnishings;

(E) inventory;

(F) livestock;

(G) personal effects;

(H) similar items from which a determinate amount of money can be realized; and

(I) vehicles.

(3) "Personal property" means all property, excluding real property.

(b) Treatment of personal property. Personal property, unless exempted, shall be considered a resource. Each trust fund shall be subject to subsection (c).

(c) Treatment of trust funds. For purposes of determining an individual's eligibility for assistance or the amount of assistance, the requirements in this subsection shall apply to trust funds. The term "trust" shall include any legal instrument or device that is similar to a trust, including an annuity. The term "assets" shall be defined as specified in K.A.R. 129-6-57(a).

(1) For a revocable trust, the value of the trust shall be considered a resource available to the individual. Payments from the trust to or for the benefit of the individual shall be considered to be income. All other payments made from the trust shall be considered under the property transfer provisions of K.A.R. 129-6-57.

(2) For an irrevocable trust established after August 10, 1993, the following requirements shall apply:

(A) If there are any circumstances under which payment from an irrevocable trust could be made to the individual or for the benefit of the individual, the portion of the trust from which payment could be made shall be considered as a resource available to the individual. Each payment made from the trust to the individual or for the benefit of the individual shall be considered income. All other payments made from the trust shall be considered under the property transfer provisions of K.A.R. 129-6-57.

(B) Each portion of the trust from which no payment could be made to the individual under any circumstances shall be considered under the transfer of assets provisions of K.A.R. 129-6-57 from the date of establishment of the trust or, if later, the date on which payment to the individual was restricted or foreclosed.

(C) An individual shall be considered to have established a trust if any assets of the individual were used to form all or part of the trust and if any of the following individuals established the trust, other than by will:

(i) The individual or the individual's spouse;

(ii) any person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual's spouse; or

(iii) any person, including any court or administrative body, acting at the direction or upon the request of the individual or the individual's spouse.

(D) If the principal of the trust includes assets of any other person or persons, this subsection shall apply to the portion of the trust attributable to the assets of the individual.

(E) This subsection shall apply without regard to the purposes for which the trust was established, whether or not the trustees have or exercise any discretion under the trust, any restrictions on when or whether distributions can be made from the trust, or any restrictions on the use of distributions from the trust.

(F) This subsection shall not apply to a trust that contains the assets of an individual under the age of 65 who meets the blindness or disability criteria of K.A.R. 129-6-85 and that is established for the benefit of the individual by a parent, grandparent, or legal guardian of the individual, or a court. The state shall receive all amounts remaining in the trust upon the death of the individual, up to an amount equal to the total medical assistance paid on behalf of the individual;

(G) This subsection shall not apply to a trust that contains the assets of an individual who meets the blindness or disability criteria of K.A.R. 129-6-85 if the trust meets all the following conditions:

(i) The trust is established by a nonprofit association.

(ii) A separate account is maintained for each beneficiary of the trust.

(iii) Accounts in the trust are established solely for the benefit of individuals who meet the blindness or disability criteria of K.A.R. 129-6-85.

(iv) Each account in the trust is established by that individual; the parent, grandparent, or legal guardian of the individual; or a court. The state shall receive all amounts remaining in the individual's account upon the death of the individual, up to an amount equal to the total medical assistance paid on behalf of the individual.

Establishment of a trust under paragraph (c)(2)(G) for an individual who is at least 65 shall be subject to the transfer of assets provisions of K.A.R. 129-6-57.

(H) The requirements of K.A.R. 129-6-109(c)(2) shall be waived if the secretary determines that a waiver is necessary to avoid undue hardship on the individual. A finding of undue hardship may be granted if the individual verifies that all of the following conditions have been met:

(i) The individual has exhausted all legal remedies for gaining access to the principal or income of the trust.

(ii) All otherwise available assets have been expended to meet living and medical expenses.

(iii) The individual's health or life would be endangered if the individual were deprived of medical care.

(3) For an irrevocable trust established with the individual's own assets on or before August 10, 1993, the following provisions shall apply:

(A) The trust shall be considered available up to the maximum value of the funds that can be made available under the terms of the trust on behalf of the individual if both of the following conditions are met:

(i) The individual is a beneficiary.

(ii) The trustees are permitted to exercise any discretion with respect to distribution to the individual.

(B) The trust may be established by the individual, the individual's spouse or parent, a legal guardian, or a legal representative who is acting on behalf of the individual.

(C) The amount from the trust that shall be considered as an available resource is the amount that could have been distributed but was not distributed within an eligibility base period. Each amount actually distributed shall be regarded as income. Each portion of the trust that is unavailable to the individual or is not used for the benefit of the individual shall be considered a transfer of property for less than fair market value in accordance with K.A.R. 129-6-57. K.A.R. 129-6-109(c)(3) shall not be applicable to any trust established before April 7, 1986 if the individual is a developmentally disabled individual who is residing in an intermediate care facility for people with intellectual disability and the trust is solely for the benefit of the individual.

(4)For any other trust, including a trust established with assets of someone other than the individual, the trust shall be considered available to the individual only if the individual has the ability to revoke or terminate the trust or to direct the use of the trust assets for the individual's own support and maintenance. Mandatory periodic payments received from a trust by the individual shall be considered an available resource equal to the present value of the anticipated payments, unless there is a valid spendthrift clause or other language in the trust that specifically prohibits anticipation of payments. If a valid spendthrift clause or other restrictive language exists, the periodic payments shall be considered countable unearned income.

(d)Treatment of annuities. The term "annuity" shall include any contract or device that conveys a right to receive a fixed, periodic source of income for a specified period of time. For purposes of determining an individual's eligibility for assistance or the amount of assistance, the following requirements shall apply:

(1) Each individual requesting medical assistance shall disclose any interest in an annuity. Failure to meet this requirement shall result in ineligibility for medical assistance due to noncooperation in accordance with K.A.R. 129-6-56.

(2) Retirement annuities, including civil service and railroad retirement annuities, shall be exempt as a resource, but the income received shall be countable unearned income.

(3) All other revocable and irrevocable annuities, including those reported to be nonassignable, shall be presumed to be an available resource. The right to either the principal or the income stream from an annuity shall be considered a countable resource. If the annuity can be sold, assigned, encumbered, or structured so that the benefit of the annuity can be received by someone other than the designated beneficiary, the annuity shall be considered available and shall be assigned a value.

(4) The fair market value of a revocable annuity shall be the cash value of the annuity. The fair market value of an irrevocable annuity shall be the amount yet to be paid out under the terms of the contract.

(5) If the individual can furnish evidence from a reliable source that the annuity or the income stream from the annuity is not able to be received by someone other than the designated beneficiary, the annuity shall be reevaluated. Reliable sources concerning the availability of the annuity or income stream shall include banks and other financial institutions, insurance companies, and brokers.

(e)Exempted personal property. The resource value of the following types of personal property shall be exempt:

(1) Personal effects;

(2) household equipment and furnishings in use or only temporarily not in use;

(3) tools in use and necessary for the maintenance of a house or a garden;

(4) the stock and inventory of any self-employed person that are reasonable and necessary in the production of goods and services;

(5) items for home consumption, which shall consist of the following:

(A) Produce from a garden consumed from day to day and any excess that can be canned or stored; and

(B) a small flock of fowl or herd of livestock that is used to meet the food requirements of the family;

(6) cash assets that are traceable to income exempted as income and as a cash asset;

(7) any contract for the sale of property, if the proceeds from the contract are considered as income and the income is consistent with the repayment terms and conditions specified in the written contract;

(8) one vehicle for each family group receiving medical assistance if the primary purpose of the vehicle is to serve the needs of that family group. If someone who is not a member of that family group has the primary use, enjoyment, and possession of the vehicle, the vehicle shall not be exempted under this paragraph. Additional vehicles may be exempt if used over 50 percent of the time for employment or self-employment, if used as the family's home, if needed for medical treatment of a specific medical problem, or if specially equipped for use by a handicapped person;

(9) any individual development account (IDA) that meets the following requirements:

(A) The account shall be established by or on behalf of a temporary assistance for needy families (TANF) recipient or by or on behalf of an individual participating in the assets for independence demonstration program (AFIA) and shall be used for a qualified purpose. A qualified purpose shall mean one or more of the following: postsecondary education expenses for college or vocational-technical school, excluding learning quest and other 529 accounts; first home purchase, if the person has not owned a home within three years of acquisition; or business capitalization, if the business plan has been approved by a financial institution or nonprofit loan fund. All funds withdrawn from an IDA and used for any purpose other than one of those listed in this paragraph shall count as unearned income in the month withdrawn; and

(B) the IDA shall be a trust funded through periodic contributions by the establishing individual and may be matched by or through a qualified entity for a qualified purpose. A qualified entity to match IDA funds for a TANF recipient shall be either a not-for-profit organization described in 8 U.S.C. 501(c)(3) and exempt from taxation under 8 U.S.C. 501(a) or a state or local government agency acting in cooperation with a 501(c)(3) organization. For AFIA participants, matching contributions shall be made by the federal government through a grantee;

(10) low-income family postsecondary savings accounts incentive program established pursuant to K.S.A. 2012 Supp. 75-650, and amendments thereto;

(11) life insurance that is owned by an applicant or recipient if one of the following conditions is met:

(A) The policy has no potential cash surrender value;

(B) the policy does not exceed $1,500 face value. The face value shall not include and shall not be increased by accumulated dividends, but shall be decreased by any outstanding policy loan. If the total face value of insurance policies owned by any one individual exceeds $1,500, the total cash surrender value of those policies shall be a nonexempt resource; or

(C) the policy is in excess of $1,500 face value and has been irrevocably collaterally assigned to the state. The assignment shall be for an amount not to exceed the amount of benefits paid under the medical assistance program for the individual;

(12) any personal property of a blind or disabled person that is covered by an approved plan of self-support;

(13) burial spaces in accordance with the following:

(A) "Burial spaces" shall mean conventional grave sites, crypts, mausoleums, caskets, urns, and other repositories that are traditionally used for the remains of deceased persons. This term shall include vaults, headstones, and grave markers, as well as monies set aside for opening and closing the grave; and

(B) burial spaces purchased through a revocable or irrevocable prepaid contract shall be exempt under this paragraph, including the account in which the funds are deposited under the contract and the interest that accrues on the funds;

(14) burial funds of up to $1,500 each, plus any interest that has accumulated in that fund beginning with the month of application but no earlier than November 1, 1984, for members of the assistance plan that are separately identifiable and clearly designated as set aside for each member's burial expenses. "Burial funds" shall mean revocable burial contracts and trusts as well as other revocable burial arrangements:

(A) The fund shall be considered separately identifiable if it is set up in a separate account and not commingled with any other funds, except funds for burial purposes including a prepaid contract fund for burial merchandise in accordance with paragraph (e)(13);

(B) the fund shall be considered as clearly designated if the account is noted "for burial purposes only" or if the client provides a signed, written statement attesting to the fact that the funds have been set aside and are intended for burial purposes only;

(C) if the fund is exempted and the client withdraws all or a portion of the funds, the amount withdrawn shall be considered as a nonexempt resource and, if transferred, shall be subject to the transfer provisions of K.A.R. 129-6-57;

(D) the $1,500 amount that can be exempted under paragraph (e)(14) shall be reduced by the amount of any irrevocable burial agreements established under K.S.A. 16-303 and amendments thereto, except to the extent that the irrevocable burial agreement represents excludable burial spaces under paragraph (e)(13), as well as the face value of all life insurance policies that do not exceed the $1,500 face value limitation in accordance with paragraph (e)(11). The face value of life insurance policies that exceed this $1,500 limit shall not reduce the amount that can be exempted for burial purposes;

(15) proceeds from the sale of a home if the proceeds are conserved for the purchase of a new home and the funds so conserved are expended or committed to be expended within three months of the sale;

(16) a retroactive social security payment received by the applicant or recipient or an ineligible legally responsible person for the nine months following the month of receipt;

(17) the cash value of pension plans or funds under any of the following conditions:

(A) The person is employed and would have to terminate employment in order to obtain any payment. Each pension plan or fund that can be converted to periodic payments shall be exempt if the plan or fund is converted to periodic payments by the month following the month in which the plan or fund is eligible for conversion;

(B) the person is not retired or claiming permanent disability; or

(C) the applicant's or recipient's spouse or parent has funds in a work-related pension plan or fund, including Keogh plans, and IRAs and is not applying for or receiving medical assistance;

(18) retirement accounts and pensions of any employed individual who meets the requirements of K.A.R. 129-6-88;

(19) income-producing personal property, other than cash assets, that is essential for employment or self-employment or producing income consistent with its fair market value. Income-producing property may include any of the following items:

(A) Tools;

(B) equipment;

(D) livestock;

(20) escrow accounts established for families participating in the family self-sufficiency program through the U.S. department of housing and urban development. Interest earned on the accounts shall also be exempted as income; and

(21) monies paid as part of a contract or agreement to receive medical or assistive services from an unlicensed individual or entity if all of the following conditions are met:

(A) A written contract is executed before providing or paying for any service. The contract shall specify services to be provided and the rates for these services;

(B) the contracted amount paid for services is consistent with the market rate for the services. If there is no established rate, the federal minimum wage shall be used;

(C) the provider of the service is reporting all monies as income to the appropriate state and federal governmental revenue agencies as required by law;

(D) any amounts due under the contract are paid after the services are rendered;

(E) the agreement is revocable; and

(F) upon the death of the individual, the contract ceases.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-110 Income

(a) Treatment of in come for MAGI-based coverage groups. For purposes of this regulation, "prospective monthly amount" shall mean an amount that is projected for purposes of determining an applicant's or recipient's monthly income. For those groups specified in K.A.R. 129-6-34(c)(1), all earned income and unearned income expected to be received in the month of application shall be used to determine a prospective monthly amount. This amount shall be used in the determination of both eligibility in the prior three months and current eligibility. For changes in earned income and unearned income, an estimate of those changes shall be used to determine a prospective monthly amount. For self-employment income, a prospective monthly amount shall be based on annual federal tax information from the most recent tax year. In the absence of federal tax information from the most recent tax year, an estimate shall be used to determine a prospective monthly amount.

(b) Treatment of income for MAGI-excepted coverage groups. For those groups specified in K.A.R. 129-6-34(c)(2), income shall be classified as income in the eligibility base period in which the income is received and as a cash asset following this eligibility base period.

(1) Prior eligibility. For individuals in independent living, current income as defined in paragraph (b)(2) shall be considered in the determination of eligibility for the prior three months. For individuals in long-term care arrangements, income received in the prior three months shall be considered in the determination of eligibility for the prior three months, except that self-employment income shall be averaged.

(2) Current eligibility. Income shall be considered prospectively to determine eligibility, beginning with the month of application. All income received or reasonably expected to be received shall be considered in determining the applicable income for the eligibility base period. Income from self-employment and intermittent income shall be considered and averaged. Intermittent income shall be divided by the applicable number of months to establish the monthly amount. Intermittent income shall be considered as income beginning with the eligibility base period in which this income is received.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-111 Applicable income

"Applicable income" shall mean the amount of earned and unearned income that is compared with the appropriate income standard to establish financial eligibility.

(a) MAGI-based coverage groups. For those groups specified in K.A.R. 129-6-34(c)(1), all earned income and unearned income shall be considered applicable, unless exempted in accordance with K.A.R. 129-6-53(a)(2), and shall be determined as follows:

(1) Applicable income shall be based on the methodologies used to determine modified adjusted gross income, as specified in K.A.R. 129-6-53(a), for persons in the household, as specified in K.A.R. 129-6-53(b).

(2) An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted from the combined household income in accordance with K.A.R. 129-6-53(a) when determining eligibility for the MAGI-based coverage groups under K.A.R. 129-6-34(c)(1) with the highest income standard for which the individual's eligibility is being determined.

(b) MAGI-excepted coverage groups. For those groups specified in K.A.R. 129-6-34(c)(2), all earned income and unearned income shall be considered applicable income, unless exempted in accordance with K.A.R. 129-6-112 and 129-6-113. For all aged, blind, and disabled groups, applicable income shall be determined as follows:

(1) Wages. All earned income shall be considered applicable income, except that K.A.R. 129-6-112 and 129-6-113 shall apply to persons in an independent living arrangement or in the HCBS program. The applicable earned income shall be gross income less income deductions, if applicable.

(2) Self-employment. The applicable earned income for a self-employed person shall equal the modified adjusted gross earned income less the income deductions of paragraph (b)(4), if applicable. Paragraph (b)(1) regarding modified adjusted gross earned income shall apply to calculations made pursuant to this paragraph. Annual tax information from the most recent tax year shall be converted to a monthly prospective amount. This amount shall be used in the determination of both eligibility in the prior three months and current eligibility. In the absence of tax information from the most recent tax year, the most current income shall be used to determine a monthly amount.

(3) Unearned income. All net unearned income shall be considered to be applicable income, except that K.A.R. 129-6-112 and 129-6-113 shall apply to persons in an independent living arrangement or in the HCBS program. K.A.R. 129-6-113 (a), (m), (n), (w), (bb), (cc), (ff), (kk), (nn), and (oo) shall apply to persons in long-term care arrangements. Net unearned income shall equal gross unearned income less the costs of the production of the income. Income-producing costs shall include only those expenses directly related to the actual production of income.

(4) Income deductions.

(A) For persons in an independent living arrangement or in the HCBS program, the following deductions shall apply:

(i) The first $20 of any nonexempt unearned income; and

(ii) an applicable earned income deduction calculated as follows: gross earned income minus any portion of the unearned income deduction that exceeds monthly earned income, plus $65 of monthly earned income, plus one-half of the remainder of the monthly earned income.

(B) For persons in long-term institutional arrangements who are employed, an applicable earned income deduction shall be calculated as follows: gross earned income minus $65 of monthly earned income, plus one-half of the remainder of the monthly earned income.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-112 Income exempt from consideration as income and as a cash asset for MAGI-excepted groups

For those groups specified in K.A.R. 129-6-34(c)(2), exempted income shall be the following: (a) Grants, scholarships, and loans provided for educational purposes;

(b) the value of benefits provided under the federal supplemental nutrition assistance program;

(d) benefits received under title V, community services employment program, or title VII, nutrition program for the elderly, of the older Americans act of 1965, as amended by public law 109-365;

(e) Indian funds distributed or held in trust by the secretary of the interior, including interest and investment income accrued on these funds while held in trust and initial purchases made with these funds;

(f) distributions to natives under the Alaska native claims settlement act;

(g) payments provided to individual volunteers serving as foster grandparents, senior health aides, and senior companions under title II of the domestic volunteer service act of 1973 as amended by public law 106-170;

(h) any payments provided through americorps, except that volunteers in service to America (VISTA) payments shall be exempt only as income;

(i) relocation payments received under public law 91-646;

(j) death benefits from social security administration (SSA), veterans administration (VA), railroad retirement, or other burial insurance policy if the benefits are used toward the cost of burial. This shall include payments occasioned by the death of another person to the extent that the payments have been expended or committed to be expended for purposes of the deceased person's last illness and burial;

(k) money held in trust by the VA for a child that the VA determines shall not be used for subsistence needs;

(l) retroactive corrective assistance payments in the month received or in the following month;

(m) maintenance income directly provided by rehabilitation services of the Kansas department for children and families;

(n) mandatory deductions from military pay for educational purposes while the individual is enlisted in the armed services;

(o) reimbursements for out-of-pocket expenses in the month received and the following month;

(p) proceeds from any bona fide loan requiring repayment;

(q) payments granted to certain United States citizens of Japanese ancestry and resident Japanese aliens under title I of public law 100-383;

(r) payments granted to certain eligible Aleuts under title II of public law 100-383;

(s) agent orange settlement payments;

(t) federal major disaster and emergency assistance and comparable disaster assistance provided by state or local government agencies or by disaster-assistance organizations in conjunction with a presidentially declared disaster;

(u) payments granted to the Aroostook band of Micmac Indians under public law 102-171;

(v) payments from the radiation exposure compensation trust fund made by the department of justice;

(w) special federal allowances paid monthly to children of Vietnam veterans who are born with spina bifida, under public law 104-204, or other certain birth defects, under public law 106-419;

(x) payments made from any fund established pursuant to a class settlement in the case of Susan Walker v. Bayer corporation, except for interest or other investment income earned on the payments;

(y) except for aged, blind, and disabled persons, a one-time payment or a portion of a one-time payment from a cash settlement for the repair or replacement of property or for legal services, medical costs, or other required obligations to a third party, if the payment is expended or committed to be expended for the intended purpose within six months of its receipt;

(z) cash donations that are based on need, do not exceed $300 in any calendar quarter, and are received from one or more private, nonprofit, charitable organizations;

(aa) foster care and adoption support payments;

(bb) the amount of any earned income tax credit received. This credit shall not be regarded as a cash asset in the month of receipt and in the following 12 months;

(cc) for aged, blind and disabled persons, a one-time payment or a portion of a one-time payment from a cash settlement for the repair or replacement of property or for legal services, medical costs, or other required obligations to a third party, if the payment is expended or committed to be expended for the intended purpose within nine months of its receipt. This time period may be extended for good cause;

(dd) for blind and disabled persons, income necessary for fulfillment of a plan to achieve selfsupport established for a blind or disabled person, as approved by the social security administration;

(ee) any interest earned on excluded burial funds and any appreciation in the value of an excluded burial arrangement that are left to accumulate and become a part of that burial fund, according to K.A.R. 129-6-109;

(ff) housing assistance from federal housing programs operated by state and local subdivisions;

(gg) family subsidy payments provided through the mental health and developmental disabilities commission or family support payments provided through the prevention and protection services commission;

(hh) relocation assistance provided by a state or local government that is comparable to assistance provided under title II of the uniform relocation assistance and real property acquisitions act of 1970, public law 91-646;

(ii) interest on an allowable individual development account (IDA) that meets the requirements of K.A.R. 129-6-109(e)(9), including authorized matching contributions and accrued interest. Earnings deposited in an individual development account shall also be exempted for a person who meets the requirements of K.A.R. 129-6-88;

(jj) the portion withheld to repay a prior overpayment received from a program not based on financial need, including certain programs administered by the SSA, VA, and the division of workers compensation or the division of employment security in the Kansas department of labor; and

(kk) payments made pursuant to the Ricky Ray hemophilia relief fund act, public law 105-369.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-113 Income exempt as applicable income for MAGI-excepted groups

For those groups specified in K.A.R. 129-6-34(c)(2), the following types of income shall be exempt as applicable income in the determination of eligibility:

(a) Income-in-kind;

(b) shelter cost participation payments. In shared living arrangements in which two families contribute toward the shelter obligations, cash paid toward the shared shelter obligation by one family to the second family in the shared arrangement shall not be considered as income to the second family. This exemption shall not be applicable in a bona fide, commercial landlord-tenant arrangement;

(d) payments made pursuant to the crime victims fund, public law 103-322, as amended, and by the Kansas crime victims compensation board pursuant to K.S.A. 74-7301 et seq., and amendments thereto;

(e) payments received through the senior community service employment program;

(f) payments or allowances made under federal laws for the purpose of providing energy assistance. Home energy assistance furnished on the basis of need by a federally regulated or state-regulated entity whose revenues are primarily derived on a rate-of-return basis, by a private nonprofit organization, by a supplier of home heating oil or gas, or by a municipal utility company that provides home energy shall also be exempted;

(g) income received from the workforce investment act of 1998, public law 105-220. However, earnings received by individuals who are participating in on-the-job training programs shall be countable unless the individual is under the age of 19;

(h) the values of any services or monies received for support or transitional services paid directly to the customer through work programs as defined in article 4 of the regulations of the department for children and families;

(i) income of an SSI recipient, including a deemed recipient, and retroactive SSI benefits. This subsection shall not be applicable to any person residing in a long-term institutional arrangement in accordance with K.A.R. 129-6-111(b)(3);

(j) incentive payments received by renal dialysis patients;

(k) irregular, occasional, or unpredictable monetary gifts that do not exceed $50 per month per family group;

(l) tax refunds and rebates, except for earned income tax credits in accordance with K.A.R 129-6-112 (bb);

(m) VA aid and attendance and housebound allowances;

(n) VA payments resulting from unusual medical expenses;

(o) up to $2,000 per year of income received by an individual Indian that is derived from leases or other uses of an individually owned trust or restricted lands;

(p) lump sum income;

(q) earned income of a child who is under the age of 19 if the child is a student in elementary or secondary school or is working towards attainment of a G.E.D.;

(r) interest and dividend income that does not exceed $50 per month per family group;

(s) child care payments made to persons other than a child care provider;

(t) child support pass-through payments;

(u) payments from any bona fide loan;

(v) the amount of any child support arrearage payment paid for a child under the age of 18;

(w) reparation payments made to holocaust survivors;

(x) vendor payments that are not payable directly to a household but are paid to a third party for a household expense, as follows:

(1) Each payment made in money on behalf of a household shall be considered a vendor payment whenever a person or organization outside of the household uses its own funds to make a direct payment to either the household's creditors or a person or organization providing a service to the household;

(2) each assistance payment financed by state or local funds that is not made directly to the household but is paid to a third party on behalf of the household to pay a household expense shall be considered a vendor payment if the payment is for medical care, child care, or temporary housing assistance;

(3) each assistance vendor payment financed by state or local funds that is made on behalf of migrants in the labor stream pursuant to 7 C.F.R. 273.9(c)(1) shall be exempt and not counted as income, regardless of the purpose of the vendor payment;

(4) each payment in money that is not made to a third party, but is made directly to the household, shall be counted as income and shall not be excludable as a vendor payment; and

(5) each payment or other assistance financed by state or local funds that is provided over and above the normal grant or other assistance payment and would not normally be provided in a money payment to the household shall be considered emergency or special assistance and exempted as income if provided directly to a third party for a household expense;

(y) payments provided through youth service corps;

(z) allocation payments made to individuals under a WORK plan according to K.A.R. 129-6-84;

(aa) for aged, blind, and disabled persons, one-third of the child support payments received by an eligible child from an absent parent;

(bb) for blind and disabled persons, work expenses of a blind recipient. The first $300 of earned income or verified actual average expenses, if in excess of this amount, shall be exempted under this subsection;

(cc) for blind and disabled persons, impairment-related work expenses of a disabled recipient. The first $100 of earned income or verified actual average expenses, if in excess of this amount, shall be exempted under this subsection;

(dd) for aged, blind, or disabled persons, the difference between the social security benefit entitlement in August 1972 and the entitlement in September 1972 for persons who were receiving cash assistance through the programs of aid to the aged, blind, or disabled (AABD) or aid to dependent children (ADC) in September 1972 and who were entitled to a social security benefit in September 1972. This exemption shall apply only if the exemption establishes eligibility without a spenddown;

(ee) for aged, blind, or disabled persons, the amount of all social security cost-of-living adjustments for a person who was concurrently receiving SSI and social security after April 1977 and who would be eligible for SSI if the cost-of-living adjustments received since that person was last eligible for SSI were not considered as income;

(ff) for aged, blind, or disabled persons, income allocated and expended by an adult in an institutional living arrangement for the support of the adult's minor children if the adult does not have a spouse who continues to live in the community. The income allocation shall not exceed the amount necessary to bring the children's income up to the appropriate income standard described in K.A.R. 129-6-103(a)(3);

(gg) for aged, blind, and disabled persons, SSI payments that the person is not legally entitled to receive and that are subject to SSI recovery;

(hh) for aged, blind, and disabled persons, the amount of the December 1983 increase in social security disabled widow or widower benefits resulting from the changes in the actuarial reduction formula, and all subsequent cost-of-living adjustments, for a person who was concurrently receiving SSI and social security disabled widow and widower benefits under section 202(e) or 202(f) of the social security act, if the person meets all of the following conditions:

(1) The person became ineligible for SSI due solely to the 1983 actuarial increase;

(2) the person has continually received social security disabled widow or widower benefits since the 1983 actuarial increase was first received;

(3) the person would be currently eligible for SSI if it were not for the 1983 actuarial increase and all subsequent cost-of-living adjustments; and

(4) the person applied for medical assistance before July 1, 1988;

(ii) for aged, blind, and disabled persons, the amount of the social security adult disabled child benefit for an otherwise eligible SSI person aged 18 or older who meets both of the following conditions:

(1) The person was receiving SSI benefits that began before the age of 22; and

(2) the person lost SSI eligibility due solely to the person's becoming eligible for the adult disabled child benefits or to an increase in the adult disabled child benefits;

(jj) for aged, blind, and disabled persons, the amount of social security early or disabled widow or widower benefits under section 202(e) or (f) of the social security act, if the person meets all of the following conditions:

(1) The person became ineligible for SSI because of the receipt of the benefits;

(2) the person would be currently eligible for SSI in the absence of the benefits; and

(3) the person is not entitled to hospital insurance benefits under part A of title XVIII of the social security act;

(kk) for aged, blind, and disabled persons, the income of an SSI recipient that exceeds the income standard for institutionalized persons for three months following the month of admission, if the social security administration determines that the stay in the institution is temporary and the person needs to continue to maintain and provide for the expenses of the home or another living arrangement to which the person could return;

(ll) for aged, blind, and disabled persons, the income of an applicant's or recipient's spouse or parent that was counted or excluded in determining the amount of a public assistance payment, if the spouse or parent is not an applicant for or recipient of medical assistance for aged, blind, and disabled persons;

(mm) for aged, blind, and disabled persons, the income of an applicant's or recipient's spouse or parent that is used to make support payments under a court order or title IV-D support order, if the spouse or parent is not an applicant for or recipient of medical assistance for aged, blind, and disabled persons;

(nn) for aged, blind, and disabled persons, the amount of VA pension received by a single veteran with no dependents or by a surviving spouse with no children, if the pension has been reduced to $90 or less because the veteran or spouse resides in a medicaid-approved nursing facility; and

(oo) for aged, blind, and disabled persons, Austrian social insurance payments based, in whole or in part, on wage credits granted under the Austrian general social insurance act.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-120 Eligibility before the month of application

The eligibility of an applicant for the medical assistance program shall be determined for the three months immediately before the month of application if the applicant requests this determination.

(a) Automatic eligibles. The applicant shall be eligible for medical assistance in any of the three months in which the applicant would have been automatically eligible for medical assistance if the applicant would have applied for medical assistance during the month.

(b) Determined eligibles. The prior eligibility base period shall begin on the first day of the first month in which all eligibility factors other than financial are met without regard to current eligibility.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-140 Correction and discontinuance of medical assistance

(a) Overpayments. Each recipient who receives an overpayment, whether caused by the department or the individual, shall repay the amount of the overpayment, either by voluntary action or through administrative processes including recoupment and legal action.

(b) Welfare fraud penalty. Each person convicted of medical assistance program fraud, pursuant to 42 U.S.C. 1320a-7b, shall be ineligible to participate in the medical assistance program for one year from the date of the conviction.

(c) Discontinuance of medical assistance. A recipient's participation in the medical assistance program shall be discontinued if the recipient no longer meets one or more of the applicable eligibility requirements.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-150 Estate recovery

(a) Pursuant to K.S.A. 39-709 and amendments thereto and this regulation, each recipient's real and personal property or estate shall be subject to the recovery of the cost of all medical assistance provided on the recipient's behalf. By applying for and receiving medical assistance, the recipient shall agree to the department's use of liens against the recipient's property, claims against the recipient's estate, agreements with heirs, and any other collection method allowed by Kansas statutes.

(b) The amount of any medical assistance paid on behalf of a recipient after June 30, 1992 shall be a claim against the property or estate of a deceased recipient, subject to whether the medical assistance was correctly paid on behalf of an eligible recipient.

(1) If the medical assistance was correctly paid on behalf of an eligible recipient, the department's claim against the recipient's estate shall be restricted to medical assistance paid when the recipient met either of the following conditions:

(A) Was 55 years of age or older; or

(B) was admitted as an inpatient in a long-term care facility, including a PACE institutional arrangement.

(2) If the medical assistance was incorrectly paid on behalf of an ineligible recipient, the department's claim shall be the total amount of assistance paid on behalf of the ineligible recipient.

(c) The recipient's estate shall not be subject to the department's claim for correctly paid medical assistance benefits if one of the following individuals survives for at least six months after the recipient's death:

(1) A spouse; or

(2) a child who is under 21 years of age or who meets the disability criteria of K.A.R. 129-6-85(b) or (c).

(d) If a deceased recipient is survived by a spouse, all claims for correctly paid medical assistance benefits that have been paid on behalf of the deceased recipient shall be filed against the estate of the surviving spouse.

(e) The recipient may be subject to the imposition of a lien by the department on the recipient's real property before the recipient's death pursuant to K.S.A. 39-709, and amendments thereto.

(f) For a deceased recipient, the real property of the recipient may be subject to the imposition of a lien by the department for up to one year after the death of the recipient, pursuant to K.S.A. 39-709 and amendments thereto.

(g) Pursuant to K.S.A. 39-709 and amendments thereto, a deceased recipient's real and personal property may be subject to recovery of the recipient's medical assistance costs if the deceased recipient's interest in the property ended or was transferred due to the recipient's death. The department's recovery shall be limited to the recipient's interest in the property as that interest existed immediately before the death of the recipient.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2013 Supp. 39-709, 65-1,254, and 75-7403; implementing K.S.A. 2013 Supp. 39-709, K.S.A. 59-3504, K.S.A. 2013 Supp. 65-1,254, and K.S.A. 2013 Supp. 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-151 Presumptive eligibility

A presumptive period of eligibility shall be provided if a qualified entity, designated by the department in accordance with K.A.R. 129-6-152, determines that the individual meets the presumptive eligibility requirements as follows. (a) Pregnant women.

(1) Each woman shall be at least 18 years of age.

(2) Each woman shall meet the general eligibility requirements of K.A.R. 129-6-52 and 129-6-55 and the determined eligible requirements of K.A.R. 129-6-71.

(3) Financial eligibility shall be based on the requirements of K.A.R. 129-6-53.

(b) Children.

(1) Each child shall be under the age of 19.

(2) Each child shall meet the general eligibility requirements of K.A.R. 129-6-52 and 129-6-55 and the determined eligible requirements of K.A.R. 129-6-72.

(3) Financial eligibility shall be based on the requirements of K.A.R. 129-6-53.

(4) The child shall not be living in a public institution, as specified in K.A.R. 129-6-60.

(1) The presumptive period shall begin on the date on which the qualified entity makes an eligibility determination. The presumptive period shall end on the last day of the month following the month in which the determination is made, unless an application for medical assistance is received. If an application is filed in accordance with K.A.R. 129-6-35 before this date, the presumptive period shall end on the last day of the month in which a full determination is made according to this regulation.

(2) Each individual shall be eligible for only one period of presumptive eligibility within a 12-month period under this regulation or under K.A.R. 129-14-51. The 12-month period shall begin on the first day of presumptive eligibility under either of these regulations.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective June 30, 2006; amended, T-129-10-31-13, Nov. 1, 2013; amended Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-152 Presumptive eligibility when determined by qualified entities other than qualified hospitals

(a) Except for qualified hospitals pursuant to K.A.R. 129-6-153, each qualified entity shall be designated by the department to make determinations of presumptive eligibility as specified in K.A.R. 129-6-151.

(b) Each qualified entity shall meet the requirements of 42 C.F.R. 435.1101 and 435.1103.

(c) For each determination of presumptive eligibility under this regulation, a qualified entity shall perform the following:

(1) Make a finding of presumptive eligibility pursuant to K.A.R. 129-14-51(b) or 129-6-151;

(2) notify the pregnant woman or the child's parent or caretaker, by written or electronic means, of the results of the determination at the time of the determination;

(3) provide the pregnant woman or the parent or caretaker of the child with an application for ongoing medical assistance. For an individual determined to be presumptively eligible, the qualified entity shall provide notification that this application shall be required to be submitted before the last day of the month following the month of the presumptive determination or eligibility shall end on that date;

(4) assist the pregnant woman or the child's parent or caretaker in completing and filing an application for ongoing medical assistance; and

(5) notify the department of the presumptive determination within five working days after the determination.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective June 30, 2006; amended, T-129-10-31-13, Nov. 1, 2013; amended Feb. 28, 2014.)

Kan. Admin. Regs. § 129-6-153 Presumptive eligibility when determined by qualified hospitals

(a) Each hospital that meets the following requirements shall be approved to make determinations of presumptive eligibility as specified in K.A.R. 129-6-151:

(1) Participates as a medicaid provider in Kansas;

(2) indicates interest in writing to the department to make determinations of presumptive eligibility;

(3) enters into a formal written agreement with the secretary to make determinations of presumptive eligibility in accordance with department regulations and policies;

(4) uses forms and other tools approved by the secretary for determining eligibility;

(5) satisfactorily completes state-provided training; and

(6) meets the performance standards established by the secretary, which shall include the following:

(A) Processing applications for presumptive eligibility within prescribed time limits; and

(B) achieving an accuracy rate of at least 90 percent in eligibility determinations made by the hospital.

(b) Presumptive eligibility determinations shall be made for pregnant women and children as specified in K.A.R. 129-6-151 and for qualifying families as specified in K.A.R. 129-6-70.

(1) Make a finding of presumptive eligibility pursuant to K.A.R. 129-6-151;

(2) notify the family, the pregnant woman, or the child's parent or caretaker of the results of the determination at the time of the determination;

(3) provide the family, the pregnant woman, or the parent or caretaker of the child with an application for ongoing medical assistance. For an individual determined to be presumptively eligible, the qualified hospital shall provide notification that this application shall be required to be submitted before the last day of the month following the month of the presumptive determination or eligibility shall end on that date;

(4) assist the family, the pregnant woman, or the child's parent or caretaker in completing and filing an application for ongoing medical assistance; and

(5) notify the department of the presumptive determination within five working days after making the determination.

(d) Each qualified hospital shall be required to be recertified by the department each year to determine if the qualified hospital continues to meet the requirements in this regulation. The qualified hospital's certification shall be terminated by the department under either of the following circumstances:

(1) The qualified hospital is not making, or is incapable of making, presumptive eligibility determinations in accordance with the agreement established in accordance with subsection (a).

(2) The qualified hospital is failing to meet the performance standards specified in this regulation.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Article 7 Medical Assistance Grievances and State Fair Hearings for Eligibility and Fee-for-Service

Kan. Admin. Regs. § 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 K.A.R. 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 K.A.R. 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 K.A.R. 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 K.A.R. 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 K.A.R. 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 K.A.R. 129-7-4.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-2 FFS beneficiary grievance

(a) Any FFS beneficiary may submit a grievance about any FFS matter, including an action.

(b) Any FFS beneficiary may submit an oral or written grievance to the secretary or secretary's designee at any time. Any applicant or beneficiary may submit an FFS grievance in person, by telephone, by U.S. mail, or by facsimile. Each written grievance delivered by the postal service or submitted by facsimile to the secretary or secretary's designee shall be date-stamped when received as proof of receipt.

(c) Each grievance involving an FFS matter shall be resolved by the secretary or the secretary's designee within 30 days from the date the secretary receives the grievance from the FFS beneficiary. The resolution of the grievance shall be communicated by the secretary or the secretary's designee to the FFS beneficiary by telephone or letter.

(d) An FFS beneficiary's right to submit an FFS grievance shall not be limited or interfered with by the secretary or the secretary's designee.

(e) If the secretary delegates the tracking and resolution of grievances involving an FFS matter to a contractor, that contractor shall cooperate with the state, the state's fiscal agent, or representatives of either to resolve all FFS beneficiary grievances. Cooperation may include providing internal FFS beneficiary grievance information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-3 Eligibility grievance

(a) Any applicant or beneficiary may submit a grievance about any eligibility matter other than an action.

(b) Any applicant or beneficiary may submit an oral or written eligibility grievance to the secretary or secretary's designee at any time. Any applicant or beneficiary may submit an eligibility grievance in person, by telephone, by U.S. mail, or by facsimile. Each written grievance delivered by the postal service or submitted by facsimile to the secretary or secretary's designee shall be date-stamped when received as proof of receipt.

(c) Each grievance involving an eligibility matter shall be resolved by the secretary or the secretary's designee within 30 days, or sooner as directed by the secretary, from the date the secretary receives the grievance from the applicant or beneficiary. Three attempts shall be made by the secretary to reach the applicant or beneficiary by telephone regarding the grievance resolution. If the applicant or beneficiary cannot be reached by telephone, a letter shall be sent by the secretary to the applicant or beneficiary regarding the grievance resolution.

(d) An applicant's or beneficiary's right to submit an eligibility grievance shall not be limited or interfered with by the secretary or the secretary's designee.

(e) If the secretary delegates the tracking and resolution of grievances involving an eligibility matter to a contractor, that contractor shall cooperate with the state, the state's fiscal agent, or representatives of either, to resolve all eligibility grievances. Cooperation may include providing internal eligibility grievance information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 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 K.A.R. 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.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 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 K.A.R. 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 K.A.R. 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.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-8 Notices to applicants and beneficiaries; applicability

This regulation shall apply to adequate and timely notices of approval sent by the secretary to applicants and beneficiaries regarding approval of eligibility or approval of an FFS covered service authorization request.

(a) An adequate notice of approval shall be sent by the secretary to an applicant for medical assistance when the secretary approves an applicant's claim for eligibility, or to a beneficiary of medical assistance when the secretary fully or partially approves an FFS covered service authorization request, and to an applicant or a beneficiary following a decision by a presiding officer that reverses the secretary's action. Each adequate notice of approval shall include the following:

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

(2) the approved eligibility, including the basis of the eligibility;

(3) the effective date and, if applicable, the end date of the approved eligibility or approved FFS covered service authorization request. If no effective date is specified, the effective date shall be the date of the adequate notice of approval;

(4) the circumstances under which the applicant or beneficiary must report, and procedures for reporting, any changes that could affect the applicant's or beneficiary's eligibility;

(5) if applicable, the amount of medical expenses, if any, that must be incurred to establish eligibility for a medically needy applicant or beneficiary under a spenddown program, including the following:

(A) The budget period used to determine the spenddown amount;

(B) medical expenses, if any, applied toward the spenddown amount; and

(6) basic information on the level of benefits and services available based on the applicant's or beneficiary's eligibility, including the following, if applicable:

(A) A description of any premiums and cost sharing required;

(B) an explanation of how to receive additional detailed information on benefits and financial responsibilities; and

(b) A timely notice of approval shall be sent by the secretary to the applicant or beneficiary within the time frames specified in paragraphs (b)(1) and (b)(2). A timely notice of approval shall include the contents of an adequate notice of approval as specified in subsection (a).

(1) An adequate notice of approval shall be sent by the secretary to an applicant or beneficiary no later than one business day following the date upon which the secretary makes the eligibility or FFS covered service authorization approval decision that is the subject of the adequate notice of approval.

(2) An adequate notice of approval shall be sent by the secretary to an applicant or beneficiary no later than one business day following the date upon which notice of the presiding officer's reversal of the secretary's action is received by the secretary. If a petition for review to SAC is filed by the secretary, the adequate notice of approval shall be delayed until notice of the SAC decision affirming the presiding officer's reversal of the secretary's action is received by the secretary.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-10 When a state fair hearing is required

(a) Any applicant or beneficiary may submit a request for a standard state fair hearing if the applicant or beneficiary identifies an action by the department as the basis for the request.

(b) Any applicant or beneficiary may submit a request for an expedited state fair hearing if an action by the department is identified as the basis for the request. The applicant or beneficiary shall submit medical documentation that supports the need for an expedited state fair hearing at the time of the request.

(1) The department taking the adverse action shall review the medical documentation submitted with the expedited state fair hearing request to determine if processing the applicant's or beneficiary's request for a state fair hearing in the 90-day time frame ordinarily permitted for a standard state fair hearing decision could jeopardize the individual's life, health, or ability to attain, maintain, or regain maximum function. The department shall make that determination as expeditiously as possible following receipt of the request. The department shall communicate that determination to the presiding officer.

(2) The department shall communicate an adverse determination in writing to the appellant. The presiding officer shall communicate an approval of the expedited request in writing to the appellant by issuing a notice of a state fair hearing. For denied expedited hearing requests, the presiding officer shall schedule state fair hearings in the usual time frame.

(3) The applicant's or beneficiary's request for an expedited state fair hearing, when combined with the department's approval of the request, 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 applicant or beneficiary shall submit the request for an expedited state fair hearing in accordance with the timeliness requirements in K.A.R. 129-7-11.

(c) 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 beneficiaries.

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

(e) The applicant's or beneficiary's right to request a state fair hearing shall not be limited or interfered with by the secretary.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-11 Request for state fair hearing; timeliness

(a)(1) For each request for a standard state fair hearing by an applicant or beneficiary under this article of the division's regulations to be considered timely, the request shall be received by the secretary or the secretary's designee for the state fair hearing within 30 days from the date of the written notice of action. If the 30th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) The presiding officer shall issue an initial order in a standard state fair hearing within 90 days from the date the presiding officer receives a request for a state fair hearing, except when the presiding officer allows an extension.

(b) Any applicant or beneficiary may request an expedited state fair hearing. For each request for an expedited state fair hearing to be considered timely, the request shall be received by the secretary or the secretary's designee for the state fair hearing within 30 days from the date of the written notice of action. If the 30th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(1) The processing of the state fair hearing request shall be expedited by the department if the department determines that the 90-day time frame ordinarily permitted for a standard state fair hearing decision could jeopardize the individual's life, health, or ability to attain, maintain, or regain maximum function.

(2) The time limits specified by binding regulations issued by federal medicaid authorities shall be used by the secretary or the secretary's designee for the state fair hearing in scheduling an expedited state fair hearing. If no binding federal regulations have been promulgated or the binding federal regulations have been promulgated but are currently not effective, the expedited state fair hearing shall be scheduled as expeditiously as possible by the presiding officer as required by 42 C.F.R. 431.244(f)(3), as in effect on February 8, 2023, which is hereby adopted by reference.

(3) The presiding officer shall issue an initial order following an expedited state fair hearing as expeditiously as possible as required by the secretary.

(c) Any applicant or beneficiary may submit an oral or written request for a standard or expedited state fair hearing to the secretary. Oral, telephonic, or electronic requests for a standard or expedited state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(d) Any request for a standard or expedited state fair hearing made by telephone or other electronic means and received by the secretary during normal business hours may be accepted as a valid request for a standard or expedited state fair hearing by the secretary if the request and proof of receipt by the secretary are documented, dated, and reduced to writing. The date and time of the telephonic or electronic request for a standard or expedited state fair hearing shall be used to determine the timeliness of the request even if there is a delay by the secretary in reducing the request to writing. Oral, telephonic, or electronic requests for a standard or expedited state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(e) Each request for a standard or expedited state fair hearing shall be forwarded by the secretary to the secretary's designee for the state fair hearing within one business day of receipt.

(f) If a written request for a standard or expedited state fair hearing is received by the secretary or the secretary's designee for the state fair hearing, the request shall be date-stamped by the secretary or the secretary's designee when received as proof of receipt. The timeliness standards specified in subsections (a) and (b) shall apply with the date of receipt by the secretary or the secretary's designee being used to determine the timeliness of the request.

(g) If an applicant or beneficiary sends a written request for a standard or expedited state fair hearing directly to the secretary's designee for the state fair hearing, the timeliness standards specified in subsections (a) and (b) shall apply, with the date of receipt by the secretary's designee being used to determine the timeliness of the request.

(h) If the request for a standard or expedited state fair hearing is not received within the response periods specified in subsections (a) and (b), the request shall be deemed untimely and shall be dismissed.

(i) The presiding officer shall issue an initial order on a standard or expedited state fair hearing request within the time limits specified in subsections (a) and (b), unless one of the following conditions is met:

(1) The presiding officer cannot reach a decision because the appellant requests a delay or fails to take a required action.

(2) There is an administrative or other emergency beyond the control of the presiding officer or the secretary. The presiding officer shall document the reasons for any delay in the appellant's record.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-12 Evidentiary standard; burden of proof

(a) Unless preempted by federal or state law, a preponderance of the evidence shall be the evidentiary standard used for state fair hearings under this article of the division's regulations.

(b) Any appellant or respondent may sustain that individual's burden of proof by using testimony, documents, statutes, regulations, the state plan and its amendments, the MCE contract, and policy to support the appellant's or respondent's case.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-13 Parties

(a) The parties to each state fair hearing shall be an appellant and a respondent. The case caption in each medical assistance state fair hearing case shall identify the appellant and the respondent as follows:

(1) The named appellant in the case caption shall be an applicant or beneficiary. Any authorized representative of the applicant or beneficiary may request a state fair hearing.

(A) A state fair hearing may be requested only by or on behalf of the appellant applying for or receiving covered services and benefits.

(B) Any appellant applying for or receiving covered services and benefits may designate, in writing, an individual or entity to request a state fair hearing and represent the appellant in a state fair hearing. The appellant shall be the only individual who can grant another individual or entity the authorization to request a state fair hearing and represent the appellant in a state fair hearing subject to the exception in paragraph (a)(1)(C).

(C) The individual or entity authorized to request a state fair hearing and represent the appellant in a state fair hearing shall not transfer written authorization to another individual or entity unless the authorized individual or entity has a power of attorney or is a guardian or conservator appointed by a court of competent jurisdiction. Any power of attorney, guardian, or conservator may authorize an individual or entity, in writing, to request a state fair hearing and represent the appellant in a state fair hearing.

(D) Written authorization, including power of attorney, letters of guardianship, or letters of conservatorship, shall accompany all state fair hearing requests made on an appellant's behalf, with the following exceptions:

(i) An unemancipated minor appellant's parent or legal guardian may request a state fair hearing on behalf of the appellant and represent the appellant in a state fair hearing without written authorization.

(ii) Any attorney-at-law retained by the appellant or the appellant's representative may request a state fair hearing on behalf of the appellant using the attorney's official letterhead or other proof of representation as written authorization.

(2) The named respondent in the case caption shall be the department, nursing facility, or skilled nursing facility taking the action.

(A) If the matter involves an action regarding eligibility, the respondent shall be the department that took the action. If the eligibility determination process requires several agencies to act consecutively, the respondent shall be the department that took the action involving the portion of the eligibility process that is being appealed in the state fair hearing.

(B) If the matter involves the termination, suspension, or reduction of previously authorized and ongoing FFS covered services, the respondent shall be the secretary.

(C) If the matter involves determinations concerning the preadmission screening and annual resident review, the respondent shall be the department designated as responsible for these determinations.

(D) The department shall review the matters identified in paragraphs (a)(2)(A) through (a)(2)(C) to determine whether both of the following conditions are met:

(i) The matter was filed within the regulatory time frame.

(ii) The matter involves an action.

(E) If the department determines that the matter has not satisfied each of the conditions specified in paragraph (a)(2)(D), the department shall submit a request to the presiding officer to dismiss the matter.

(F) If the matter involves the transfer or discharge of a medicaid or non-medicaid resident in a nursing facility or skilled nursing facility, the respondent shall be the nursing facility or skilled nursing facility that made the transfer or discharge decision. A designation of legal counsel for the respondent shall not affect the identification of the respondent as named party in the case caption.

(b) The presiding officer conducting the state fair hearing may grant a motion to modify the case caption to clarify the parties.

(c) Any applicant or beneficiary may authorize representation by legal counsel, a relative, a friend, or a spokesperson in the state fair hearing if the applicant or beneficiary has authorized the representation in writing. This regulation shall not authorize the secretary or the presiding officer to grant exceptions to the Kansas supreme court rules concerning the practice of law in Kansas if the applicant or beneficiary is represented by an attorney who is not licensed in Kansas.

(d) If the applicant for or beneficiary of medical assistance has died before filing a request for a state fair hearing, then an administrator or executor appointed by a court in the estate proceedings of the deceased applicant or beneficiary may file the request for a state fair hearing. The appellant shall be the estate of the deceased applicant or beneficiary.

(e) If the applicant for or beneficiary of medical assistance has died after filing a request for a state fair hearing, then an administrator or executor appointed by a court in the estate proceedings of the deceased applicant or beneficiary may request to substitute the estate of the deceased applicant or beneficiary as the appellant.

(f) If a presiding officer allows an entity to intervene in a state fair hearing covered by this article of the division's regulations pursuant to KAPA, the intervening entity shall be identified in the caption of the case as an intervenor.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-14 Department's review of decision

(a) Upon receipt of notice that a request for state fair hearing has been made, the action shall be reviewed by the department. Upon review, the action may be amended or changed before or during the state fair hearing as directed by the department.

(b) If the parties reach a satisfactory adjustment before the state fair hearing, a written request to dismiss the state fair hearing request shall be submitted by the department to the presiding officer, but the state fair hearing request shall remain pending until the following are completed:

(1) Upon receipt of the department's request to dismiss, the presiding officer shall issue a prehearing order to the appellant providing a 15-day response time. If the 15th day falls on a non-business day for the state, the 15-day response time shall be extended to the next business day on which the department is open for business. Pursuant to K.S.A. 77-531 and amendments thereto, three days shall be added to the 15-day response period if the order is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) If the appellant responds to the presiding officer within the above response time, the respondent may reply within five days.

(3) The presiding officer shall review the appellant's response and any respondent's reply and make a determination regarding the department's request to dismiss.

(4) If the appellant fails to respond to the presiding officer's order within the above response time, the presiding officer may dismiss the state fair hearing request.

(c) If the parties reach a satisfactory adjustment during the state fair hearing, an oral withdrawal stated on the record by the appellant or the appellant's representative before the presiding officer shall be acceptable.

(d) If the appellant withdraws the state fair hearing request, withdrawal of the state fair hearing request by means of the internet, telephone, U.S. mail, in-person contact, or facsimile shall be accepted by the department.

(1) For telephonic, internet, and in-person withdrawals, the appellant shall be provided with written confirmation, by regular U.S. mail or electronic notification.

(2) For telephonic state fair hearing withdrawals, the appellant's statement shall be recorded by the department. This recording process shall include electronic or contemporaneous written documentation of the appellant's oral statement by the department.

(3) If the appellant submits a signed, written statement withdrawing the appellant's request for state fair hearing, the presiding officer shall close the state fair hearing request.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-16 State fair hearings for income and resource allowance determinations

(a) For purposes of this regulation, "significant financial duress" shall mean circumstances in which expenses are unforeseen or are ongoing and are reasonable and necessary for the health, safety, or well-being of the community spouse, as specified in K.A.R. 129-6-106(k). "Expenses" shall include the costs of medical or other necessary support services or the costs associated with unforeseen circumstances, including a fire or flood.

(b) Any applicant or beneficiary may request a state fair hearing when challenging any adverse consequence of any of the following department determinations:

(1) The income allowance in accordance with K.A.R. 129-6-106(k)(2);

(2) the amount of monthly income available to the community spouse as specified in K.A.R. 129-6-106(k)(2)(B);

(3) the share of resources for the institutionalized and community spouse in accordance with K.A.R. 129-6-106(k)(6);

(4) the consideration of resources in determining the eligibility of the institutionalized spouse as specified in K.A.R. 129-6-106(k)(4); or

(5) the community spouse resource allowance in accordance with K.A.R. 129-6-106(k)(6).

(d) The presiding officer shall increase the amount of the community spouse income allowance if either spouse establishes that a greater allowance is necessary due to exceptional circumstances resulting from significant financial duress. The community spouse income allowance shall be increased sufficient to cover the expenses and based on whether the condition is temporary or ongoing.

(e) If the community spouse income allowance determined to be needed for exceptional circumstances resulting from significant financial duress has not been reached after application of subsection (d), the presiding officer may consider and grant an increase to the community spouse resource allowance if either the community or institutionalized spouse establishes that additional income producing resources from the institutional spouse need to be provided to the community spouse in order to raise the community spouse's income to the allowable community spouse income allowance amount determined in accordance with K.A.R. 129-6-106(k)(2) or as determined through a state fair hearing under subsection (d). Each decision to grant an increase in the community spouse resource allowance shall require that all of the following criteria be met:

(1) The institutionalized spouse has allocated the maximum amount of available income to the community spouse.

(2) The additional income producing resources allocated to the community spouse does not exceed an amount necessary to generate income sufficient to raise the total community spouse income to the allowable amount.

(3) The income value of both the current resources allowed and the additional resources to be allocated are based on the income that could be generated by the sale of the property and the investment of the proceeds into a single premium life annuity.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-17 Department's summary

(a) Within 30 days of the date of the acknowledgment and order issued by the presiding officer in response to a request for state fair hearing, the appellant and the presiding officer shall be furnished by the department with a summary providing the following information and exhibits:

(1) The appellant's name and address;

(2) a summary statement concerning why the appellant is filing a request for a state fair hearing;

(3) a brief and relevant chronological summary of the events that occurred in relationship to the appellant's request for a state fair hearing;

(4) a statement of the basis of the adverse action;

(5) a citation to and copy of the applicable policies or manual excerpts relied upon for the decision. The applicable medical necessity criteria or guidelines used in making medical necessity decisions shall be included;

(6) a citation to or copy of the applicable Kansas and federal statutes and regulations relied upon for the adverse action;

(7) a citation to or copy of the applicable state plan or waiver documents relied upon for the adverse action;

(8) a copy of the notice which notified the appellant of the decision in question and any subsequent notices;

(9) a copy of any applicable correspondence; and

(10) the name and title of each person who will testify or represent the secretary at the state fair hearing.

(b) Upon written request by the department, the presiding officer may grant additional time for the completion of the summary. The presiding officer shall file notification of the approval or denial of the extension request. If approved, the notification shall include the revised due date for the department's summary.

(c) The department's summary shall be submitted to the presiding officer and the appellant within 30 days as specified in subsection (a) or by the date approved by the presiding officer as specified in subsection (b), unless there is an administrative or other emergency beyond the control of the presiding officer or the department. The due date for the department's summary may be modified by the presiding officer before or after the administrative or other emergency.

(d) If the responsibility for the preparation of the department's summary has been given to the secretary's designee, the secretary's designee shall meet the requirements of this regulation and any additional directives by the department.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-1-6-23, Jan. 6, 2023; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-18 Motions

(a) Each motion shall meet the following requirements, unless the motion is made during a state fair hearing:

(1) Be submitted in writing; and

(2) state with specificity the basis of the motion.

(b) Unless otherwise specified by the presiding officer, the opposing party shall have 15 days from the date of mailing, electronic filing, or personal delivery of the motion within which to file a response. The presiding officer may waive or change the deadline for good cause.

(c) Unless otherwise specified by the presiding officer, the party that filed the motion shall have five days from the date of mailing, electronic filing, or personal delivery of the response filed under subsection (b) within which to file a reply.

(d) The presiding officer on that individual's own motion or at the request of either party may conduct a state fair hearing on the motion. Each party requesting a state fair hearing shall include the request in the motion or response. The presiding officer may render a decision on the motion after receipt of the response, reply, and any state fair hearing on the motion.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-19 Prehearing resolution

The parties may settle or otherwise resolve the dispute before the date of the state fair hearing. The parties may also narrow and define the issues before the date of the state fair hearing.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-20 Dismissal; limitations

(a) Any state fair hearing may be considered for dismissal before the state fair hearing is convened. The party seeking to dismiss the state fair hearing shall use a written motion to dismiss the state fair hearing. Written motions to dismiss may be submitted in lieu of the department's summary when based on one of the reasons specified in this subsection. Each written motion to dismiss the state fair hearing shall state one of the following reasons and provide evidence, argument, and citations to federal or state law, regulation, policy, or manual that support the reason for dismissal:

(1) The appellant failed to submit a request for a state fair hearing within the timeliness standards specified in K.A.R. 129-7-11.

(2) The appellant failed to state a claim.

(3) The secretary has not taken an action adverse to the appellant.

(4) The secretary reversed its action.

(5) The request for a state fair hearing was submitted by an individual or entity without documentation of authorization from the applicant or beneficiary.

(6) The appellant challenges the validity of or states a disagreement with federal or state law, regulation, or policy. The department shall not submit a written motion to dismiss for a state fair hearing request in which the appellant is challenging an incorrect computation or determination by the secretary using the law, regulation, or policy.

(7) The secretary has taken an action required by federal or state law or regulation, including an automatic or mandated adjustment that is applied to a class of beneficiaries that included the appellant. The department shall not submit a written motion to dismiss for a state fair hearing in which the appellant is challenging an incorrect computation or determination by the secretary using the law, regulation, or policy.

(8) The secretary has taken an action required by the governor of the state of Kansas that is applied to a class of beneficiaries that included the appellant.

(b) Any written motion to dismiss may be filed with the presiding officer by the secretary or the secretary's designee who has been delegated authority to file the motion.

(d) If the secretary seeks to dismiss a state fair hearing on the basis that the action being appealed is based on federal or state law, regulations, or policy, including an action based upon changes in federal or state law, regulations, or policy, and the action taken by the secretary shall result in the termination, suspension, or reduction of medical assistance, including previously authorized and ongoing covered services, medical assistance shall continue until a decision concerning the request for dismissal is rendered.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-21 Presiding officer; decisions

(a) The presiding officer shall conduct a state fair hearing requested by an appellant concerning an action, as defined in K.A.R. 129-7-1, taken against the appellant by a respondent.

(b) The presiding officer shall weigh the evidence and determine the facts and conclusions of law pertinent to the state fair hearing.

(c) The presiding officer shall determine the facts and conclusions of law based on supporting and detracting testimony, documents, statutes, regulations, the state plan and its amendments, and policies allowed into the record of the state fair hearing by the presiding officer.

(d) The presiding officer shall control the state fair hearing. Unless preempted by federal or state law, the presiding officer conducting a state fair hearing under this article of the division's regulations shall use KAPA and may use Kansas civil procedure in the state fair hearing as needed.

(e) The presiding officer shall determine whether the action made by the respondent is due to a correct interpretation of the applicable statute, regulation, or policy.

(f) The presiding officer shall determine the basis for the state fair hearing. If the presiding officer determines the state fair hearing in favor of the appellant, the remedy ordered by the presiding officer shall be limited to orders that are within the lawful authority of the secretary to execute.

(1) If the basis for the appellant's state fair hearing request is a belief that the department has failed to determine eligibility in a timely manner and the presiding officer determines that the secretary has not determined eligibility in a timely manner, the presiding officer shall direct the secretary to determine eligibility within a specified period of time as the remedy. The presiding officer may determine whether to keep the current state fair hearing case open pending the completion of the eligibility process or may dismiss the case.

(2) If the presiding officer determines that the eligibility action challenged by the appellant required sequential decisions by the secretary or by two or more of the secretary's designees before eligibility could be correctly determined and that the sequential eligibility process had not been completed, the presiding officer may return the matter to the department that last took action. The presiding officer may direct the department to complete the sequential eligibility process, including forwarding the eligibility matter to the next secretary's designee in sequence, as the remedy. The presiding officer may determine whether to keep the current state fair hearing case open pending the completion of the eligibility process or to dismiss the case.

(3) If the presiding officer determines the state fair hearing in favor of the respondent, the action of the respondent shall be affirmed.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-22 Rehearing

(a) Any party, within 15 days after service of the presiding officer's decision, may file a petition for rehearing stating the specific grounds upon which the rehearing of the presiding officer's decision is requested.

(b) The presiding officer may grant a rehearing to either party on all or part of the issues when it appears that the rights of the party are substantially affected for any of the following reasons:

(1) An erroneous ruling by the presiding officer;

(2) a decision that, in whole or in part, is contrary to the evidence;

(3) newly discovered evidence that the moving party could not with reasonable diligence have discovered or produced at the hearing; or

(4) fraud, misrepresentation, or misconduct by an opposing party resulting in the order or proceeding.

(c) The filing of a petition for rehearing is not a prerequisite for review at any stage of the proceedings. The filing of a petition for rehearing does not stay any time limits or further proceedings that may be conducted under the Kansas administrative procedures act, K.S.A. 77-501 et seq. and amendments thereto, or any other provision of law.

(d) Once an initial order has been rendered, relief may be sought only through a petition for review to the secretary or the state appeals committee.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-23 Relief from preliminary or prehearing order

(a) During the pendency of a state fair hearing proceeding and before the rendering of the initial order by the presiding officer, any party to the state fair hearing proceeding may file with the presiding officer a motion for review of the ruling made by the presiding officer, stating the specific grounds upon which the review of the presiding officer's decision is requested.

(b) The presiding officer may relieve a party or its legal representative from order or proceeding for any of the following reasons:

(1) An erroneous ruling by the presiding officer;

(2) a decision that, in whole or in part, is contrary to the evidence;

(3) newly discovered evidence that the moving party could not with reasonable diligence have discovered or produced at the state fair hearing; or

(4) fraud, misrepresentation, or misconduct by an opposing party resulting in the order or proceeding.

(c) The filing of a motion for review under this regulation concerning preliminary matters shall not be a prerequisite for review at any other stage of the proceedings. The filing of a motion for review shall not affect any time limits or further proceedings that may be conducted under KAPA or any other provision of law.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-24 Transcripts

(a) If a transcript of a state fair hearing is requested, the requestor shall receive a digital recording from the presiding officer. A transcript of the state fair hearing may be prepared by a certified court reporter if requested by an appellant, the department, the presiding officer, the state appeals committee, or the secretary. The party requesting the transcript or review of the presiding officer's decision shall pay any costs associated in obtaining a transcript.

(b) If an appellant requests a transcript and signs a poverty affidavit, the costs of transcribing the recording shall be paid by the department.

(c) A transcript shall be prepared as required by K.S.A. 77-620, and amendments thereto, and have a signed certification on all copies as follows: "This is to certify that [Name of presiding officer] conducted a state fair hearing involving [Name of appellant] in [County], state of Kansas, on [Date] at [Time] and that the foregoing is a true and correct transcript of the record of the state fair hearing. [Signature of reporter]."

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-25 Review of an initial order or final order

(a) Any initial order may be reviewed by the secretary by giving notice of intent to do so and identifying the issues to be reviewed. This review shall include any proposed default order that becomes effective.

(1) Any party to a state fair hearing may request a review of the initial order within 15 days of the date the presiding officer served the order upon the parties pursuant to K.S.A. 77-527, and amendments thereto. When the order is served by U.S. mail or electronic means, pursuant to K.S.A. 77-531 and amendments thereto, three days shall be added to the 15-day review request period. The initial order may be reviewed by the secretary or the state appeals committee.

(2) Upon written request, authority may be granted by the secretary or the state appeals committee for the submission of additional written briefs or arguments that would assist in their deliberations.

(3) If the parties submit new evidence during the review of the initial order, the state appeals committee shall have discretion to remand the matter to the presiding officer for consideration of the new evidence if the new evidence could not have been presented during the state fair hearing.

(4) The decision from the secretary or the state appeals committee shall be the final order.

(5) The final order of the secretary or the state appeals committee shall be effective upon service unless stated otherwise in the final order or unless a stay has been granted pursuant to K.S.A. 77-528, and amendments thereto.

(b) Any final order may be reconsidered by the secretary in accordance with K.S.A. 77-529, and amendments thereto.

(c) The record, as defined in K.S.A. 77-532 and amendments thereto, shall be the basis for the review of the initial order or final order by the secretary or the state appeals committee.

(d) This regulation shall not apply to orders concerning determinations by skilled nursing facilities and nursing facilities to transfer or discharge a resident since the secretary is not the respondent.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-7-65 Revoked

Publisher status: INEFFECTIVE (not currently effective).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2005 Supp. 75-7412; effective June 30, 2006; revoked Dec. 27, 2024.)

Article 8 Medical Assistance Grievances, Appeals, and State Fair Hearings for Managed Care Enrollees

Kan. Admin. Regs. § 129-8-1 Applicability; definitions

(a) Applicability. This article of the division's regulations shall apply to grievances, appeals, and state fair hearings involving medical assistance enrollees who are receiving covered services from a managed care entity with a CMS approved contract with the secretary.

(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) "Adequate notice of adverse benefit determination" means a written document that is sent by the MCE to the enrollee or requesting provider at the time the MCE makes an adverse benefit determination and that meets the requirements specified in K.A.R. 129-8-4.

(2) "Adequate notice of appeal resolution" means a written document that is sent by the MCE to the enrollee and requesting provider that includes the MCE's resolution of the enrollee's appeal request and that meets the requirements specified in K.A.R. 129-8-4.

(3) "Adequate notice of approval" means a written document that is sent by the MCE to the enrollee and the requesting provider at the time the MCE approves a covered service authorization request and that meets the requirements specified in K.A.R. 129-8-8.

(4) "Adequate notice of external review decision" means a written document that is sent by the MCE to the enrollee and the provider that includes the external independent third-party reviewer's decision and meets the requirements specified in K.A.R. 129-9-4.

(5) "Adverse benefit determination" means a decision by the MCE for any of the following:

(A) The denial or limited authorization of a requested non-covered service or covered service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered service;

(B) the reduction, suspension, or termination of a previously authorized covered service;

(D) the failure of the MCE to act within required time frames, which constitutes a denial and an adverse benefit determination and are the following:

(i) The failure to resolve a grievance and send notice within the time frames specified in K.A.R. 129-8-3;

(ii) the failure of the MCE to resolve an appeal and send notice within the time frames specified in K.A.R. 129-8-7; and

(iii) the failure of the MCE to reach service authorization decisions within the time frames specified in K.A.R. 129-8-4;

(E) the denial of the enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities; and

(F) the placement of the enrollee into administrative lock-in due to the enrollee's persistent noncompliance with the requirements of care and treatment, abusive or threatening conduct by the enrollee, fraud or waste by the enrollee, or overuse of covered services, including LTSS, at a frequency or amount that is not medically necessary.

(6) "Appeal" means a review by the MCE of an adverse benefit determination. An appeal is not a local evidentiary hearing, a request to the presiding officer for a state fair hearing, or a grievance.

(7) "Days" means calendar days unless otherwise specified.

(8) "Grievance" means the expression of dissatisfaction to an MCE by the enrollee about any matter other than an adverse benefit determination. This term may include dissatisfaction with the quality of care or services provided, aspects of interpersonal relationships including rudeness of the provider or employee, and failure to respect the enrollee's rights regardless of whether the enrollee requests remedial action. This term shall include the enrollee's right to dispute an extension of time proposed by the MCE to make an authorization decision or resolve an appeal or grievance. An enrollee submitting a grievance shall not have state fair hearing rights.

(9) "Grievance and appeal system" means the grievance, appeal, and state fair hearing processes that are available to enrollees for expressions of dissatisfaction and for contesting adverse benefit determinations regarding covered services and non-covered services, as well as the process by which information is collected and tracked.

(10) "Lock-in" means the MCE's restriction of the enrollee's access to medical services because of the enrollee's abuse of medical services. Lock-in is accomplished through limitation of the use of the MCE's medical identification card to designated medical providers.

(11) "New healthcare service" means a covered service that an MCE has not previously authorized or a covered service that an MCE has previously authorized, but the authorization period for that covered service has expired at the time of the request for additional covered services.

(12) "PCCM" means a primary care case manager, including a physician, a physicians' group practice, or an entity that uses physicians, who provides primary care to the enrollee under a contract with the Kansas medical assistance program.

(13) "Send" means to deliver by U.S. mail or in electronic format.

(14) "Timely notice of adverse benefit determination" means an adequate notice of adverse benefit determination sent by the MCE to the enrollee within the time frames specified in K.A.R. 129-8-4.

(15) "Timely notice of appeal resolution" means an adequate notice of appeal resolution that is sent by the MCE to the enrollee within the time frames specified in K.A.R. 129-8-7.

(16) "Timely notice of approval" means an adequate notice of approval that is sent by the MCE to the enrollee within the time frames specified in K.A.R. 129-8-8.

(17) "Timely notice of external review decision" means an adequate notice of external review decision that is sent by the MCE to the enrollee and requesting provider within the time frame specified in K.A.R. 129-9-4.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-3 MCE member grievance

(a) Any enrollee may submit a grievance about any MCE matter other than an adverse benefit determination.

(b) Any enrollee may submit an oral or written grievance to the MCE at any time. Any enrollee may submit a grievance in person, by telephone, by U.S. mail, or by facsimile. Each written grievance delivered by the postal service or submitted by facsimile to the MCE shall be date-stamped when received by the MCE as proof of receipt.

(c) The MCE shall acknowledge each oral or written grievance received from the enrollee in writing within 10 days of receipt.

(d) The MCE shall resolve enrollee grievances and issue a notice of grievance resolution within 30 days from the date the MCE receives the grievance from the enrollee. The notice of grievance resolution shall meet with the requirements specified by the secretary.

(1) The MCE may extend this 30-day resolution time period up to 14 days, if the enrollee requests the extension or the MCE shows to the satisfaction of the secretary, upon the secretary's request, that there is need for additional information and how the delay is in the enrollee's interest.

(2) If the MCE extends the time frames not at the request of the enrollee, the MCE shall perform the following:

(A) Make reasonable efforts to give the enrollee prompt oral notice of the delay;

(B) within two days, give the enrollee written notice of the reason for the decision to extend the time frame and inform the enrollee of the right to submit a grievance if the enrollee disagrees with that decision; and

(C) resolve the grievance as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(e) Any enrollee may submit a request for grievance to the secretary if the enrollee is unable to obtain medical care that accommodates the member's culturally based attitudes, beliefs, and needs. The enrollee shall complete the MCE's grievance process before submitting a request for grievance to the secretary.

(f) The enrollee's right to submit a grievance shall not be limited or interfered with by the secretary or the MCE.

(g) The MCE shall cooperate with the state, the state's fiscal agent, or representatives of either, to resolve all enrollee grievances. Cooperation may include providing internal enrollee grievance information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 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 K.A.R. 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 self-representation 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.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-5 Continuation of covered services for MCE enrollees; applicability

This regulation shall apply to continuation of non-waiver and waiver covered services when an enrollee requests an appeal or a state fair hearing involving an adverse benefit determination by the MCE.

(a) Any enrollee currently receiving non-waiver covered services may submit a request to the MCE to continue receiving non-waiver covered services while an appeal and state fair hearing decision are pending.

(1) Any enrollee who has received an MCE's adequate notice of adverse benefit determination that reduces, suspends, or terminates a previously authorized non-waiver covered service may submit a request to the MCE to continue the enrollee's covered services while an appeal decision is pending. To timely file a request, the enrollee shall submit a request to continue the enrollee's covered services on or before the later of the following:

(A) Within 10 days of the MCE sending the adequate notice of adverse benefit determination; or

(B) on the intended effective date of the MCE's proposed adverse benefit determination.

(2) The MCE shall continue the enrollee's non-waiver covered services while the appeal decision is pending if all of the following conditions are met:

(A) The enrollee timely files a request for an appeal, as timely is defined in K.A.R. 129-8-7.

(B) The appeal involves the termination, suspension, or reduction of previously authorized covered services.

(D) The period covered by the original authorization has not expired.

(E) The enrollee timely files for continuation of covered services.

(3) Any enrollee who has received an MCE's adequate notice of appeal resolution that upholds the MCE's decision to reduce, suspend, or terminate a previously authorized non-waiver covered service may submit a request to the MCE to continue the enrollee's covered services while a state fair hearing decision is pending. To timely file a request, the enrollee shall submit a request for a state fair hearing and a request to continue the enrollee's covered services within 10 days after the MCE sends the adequate notice of appeal resolution.

(4) If the enrollee fails to request a state fair hearing and continuation of covered services within 10 days, the covered services continued pending the appeal decision shall end 10 days following the sending date of the MCE's adequate notice of appeal resolution. If the enrollee requests a state fair hearing and continuation of covered services within 10 days, the MCE shall continue the covered services until the presiding officer in the state fair hearing issues the decision.

(5) The MCE shall continue the enrollee's non-waiver covered services while the appeal or state fair hearing decisions are pending until one of the following conditions is met:

(A) The enrollee withdraws the appeal or request for state fair hearing.

(B) The enrollee fails to request a state fair hearing and continuation of non-waiver covered services within 10 days after the MCE sends the adequate notice of appeal resolution.

(D) 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.

(6) If the authorized time period for non-waiver covered services has not expired at the time of the request for continued covered services but would expire while the covered services were being continued pending the appeal or state fair hearing decision, the MCE shall continue the covered services until 10 days following the sending date of the MCE's adequate notice of appeal resolution unless the enrollee requests a state fair hearing and continuation of covered services. If the enrollee requests a state fair hearing and continuation of covered services within 10 days, the MCE shall continue the covered services until the presiding officer in the state fair hearing issues the decision.

(7) If the final resolution of the appeal or state fair hearing is adverse to the enrollee and upholds the MCE's adverse benefit determination, the MCE may institute recovery procedures against the enrollee to recover the cost of any non-waiver covered services furnished the enrollee, to the extent that the covered services were furnished solely by reason of this regulation.

(b) Any enrollee currently receiving waiver covered services may continue to receive waiver covered services while an appeal and state fair hearing decision are pending.

(1) The enrollee who has received an MCE's adequate notice of adverse benefit determination that reduces, suspends, or terminates a previously authorized waiver covered service shall not be required to submit a request to the MCE to continue the enrollee's covered services while an appeal decision is pending.

(2) The MCE shall continue the enrollee's current waiver covered services for 63 days following the date of the adequate notice of adverse benefit determination.

(3) If the enrollee fails to timely file a request for an appeal, as timely is defined in K.A.R. 129-8-7, the continued waiver covered services shall end.

(4) If the enrollee timely files a request for an appeal, the MCE shall continue the enrollee's current waiver covered services as specified in the state plan, an amendment to the state plan, a waiver, or a CMS-approved contract between the secretary and the MCE.

(5) If the enrollee fails to timely file a request for a state fair hearing, as timely is defined in K.A.R. 129-8-11, the continued waiver covered services shall end.

(6) If the enrollee timely files a request for a state fair hearing, the MCE shall continue the enrollee's current waiver covered services until the presiding officer in the state fair hearing issues the decision.

(7) If the enrollee withdraws the appeal or state fair hearing request, the continued waiver covered services shall end on the date the enrollee requests the withdrawal.

(8) If the final resolution of the appeal or state fair hearing is adverse to the enrollee receiving waiver covered services and upholds the MCE's adverse benefit determination, then to the extent that the waiver covered services were furnished solely by reason of this regulation, the enrollee shall not have to pay the MCE for waiver covered services unless fraud has occurred.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-7 Enrollee appeal

(a) Any enrollee may submit a request for an appeal to the MCE if the basis of the request is an adverse benefit determination.

(b) Any enrollee may submit an oral or written appeal to the MCE. Any enrollee may request an appeal in person, by telephone, by U.S. mail, or by facsimile. Each written appeal delivered by the postal service or submitted by facsimile to the MCE shall be date-stamped when received by the MCE as proof of receipt. The MCE shall use the date of receipt to determine timeliness of the request.

(c) Following receipt of an oral appeal, the MCE shall attempt to obtain the appeal in writing. The MCE shall not require a written form from the enrollee for an oral appeal and shall process and resolve the oral appeal in accordance with subsections (d) through (g).

(d) Each MCE shall provide the enrollee with the opportunity to submit a request for an appeal following receipt of the MCE's notice of adverse benefit determination. For each appeal under this article of the division's regulations to be considered timely, the request shall be received by the MCE within 60 days from the date of the 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.

(e) The MCE shall acknowledge, in writing, each appeal received from the enrollee within five days of receipt.

(f) The MCE shall resolve each appeal and send a notice of appeal resolution within 30 days from the date the MCE receives the appeal from the enrollee, unless the appeal requires expedited resolution. The notice of appeal resolution shall meet the requirements specified in K.A.R. 129-8-4.

(1) The MCE may extend this 30-day resolution time period up to 14 days if the enrollee requests the extension or the MCE shows, to the satisfaction of the secretary, upon the secretary's request, that there is need for additional information and how the delay is in the enrollee's interest.

(2) If the MCE extends the time frame not at the request of the enrollee, the MCE shall perform the following:

(A) Make reasonable efforts to give the enrollee prompt oral notice of the delay;

(B) within two days, give the enrollee written notice of the reason for the decision to extend the time frame and inform the enrollee of the right to file a grievance if the enrollee disagrees with that decision; and

(C) resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(g) Each MCE shall provide the enrollee with the opportunity to submit a request for an expedited appeal if the enrollee indicates that there is a risk to the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. Each MCE shall establish and maintain an expedited review process for appeals if the MCE determines that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function.

(1) The MCE shall resolve expedited appeals and issue a notice of appeal resolution within 72 hours from the time the MCE received the earliest request for an expedited appeal from the enrollee. The notice of appeal resolution shall meet the requirements specified in K.A.R. 129-8-4.

(2) The MCE may extend the 72-hour resolution time period up to 14 days if the enrollee requests the extension or the MCE shows to the satisfaction of the secretary, upon the secretary's request, that there is need for additional information and how the delay is in the enrollee's interest.

(3) If the MCE extends the time frame not at the request of the enrollee, the MCE shall complete the following:

(A) Make reasonable efforts to give the enrollee prompt oral notice of the delay;

(B) within two calendar days, give the enrollee written notice of the reason for the decision to extend the time frame and inform the enrollee of the right to file a grievance if the individual disagrees with that decision; and

(C) resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(h) The enrollee shall complete the MCE's appeal process before requesting a state fair hearing.

(i) If the MCE fails to adhere to the resolution and notification requirements in this regulation or in K.A.R. 129-8-3, the enrollee shall be deemed to have exhausted the MCE's appeal process. The enrollee may initiate a state fair hearing.

(j) The enrollee's right to request an appeal shall not be limited or interfered with by the department or the MCE.

(k) The MCE shall consider the enrollee or an estate representative of a deceased enrollee as a party to the appeal. The enrollee may seek a state fair hearing if the enrollee is not satisfied with the MCE decision in response to an appeal.

(l) If the MCE reverses a decision to deny, limit, or delay covered services that were not furnished while the appeal was pending, the MCE shall authorize or provide the disputed covered services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date the MCE reverses its decision.

(m) If the MCE reverses a decision to deny authorization of covered services and the enrollee received the disputed covered services while the appeal was pending, the MCE shall pay for those covered services.

(n) The MCE shall ensure that punitive action is not taken against any provider who requests an appeal on the enrollee's behalf or supports the enrollee's appeal request.

(o) The MCE shall cooperate with the secretary, the secretary's fiscal agent, or representatives of either to resolve all enrollee appeals. Cooperation may include providing internal enrollee appeal information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-8 Notices to enrollees; applicability

This regulation shall apply to adequate and timely notices of approval sent to enrollees by the MCE regarding approval of a covered service authorization request.

(a) Each MCE shall send an adequate notice of approval to the enrollee, the enrollee's authorized representative, and the requesting provider when the MCE fully or partially approves a covered service authorization request submitted by an enrollee or on behalf of an enrollee, when the MCE fully or partially approves a covered service authorization request following an appeal resolution, and when the MCE approves a covered service authorization request following a decision by a presiding officer that reverses the MCE's adverse benefit determination.

(b) Each adequate notice of approval shall include the following:

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

(2) the date the MCE made the approval;

(3) the approval decision the MCE has made, including the dates, types, and amount of service requested; and

(4) the effective date and, if applicable, the end date of the approved covered service authorization request.

(c) The MCE shall send a timely notice of approval to the enrollee, the enrollee's authorized representative, and the requesting provider within the time frames specified in paragraphs (c)(1) through (c)(3). A timely notice of approval shall include the contents of an adequate notice of approval as specified in subsection (b).

(1) The MCE shall send an adequate notice of approval when the MCE approves a covered service authorization request within the following time frames:

(A) For standard authorization decisions, the MCE shall make an authorization decision and send an adequate notice of approval 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 the reason that the extension is in the enrollee's interest. If the time frame for the decision is extended by up to 14 days, the MCE shall send an adequate notice of approval no later than 28 days after the MCE's receipt of the request for service.

(B) For expedited authorization decisions, 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 of approval 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 time frame for the decision is extended by up to 14 days, the MCE shall send an adequate notice of approval no later than 14 days after the date of the extension decision.

(2) The MCE shall send a timely notice of approval when the MCE approves a covered service authorization request following resolution of an enrollee's appeal within the following time frames:

(A) For standard authorization approval decisions made by the MCE following resolution of an appeal, the MCE shall resolve the appeal and send an adequate notice of approval as expeditiously as the enrollee's condition requires and no later than 30 days after the MCE's receipt of the appeal. The MCE may extend the 30-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 the reason that the extension is in the enrollee's interest. If the resolution time frame is extended by up to 14 days, the MCE shall resolve the appeal and send an adequate notice of approval no later than 14 days after the date of the extension decision.

(B) For expedited authorization approval decisions made by the MCE following resolution of an appeal, if the provider indicates, or the MCE determines, that following the standard time frame for appeal resolution could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, the MCE shall resolve the appeal and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE's receipt of the request for appeal. 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 the reason that the extension is in the enrollee's interest. If the resolution time frame is extended by up to 14 days, the MCE shall resolve the appeal and send an adequate notice of approval no later than 14 days after the date of the extension decision.

(C) If the MCE extends the resolution time frames in paragraph (b)(2)(A) or (b)(2)(B), the MCE shall make reasonable efforts to give the enrollee prompt oral notice of the delay. Within two calendar days, the MCE shall give the enrollee written notice of the reason for the decision to extend the time frame and inform the enrollee of the right to file a grievance if the enrollee disagrees with that decision. The MCE shall resolve the appeal and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(3) The MCE shall send a timely notice of approval when a presiding officer reverses an MCE's adverse benefit determination within the time frame specified in this paragraph. For adverse benefit determination decisions reversed by a presiding officer, the MCE shall authorize the disputed services and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE receives notice of the presiding officer's reversal of the determination. If the department files a petition for review to SAC, the adequate notice of approval shall be delayed until the department receives notice of the SAC decision affirming the presiding officer's reversal of the adverse benefit determination.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 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 K.A.R. 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 K.A.R. 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 K.A.R. 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 K.A.R. 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.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-11 Request for state fair hearing; timeliness

(a) For each request for a standard state fair hearing under this article of the division's regulations to be considered timely, the request shall be received by the MCE or the secretary's designee for the state fair hearing according to the following time frames:

(1) For each standard state fair hearing request by the enrollee involving the MCE's adverse benefit determination, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 120 days from the date of the adequate notice of appeal resolution. If the 120th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) For each standard state fair hearing request by the enrollee involving the MCE's denial of an authorization for a new healthcare service that was reviewed by the external independent third-party reviewer, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 30 days from the date of the MCE's adequate notice of external review decision pursuant to K.S.A. 39-709i, and amendments thereto. If the 30th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(3) For each standard state fair hearing request by the enrollee involving the enrollee's request to disenroll from the enrollee's MCE, the request shall be received by the secretary or the secretary's designee for the state fair hearing within 30 days from the date of the secretary's adequate notice of action. If the 30th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(4) The presiding officer shall issue an initial order in a standard state fair hearing within 90 days from the date the presiding officer receives a request for a state fair hearing, except when the request for a state fair hearing involves the issue being reviewed by the external independent third-party reviewer or when the presiding officer allows an extension.

(b) For each request for an expedited state fair hearing under this article of the division's regulations to be considered timely, the request shall be received by the MCE or the secretary's designee for the state fair hearing according to the following time frames:

(1) For each request for an expedited state fair hearing involving the MCE's adverse benefit determination, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 120 days from the date of the written adequate notice of appeal resolution. If the 120th day falls on a non-business day for the state, the time period for receipt of a request for an expedited state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) For each expedited state fair hearing request by the enrollee involving the MCE's denial of an authorization for a new healthcare service that was reviewed by the external independent third-party reviewer, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 30 days from the date of the MCE's adequate notice of external review decision pursuant to K.S.A. 39-709i, and amendments thereto. If the 30th day falls on a non-business day for the state, the time period for receipt of a request for an expedited state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(3) Any enrollee may request an expedited state fair hearing following any appeal of a denial of a service that, as indicated by the MCE, meets the criteria for expedited resolution of the appeal but was not resolved within the time frame for expedited resolution of the appeal by the MCE or was resolved within the time frame for expedited resolution of the appeal, but the MCE reached a decision wholly or partially adverse to the enrollee.

(4) The presiding officer shall schedule the expedited state fair hearing and issue an initial order as expeditiously as the enrollee's health condition requires, but no later than three business days after the presiding officer receives from the MCE the case file and information for any request that meets the criteria specified in subsection (b).

(c) Any enrollee may submit an oral or written request for a standard or expedited state fair hearing with the MCE. Any enrollee may submit a written request for a standard or expedited state fair hearing with the secretary's designee for the state fair hearing. Oral, telephonic, or electronic requests for a standard or an expedited state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(d) Any request for a standard or expedited state fair hearing made by telephone or other electronic means and received by the MCE during normal business hours may be accepted as a valid request for a standard or expedited state fair hearing by the MCE if the request and proof of receipt are documented, dated, and reduced to writing by the MCE. The date and time of the telephonic or electronic request for a standard or expedited state fair hearing shall be used to determine the timeliness of the request even if there is a delay by the MCE in reducing the request to writing. Oral, telephonic, or electronic requests for a standard or expedited state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(e) The MCE shall forward each request for a standard or expedited state fair hearing received by the MCE to the secretary's designee for the state fair hearing within one business day of receipt.

(f) If a written request for a standard or expedited state fair hearing is received by the MCE, the MCE shall date-stamp the request when received as proof of receipt. The timeliness standards specified in subsections (a) and (b) shall apply with the date of receipt by the MCE being used to determine the timeliness of the request.

(g) If the enrollee sends a written request for a standard or expedited state fair hearing directly to the secretary's designee for the state fair hearing, the timeliness standards specified in subsections (a) and (b) shall apply with the date of receipt by the secretary's designee being used to determine the timeliness of the request.

(1) The presiding officer cannot reach a decision because the appellant requests a delay or fails to take a required action.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 39-709i, 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-12 Evidentiary standard; burden of proof

(a) Unless preempted by federal or state law, a preponderance of the evidence shall be the evidentiary standard used for state fair hearings under this article of the division's regulations.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-13 Parties

(1) The named appellant in the case caption shall be the enrollee, except as specified in subsections (d) through (g). Any authorized representative of the enrollee may request a state fair hearing.

(A) A state fair hearing may be requested only by or on behalf of the appellant receiving covered services and benefits.

(B) Any appellant receiving covered services and benefits may designate, in writing, an individual or entity to request a state fair hearing and represent the appellant in a state fair hearing. The appellant shall be the only individual who can grant another individual or entity the authorization to request a state fair hearing and represent the appellant in a state fair hearing subject to the exception in paragraph (a)(1)(C).

(2) The named respondent in the case caption shall be the department that administers the program involved in the MCE's adverse benefit determination or the secretary involved in the adverse disenrollment decision, except as specified in subsection (h).

(A) If the matter involves the MCE's adverse benefit determination, the department that administers the program shall be the real party in interest. The respondent shall be the department and the case caption shall note the MCE beneath the case number. The MCE shall be an interested party in the matter. As an interested party, the MCE, in meeting its contractual responsibilities, shall review the state fair hearing matter to determine whether the following conditions are met:

(i) The MCE appeal process has been completed.

(ii) The matter was filed within the regulatory time frames.

(iii) The matter involves an adverse benefit determination.

(B) If the MCE determines that the matter has not met any of the conditions specified in paragraphs (a)(2)(A)(i)-(iii), the MCE shall submit a request to the presiding officer to dismiss the matter, subject to the approval by the department.

(C) If the matter involves an adverse disenrollment decision made by the secretary against the enrollee, the secretary shall be the real party in interest. The secretary shall be named as the respondent. The state fair hearing matter shall be reviewed by the secretary or the secretary's designee to determine whether the following conditions are met:

(i) The matter was filed within the regulatory time frames.

(ii) The matter involves an adverse disenrollment decision.

(D) If the secretary determines that the matter has not met either of the conditions specified in paragraphs (a)(2)(C)(i) and (ii), a request to the presiding officer to dismiss the matter shall be submitted by the secretary or the secretary's designee.

(b) The presiding officer conducting the state fair hearing may grant a motion to modify the case caption to clarify the parties.

(c) Any enrollee may authorize representation by legal counsel, a relative, a friend, or a spokesperson in the state fair hearing if the enrollee has authorized the representation in writing. This regulation shall not authorize the secretary or the presiding officer to grant exceptions to the Kansas supreme court rules concerning the practice of law in Kansas if the enrollee is represented by an attorney who is not licensed in Kansas.

(d) If the enrollee has died before filing a request for a state fair hearing, then an administrator or executor appointed by a court in the estate proceedings of the deceased enrollee may file the request for a state fair hearing. The appellant shall be the estate of the deceased enrollee.

(e) If the enrollee has died after filing a request for a state fair hearing, then an administrator or executor appointed by a court in the estate proceedings of the deceased enrollee may move to substitute the estate of the deceased enrollee as the appellant.

(f) The appellant may be an entity other than the enrollee in any of the following circumstances:

(1) If the matter involves a denial of an authorization for a new healthcare service made by the MCE against the enrollee, the appellant may be the provider who would have received reimbursement if the MCE had approved the authorization.

(2) If the matter involves an action by the MCE concerning a claim for payment for medical services that have already been provided to the enrollee and the enrollee will not be responsible for the payment of the medical services if the claim is denied by the MCE, the appellant may be the provider, and the case shall follow the requirements stated in article 9 of the division's regulations.

(3) If the matter involves an adverse benefit determination and an entity other than the enrollee seeks to be named the appellant, the presiding officer shall determine whether the entity seeking to be named as appellant is the real party in interest instead of the enrollee.

(g) For each state fair hearing requested by the losing party of the external independent third-party review, the appellant may be the department that administers the program or payment involved in the MCE's denial of an authorization for a new healthcare service.

(h) For each state fair hearing requested by the losing party of the external independent third-party review, the respondent may be the enrollee if the issue is a denial of an authorization for a new healthcare service.

(i) If a presiding officer allows an entity to intervene in a state fair hearing covered by this article of the division's regulations pursuant to KAPA, the intervening entity shall be identified in the caption of the case as an intervenor.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-14 Department's review of decision

(a) Upon receipt of notice that a request for state fair hearing has been made, the MCE's adverse benefit determination, and any decision by the external independent third-party reviewer, shall be reviewed by the department. Upon review, the MCE's decision may be amended or changed before or during the state fair hearing as directed by the department.

(b) If the parties reach a satisfactory adjustment before the state fair hearing, a written request to dismiss the state fair hearing request shall be submitted by the MCE or the department to the presiding officer, but the state fair hearing request shall remain pending until the following are completed:

(1) Upon receipt of the MCE's or the department's request to dismiss, the presiding officer shall issue a prehearing order to the appellant providing a 15-day response time. If the 15th day falls on a non-business day for the state, the 15-day response time shall be extended to the next business day on which the department is open for business. Three days shall be added to the 15-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) If the appellant responds to the presiding officer within the above response time, the respondent may reply within five days.

(3) The presiding officer shall review the appellant's response and any respondent's reply and make a determination regarding the MCE's or the department's request to dismiss.

(4) If the appellant fails to respond to the presiding officer's order within the above response time, the presiding officer may dismiss the state fair hearing request.

(1) For telephonic, internet, and in-person withdrawals, the appellant shall be provided with written confirmation, by regular U.S. mail or electronic notification.

(3) If the appellant submits a signed, written statement withdrawing the appellant's request for a state fair hearing, the presiding officer shall close the state fair hearing request.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-17 Department's summary

(a) Within 30 days of the date of the acknowledgement and order issued by the presiding officer in response to a request for state fair hearing, the appellant and the presiding officer shall be furnished by the department with a summary providing the following information and exhibits:

(1) The appellant's name and address;

(2) a summary statement concerning why the appellant is filing a request for a state fair hearing;

(3) a brief and relevant chronological summary of the events that occurred in relationship to the appellant's request for a state fair hearing;

(4) a statement of the basis of the adverse benefit determination;

(5) a citation to and copy of the applicable policies or member handbook excerpts relied upon for the adverse benefit determination. The applicable medical necessity criteria or guidelines used in making medical necessity decisions shall be included;

(6) a citation to or copy of the applicable Kansas and federal statutes and regulations relied upon for the adverse benefit determination;

(7) a citation to or copy of the applicable state plan or waiver documents relied upon for the adverse benefit determination;

(8) a copy of the notice that notified the appellant of the decision in question and any subsequent notices;

(9) a copy of any applicable correspondence;

(10) the name and title of each person who will testify or represent the department at the state fair hearing; and

(11) for state fair hearings involving a decision by the external independent third-party reviewer, copies of the notice of provider appeal resolution, all of the provider appeal documentation submitted to and reviewed by the external reviewer, the MCE's acknowledgement of receipt of the request for external review, the external reviewer's decision letter, and the MCE's notice of external reviewer's decision.

(b) Upon written request by the department, the presiding officer assigned to the state fair hearing may grant additional time for the completion of the summary. The presiding officer shall file notification of the approval or denial of the extension request. If approved, the notification shall include the revised due date for the department's summary.

(c) If the responsibility for the preparation of the department's summary has been given to the secretary's designee, the secretary's designee shall meet the requirements of this regulation and any additional directives by the department.

(d) If a member or a provider submits a state fair hearing request regarding an MCE's decision that is subsequently reviewed by the external independent third-party reviewer and a department summary has been submitted to the presiding officer for one or both state fair hearing requests, the department or the department's designee shall not be required to submit a second department summary if a member or a provider submits a state fair hearing request regarding the same MCE decision following the decision by the external independent third-party reviewer. An addendum to the department summary may be submitted in lieu of an additional department summary.

(e) If the state fair hearing request involves a decision by the external independent third-party reviewer and the department is the appellant, the department or the department's designee shall furnish to the respondent and the presiding officer a summary providing the information and exhibits specified in subsection (a). The exhibits shall include all documents reviewed and relied upon by the external independent third-party reviewer for its decision.

(f) The department's summary shall be submitted to the presiding officer and the appellant within 30 days as specified in subsection (a) or by the date approved by the presiding officer as specified in subsection (b) unless there is an administrative or other emergency beyond the control of the presiding officer or the department. The due date for the department's summary may be modified by the presiding officer before or after the administrative or other emergency.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-1-6-23, Jan. 6, 2023; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-18 Motions

(a) Each motion shall meet the following requirements, unless the motion is made during a state fair hearing:

(1) Be submitted in writing; and

(2) state with specificity the basis of the motion.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-19 Prehearing resolution

The parties may settle or otherwise resolve the dispute before the date of the state fair hearing. The parties may also narrow and define the issues before the date of the state fair hearing.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-20 Dismissal; limitations

(1) The appellant failed to submit a request for a state fair hearing within the timeliness standards specified in K.A.R. 129-8-11.

(2) The appellant failed to submit a request for appeal of the adverse benefit determination to the MCE in accordance with K.A.R. 129-8-7 before submitting a request for a state fair hearing.

(3) The appellant failed to state a claim.

(4) The department or the MCE has not taken an action pursuant to K.A.R. 129-7-1 or made a benefit determination adverse to the appellant pursuant to K.A.R. 129-8-1.

(5) The department or MCE reversed its action or adverse benefit determination.

(6) The request for a state fair hearing was submitted by an individual or entity without documentation of authorization from the appellant.

(7) The appellant challenges the validity of or states a disagreement with federal or state law, regulation, or policy. The department shall not submit a written motion to dismiss for a state fair hearing request in which the appellant is challenging an incorrect computation or determination by the department or the MCE using the law, regulation, or policy.

(8) The department or the MCE has taken an action, required by federal or state law or regulation, including an automatic or mandated adjustment that is applied to a class of enrollees that included the appellant. The department shall not submit a written motion to dismiss for a state fair hearing request in which the appellant is challenging an incorrect computation or determination by the department or the MCE using the law, regulation, or policy.

(9) The department has taken an action required by the governor of the state of Kansas that is applied to a class of enrollees that included the appellant.

(b) Any written motion to dismiss may be filed with the presiding officer by the department or the department's designee who has been delegated authority to file the motion.

(d) If the department or the MCE seeks to dismiss a state fair hearing on the basis that the adverse benefit determination being appealed is based on federal or state law, regulations, or policy, including an adverse benefit determination based upon changes in federal or state law, regulations, or policy, and the adverse benefit determination made by the department or the MCE shall result in the termination, suspension, or reduction of covered services, the covered services shall continue until a decision concerning the request for dismissal is rendered.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-21 Presiding officer; decisions

(a) The presiding officer shall conduct a state fair hearing requested by an appellant concerning an adverse benefit determination as defined in K.A.R. 129-8-1, a denial by the secretary of the enrollee's request to disenroll from the enrollee's MCE, or a decision by the external independent third-party reviewer.

(b) The presiding officer assigned to administer the state fair hearing shall weigh the evidence and determine the facts and conclusions of law pertinent to the state fair hearing.

(e) The presiding officer shall determine the basis for the state fair hearing.

(f) If the presiding officer determines the state fair hearing in favor of the appellant, the remedy ordered by the presiding officer shall be limited to orders that are within the lawful authority of the secretary to execute.

(g) For state fair hearings that do not involve a decision by the external independent third-party review, the presiding officer shall determine whether the adverse benefit determination made by the respondent is due to a correct interpretation of the applicable statute, regulation, or policy. If the presiding officer determines the state fair hearing in favor of the respondent, the presiding officer shall affirm the adverse benefit determination of the respondent. If the presiding officer determines the state fair hearing in favor of the appellant, the remedy ordered by the presiding officer shall be limited to orders that are within the lawful authority of the secretary to execute.

(h) For state fair hearings that involve a decision by the external independent third-party review, the presiding officer shall determine whether the decision made by the external independent third-party reviewer is due to a correct interpretation of the applicable statute, regulation, or policy.

(1) If the presiding officer determines the state fair hearing in favor of the respondent and the respondent is a department, the remedy ordered by the presiding officer shall be limited to orders that affirm the department's action reviewed by the external independent third-party reviewer. If the presiding officer determines the state fair hearing in favor of the appellant and the appellant is the enrollee, the remedy ordered by the presiding officer shall be limited to orders that reverse the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. The presiding officer shall issue orders that are within the lawful authority of the secretary to execute.

(2) If the presiding officer determines the state fair hearing in favor of the respondent and the respondent is the enrollee, the remedy ordered by the presiding officer shall be limited to orders that reverse the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. If the presiding officer determines the state fair hearing in favor of the appellant and the appellant is a department, the remedy ordered by the presiding officer shall be limited to orders that affirm the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. The presiding officer shall issue orders that are within the lawful authority of the secretary to execute.

(i) If the presiding officer determines that the adverse benefit determination challenged by the appellant required sequential decisions by the same department, or by two or more departments, before a decision could be correctly determined and that the sequential process had not been completed, the presiding officer may remand the matter to the department that last took action in the matter. The presiding officer may direct the departments to complete the sequential process, including forwarding the matter to the next department in sequence, as the remedy. The presiding officer may determine whether to keep the current state fair hearing case open pending the completion of the process or to dismiss the case.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-22 Rehearing

(b) The presiding officer may grant a rehearing to either party on all or part of the issues when it appears that the rights of the party are substantially affected for any of the following reasons:

(1) An erroneous ruling of the presiding officer;

(2) a decision that, in whole or in part, is contrary to the evidence;

(3) newly discovered evidence that the party which filed the motion could not with reasonable diligence have discovered or produced at the hearing; or

(4) fraud, misrepresentation, or misconduct by an opposing party resulting in the order or proceeding.

(d) Once an initial order has been rendered, relief may be sought only through a petition for review to the secretary or the state appeals committee.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-23 Relief from preliminary or prehearing order

(b) The presiding officer may relieve a party or its legal representative from an order or proceeding for any of the following reasons:

(1) An erroneous ruling by the presiding officer;

(2) a decision that, in whole or in part, is contrary to the evidence;

(3) newly discovered evidence that the moving party could not with reasonable diligence have discovered or produced at the state fair hearing; or

(4) fraud, misrepresentation, or misconduct by an opposing party resulting in the order or proceeding.

(c) The filing of a motion for review under this regulation shall not be a prerequisite for review at any stage of the proceedings. The filing of a motion for review shall not affect any time limits or further proceedings that may be conducted under KAPA or any other provision of law.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-24 Transcripts

(b) If an appellant requests a transcript and signs a poverty affidavit, the costs of transcribing the recording shall be paid by the department.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-8-25 Review of an initial order or final order

(a) Any initial order of a presiding officer may be reviewed by the secretary by giving notice of intent to do so and identifying the issues to be reviewed. This review shall include any proposed default order that becomes effective.

(1) Any party to a state fair hearing may request a review of the initial order within 15 days of the date the presiding officer served the order upon the parties pursuant to K.S.A. 77-527, and amendments thereto. When the order is served by U.S. mail or electronic means, three days shall be added to the 15-day review request period. The initial order may be reviewed by the secretary or the state appeals committee.

(4) The decision from the secretary or the state appeals committee shall be the final order.

(b) Any final order may be reconsidered by the secretary in accordance with K.S.A. 77-529, and amendments thereto.

(c) The record, as defined in K.S.A. 77-532 and amendments thereto, shall be the basis for the review of the initial order or final order by the secretary or the state appeals committee.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Article 9 Medical Assistance Grievances, Reconsideration, Appeals, External Independent Third-Party Review, and State Fair Hearings Involving Providers

Kan. Admin. Regs. § 129-9-1 Applicability; definitions

(a) Applicability. This article of the division's regulations shall apply to grievances, reconsiderations, appeals, external independent third-party reviews, and state fair hearings involving providers of medical care to enrollees of MCEs and to grievances and state fair hearings involving providers of medical care to FFS beneficiaries.

(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) "Action" and "adverse action" mean a decision by the secretary or the MCE to perform any of the following:

(A) Deny payment for a requested non-covered service or covered service, in whole or in part;

(B) determine and recoup an overpayment of funds made to a provider that was identified through a post-payment review;

(C) terminate a KMAP provider's status as a KMAP provider as specified by K.A.R. 129-9-15. A decision by the MCE to terminate, suspend, or limit a provider's status as an MCE network provider shall not be included in this definition; or

(D) deny a provider's KMAP application as specified by K.A.R. 129-9-15. A decision by the MCE to deny a provider's application to be an MCE network provider shall not be included in this definition.

(2) "Adequate notice of action" means a written document or remittance advice that is sent by the MCE to a provider for an action taken, or sent by the secretary to a provider for an action taken, that meets the requirements specified in K.A.R. 129-9-4 and K.A.R. 129-9-5.

(3) "Adequate notice of administrative review" means a written document that is sent by the secretary to a provider that includes the secretary's decision following the administrative review and that meets the requirements specified in K.A.R. 129-9-5.

(4) "Adequate notice of appeal resolution" means a written document or remittance advice that is sent by the MCE to the provider that includes the MCE's resolution of the provider's appeal request and that meets the requirements specified in K.A.R. 129-9-4.

(5) "Adequate notice of approval" means a written document or remittance advice that is sent by the MCE to the provider at the time the MCE approves a service authorization request or payment and that meets the requirements specified in K.A.R. 129-9-8.

(6) "Adequate notice of external review decision" means a written document that is sent by the MCE to the enrollee and the provider that includes the external independent third-party reviewer's decision and that meets the requirements specified in K.A.R. 129-9-4.

(7) "Adequate notice of reconsideration resolution" means a written document or remittance advice that is sent by the MCE to the provider that includes the MCE's resolution of the provider's reconsideration request and that meets the requirements specified in K.A.R. 129-9-4.

(8) "Administrative review" means a review by the secretary of evidence submitted by the provider following notification from the secretary of KMAP's intent to terminate the provider's participation in KMAP.

(9) "Appeal" means a review by the MCE of an adverse action or adverse benefit determination. An appeal is not a local evidentiary hearing, a request for a state fair hearing, or a grievance.

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

(11) "External independent third-party review" means a review by the secretary or secretary's designee of a final decision of the MCE's internal appeal process involving a denial of an authorization for a new healthcare service to the enrollee or a claim for reimbursement to the provider for a healthcare service rendered to the enrollee.

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

(A) The expression of dissatisfaction to an MCE by a provider of covered services to an enrollee about any matter other than an MCE's adverse benefit determination as defined in 129-8-1 or an MCE's action as defined in this subsection. A provider submitting a grievance to an MCE shall not have state fair hearing rights.

(B) The expression of dissatisfaction to the secretary by a provider of covered services to an FFS beneficiary about any FFS matter including actions involving payment for FFS covered services. A provider submitting an FFS grievance shall have state fair hearing rights if the matter involves an action.

(13) "Grievance and appeal system" means either of the following:

(A) The grievance, reconsideration, appeal, and state fair hearing processes that are available to providers of medical care to enrollees for expressions of dissatisfaction and for contesting adverse actions regarding payment for covered services rendered to enrollees, as well as the process to collect and track information; or

(B) the grievance and state fair hearing processes that are available to providers of services to FFS beneficiaries for expressions of dissatisfaction and for contesting adverse actions regarding payment for covered services rendered to FFS beneficiaries, as well as the process to collect and track information.

(14) "New healthcare service" means a covered service that an MCE has not previously authorized or a covered service that an MCE has previously authorized, for which the authorization period for that covered service has expired at the time of the request for additional covered services.

(15) "Non-participating provider" means a provider without a provider agreement.

(16) "PCCM" means a primary care case manager, including a physician, a physicians' group practice, or an entity that uses physicians, who provides primary care to the enrollee under a contract with the Kansas medical assistance program.

(17) "Participating provider" means a provider with a provider agreement.

(18) "Provider agreement" means a contract between a claims reimbursing entity, the secretary or the MCE, and the provider that specifies the terms and conditions of the provider's participation within the network of providers created by the reimbursing entity. This term shall include a contract that is limited by time or instance to specific goods or services.

(19) "Reconsideration" means a request by the provider to the MCE to review the MCE's action. A reconsideration is not an appeal, a request for a state fair hearing, or a grievance. Submission of a reconsideration request shall be optional and shall not be required before completion of the required provider appeal process.

(20) "Reimbursing entity" means the secretary or the MCE that reviews, determines, and pays claims submitted by providers.

(21) "Remittance advice" and "RA" mean a document supplied by the MCE or KMAP that provides notice and explanation of reasons for payment, adjustment, denial, or noncovered charge of a medical claim.

(22) "Send" means to deliver by U.S. mail or in electronic format.

(23) "Timely notice of action" means an adequate notice of action or remittance advice that is sent by the MCE or the secretary to the provider within the time frames specified in K.A.R. 129-9-4 or K.A.R. 129-9-5.

(24) "Timely notice of administrative review" means an adequate notice of administrative review that is sent by the secretary to the provider within the time frames specified in K.A.R. 129-9-5.

(25) "Timely notice of appeal resolution" means an adequate notice of appeal resolution that is sent by the MCE to the provider within the time frames specified in K.A.R. 129-9-4.

(26) "Timely notice of approval" means an adequate notice of approval that is sent by the MCE to the provider within the time frames specified in K.A.R. 129-9-8.

(27) "Timely notice of external review decision" means an adequate notice of external review decision that is sent by the MCE to the enrollee and the provider within the time frame specified in K.A.R. 129-9-4.

(28) "Timely notice of reconsideration resolution" means an adequate notice of reconsideration resolution or remittance advice that is sent by the MCE to the provider within the time frame specified in K.A.R. 129-9-4.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-2 FFS provider grievance

(a) Any provider rendering services to a beneficiary of the FFS medical assistance program may submit a grievance about any FFS matter, including an action.

(b) Any provider rendering services to a beneficiary of the FFS medical assistance program may submit an oral or written grievance to the secretary or the secretary's designee at any time. Any provider may submit a grievance involving an FFS matter in person, by telephone, by U.S. mail, or by facsimile. Each written grievance delivered by the postal service or submitted by facsimile to the secretary or the secretary's designee shall be date-stamped when received as proof of receipt.

(c) Each grievance involving an FFS matter shall be resolved by the secretary or the secretary's designee within 30 days from the date the secretary receives the grievance from the provider. The resolution of the grievance shall be communicated by the secretary or the secretary's designee to the provider by telephone or letter.

(d) A provider's right to submit a grievance involving an FFS matter shall not be limited or interfered with by the secretary or the secretary's designee.

(e) If the secretary delegates the tracking and resolution of grievances involving an FFS matter to a contractor, that contractor shall cooperate with the state, the state's fiscal agent, or representatives of either, to resolve all provider grievances. Cooperation may include providing internal provider grievance information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-3 MCE provider grievance

(a) Any provider rendering services to an enrollee may submit a grievance about any MCE matter other than an action.

(b) Any provider may submit an oral or written grievance to the MCE within 180 days of the date of the incident. Any provider may submit a grievance in person, by telephone, by U.S. mail, or by facsimile. Each written grievance delivered by the postal service or submitted by facsimile to the MCE shall be date-stamped when received by the MCE as proof of receipt. The date of receipt shall be used to determine the timeliness of the request.

(c) The MCE shall resolve each grievance within 30 days from the date the MCE receives the grievance from the provider and provide notice of grievance resolution no later than five business days following the date of grievance resolution as specified in the state's managed care contract. The notice of grievance resolution shall meet the requirements specified by the secretary.

(d) The provider's right to request a grievance shall not be limited or interfered with by the secretary or the MCE.

(e) The MCE shall cooperate with the state, the state's fiscal agent, or representatives of either to resolve all grievances. Cooperation may include providing internal provider grievance information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-4 Notices to providers rendering services to enrollees; applicability

This regulation shall apply to adequate and timely notices of action, adequate and timely notices of reconsideration resolution, adequate and timely notices of appeal resolution, and adequate and timely notices of external review decision issued by the MCE to the provider regarding a denial of payment for services rendered to enrollees. This regulation shall also apply to adequate and timely notices of appeal resolution and adequate and timely notices of external review decision issued by the MCE to the provider and to the affected enrollee regarding a denial of an authorization for a new healthcare service to the enrollee.

(a) The MCE shall send an adequate notice of action to the provider when the MCE takes an action, as defined in K.A.R. 129-9-1(b)(1)(A) and (b)(1)(B). The adequate notice for an action defined in K.A.R. 129-9-1(b)(1)(A) may take the form of a remittance advice. Each adequate notice of action shall include the following:

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

(2) the action the MCE has taken or intends to take;

(3) the date the MCE made the adverse action;

(4) the reasons for the action, 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 action is based upon a determination that the service is not medically necessary;

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

(6) an explanation of the provider's right to request either a reconsideration or an appeal following receipt of the MCE's adequate notice of action;

(7) an explanation of the optional nature of the MCE's reconsideration process and the MCE's requirement for the provider to complete the MCE's appeal process before requesting a state fair hearing;

(8) an explanation of the provider's right to request a reconsideration within 120 days of the date of the adequate notice of action and the provider's right to request an appeal within 60 days of the date of the adequate notice of action. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The adequate notice of action shall include the address and contact information for submission of the reconsideration and submission of the appeal;

(9) an explanation of the provider's right to terminate the reconsideration process and request an appeal with the MCE within 60 days of the date of the adequate notice of action. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The adequate notice of action shall include an explanation that submission of the appeal request is not dependent upon completion of the reconsideration process or receipt of an adequate notice of reconsideration resolution;

(10) an explanation that if the provider chooses to request a reconsideration and wait until receipt of the adequate notice of reconsideration resolution, the provider has the right to request an appeal to the MCE within 60 days of the date of the adequate notice of reconsideration resolution. 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 provider may request a reconsideration or an appeal regarding the MCE's action;

(12) a statement of the provider's right, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, 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 notice is served by U.S. mail or electronic means;

(13) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(14) any change in federal or state law that requires the action;

(15) a statement of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

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

(b) The MCE shall send a timely notice of action to the provider within one business day following the date of action. The MCE shall send an adequate notice of action to the provider as specified in paragraph (a) in accordance with the timeliness standards specified in this subsection.

(c) The MCE shall send an adequate notice of reconsideration resolution to the provider when the MCE reviews a request for reconsideration of an action. Each adequate notice of reconsideration resolution shall include the following:

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

(2) the action that is the subject of the reconsideration;

(3) the results of the resolution process and the date of the reconsideration resolution;

(4) the reasons for the reconsideration resolution, including an explanation of the medical basis for the reconsideration 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;

(5) the statute, regulation, policy, or procedure supporting the reconsideration resolution;

(6) a statement of the provider's right to request an appeal within 60 days of the date of the adequate notice of reconsideration resolution. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The explanation shall include the address and contact information for submission of the request;

(7) the procedures by which a provider may request an appeal following receipt of the MCE's adequate notice of reconsideration resolution;

(8) a statement of the MCE's requirement for the provider to complete the MCE's appeal process before requesting a state fair hearing;

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

(10) a statement of the provider's right to request a state fair hearing within 120 days of the date of the adequate notice of appeal resolution following completion of the provider appeal process;

(11) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

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

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

(d) The MCE shall send a timely notice of reconsideration resolution to the provider within five business days following the date the MCE resolves the reconsideration. The MCE shall send an adequate notice of reconsideration resolution to the provider as specified in paragraph (c) in accordance with the timeliness standards specified in this subsection.

(e) The MCE shall send an adequate notice of appeal resolution to the provider when the MCE reviews a request for an appeal of an action or 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 action or adverse benefit determination that is the subject of the appeal;

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

(4) 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 MCE based its resolution upon a determination that the service is not medically necessary;

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

(6) a statement that the provider has completed the appeal process with the MCE;

(7) a statement of the provider's right to request an external independent third-party review following receipt of the adequate notice of appeal resolution;

(8) a statement of the procedures by which a provider may request an external independent third-party review with the MCE issuing the decision to be reviewed within 60 days of the date of the adequate notice of appeal resolution. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The explanation shall include the address and contact information for submission of the request;

(9) a statement that if the provider does not request an external independent third-party review, the provider has a right, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, 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 notice is served by U.S. mail or electronic means;

(10) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(11) a statement of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

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

(f) The MCE shall send a timely notice of appeal resolution to the provider within five business days following the date the MCE resolves the appeal. The MCE shall send an adequate notice of appeal resolution to the provider as specified in paragraph (e) in accordance with the timeliness standards specified in this subsection.

(g) The MCE shall send an adequate notice of external review decision to the provider following receipt of the external independent third-party reviewer's decision involving a denial of payment and to the provider and the affected enrollee involving a denial of an authorization for a new healthcare service to the enrollee. Each adequate notice of external review decision shall include the following:

(1) The date of receipt of the external review decision;

(2) the date of the adequate notice of the external review decision;

(3) the action or denial of an authorization for a new healthcare service that is the subject of the review;

(4) the results of the review by the external independent third-party reviewer and the date of that decision;

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

(6) the statute, regulation, policy, or procedure supporting the external review decision;

(7) a statement of the provider's right to request a state fair hearing within 30 days of the date of the MCE's adequate notice of external review decision. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means;

(8) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request;

(9) a statement of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

(10) any other information required by Kansas statute or regulation that involves an MCE's adequate notice of external review decision.

(h) The MCE shall send a timely notice of external review decision to the provider and any affected enrollee within 10 business days following the date the MCE receives the external reviewer's decision. The MCE shall send an adequate notice of external review decision to the provider and any affected enrollee as specified in paragraph (g) in accordance with the timeliness standards specified in this subsection.

(i) A response by the MCE, the secretary, or the department to an inquiry concerning a prior action or denial of an authorization for a new healthcare service shall not be a new action or a new denial of a healthcare service.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 39-709h(e)(4), 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-5 Notices to providers rendering services to beneficiaries of the FFS medical assistance program; notices to providers regarding participation in KMAP; applicability

This regulation shall apply to adequate and timely notices of action sent by the secretary to the provider regarding a denial of payment for services rendered to FFS beneficiaries. This regulation shall also apply to adequate and timely notices of action sent by the secretary to the provider regarding termination of the provider's participation in KMAP, denial of a provider's application to KMAP, and to adequate and timely notices of administrative review sent by the secretary to the provider.

(a) An adequate notice of action shall be sent by the secretary to the provider when the secretary takes an action, as defined in K.A.R. 129-9-1(b)(1)(A) through (b)(1)(D). The adequate notice for an action defined in K.A.R. 129-9-1(b)(1)(A) may take the form of a remittance advice. Each adequate notice of action shall include the following:

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

(2) the action the secretary has taken or intends to take;

(3) the date the secretary took the adverse action or the effective date of the action;

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

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

(6) for an action defined in K.A.R. 129-9-1(b)(1)(C), an explanation of the provider's right to request an administrative review before the secretary, the provider's right to present evidence at the administrative review regarding the proposed termination, and the procedures by which the provider may submit a request for an administrative review, including the address and contact information for submission of the request;

(7) for an action defined in K.A.R. 129-9-1(b)(1)(C), an explanation of the provider's right to request a state fair hearing within 30 days of the date of the adequate notice of administrative review. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means;

(8) for an action defined in K.A.R. 129-9-1(b)(1)(C), an explanation of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson in the administrative review;

(9) an explanation of the provider's right to request a 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;

(10) the procedures by which the provider may submit a request for a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(11) any change in federal or state law that requires the action;

(12) an explanation of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson in the state fair hearing; and

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

(b) A timely notice of action shall be sent by the secretary to the provider 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. An adequate notice of action shall be sent by the secretary to the provider as specified in subsection (a) in accordance with the timeliness standards specified in this subsection.

(c) An adequate notice of administrative review shall be sent by the secretary to the provider when the secretary affirms the decision to terminate a provider's participation in KMAP. Each adequate notice of administrative review shall include the following:

(1) The date of the adequate notice of administrative review;

(2) the action the secretary has taken or intends to take;

(3) the effective date of the action;

(4) the reasons for the action;

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

(6) an explanation of the provider's right to request a state fair hearing within 30 days of the date of the adequate notice of administrative review that affirms the decision to terminate the provider's participation in KMAP. 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 procedures by which the provider may submit a request for a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(8) any change in federal or state law that requires the action; and

(9) an explanation of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson in the state fair hearing.

(d) A timely notice of administrative review shall be sent by the secretary to the provider 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 administrative review. An adequate notice of administrative review shall be sent by the secretary to the provider as specified in subsection (c) in accordance with the timeliness standards specified in this subsection.

(e) A response by the secretary or department to an inquiry concerning a prior action shall not be a new action.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-6 Provider reconsideration

(a) Any provider may submit a request for a reconsideration to the MCE if the basis of the request is an action by an MCE as defined in K.A.R. 129-9-1(b)(1)(A) and (b)(1)(B).

(b) Any provider may submit either a reconsideration request or an appeal request following receipt of the notice of action. The MCE may require that the provider submit the reconsideration in writing. Each written reconsideration delivered by the postal service or submitted by facsimile to the MCE shall be date-stamped when received by the MCE as proof of receipt. The MCE shall use the date of receipt to determine timeliness of the request.

(c) Each MCE shall provide the provider with the opportunity to submit a request for a reconsideration following receipt of the MCE's notice of action. For each reconsideration under this article of the division's regulations to be considered timely pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, the request shall be received by the MCE within 120 days of the date of the notice of action. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means.

(d) The MCE shall not be required to send an acknowledgement letter after receipt of the reconsideration request.

(e) The MCE shall not be required to resolve the reconsideration request within a defined period of time. The MCE shall send notice of reconsideration resolution no later than five business days of the date of reconsideration resolution as specified in the state's managed care contract. The notice of reconsideration resolution shall meet the requirements in K.A.R. 129-9-4.

(f) The reconsideration process shall be optional, but the provider shall complete the MCE's appeal process before requesting a state fair hearing.

(g) The provider's right to appeal shall be preserved throughout the reconsideration process. The provider may terminate the reconsideration process and submit an appeal request within 60 days of the date of the notice of action. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means.

(h) If the provider terminates the reconsideration process more than 63 days after the date of the notice of action, the provider shall wait to receive the MCE's notice of reconsideration resolution before submitting an appeal or the appeal will be untimely.

(i) The provider's right to request a reconsideration shall not be limited or interfered with by the secretary or the MCE.

(j) The MCE shall cooperate with the state, the state's fiscal agent, or representatives of either to resolve all provider reconsiderations. Cooperation may include providing internal provider reconsideration information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-7 Provider appeal

(a) Any provider may submit a request for an appeal to the MCE if the basis of the request is an action by the MCE as defined in K.A.R. 129-9-1(b)(1)(A) and (b)(1)(B) or a denial of an authorization for a new healthcare service to the enrollee.

(b) Any provider may submit an appeal request or a reconsideration request following receipt of the MCE's notice of action. The provider's right to appeal shall not be dependent upon the completion of the reconsideration process. The MCE may require that the provider submit the appeal in writing. Each written appeal delivered by the postal service or submitted by facsimile to the MCE shall be date-stamped when received by the MCE as proof of receipt. The MCE shall use the date of receipt to determine timeliness of the request.

(c) Each MCE shall provide the opportunity to a provider to submit a request for an appeal following receipt of the MCE's notice of adverse benefit determination or notice of action. For each appeal under this article of the division's regulations to be considered timely pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, the request shall be received by the MCE within 60 days of the date of the notice of adverse benefit determination or notice of action. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means.

(d) The MCE shall acknowledge, in writing, each appeal received from the provider within 10 days of receipt.

(e) The MCE shall resolve each appeal within 30 days from the date the MCE receives the appeal from the provider and issue a notice of appeal resolution no later than five business days following the date of appeal resolution, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto. The notice of appeal resolution shall meet the requirements specified in K.A.R. 129-9-4.

(f) The provider shall complete the MCE's appeal process before requesting an external independent third-party review pursuant to K.A.R. 129-9-9 or a state fair hearing.

(g) The provider's right to request an appeal shall not be limited or interfered with by the department or the MCE.

(h) The MCE shall cooperate with the state, the state's fiscal agent, or representatives of either to resolve all provider appeals. Cooperation may include providing internal provider appeal information to the state.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-8 Notices to providers rendering covered services to enrollees and FFS beneficiaries; applicability

This regulation shall apply to adequate and timely notices of approval sent to providers by the MCE or the secretary regarding approval of payment, approval of an enrollee covered service authorization request, or approval of an FFS covered service authorization request.

(a) Each MCE shall send an adequate notice of approval to the provider when the MCE fully or partially approves payment to the provider following a claim submission for covered services rendered to an MCE enrollee, when the MCE fully or partially approves a covered service authorization request submitted by a provider on behalf of an enrollee, when the MCE fully or partially approves payment following a reconsideration resolution, when the MCE fully or partially approves payment or a covered service authorization request following an appeal resolution, and when the MCE approves payment or a covered service authorization request following a decision by a presiding officer that reverses the MCE's action or adverse benefit determination. The adequate notice of approval involving payment may take the form of a remittance advice.

(b) An adequate notice of approval shall be sent when the secretary fully or partially approves payment to the provider following a claim submission for covered services rendered to an FFS beneficiary, when the secretary fully or partially approves a covered service authorization request submitted by a provider on behalf of an FFS beneficiary, and when the secretary approves payment or an FFS covered service authorization request following a decision by a presiding officer that reverses the secretary's action. The adequate notice of approval involving payment may take the form of a remittance advice.

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

(2) the date the MCE made the approval;

(3) the approval decision the MCE has made, including the dates and type of service requested, if the approval is for payment, and the dates, types, and amount of service requested if the approval is for a covered service authorization request; and

(4) the effective date and, if applicable, the end date of the approved covered service authorization request.

(d) The MCE shall send a timely notice of approval to the provider within the time frames specified in paragraphs (d)(1) through (d)(5). A timely notice of approval shall include the contents of an adequate notice of approval as specified in subsection (c).

(1) For approval of full or partial payment for enrollee covered services following a claim submission, the MCE shall send an adequate notice of approval to the provider within one business day of the approval decision.

(2) For approval of a standard or expedited covered service authorization request submitted by a provider on behalf of an enrollee, the MCE shall send an adequate notice of approval to the requesting provider within the time frames specified in 129-8-8(c)(1).

(3) For approval of full or partial payment following an MCE's reconsideration resolution, the MCE shall send an adequate notice of approval to the provider within five business days of the approval decision.

(4) For approval of full or partial payment following an MCE's appeal resolution, the MCE shall send an adequate notice of approval to the provider within five business days of the approval decision.

(5) For approval of full or partial payment or approval of a covered service authorization request following a presiding officer's reversal of an MCE's action or adverse benefit determination, the MCE shall send an adequate notice of approval within the following time frames:

(A) For adverse payment decisions reversed by a presiding officer, the MCE shall authorize payment and send an adequate notice of approval within five business days of the date the MCE receives notice of the presiding officer's reversal of the MCE's action. If the department files a petition for review to SAC, the adequate notice of approval shall be delayed until the department receives notice of the SAC decision affirming the presiding officer's reversal of the action. The MCE shall send an adequate notice of approval within five business days of the date the MCE receives notice of the SAC decision.

(B) For adverse benefit determination decisions reversed by a presiding officer, the MCE shall authorize the disputed services and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE receives notice of the presiding officer's reversal of the MCE's determination. If the department files a petition for review to SAC, the adequate notice of approval shall be delayed until the department receives notice of the SAC decision affirming the presiding officer's reversal of the adverse benefit determination. The MCE shall send an adequate notice of approval no later than 72 hours after the date the MCE receives notice of the SAC decision.

(e) A timely notice of approval shall be sent by the secretary or the secretary's designee to the provider within the time frames specified in paragraphs (e)(1) through (e)(4). A timely notice of approval shall include the contents of an adequate notice of approval as specified in subsection (c).

(1) For approval of full or partial payment for FFS covered services following a claim submission, an adequate notice of approval shall be sent by the secretary to the provider within seven business days of the approval decision.

(2) For adverse payment decisions reversed by a presiding officer, payment for FFS covered services shall be authorized by the secretary and an adequate notice of approval shall be sent by the secretary within seven business days of the date the secretary receives notice of the presiding officer's reversal of the secretary's action. If a petition for review to SAC is filed by the secretary, the adequate notice of approval shall be delayed until notice of the SAC decision affirming the presiding officer's reversal of the secretary's action is received by the secretary. An adequate notice of approval shall be sent by the secretary to the provider no later than seven business days following the date upon which the secretary receives notice of the SAC decision.

(3) For approval of an FFS covered service authorization request submitted by a provider on behalf of an FFS beneficiary, an adequate notice of approval shall be sent by the secretary to the requesting provider within three business days of the approval decision.

(4) For adverse FFS covered service authorization decisions reversed by a presiding officer, the disputed services shall be authorized by the secretary and an adequate notice of approval shall be sent by the secretary within three business days after the date the secretary receives notice of the presiding officer's reversal of the secretary's action. If a petition for review to SAC is filed by the secretary, the adequate notice of approval shall be delayed until notice of the SAC decision affirming the presiding officer's reversal of the secretary's action is received by the secretary.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-9 External independent third-party review for providers

(a) Effective with each denial issued by a managed care organization (MCO) on or after January 1, 2020, each provider who has been denied an authorization for a new healthcare service to an enrollee or a claim for reimbursement to the provider for a healthcare service rendered to an enrollee shall be entitled to an external independent third-party review pursuant to K.S.A. 39-709i, and amendments thereto. Each MCO denial reviewed by the external independent third-party reviewer shall have been issued pursuant to a contract between the MCO and the Kansas medical assistance program (KMAP). The contract shall have been effective January 1, 2020 or later.

(b) The request for an external independent third-party review shall apply only to denials for which the provider has completed the internal written appeals process of an MCO on or after January 1, 2020. Each provider shall have the right to submit a request for an external independent third-party review following receipt of the MCO's adequate notice of appeal resolution or remittance advice.

(c) The MCO shall send an adequate notice of appeal resolution to the provider when the MCO reviews the request for an appeal of an action or adverse benefit determination. Each adequate notice of appeal resolution shall meet the requirements of the secretary and shall include the following:

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

(2) the action or adverse benefit determination that is the subject of the appeal;

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

(4) 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 MCO based its resolution upon a determination that the service is not medically necessary;

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

(6) a statement that the provider has completed the appeal process with the MCO;

(7) a statement of the provider's right to request an external independent third-party review following receipt of the adequate notice of appeal resolution;

(8) a statement of the required procedures by which a provider may request an external independent third-party review with the MCO issuing the decision to be reviewed within 60 days of the date of the adequate notice of appeal resolution. Pursuant to K.S.A. 77-531 and amendments thereto, three days shall be added to the 60-day response period if the notice is served by U.S. mail or by electronic means. The statement shall include the address and contact information for submission of the request;

(9) a statement that if the provider does not request an external independent third-party review, the provider has a right, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, to request a state fair hearing within 120 days of the date of the adequate notice of appeal resolution. Pursuant to K.S.A. 77-531 and amendments thereto, three days shall be added to the 120-day response period if the notice is served by U.S. mail or by electronic means;

(11) a statement of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

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

(d) Each provider receiving an adequate notice of appeal resolution from an MCO that does not include the information specified in paragraphs (c)(6) through (c)(8) shall be entitled to a penalty fee of $333.00, $666.00, or $1,000.00 pursuant to paragraphs (d)(1)(A) through (C). The provider shall notify the secretary of the deficient notice.

(1) The penalty fee for each deficient notice of appeal resolution shall be calculated by the secretary according to the following fee structure:

(A) A notice failing to include one of the three requirements specified in paragraphs (c)(6) through (c)(8) shall incur a penalty fee of $333.00.

(B) A notice failing to include two of the three requirements specified in paragraphs (c)(6) through (c)(8) shall incur a penalty fee of $666.00.

(C) A notice failing to include three of the three requirements specified in paragraphs (c)(6) through (c)(8) shall incur a penalty fee of $1,000.00.

(2) The MCO issuing the deficient notice shall pay the penalty fee to the provider receiving the deficient notice within 10 business days of the secretary's notification to the MCO of the deficient notice.

(3) The provider shall notify the secretary of any dispute that arises regarding the penalty fee. This dispute shall be resolved by the secretary and shall not include the right to request a reconsideration, an appeal, or a state fair hearing.

(e) Any provider may submit a written request for an external independent third-party review to the MCO issuing the decision to be reviewed. The provider's request for this review shall include the following:

(1) Identification of each specific issue and dispute directly related to the adverse appeal decision issued by the MCO;

(2) a statement of the basis upon which the provider believes the MCO's decision to be erroneous; and

(3) the provider's designated contact information, including name, postal mailing address, telephone number, fax number, and electronic-mail address.

(f)(1) Within five business days of receiving a provider's request for external independent third-party review, the MCO shall perform the following:

(A) Send to the provider's designated contact a written acknowledgement letter specifying that the MCO has received the request for review;

(B) notify the secretary of the provider's request for review; and

(C) send a copy of the written acknowledgement letter to the enrollee, if related to the denial of an authorization for a new healthcare service.

(2) If the secretary determines that the MCO failed to meet the requirements of paragraphs (f)(1)(A) through (C), then the provider who submitted the request for review shall automatically prevail in the review. Within five business days of receipt of the secretary's notification that the provider automatically prevails, the MCO shall issue an approval letter regarding the reversal of the MCO's appeal decision to the prevailing provider and the secretary. The MCO shall also issue an approval letter to the affected enrollee if the request for review is related to the denial of an authorization for a new healthcare service. The MCO shall not be required to reverse its decision for a request that does not include the information specified in paragraphs (e)(1) through (e)(3), is submitted by a provider who fails to complete the MCO's appeal process, is untimely, or does not involve a denied authorization for a new healthcare service or a claim for reimbursement.

(g)(1) Within 15 business days of receiving a provider's request for external independent third-party review, the MCO shall perform the following:

(A) Submit to the secretary all documentation submitted by the provider for the MCO's internal appeal process; and

(B) provide the MCO's designated contact information, including name, postal mailing address, telephone number, fax number, and electronic-mail address.

(2) If the secretary determines that the MCO failed to meet the requirements of paragraphs (g)(1)(A) and (B), then the provider who submitted the request for review shall automatically prevail in the review. Within five business days of receipt of the secretary's notification that the provider automatically prevails, the MCO shall issue an approval letter regarding the reversal of the MCO's appeal decision to the prevailing provider and the secretary. The MCO shall also issue an approval letter to the affected enrollee if the request for review is related to the denial of an authorization for a new healthcare service. The MCO shall not be required to reverse its decision for a request that does not include the information specified in paragraphs (e)(1) through (e)(3), is submitted by a provider who fails to complete the MCO's appeal process, is untimely, or does not involve a denied authorization for a new healthcare service or a claim for reimbursement.

(h) Each request for an external independent third-party review shall be approved or denied by the secretary. A request for an external independent third-party review that does not include the information specified in paragraphs (e)(1) through (e)(3), is submitted by a provider who fails to complete the MCO's appeal process, is untimely, or does not involve a denied authorization for a new healthcare service or a claim for reimbursement shall be denied by the secretary. A letter regarding the denial of the request for an external independent third-party review shall be issued by the secretary to the requesting provider and the MCO. A denial letter shall also be issued to the affected enrollee if the request for review is related to the denial of an authorization for a new healthcare service.

(i) The decision by the external independent third-party reviewer shall be based solely upon the documentation submitted by the provider during the MCO's appeal process.

(j) The parties to each external independent third-party review shall be the following:

(1) A provider or the provider's authorized representative; and

(2) the MCO that made the decision involved in the review.

(k) Upon the request of a party, the external independent third-party reviewer may determine in one action multiple requests made to the reviewer regarding the same enrollee, a common question of fact, a common interpretation of applicable regulations, or a common reimbursement requirement. The provider shall complete the MCO's appeal process and submit a request for external review for each denial of an authorization for a new healthcare service or denial of a claim for reimbursement that the reviewer determines in one action.

(l) Any provider that initiated a request for an external independent third-party review, or one or more other providers, may add other initial denials of claims to the review before the reviewer's decision if the claims involve a common question of fact, a common interpretation of applicable regulations, or a common reimbursement requirement. The provider shall complete the MCO's appeal process for each denial of a claim for reimbursement reviewed by the reviewer. The provider shall submit a request for external independent third-party review to the MCO that denied the claim, for each additional claim.

(m) The external independent third-party reviewer shall conduct an external independent third-party review of any denial of authorization for a new healthcare service or denial of a claim for reimbursement submitted to the reviewer.

(n) The external independent third-party reviewer shall issue the reviewer's final decision in a letter to the provider's designated contact, the MCO's designated contact, and the department within 30 days from the date of receipt of the appeal documentation forwarded by the secretary. The reviewer may extend the time to issue a final decision by 14 days upon agreement of both parties to the review. The reviewer's letter shall include the following:

(1) The date of the reviewer's decision letter;

(2) the date of receipt of the provider's appeal documentation from the secretary;

(3) the date of the reviewer's decision and, if an extension was requested by the reviewer, the date of the extension request;

(4) the name and address of the requesting provider. If the reviewer determines in one action multiple provider requests or requests involving multiple claims, the reviewer shall issue a separate decision letter for each MCO, enrollee, and provider as required to protect health information;

(5) a summary statement of the reason the provider requested the external independent third-party review;

(6) the specialty or professional certification of each individual reviewing the provider appeal documentation;

(7) a summary statement of the reviewer's rationale for affirming or reversing the MCO's appeal decision. The statement shall include citation to the applicable policies, research articles, medical necessity criteria, or any other documentation relied upon by the reviewer in reaching its decision;

(8) the name of the medical director who reviewed and approved the reviewer's decision;

(9) a statement directing the losing party of the review to pay an amount equal to the costs of the review to the reviewer and the due date for payment. The statement shall include the following:

(A) A statement that if the decision of the external independent third-party reviewer is reviewed in a state fair hearing, the payment due to the reviewer under this subsection shall be delayed until the decision of the state fair hearing has been issued in the initial order;

(B) a statement that the losing party of the state fair hearing's initial order shall pay the costs of the review to the reviewer within 45 days of service of the initial order;

(C) a statement that if the decision in the initial order is reviewed by the state appeals committee, the payment due to the reviewer under this subsection shall be delayed until the decision by the state appeals committee has been issued in the final order; and

(D) a statement that the losing party of the state appeal committee's final order shall pay the costs of the review to the reviewer within 45 days of service of the final order;

(10) the unique number assigned by the MCO to each provider appeal;

(11) the unique number assigned by the reviewer to each request for external independent third-party review; and

(12) a statement that the provider will receive an additional notice from one or more MCOs that includes the right to request a state fair hearing regarding the reviewer's decision.

(o) Within 10 business days of the MCO's receipt of the external independent third-party reviewer's decision letter, the MCO shall issue a notice of the reviewer's decision to the provider and the department. The MCO shall also issue a notice of the reviewer's decision to the affected enrollee if the request for review is related to the denial of an authorization for a new healthcare service. The notice shall include the state fair hearing rights for the enrollee and the provider.

(p) Each request for an external independent third-party review shall automatically extend the deadline to request a state fair hearing pending the outcome of the review. Any party, including the affected enrollee, may request a state fair hearing within 30 days of the date of the MCO's notice of the reviewer's decision. Pursuant to K.S.A. 77-531 and amendments thereto, three days shall be added to the 30-day response period if the notice is served by U.S. mail or by electronic means.

(q) The decision of the external independent third-party reviewer shall be reviewed by the secretary or the secretary's designee. If the MCO is the losing party of the review, a determination regarding a review by OAH of the reviewer's decision shall be made by the secretary.

(r) The scheduling of any state fair hearing that involves a denial of an authorization for a new healthcare service or a claim for reimbursement for which the provider has requested an external independent third-party review shall be delayed until after the reviewer's decision has been issued. The reviewer's decision letter, the documents relevant to the reviewer's decision, and the MCO's notice of the reviewer's decision shall be included in the state fair hearing case file for consideration by the presiding officer, together with any other facts of the case.

(s) Any provider requesting an external independent third-party review may withdraw the request for review and request a state fair hearing within 123 days of the date of the MCO's adequate notice of appeal resolution.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2019 Supp. 39-709i, K.S.A. 65-1,254, and K.S.A. 75-7403; effective, T-129-5-4-20, May 4, 2020; effective Aug. 21, 2020.)

Kan. Admin. Regs. § 129-9-10 When a state fair hearing is required

(a) Any provider may submit a request for a state fair hearing if the provider identifies an action by the MCE or the secretary as the basis for the request. Any provider may submit a request for a state fair hearing following receipt of the MCE's notice of external review decision if the provider identifies the MCE's denial of an authorization for a new healthcare service or an action 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 action by the MCE or a denial of an authorization for a new healthcare service by the MCE, the provider shall first meet any requirements stated in the state plan, an amendment to the state plan, a waiver, or a CMS-approved contract between the secretary and the MCE before the provider 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 provider shall submit the request for a state fair hearing in accordance with the timeliness requirements in K.A.R. 129-9-11(a)(1).

(c) If the basis for the state fair hearing request is an action by the secretary, the provider shall first meet any requirements stated in the state plan, an amendment to a state plan, or a waiver before the provider may request a state fair hearing. Failure to meet any contractual preconditions shall be grounds for dismissing the request for a state fair hearing. If the secretary's action is a termination or limitation of the KMAP provider's status as the KMAP provider, the KMAP provider may appear before the secretary regarding the question of continuing eligibility as a KMAP provider according to K.A.R. 129-9-15. The provider shall submit the request for a state fair hearing in accordance with the timeliness requirements in K.A.R. 129-9-11(a)(3).

(d) If the basis for the state fair hearing request is an action by the MCE or 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 provider shall first meet any requirements stated in the state plan, an amendment to a state plan, a waiver, or a CMS-approved contract between the secretary and the MCE before the provider 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 provider shall submit the request for a state fair hearing in accordance with the timeliness requirements in K.A.R. 129-9-11(a)(2).

(e) 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 providers.

(f) 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.

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

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-11 Request for state fair hearing; timeliness

(a) For each request for a standard state fair hearing under this article of the division's regulations to be considered timely, the request shall be received by the MCE, the secretary, or the secretary's designee for the state fair hearing according to the following time frames:

(1) For each request by the provider involving the MCE's action or the MCE's denial of an authorization for a new healthcare service that was not reviewed by the external independent third-party reviewer, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 120 days from the date of the adequate notice of appeal resolution, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto. If the 120th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) For each request by the provider involving the MCE's action or the MCE's denial of an authorization for a new healthcare service that was reviewed by the external independent third-party reviewer, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 30 days from the date of the MCE's adequate notice of external review decision, pursuant to K.S.A. 39-709i and amendments thereto. If the 30th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(3) For each request by the provider involving an action by the secretary, the request shall be received by the secretary or the secretary's designee within 30 days from the date of the secretary's adequate notice of action, pursuant to K.A.R. 129-9-10. If the 30th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(b) Any provider may submit an oral or written request for a state fair hearing with the MCE or the secretary. The MCE, the secretary, or the secretary's designee for the state fair hearing may require that the provider submit the request for a state fair hearing in writing. Oral, telephonic, or electronic requests for a standard or expedited state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(c) Any request for a state fair hearing made by telephone or other electronic means and received by the MCE or the secretary during normal business hours may be accepted as a valid request for a state fair hearing by the MCE or the secretary if the request and proof of receipt are documented, dated, and reduced to writing by the MCE or the secretary. The date and time of the telephonic or electronic request for a state fair hearing shall be used to determine the timeliness of the request even if there is a delay by the MCE or the secretary in reducing the request to writing. Oral, telephonic, or electronic requests for a state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(d) Each request for a state fair hearing received by the MCE or the secretary shall be forwarded to the secretary's designee for the state fair hearing within one business day of receipt.

(e) If a written request for a state fair hearing is received by the MCE, the MCE shall date-stamp the request when received as proof of receipt. The timeliness standards specified in subsection (a) shall apply with the date of receipt by the MCE being used to determine the timeliness of the request.

(f) If the provider sends a written request for a state fair hearing directly to the secretary's designee for the state fair hearing, the timeliness standards specified in subsection (a) shall apply with the date of receipt by the secretary's designee being used to determine the timeliness of the request.

(g) If the request for a state fair hearing is not received within the response periods specified in subsection (a), the request shall be deemed untimely and shall be dismissed.

(h) The presiding officer shall issue an initial order in a standard state fair hearing within 90 days from the date the presiding officer receives a request for a state fair hearing, except when the request for a state fair hearing involves the issue being reviewed by the external independent third-party reviewer or when the presiding officer allows an extension.

(i) Unless preempted by federal law, a request for payment of a claim by a non-participating provider to a reimbursing entity shall be treated as a request to use all applicable provisions from statutes, regulations, policies, state plans, amendments to a state plan, waivers, CMS-approved contracts between the secretary and the MCE, and the provider agreements that the reimbursing entity would use in determining a claim for reimbursement from a participating provider.

(j) The presiding officer shall issue an initial order on each state fair hearing request within the time limits specified in subsection (h), unless one of the following conditions is met:

(1) The presiding officer cannot reach a decision because the appellant requests a delay or fails to take a required action.

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History

History: (Authorized by and implementing K.S.A. 39-709i, 65-1,254, and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-12 Evidentiary standard; burden of proof

(a) Unless preempted by federal or state law, a preponderance of the evidence shall be the evidentiary standard used for state fair hearings under this article of the division's regulations.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-13 Parties

(1) The named appellant in the case caption shall be a provider, except as specified in subsection (e). Any authorized representative of the provider may request a state fair hearing.

(2) The named respondent in the case caption shall be the department that administers the program or payment for program services involved in the MCE's denial of an authorization for a new healthcare service, the MCE's action, or the secretary's action except as specified in subsection (f).

(A) If the matter involves an MCE's denial of an authorization for a new healthcare service or an MCE's action, the department that administers the program or payment for the program services shall be the real party in interest. The respondent shall be the department and the case caption shall note the MCE beneath the case number. The MCE shall be an interested party in the matter. As an interested party, the MCE, in meeting its contractual responsibilities, shall review the state fair hearing matter to determine whether the following conditions are met:

(i) The MCE appeal process has been completed.

(ii) The matter was filed within the regulatory time frames.

(iii) The matter involves a denial of an authorization for a new healthcare service to the enrollee or a denial of a claim for reimbursement to the provider for an authorization of a new healthcare service rendered to the enrollee.

(B) If the MCE determines that the matter has not met any of the conditions specified in paragraphs (a)(2)(A)(i)-(iii), the MCE, subject to approval by the department, shall submit a request to the presiding officer to dismiss the matter.

(C) If the matter involves an action by the secretary, the department that administers payment for the program services shall be the real party in interest. The respondent shall be the department. The state fair hearing matter shall be reviewed by the secretary or the secretary's designee to determine whether the following conditions are met:

(i) The matter was filed within the regulatory time frames.

(ii) The matter involves an action.

(D) If the secretary determines that the matter has not met either of the conditions specified in paragraphs (a)(2)(C)(i) and (ii), the secretary or the secretary's designee shall submit a request to the presiding officer to dismiss the matter.

(b) The presiding officer conducting the state fair hearing may grant a motion to modify the case caption to clarify the parties.

(c) Any provider may authorize representation by legal counsel, a relative, a friend, or a spokesperson in the state fair hearing if the provider has authorized the representation in writing. This regulation shall not authorize the secretary or the presiding officer to grant exceptions to the Kansas supreme court rules concerning the practice of law in Kansas if the provider is represented by an attorney who is not licensed in Kansas.

(d) The appellant may be a provider in any of the following circumstances:

(2) If the matter involves an action by an MCE concerning a claim for payment for medical services that have already been provided to the enrollee and the enrollee will not be responsible for the payment of the medical services if the claim is denied by the MCE, the appellant may be the provider.

(3) If the matter involves an adverse benefit determination and an entity other than the provider seeks to be named the appellant, the presiding officer shall determine whether the entity seeking to be named as appellant is the real party in interest instead of the provider.

(e) For each state fair hearing requested by the losing party of the external independent third-party review, the appellant may be the department that administers the program or payment involved in the MCE's denial of an authorization for a new healthcare service or the MCE's action.

(f) For each state fair hearing requested by the losing party of the external independent third-party review, the respondent may be the provider who requested the external independent third-party review.

(g) If a presiding officer allows an entity to intervene in a state fair hearing covered by this article of the division's regulations pursuant to KAPA, the intervening entity shall be identified in the caption of the case as an intervenor.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-14 Department's review of decision

(a) Upon receipt of notice that a request for a state fair hearing has been made, the MCE's denial of an authorization for a new healthcare service, the MCE's action, any decision by the external independent third-party review, or the secretary's action shall be reviewed by the department. Upon review, the decision may be amended or changed before or during the state fair hearing as directed by the department.

(1) Upon receipt of the MCE's or the department's request to dismiss, the presiding officer shall issue a prehearing order to the appellant providing a 15-day response time. If the 15th day falls on a non-business day for the state, the 15-day response time shall be extended to the next business day on which the department is open for business. Three days shall be added to the 15-day response period if the order is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) If the appellant responds to the presiding officer within the above response time, the respondent may reply within five days.

(3) The presiding officer shall review the appellant's response and any respondent's reply and make a determination regarding the MCE's or the department's request to dismiss.

(4) If the appellant fails to respond to the presiding officer's order within the above response time, the presiding officer may dismiss the state fair hearing request.

(1) For telephonic, internet, and in-person withdrawals, the appellant shall be provided with written confirmation, by regular U.S. mail or electronic notification.

(3) If the appellant submits a signed, written statement withdrawing the appellant's request for a state fair hearing, the presiding officer shall close the state fair hearing request.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-15 Provider termination or denial of enrollment

(a) Any provider's participation in KMAP may be terminated by the secretary for one or more of the following reasons:

(1) Voluntary withdrawal of the provider from participation in the program;

(2) non-compliance with applicable state laws, administrative regulations, or program issuances concerning medical providers;

(3) non-compliance with the terms of a provider agreement;

(4) non-compliance with the terms and certification set forth on claims submitted to the secretary for reimbursement;

(5) assignment, granting a power of attorney over, or otherwise transferring right to payment of program claims except as set forth in 42 U.S.C. 1396a (32), as in effect on February 8, 2023, which is hereby adopted by reference;

(6) pattern of submitting inaccurate billings or cost reports;

(7) pattern of submitting billings for services not covered under the program;

(8) pattern of unnecessary utilization;

(9) unethical or unprofessional conduct;

(10) suspension, termination, or expiration of license, registration, or certification in any state;

(11) provision of goods, services, or supplies harmful to individuals or of an inferior quality;

(12) civil or criminal fraud against medicare, the Kansas medicaid or social service programs, or any other state's medicaid or social service programs;

(13) suspension or exclusion by the secretary of health and human services from the title XVIII or title XIX programs;

(14) direct or indirect ownership or controlling interest of five percent or more in a provider institution, organization or agency by a person who has been found guilty of civil or criminal fraud against the medicare program or the Kansas medicaid or social service programs or any other state's medicaid or social service programs;

(15) employment or appointment by a provider of a person in a managerial capacity or as an agent if the person has been found guilty of civil or criminal fraud against the medicare program, or the Kansas medicaid or social service programs, or any other state's medicaid or social service programs;

(16) insolvency;

(17) non-compliance with the requirements of 42 C.F.R. 455.416, as in effect on February 8, 2023, which is hereby adopted by reference; or

(18) discovery of information by the secretary that requires termination pursuant to 42 C.F.R. 455.416.

(b) Prior to the termination of a provider from the program pursuant to subsection (a), an adequate and timely notice of action shall be sent by the secretary to the provider. Each adequate and timely notice of action shall meet the requirements of K.A.R. 129-9-5(a) and (b).

(c) Any provider terminated pursuant to subsection (a) may request an administrative review by the secretary and may request a state fair hearing.

(1) An administrative review shall be scheduled by the secretary not less than five days nor more than 15 days from the date of the adequate notice of action.

(2) All evidence presented, including that of the provider, shall be considered by the secretary in the administrative review. If the decision following the administrative review is to affirm the decision to terminate the provider's participation in KMAP, an adequate and timely notice of administrative review shall be sent by the secretary as specified in K.A.R. 129-9-5(a) and (b).

(d) Termination, unless based upon civil or criminal fraud against the program, suspension or exclusion by the secretary of health and human services, or suspension or exclusion by any other state medicaid agency or medicare, shall remain in effect until the secretary determines that the reason for the termination has been removed and that there is a reasonable assurance that it shall not recur. Terminations based upon civil or criminal fraud shall remain in effect for such time period as deemed appropriate by the secretary. Termination based upon suspension or exclusion by the secretary of health and human services shall remain in effect no less than the time period specified in the notice of suspension issued by the secretary of health and human services. Termination based upon suspension or exclusion by any other state medicaid agency or medicare, shall remain in effect no less than the time period specified by another state medicaid agency or medicare.

(e) A request for reinstatement by a provider terminated from participation in KMAP shall not be considered for a period of 60 days following the effective date of the termination. As a prerequisite for reinstatement in the program, one or more of the following conditions may be imposed by the secretary:

(1) Implementation and documentation of corrective action taken by the provider to comply with program policies and to reasonably ensure that the reason for the termination shall not recur;

(2) probationary period not to exceed one year;

(3) attendance at provider education sessions;

(4) prior authorization of services;

(5) peer supervision; and

(6) other conditions as the specific situation may warrant.

(f) Any provider who is noncompliant with one or more requirements of KMAP participation may be subject to suspension of payment pursuant to 42 C.F.R. 455.23, as in effect on February 8, 2023, which is hereby adopted by reference or other remedies in lieu of termination.

(g) Any provider's application for enrollment in KMAP may be denied by the secretary for one or more of the following reasons:

(1) as required by 42 C.F.R. 455.416;

(2) as required by 42 C.F.R. 455.106, as in effect on February 9, 2023, which is hereby adopted by reference;

(h) Following the denial of a provider's application to KMAP pursuant to subsection (g), an adequate and timely notice of action shall be sent by the secretary to the provider. Each adequate and timely notice of action shall meet the requirements of K.A.R. 129-9-5(a) and (b).

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-17 Department's summary

(a) Within 30 days of the date of the acknowledgement and order issued by the presiding officer in response to a request for a state fair hearing, the appellant and the presiding officer shall be furnished by the department with a summary providing the following information and exhibits:

(1) The appellant's name and address;

(2) a summary statement concerning why the appellant is filing a request for a state fair hearing;

(3) a brief and relevant chronological summary of the events that occurred in relationship to the appellant's request for a state fair hearing;

(4) a statement of the basis of the adverse action;

(5) a citation to and copy of the applicable policies or provider manual excerpts relied upon for the adverse decision. The applicable medical necessity criteria or guidelines used in making medical necessity decisions shall be included;

(6) a citation to or copy of applicable Kansas and federal statutes and regulations relied upon for the adverse action;

(7) a citation to or copy of applicable state plan or waiver documents relied upon for the adverse action;

(8) a copy of the notice that notified the appellant of the decision in question and any subsequent notices;

(9) a copy of any applicable correspondence;

(10) a copy of the provider's contract with the MCE or the provider's contract with KMAP, as applicable to the issue involved in the state fair hearing;

(11) the name and title of each person who will testify or represent the department at the state fair hearing; and

(12) for state fair hearings involving a decision by the external independent third-party reviewer, copies of the notice of the provider appeal resolution, all of the provider appeal documentation submitted to and reviewed by the external reviewer, the MCE's acknowledgement of receipt of the request for external review, the external reviewer's decision letter, and the MCE's notice of external reviewer's decision.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-1-6-23, Jan. 6, 2023; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-18 Motions

(a) Each motion shall meet the following requirements, unless the motion is made during a hearing:

(1) Be submitted in writing; and

(2) state with specificity the basis of the motion.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-19 Prehearing resolution

The parties may settle or otherwise resolve the dispute before the date of the state fair hearing. The parties may also narrow and define the issues before the date of the state fair hearing.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-20 Dismissal; limitations

(1) The appellant failed to submit a request for a state fair hearing within the timeliness standards specified in K.A.R. 129-9-11.

(2) The appellant failed to submit a request for an appeal of the adverse benefit determination or action to the MCE in accordance with K.A.R. 129-9-7 before submitting a request for a state fair hearing.

(3) The appellant failed to state a claim.

(4) The department or the MCE has not taken an action or made a benefit determination adverse to the appellant.

(5) The department or MCE reversed its action or adverse benefit determination.

(6) The request for a state fair hearing was submitted by an individual or entity without documentation of authorization from the appellant.

(8) The department or the MCE has taken an action required by federal or state law or regulation, including an automatic or mandated adjustment that is applied to a class of enrollees or providers that included the appellant. The department shall not submit a written motion to dismiss for a state fair hearing request in which the appellant is challenging an incorrect computation or determination by the department or the MCE using the law, regulation, or policy.

(9) The secretary or the department has taken an action required by the governor of the state of Kansas that is applied to a class of providers that included the appellant.

(b) Any written motion to dismiss may be filed with the presiding officer by the department or the department's designee who has been delegated authority to file the motion.

(d) If the department or the MCE seeks to dismiss a state fair hearing on the basis that the action or adverse benefit determination being appealed is based on federal or state law, regulations, or policy, including an action or adverse benefit determination based upon changes in federal or state law, regulations, or policy, and the action or adverse benefit determination made by the department or the MCE shall result in the termination, suspension, or reduction of covered services, the covered services shall continue until a decision concerning the request for dismissal is rendered.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-21 Presiding officer; decisions

(a) The presiding officer shall conduct a state fair hearing requested by an appellant concerning an action or a decision by the external independent third-party reviewer.

(b) The presiding officer assigned to administer the state fair hearing shall weigh the evidence and determine the facts and conclusions of law pertinent to the state fair hearing.

(e) The presiding officer shall determine the basis for the state fair hearing.

(f) For state fair hearings that do not involve a decision by the external independent third-party reviewer, the presiding officer shall determine whether the action taken by the respondent is due to a correct interpretation of the applicable statute, regulation, or policy. If the presiding officer determines the state fair hearing in favor of the respondent, the presiding officer shall affirm the action of the respondent. If the presiding officer determines the state fair hearing in favor of the appellant, the remedy ordered by the presiding officer shall be limited to orders that are within the lawful authority of the secretary to execute.

(g) For state fair hearings that involve a decision by the external independent third-party reviewer, the presiding officer shall determine whether the decision made by the external independent third-party reviewer is due to a correct interpretation of the applicable statute, regulation, or policy.

(1) If the presiding officer determines the state fair hearing in favor of the respondent and the respondent is the department, the remedy ordered by the presiding officer shall be limited to orders that affirm the department's action or denial of an authorization for a new healthcare service to the enrollee reviewed by the external independent third-party reviewer. If the presiding officer determines the state fair hearing in favor of the appellant and the appellant is a provider, the remedy ordered by the presiding officer shall be limited to orders that reverse the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. The presiding officer shall issue orders that are within the lawful authority of the secretary to execute.

(2) If the presiding officer determines the state fair hearing in favor of the respondent and the respondent is a provider, the remedy ordered by the presiding officer shall be limited to orders that reverse the department's action or denial of an authorization for a new healthcare service to the enrollee reviewed by the external independent third-party reviewer. If the presiding officer determines the state fair hearing in favor of the appellant and the appellant is a department, the remedy ordered by the presiding officer shall be limited to orders that affirm the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. The presiding officer shall issue orders that are within the lawful authority of the secretary to execute.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-22 Rehearing

(b) The presiding officer may grant a rehearing to either party on all or part of the issues when it appears that the rights of the party are substantially affected for any of the following reasons:

(1) An erroneous ruling by the presiding officer;

(2) a decision that, in whole or in part, is contrary to the evidence;

(3) newly discovered evidence that the moving party could not with reasonable diligence have discovered or produced at the hearing; or

(4) fraud, misrepresentation, or misconduct by an opposing party resulting in the order or proceeding.

(d) Once an initial order has been rendered, relief may be sought only through a petition for review to the secretary or the state appeals committee.

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History

History: (Authorized by K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-23 Relief from preliminary or prehearing order

(b) The presiding officer may relieve a party or its legal representative from order or proceeding for any of the following reasons:

(1) An erroneous ruling by the presiding officer;

(2) a decision that, in whole or in part, is contrary to the evidence;

(3) newly discovered evidence that the moving party could not with reasonable diligence have discovered or produced at the state fair hearing; or

(4) fraud, misrepresentation, or misconduct by an opposing party resulting in the order or proceeding.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-24 Transcripts

(b) If an appellant requests a transcript and signs a poverty affidavit, the costs of transcribing the recording shall be paid by the department.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Kan. Admin. Regs. § 129-9-25 Review of an initial order or final order

(1) Any party to a state fair hearing may request a review of the initial order within 15 days of the date the presiding officer served the order upon the parties pursuant to K.S.A. 77-527, and amendments thereto. When the order is served by U.S. mail or electronic means, three days shall be added to the 15-day review request period. The initial order may be reviewed by the secretary or the state appeals committee.

(4) The decision from the secretary or the state appeals committee shall be the final order.

(b) Any final order may be reconsidered by the secretary in accordance with K.S.A. 77-529, and amendments thereto.

(c) The record, as defined in K.S.A. 77-532 and amendments thereto, shall be the basis for the review of the initial order or final order by the secretary or the state appeals committee.

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History

History: (Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective Dec. 27, 2024.)

Article 10 Adult Care Home Program

Kan. Admin. Regs. § 129-10-15a Reimbursement

(a) Each provider with a current signed provider agreement shall be paid a per diem rate for services furnished to Kansas medical assistance-eligible residents. Payment shall be for the type of medical or health care required by the resident, as determined by the attending physician's or physician extender's certification upon admission, and the individual's level of care needs, as determined through assessment and reassessment. However, payment for services shall not exceed the type of care that the provider is certified to provide under the Kansas medical assistance program. The type of care required by the resident may be verified by the agency before and after payment.

(b) Payment for routine services and supplies, pursuant to K.A.R. 30-10-1a, shall be included in the per diem reimbursement. No provider shall otherwise bill or be reimbursed for these services and supplies.

(1) The durable medical equipment, medical supplies, and other items and services specified in paragraphs (b)(1)(A) through (OOO) shall be considered routine for each resident to attain and maintain the highest practicable physical and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. No provider shall bill or be reimbursed for the following separately from the per diem rate:

(A) Alternating pressure pads and pumps;

(B) armboards;

(D) bed rails, beds, mattresses, and mattress covers;

(E) blood glucose monitors and supplies;

(F) canes;

(G) commodes;

(H) compressors;

(I) crutches;

(J) denture cups;

(K) dialysis, including supplies and maintenance, if the service is provided in the facility by facility staff;

(L) dressing items, including applicators, tongue blades, tape, gauze, bandages, adhesive bandages, pads, compresses, elasticized bandages, petroleum jelly gauze, cotton balls, slings, triangle bandages, pressure pads, and tracheostomy care kits;

(M) emesis basins and bath basins;

(N) enemas and enema equipment;

(O) extra nursing care and supplies;

(P) facial tissues and toilet paper;

(Q) first-aid ointments and similar ointments;

(R) footboards;

(S) foot cradles;

(T) gel pads or cushions;

(U) geriatric chairs;

(V) gloves, rubber or plastic;

(W) heating pads;

(X) heat lamps and examination lights;

(Y) humidifiers;

(Z) ice bags and hot water bottles;

(AA) intermittent positive-pressure breathing (IPPB) machines;

(BB) irrigation solution, both water and normal saline;

(CC) IV stands, clamps, and tubing;

(DD) laundry, including personal laundry;

(EE) laxatives;

(FF) lifts;

(GG) lotions, creams, and powders, including baby lotion, oil, and powders;

(HH) maintenance care for residents who have head injuries;

(II) mouthwash;

(JJ) nebulizers;

(KK) nonemergency transportation;

(LL) nutritional supplements;

(MM) occupational therapy;

(NN) orthoses and splints to prevent or correct contractures;

(OO) over-the-counter analgesics and antacids taken for the occasional relief of pain or discomfort, as needed;

(PP) over-the-counter vitamins;

(QQ) oxygen, masks, stands, tubing, regulators, hoses, catheters, cannulae, humidifiers, concentrators, and canisters;

(RR) parenteral and enteral infusion pumps;

(SS) patient gowns, pajamas, and bed linens;

(TT) physical therapy;

(UU) respiratory therapy;

(VV) restraints;

(WW) sheepskins and foam pads;

(XX) skin antiseptics, including alcohol;

(YY) speech therapy;

(ZZ) sphygmomanometers, stethoscopes, and other examination equipment;

(AAA) stool softeners;

(BBB) stretchers;

(CCC) suction pumps and tubing;

(DDD) syringes and needles;

(EEE) thermometers;

(FFF) traction apparatus and equipment;

(GGG) underpads and adult diapers, disposable or nondisposable;

(HHH) walkers;

(III) water pitchers, glasses, and straws;

(JJJ) weighing scales;

(KKK) wheelchairs;

(LLL) urinary supplies, urinary catheters, and accessories;

(MMM) total nutritional replacement therapy;

(NNN) gradient compression stockings; and

(OOO) ostomy supplies.

(2) Each nursing facility shall provide at no cost to residents over-the-counter drugs, supplies, and personal comfort items that meet these criteria:

(A) Are available without a prescription at a commercial pharmacy or medical supply outlet; and

(B) are provided by the facility as a reasonable accommodation for individual needs and preferences. These over-the-counter products shall be included in the nursing facility cost report. A nursing facility shall not be required to stock all products carried by vendors in the nursing facility's community that are viewed as over-the-counter products.

(3) Occupational, physical, respiratory, speech, and other therapies. The Kansas medical assistance program cost of therapies shall be determined as follows:

(A) Compute the medicaid therapy ratio as the total number of medicaid therapy units not otherwise reimbursed to the total number of therapy units provided to all nursing facility residents during the cost report period;

(B) multiply the medicaid therapy ratio by the total reported therapy costs to determine the allowable medicaid portion of therapy costs;

(C) multiply the allowable medicaid portion of the therapy costs by the ratio of the total number of days to the number of medicaid resident days to determine the allowable therapy expenses for the cost report period;

(D) offset the nonallowable portion of the therapy cost in the provider adjustment column and on the related therapy expense line in the cost report; and

(E) submit a work paper with the cost report that supports the calculation of the allowable Kansas medical assistance program therapy expenses determined in accordance with paragraphs (b)(5)(A) through (C).

(c) Each provider of ancillary services, as defined in K.A.R. 30-10-1a, shall bill separately for each service when the services or supplies are required.

(d) Payment for specialized rehabilitative services or active treatment programs shall be included in the per diem reimbursement.

(e) Payment shall be limited to providers who accept, as payment in full, the amount paid in accordance with the fee structure established by the Kansas medical assistance program.

(f) Payment shall not be made for allowable, nonroutine services and items unless the provider has obtained prior authorization.

(g) Private rooms for recipients shall be provided if medically necessary or, if not medically necessary, at the discretion of the facility. If a private room is not medically necessary or is not occupied at the discretion of the facility, then a family member, guardian, conservator, or other third party may pay the incremental difference that would be charged to a private-pay resident to move from a semiprivate room to a private room.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-15b Financial data

(a) General. The per diem rate or rates for providers participating in the Kansas medical assistance program shall be based on an audit or desk review of the costs reported to provide resident care in each facility. The basis for conducting these audits or reviews shall be form MS-2004, as adopted by reference in K.A.R. 129-10-17. Each provider shall maintain sufficient financial records and statistical data for proper determination of reasonable and adequate rates. Standardized definitions, accounting, statistics, and reporting practices that are widely accepted in the nursing facility and related fields shall be followed, except to the extent that they conflict with or are superseded by state or federal medicaid requirements. Changes in these practices and systems shall not be required in order to determine reasonable and adequate rates.

(b) Cost reports. Pursuant to K.A.R. 129-10-17, cost reports shall be required from providers on an annual basis.

(c) Adequate cost data and cost findings. Each provider shall provide adequate cost data on the cost report. This cost data shall be in accordance with state and federal medicaid requirements and general accounting rules and shall be based on the accrual basis of accounting. Estimates of costs shall not be allowable except on projected cost reports submitted pursuant to K.A.R. 129-10-17.

(d) Recordkeeping requirements.

(1) Each provider shall furnish any information to the agency that is necessary to meet these criteria:

(A) To ensure proper payment by the program pursuant to paragraph (d)(2);

(B) to substantiate claims for program payments; and

(2) Each provider shall permit the agency to examine any records and documents that are necessary to ascertain information pertinent to the determination of the proper amount of program payments due. These records shall include the following:

(A) Documentation of the nursing facility ownership, organization, and operation, including documentation as to whether transactions occurred between related parties;

(B) fiscal, medical, and other documents;

(D) documentation of asset acquisition, lease, sale, or other action;

(E) documentation of franchise or management arrangements;

(F) documentation pertaining to costs of operations;

(G) a record of the amounts of income received, by source and purpose; and

(H) a statement of changes in financial position.

(3) Other records and documents shall be made available as necessary.

(4) Records and documents shall be made available in Kansas.

(5) Each provider, when requested, shall furnish the agency with copies of resident service charge schedules and changes to these charge schedules as they are put into effect. The charge schedules shall be evaluated by the agency to determine the extent to which the schedules may be used for determining program payment.

(6) Suspension of program payments may be made if the agency determines that any provider does not maintain or no longer maintains adequate records for the determination of reasonable and adequate per diem rates under the program or the provider fails to furnish requested records and documents to the agency. Payments to that provider may be suspended.

(7) Thirty days before suspending payment to the provider, written notice shall be sent by the agency to the provider of the agency's intent to suspend payments, except as provided in paragraph(e)(2). The notice shall explain the basis for the agency's determination with respect to the provider's records and shall identify the provider's recordkeeping deficiencies.

(8) All records of each provider that are used in support of costs, charges, and payments for services and supplies shall be subject to inspection and audit by the agency, the United States department of health and human services, and the United States general accounting office. All financial and statistical records used to support cost reports shall be retained for five years following the last day on which rates determined from those cost reports are effective.

(e) Desk review requirement.

(1) Each provider shall submit all information requested by the agency that is necessary to complete the desk review of the cost report.

(2) If a provider does not submit the information deemed necessary by the agency to complete the desk review of the cost report for a nursing facility, the provider shall be notified in writing by the agency that the provider has 10 working days from the date of this notice to submit the required information, or the Kansas medical assistance program payments shall be suspended for the nursing facility.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-17 Cost reports

(a) Historical cost data.

(1) For cost reporting purposes, each provider shall submit the "nursing facility financial and statistical report," form MS-2004, revised August 2004 and hereby adopted by reference, completed in accordance with the accompanying instructions. The MS-2004 cost report shall be submitted on diskette, using software designated by the agency for cost report periods ending on or after December 31, 1999.

(2) Each provider who has operated a facility for 12 or more months on December 31 shall file the nursing facility financial and statistical report on a calendar year basis.

(b) Projected cost data.

(1) Projected cost reports.

(A) If a provider is required to submit a projected cost report under K.A.R. 129-10-18 (c) or (e), the provider's rate shall be based on a proposed budget with costs projected on a line item basis.

(B) The projected cost report for each provider who is required to file a projected cost report shall begin according to either of the following schedules:

(i) On the first day of the month in which the nursing facility was certified by the state licensing agency if that date is on or before the 15th of the month; or

(ii) on the first day of the following month if the facility is certified by the state licensing agency on or after the 16th but on or before the 31st of the month.

(C) The projected cost report shall end on the last day of the 12-month period following the date specified in paragraph (b)(1)(B), except under either of the following:

(i) The projected cost report shall end on December 31 if that date is not more than one month before or after the end of the 12-month period.

(ii) The projected cost report shall end on the provider's normal fiscal year-end used for the internal revenue service if that date is not more than one month before or after the end of the 12-month period and the criteria in K.A.R. 129-10-18 for filing the projected cost report ending on December 31 do not apply.

(D) The projected cost report period shall cover a consecutive period of time not less than 11 months and not more than 13 months.

(E) The projected cost report shall be reviewed for reasonableness and appropriateness by the agency. The projected cost report items that are determined to be unreasonable shall be disallowed before the projected rate is established.

(2) Projected cost reports for each provider with more than one facility.

(A) Each provider who is required to file a projected cost report in accordance with this subsection and who operates more than one facility, either in state or out of state, shall allocate central office costs to each facility that is paid rates from the projected cost data. The provider shall allocate the central office cost at the end of the provider's fiscal year or the calendar year that ends during the projection period.

(B) The method of allocating central office costs to those facilities filing projected cost reports shall be consistent with the method used to allocate the costs to those facilities in the chain that are filing historical cost reports.

(1) Each provider shall submit an amended cost report revising cost report information previously submitted if an error or omission is identified that is material in amount and results in a change in the provider's rate of $.10 or more per resident day.

(2) An amended cost report shall not be allowed after 13 months have passed since the last day of the year covered by the report.

(d) Due dates of cost reports.

(1) Each calendar year cost report shall be received not later than the close of business on the last working day of February following the year covered by the report.

(2) A historical cost report covering a projected cost report period shall be received by the agency not later than the close of business on the last working day of the second month following the close of the period covered by the report.

(3) Each cost report approved for a filing extension in accordance with subsection (e) shall be received not later than the close of business on the last working day of the month approved for the extension request.

(e) Extension of time for submitting a cost report.

(1) A one-month extension of the due date for the filing of a cost report may be granted by the agency if the cause for delay is beyond the control of the provider. The causes for delay beyond the control of the provider that may be considered by the agency in granting an extension shall include the following:

(A) Disasters that significantly impair the routine operations of the facility or business;

(B) destruction of records as a result of a fire, flood, tornado, or another accident that is not reasonably foreseeable; and

(2) The provider shall make the request in writing. The request shall be received by the agency on or before the due date of the cost report. Requests received after the due date shall not be accepted.

(3) A written request for a second one-month extension may be granted by the Kansas medical assistance program director if the cause for further delay is beyond the control of the provider. The request shall be received by the agency on or before the due date of the cost report, or the request shall not be approved.

(f) Penalty for late filing. Each provider filing a cost report after the due date shall be subject to the following penalties:

(1) If the complete cost report has not been received by the agency by the close of business on the due date, all further payments to the provider shall be suspended until the complete cost report has been received. A complete cost report shall include all the required documents listed in the cost report.

(2) Failure to submit the cost report within one year after the end of the cost report period shall be cause for termination from the Kansas medical assistance program.

(g) Balance sheet requirement. Each provider shall file a balance sheet prepared in accordance with cost report instructions as part of the cost report forms for each provider.

(h) Working trial balance requirement. Each provider shall submit a working trial balance with the cost report. The working trial balance shall contain account numbers, descriptions of the accounts, the amount of each account, and the cost report expense line on which the account was reported. Revenues and expenses shall be grouped separately and totaled on the working trial balance and shall reconcile to the applicable cost report schedules. A schedule that lists all general ledger accounts grouped by cost report line number shall be attached.

(i) Allocation of hospital costs. An allocation of expenditures between the hospital and the long-term care unit facility shall be submitted through a step-down process prescribed in the cost report instructions.

(j) Interest documentation requirement. A signed promissory note and loan amortization schedule shall be submitted with the cost report for all fixed-term loan agreements with interest reported in the operating cost center. For working capital loans for one year or less, amortization schedules shall not be required.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-18 Per diem rates of reimbursement

(a) Per diem rates for existing nursing facilities.

(1) The determination of per diem rates shall be made, at least annually, using base-year cost information submitted by the provider and retained for cost auditing and analysis.

(A) The base year utilized for cost information shall be reestablished at least once every seven years.

(B) A factor for inflation may be applied to the base-year cost information.

(C) For each provider currently in new enrollment, reenrollment, or change of ownership status, the base year shall be determined in accordance with subsections (c), (d), and (e), respectively.

(2) Per diem rates shall be limited by cost centers, except where there are special level-of-care facilities approved by the United States department of health and human services. The upper payment limits shall be determined by the median in each cost center plus a percentage of the median, using base-year cost information. The percentage factor applied to the median shall be determined by the agency.

(A) The cost centers shall be as follows:

(i) Operating;

(ii) indirect health care; and

(iii) direct health care.

(B) The property component shall consist of the real and personal property fee as specified in K.A.R. 129-10-25.

(C) The upper payment limit for the direct health care cost center shall be a statewide base limit calculated on each facility's base-year costs adjusted for case mix.

(i) A facility-specific, direct health care cost center upper payment limit shall be calculated by adjusting the statewide base limit by that facility's average case mix index.

(ii) Resident assessments used to determine additional reimbursement for ventilator-dependent residents shall be excluded from the calculation of the facility's average case mix index.

(3) Each provider shall receive an annual per diem rate to become effective July 1 and, if there are any changes in the facility's average medicaid case mix index, an adjusted per diem rate to become effective January 1.

(4) Resident assessments that cannot be classified shall be assigned to the lowest case mix index.

(5) To establish a per diem rate for each provider, a factor for incentive may be added to the allowable per diem cost.

(6)(A) Resident days shall be determined from census information corresponding to the base-year cost information submitted by the provider.

(B) The total number of resident days shall be used to calculate the per diem costs used to determine the upper payment limit and rates in the direct health care cost center. The total number of resident days shall be used to calculate the per diem costs used to determine the upper payment limit and rates for food and utilities in the indirect health care cost center.

(C) For homes with more than 60 beds, the number of resident days used to calculate the upper payment limits and rates in the operating cost center and indirect health care cost center, less food and utilities, shall be subject to an 85 percent minimum occupancy requirement based on the following:

(i) Each provider that has been in operation for 12 months or longer and has an occupancy rate of less than 85 percent for the cost report period, as specified in K.A.R. 129-10-17, shall have the number of resident days calculated at the minimum occupancy of 85 percent.

(ii) The 85 percent minimum occupancy requirement shall be applied to the number of resident days and costs reported for the 13th month of operation and after. The 85 percent minimum occupancy requirement shall be applied to the interim rate of a new provider, unless the provider is allowed to file a projected cost report.

(iii) The minimum occupancy rate shall be determined by multiplying the total number of licensed beds by 85 percent. In order to participate in the Kansas medical assistance program, each nursing facility provider shall obtain proper certification for all licensed beds.

(iv) Each provider with an occupancy rate of 85 percent or greater shall have actual resident days for the cost report period, as specified in K.A.R. 129-10-17, used in the rate computation.

(7) Each provider shall be given a detailed listing of the computation of the rate determined for the provider's facility.

(8) The effective date of the rate for existing providers shall be in accordance with K.A.R. 129-10-19.

(b) Per diem rate limitations based on comparable service private-pay charges.

(1) Rates of reimbursement shall not be limited by private-pay charges.

(2) The agency shall maintain a registry of private-pay per diem rates submitted by providers.

(A) Each provider shall notify the agency of any change in the private-pay rate and the effective date of that change so that the registry can be updated.

(i) Private-pay rate information submitted with the cost reports shall not constitute notification and shall not be acceptable.

(ii) Providers may send private-pay rate notices by certified mail so that there is documentation of receipt by the agency.

(B) The private-pay rate registry shall be updated based on the notification from the providers.

(C) The effective date of the private-pay rate in the registry shall be the later of the effective date of the private-pay rate or the first day of the following month in which complete documentation of the private-pay rate is received by the agency.

(i) If the effective date of the private-pay rate is other than the first day of the month, the effective date in the registry shall be the first day of the closest month. If the effective date is after the 15th, the effective date in the register shall be the first day of the following month.

(ii) For new facilities or new providers coming into the medicaid program, the effective date of the private-pay rate shall be the date on which certification is issued.

(3) The average private-pay rate for comparable services shall be included in the registry. The average private-pay rate may consist of the following variables:

(A) Room rate differentials. The weighted average private-pay rate for room differentials shall be determined as follows:

(i) Multiply the number of private-pay residents in private rooms, semiprivate rooms, wards, and all other room types by the rate charged for each type of room. Sum the resulting products of each type of room. Divide the sum of the products by the total number of private-pay residents in all rooms. The result, or quotient, is the weighted average private-pay rate for room differentials.

(ii) Each provider shall submit documentation to show the calculation of the weighted average private-pay rate if there are room rate differentials.

(iii) Failure to submit the documentation shall limit the private-pay rate in the registry to the semiprivate room rate.

(B) Level-of-care rate differentials. The weighted average private-pay rate for level-of-care differentials shall be determined as follows:

(i) Multiply the number of private-pay residents in each level of care by the rate they are charged to determine the product for each level of care. Sum the products for all of the levels of care. Divide the sum of the products by the total number of private-pay residents in all levels of care. The result, or quotient, is the weighted average private-pay rate for the level-of-care differentials.

(ii) Each provider shall submit documentation to show the calculation of the weighted average rate when there are level-of-care rate differentials.

(iii) Failure to submit the documentation may delay the effective date of the average private-pay rate in the registry until the complete documentation is received.

(C) Extra charges to private-pay residents for items and services may be included in the weighted average private-pay rate if the same items and services are allowable in the Kansas medical assistance program rate.

(i) Each provider shall submit documentation to show the calculation of the weighted average extra charges.

(ii) Failure to submit the documentation may delay the effective date of the weighted average private-pay rate in the registry until the complete documentation is received.

(4) The weighted average private-pay rate shall be based on what the provider receives from the resident. If the private-pay charges are consistently higher than what the provider receives from the residents for services, then the average private-pay rate for comparable services shall be based on what is actually received from the residents.

The weighted average private-pay rate shall be reduced by the amount of any discount received by the residents.

(5) The private-pay rate for medicare skilled beds shall not be included in the computation of the average private-pay rate for nursing facility services.

(6) When providers are notified of the effective date of the Kansas medical assistance program rate, the following procedures shall be followed:

(A) If the private-pay rate indicated on the agency register is lower, then the Kansas medical assistance program rate, beginning with its effective date, shall be calculated as follows:

(i) If the average medicaid case mix index is greater than the average private-pay case mix index, the Kansas medical assistance program rate shall be the lower of the private-pay rate adjusted to reflect the medicaid case mix or the calculated Kansas medical assistance rate.

(ii) If the average medicaid case mix index is less than or equal to the average private-pay case mix index, the Kansas medical assistance program rate shall be the average private-pay rate.

(B) Providers who are held to a lower private pay rate and subsequently notify the agency in writing of a different private-pay rate shall have the Kansas medical assistance program rate adjusted on the later of the first day of the month following the date upon which complete private-pay rate documentation is received or the effective date of a new private-pay rate.

(1) The per diem rate for any newly constructed nursing facility or a new facility to the Kansas medical assistance program shall be based on a projected cost report submitted in accordance with K.A.R. 129-10-17.

(2) The cost information from the projected cost report and the first historic cost report covering the projected cost report period shall be adjusted to the base-year period.

(3) The provider shall remain in new enrollment status until the base year is reestablished. During this time, the adjusted cost data shall be used to determine all rates for the provider.

(4) Each factor for inflation that is applied to cost data for established providers shall be applied to the adjusted cost data for each provider in new enrollment status.

(5) No rate shall be paid until a nursing facility financial and statistical report is received and processed to determine a rate.

(d) Change of provider.

(1) The payment rate for the first 24 months of operation shall be based on the base-year historical cost data of the previous owner or provider. If base-year data is not available, data for the most recent calendar year available preceding the base-year period shall be adjusted to the base-year period and used to determine the rate. If the 85 percent minimum occupancy requirement was applied to the previous provider's rate, the 85 percent minimum occupancy requirement shall also be applied to the new provider's rate.

(2) Beginning with the first day of the 25th month of operation, the payment rate shall be based on the historical cost data for the first calendar year submitted by the new provider. The data shall be adjusted to the base-year period.

(3) The provider shall remain in change-of-provider status until the base year is reestablished. During this time, the adjusted cost data shall be used to determine all rates for the provider.

(4) Each factor for inflation that is applied to cost data for established providers shall be applied to the adjusted cost data for each provider in change-of-provider status.

(e) Determination of the per diem rate for nursing facility providers reentering the medicaid program.

(1) The per diem rate for each provider reentering the medicaid program shall be determined from either of the following:

(A) A projected cost report if the provider has not actively participated in the program by the submission of any current resident service billings to the program for 24 months or more; or

(B) the base-year cost report filed with the agency or the most recent cost report filed preceding the base year, if the provider has actively participated in the program during the most recent 24 months.

(2) If the per diem rate for a provider reentering the program is determined in accordance with paragraph (e)(1)(A), the cost data shall be adjusted to the base-year period.

(3) The provider shall remain under reenrollment status until the base year is reestablished. During this time, the cost data used to determine the initial rates shall be used to determine all subsequent rates for the provider.

(4) Each factor for inflation that is applied to cost data for established providers shall be applied to the cost data for providers in reenrollment status.

(5) If the per diem rate for a provider reentering the program is determined in accordance with paragraph (e)(1)(A), a settlement shall be made in accordance with subsection (f).

(f) Per diem rate errors.

(1) If the per diem rate, whether based upon projected or historical cost data, is audited by the agency and found to contain an error, a direct cash settlement shall be required between the agency and the provider for the amount of money overpaid or underpaid. If a provider with an identified overpayment is no longer enrolled in the medicaid program, the settlement shall be recouped from a facility owned or operated by the same provider or that provider's corporation, unless other arrangements have been made to reimburse the agency. A net settlement may occur if a provider has more than one facility involved in settlements. In all cases, settlements shall be recouped within 12 months of the implementation of the corrected rates, or interest may be assessed.

(2) The per diem rate for a provider may be increased or decreased as a result of a desk review or audit of the provider's cost reports. Written notice of this per diem rate change and of the audit findings shall be sent to the provider. Retroactive adjustment of the rate paid from a projected cost report shall apply to the same period of time covered by the projected rate.

(3) Each provider shall have 30 days from the date of the audit report cover letter to request an administrative review of an audit adjustment that results in an overpayment or underpayment. The request shall specify the finding or findings that the provider wishes to have reviewed.

(4) An interim settlement, based on a desk review of the historical cost report covering the projected cost report period, may be determined after the provider is notified of the new rate determined from the cost report. The final settlement shall be based on the rate after an audit of the historical cost report.

(5) A new provider that is not allowed to submit a projected cost report, as specified in K.A.R. 129-10-17, for an interim rate shall not be entitled to a retroactive settlement for the first year of operation.

(g) Out-of-state providers.

(1) The per diem rate for out-of-state providers certified to participate in the Kansas medical assistance program shall be the rate approved by the agency.

(2) Each out-of-state provider shall obtain prior authorization by the agency.

(h) Reserve days. Reserve days as specified in K.A.R. 30-10-21 shall be paid at 67 percent of the Kansas medical assistance program per diem rate.

(i) Determination of rate for ventilator-dependent resident.

(1) The request for additional reimbursement for a ventilator-dependent resident shall be submitted to the agency in writing for prior approval. Each request shall include the following:

(A) Sections A, I, and O in the nursing home comprehensive "minimum data set" ("MDS") of the centers for medicare and medicaid services (CMS);

(B) a current client assessment, referral, and evaluation (CARE) plan for the resident;

(C) a physician's order for ventilator use, including the frequency of ventilator use and a diagnosis that requires use of a ventilator; and

(D) a treatment administration record or respiratory therapy note showing the number of minutes used for the ventilator per shift.

(2) All of the following conditions shall be met in order for a resident to be considered ventilator-dependent:

(A) The resident is not able to breathe without mechanical ventilation.

(B) The resident uses a ventilator for life support 24 hours a day, seven days a week.

(3) The provider shall be reimbursed at the Kansas medical assistance program daily rate determined for the nursing facility plus an additional amount approved by the agency for the ventilator-dependent resident.

(4) No additional amount above that figured at the Kansas medical assistance program daily rate shall be allowed until the service has been authorized by the agency.

(5) The criteria shall be reviewed quarterly to determine if the resident is ventilator-dependent. If a resident is no longer ventilator-dependent, the provider shall not receive additional reimbursement beyond the Kansas medical assistance program daily rate determined for the facility.

(6) The additional reimbursement for the ventilator-dependent resident shall be offset to the cost center of benefit on the nursing facility financial and statistical report.

(j) Rate modification; secretary's discretion.

(1) Any of the requirements of this regulation may be waived by the secretary and a nursing facility's or nursing facility for mental health's per diem rate of reimbursement may be modified by the secretary if the secretary determines that both of the following conditions are met:

(A) Exceptional circumstances place residents of nursing facilities and nursing facilities for mental health in jeopardy of losing the availability of, or access to, "routine services and supplies," "ancillary services and other medically necessary services," "specialized mental health rehabilitation services," or "specialized services," as defined in K.A.R. 30-10-1a.

(B) The jeopardy can likely be avoided or reduced by modifying the per diem rate of reimbursement for a nursing facility or nursing facility for mental health.

(2) If the secretary exercises discretion pursuant to this subsection, the increase in the per diem rate of reimbursement shall not exceed the state average rate for reimbursement.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A 2015 Supp. 65-1,254 and 75-7403; implementing K.S.A. 2015 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008; amended Feb. 5, 2016.)

Kan. Admin. Regs. § 129-10-19 Per diem rates; effective dates

(a) Effective date of per diem rates for ongoing providers filing calendar year cost reports. The effective date of a new per diem rate that is based on information and data in the nursing facility cost report for the calendar year shall be July 1.

(b) Effective date of the per diem rate for a new provider operating on the rate from cost data of the previous provider.

(1) The effective date of the per diem rate for a new provider shall be the date of certification by the state licensing agency.

(2) The effective date of the per diem rate based on the first historical cost report filed in accordance with K.A.R. 129-10-17 shall be the first day of the 25th month of operation. Each rate paid after the effective date of the rate based on the first historical cost report shall be adjusted to the new rate from the historical cost report.

(1) The effective date of the per diem rate based on a projected cost report for a new provider, as specified in K.A.R. 129-10-18 (c) and (e), shall be the date of certification by the state licensing agency.

(2) The interim rate determined from the projected cost report filed by the provider shall be established by the agency and given to the fiscal agent on or by the first day of the third month after the receipt of a complete and workable cost report.

(3) The effective date of the final rate, which shall be determined after an audit of the historical cost report filed for the projected cost report period, shall be the date of certification by the state licensing agency.

(4) The second effective date for a provider filing an historic cost report covering a projected cost report period shall be the first day of the month following the last day of the period covered by the report, which is the date that the inflation factor is applied in determining prospective rates.

(d) Each provider shall receive an annual per diem rate to become effective July 1 and, if there are any changes in the facility's medicaid case mix index as specified in K.A.R. 129-10-18, an adjusted per diem rate to become effective January 1.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2015 Supp. 65-1,254 and 75-7403; implementing K.S.A. 2015 Supp. 75-7405 and 75-7408; effective Feb. 5, 2016.)

Kan. Admin. Regs. § 129-10-23a Nonreimbursable costs

(a) Costs not related to resident care, as set forth in K.A.R. 30-10-1a, shall not be considered in computing reimbursable costs. In addition, the following expenses or costs shall not be allowed:

(1) Fees paid to nonworking directors and the salaries of nonworking officers;

(2) uncollectable debts, which are also known as "bad debts";

(3) donations and contributions;

(4) fund-raising expenses;

(5) taxes, as follows:

(A) Federal income and excess profit taxes, including any interest or penalties paid on these taxes;

(B) state or local income and excess profits taxes;

(D) taxes on property that is not used in providing covered services;

(E) taxes levied against any resident and collected and remitted by the provider;

(F) self-employment taxes applicable to individual proprietors, partners, or members of a joint venture; and

(G) interest or penalties paid on federal and state payroll taxes;

(6) insurance premiums on lives of owners and related parties;

(7) the imputed value of services rendered by nonpaid workers and volunteers;

(8) utilization review not related to quality assurance;

(9) costs of social, fraternal, civic, and other organizations that concern themselves with activities unrelated to their members' professional or business activities;

(10) accrued expenses that are not liquidated within 180 days after the end of the cost reporting period;

(11) vending machines and related supplies;

(12) board of director costs;

(13) resident personal purchases;

(14) advertising for resident utilization;

(15) public relations expenses;

(16) penalties, fines, and late charges;

(17) prescription drugs as defined in K.A.R. 30-10-1a;

(18) dental services;

(19) radiology;

(20) lab work;

(21) items or services provided only to non-Kansas medical assistance program residents and reimbursed from third-party payors;

(22) automobiles and related accessories in excess of $25,000.00 each. Buses and vans for resident transportation shall be reviewed for reasonableness and may exceed $25,000.00 in costs;

(23) provider-owned or related party-owned, -leased, or -chartered airplanes and related expenses;

(24) bank overdraft charges or other penalties;

(25) personal expenses not directly related to the provision of long-term resident care in a nursing facility;

(26) management fees paid to a related organization that are not clearly derived from the actual cost of materials, supplies, or services provided directly to an individual nursing facility;

(27) business expenses not directly related to the care of residents in a long-term care facility. These expenses shall include business investment activities, stockholder and public relations activities, and farm and ranch operations;

(28) legal and other costs associated with litigation, unless the litigation is decided in the provider's favor and is directly related to Kansas nursing facility operations;

(29) lobbying expenses and political contributions.

(b) Purchase discounts, allowances, and refunds shall be deducted from the cost of the items purchased. Refunds of prior years' expenses shall be deducted from the related expenses.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-23b Costs allowed with limitations

(a) The following amortized expenses or costs shall be allowed with limitations:

(1) The provider shall amortize loan acquisition fees and standby fees over the life of the related loan if the loan is related to resident care.

(2) Only the following taxes shall be allowed as amortized costs:

(A) Taxes in connection with financing, refinancing, or refunding operations; and

(B) special assessments on land for capital improvements over the estimated useful life of those improvements.

(3) The start-up cost of a provider with a newly constructed facility or a facility that has been closed for 24 months or more shall be recognized if the cost meets the following criteria:

(A) Is incurred within 90 days of the opening of the facility and related to developing the ability to care for residents;

(B) is amortized over a period of at least 60 months;

(C) is consistent with the facility's federal income tax return and internal and external financial reports, with the exception of paragraph (a)(3)(B); and

(D) is identified in the cost report as a start-up expense, which may include the following:

(i) Administrative and nursing salaries;

(ii) utilities;

(iii) taxes, as identified in paragraphs (a)(2)(A) and (B);

(iv) insurance;

(v) mortgage interest;

(vi) employee training costs; and

(vii) any other allowable costs incidental to the operation of the facility.

(4) Each cost that can properly be identified as an organization expense or can be capitalized as a construction expense shall be appropriately classified and excluded from the start-up cost.

(5) Organization and other corporate costs, as defined in K.A.R. 30-10-1a, of a provider that is newly organized shall be amortized over a period of at least 60 months beginning with the date of organization.

(A) The costs shall be reasonable and limited to the preparation and filing of documents required by the various governmental entities, the costs of preparing sale or lease contracts, and the associated legal and professional fees.

(B) The costs shall not include expenses of resolving contested issues of title or disputes arising from the performance of contracts or agreements related to the purchase or sale of a property or business.

(b) Membership dues and costs incurred as a result of membership in professional, technical, or business-related organizations shall be allowable. However, similar expenses specified in paragraph (a)(9) of K.A.R. 129-10-23a shall not be allowable.

(c) Each provider shall include the costs associated with services, facilities, equipment, and supplies furnished to the nursing facility by related parties, as defined in K.A.R. 30-10-1a, in the allowable cost of the facility at the actual cost to the related party, except that the allowable cost to the nursing facility provider shall not exceed the lower of the actual cost or the market price.

(d) If a provider pays an amount in excess of the market price for equipment, supplies, or services, the agency shall use the market price to determine the allowable cost under the Kansas medical assistance program in the absence of a clear justification for the premium.

(e) The net cost of job-related training and educational activities shall be an allowable cost. The allowable cost shall include the net cost of orientation and on-the-job training.

(f) Resident-related transportation costs shall include only reasonable costs that are directly related to resident care. Transportation costs not directly related to resident care shall not be allowable. Estimates shall not be acceptable.

(g)(1) Lease payments shall be reported in accordance with the financial accounting statements of the financial accounting standards board.

(2) Sale-leaseback transactions shall have the costs limited to the amount that the provider would have included in reimbursable costs if the provider had retained legal title to the facilities and equipment. These costs shall include mortgage interest, taxes, depreciation, insurance, and maintenance costs. The lease cost shall not be allowable if it exceeds the ownership costs before the sale-leaseback transaction.

(h) If the expenses reported for the current period are not paid within one year after the invoice date, the expenses shall be disallowed.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-25 Real and personal property fee

(a) A real and personal property fee shall be developed by the agency in lieu of an allowable cost for ownership or lease expense, or both. The fee shall be facility-specific and shall not change as a result of change of ownership, a change in lease, or reenrollment in the medicaid program by providers. An inflation factor may be applied to the fee on an annual basis.

The real and personal property fee shall include an appropriate component for the following:

(1) Rent or lease expense;

(2) interest expense on a real estate mortgage;

(3) amortization of leasehold improvements; and

(4) depreciation on buildings and equipment.

(b)(1) The real and personal property fee shall be determined based on one of the following methodologies:

(A) For providers enrolled in the Kansas medical assistance program with a real and personal property fee for each facility, the real and personal property fee shall be the sum of the property allowance and value factor.

(B) For providers reenrolling in the Kansas medical assistance program or providers enrolling for the first time but operating in a facility that was previously enrolled in the program, the real and personal property fee shall be the sum of the last effective property allowance and the last effective value factor for the facility.

(C) The real and personal property fee for a newly constructed nursing facility or a nursing facility that enters the Kansas medical assistance program and has not had a fee established previously shall be calculated based on the following methodology:

(i) A projected real and personal property fee shall be calculated using a projected cost report by dividing the total of the four real and personal property fee components reported in the ownership cost center by the greater of the total number of resident days reported or 85 percent of the licensed capacity for the cost report period.

(ii) A historical real and personal property per diem shall be calculated using a historical cost report by dividing the total of the four line items reported in the ownership cost center by the greater of the total number of resident days reported or 85 percent of the licensed capacity for the cost report period.

(iii) A settlement between the projected and historical rates, which shall include the real and personal property fee, shall be made in accordance with K.A.R. 129-10-18 (e).

(2) The real and personal property fee shall be subject to an upper payment limit. The upper payment limit for the real and personal property fee shall be determined by the median real and personal property fee plus a percentage of the median. The percentage factor applied shall be determined by the secretary.

(c)(1) The depreciation and amortization component of the real and personal property fee shall meet these criteria:

(A) Be identifiable and recorded in the provider's accounting records;

(B) be based on the historical cost of the asset as established in this regulation; and

(2)(A) Appropriate recording of depreciation shall include the following:

(i) Identification of the depreciable assets in use;

(ii) the assets' historical costs;

(iii) the method of depreciation;

(iv) the assets' estimated useful life; and

(v) the assets' accumulated depreciation.

(B) Each provider shall report gains and losses on the sale of depreciable personal property on the cost report at the time of the sale. The provider shall record trading of depreciable property in accordance with the income tax method of accounting for the basis of property acquired. Under the income tax method, gains and losses arising from the trading of assets shall not be recognized in the year of trade but shall be used to adjust the basis of the newly acquired property.

(3) The cost basis shall not include costs attributable to the negotiation or final purchase of the facility, which may include legal fees, accounting fees, travel costs, and the cost of feasibility studies.

(d) Any provider may request that the agency rebase the real and personal property fee. Providers shall submit rebase requests for completed capital improvement projects or phases of capital improvements projects. The following methodology shall be used to determine a revised real and personal property fee based on the rebase request.

(1) Rebase requests shall be reviewed to determine a revised real and personal property fee if the provider meets the following capital expenditure thresholds:

(A) $25,000.00 for facilities with 50 or fewer beds; or

(B) $50,000.00 for facilities with 51 or more beds.

(2) The per diem based on the interest expense, depreciation expense, and amortization of leasehold improvements shall be added to the real and personal property fee in effect on the date that the rebase is made effective. Interest expense reported in the operating cost center shall not be included in the request for a rebase of the real and personal property fee. Interest on loans for real and personal property that is included in a rebase shall be reported with mortgage interest in the ownership cost center.

(3) The number of resident days used in the denominator of the real and personal property fee calculation shall be based on the total number of resident days from the most recent desk-reviewed cost report to rebase the property fee. The resident days shall be subject to the 85 percent minimum occupancy requirement, including any new beds documented in the request for a rebase.

(4) The revised real and personal property fee shall be subject to the upper payment limit in effect on the date the rebase is made effective.

(5)(A) If the number of beds of an existing nursing facility is increased by the construction of a new addition to the existing facility, the real and personal property fee established through the rebase shall be effective according to either of the following schedules:

(i) On the first day of the month in which the new beds were certified if the certification date was on or before the 15th of the month; or

(ii) on the first day of the month following the month in which the beds were certified if the certification date is on or after the 16th of the month.

(B) If the capital expenditure that is the basis for the rebase request is not related to an increased number of beds, the real and personal property fee established through the rebase shall be effective according to either of the following schedules:

(i) On the first day of the month in which the complete documentation is received, if the request is received on or before the 15th of the month; or

(ii) on the first day of the month following the month in which the complete documentation is received, if the request is received on or after the 16th of the month.

(i) The depreciation or amortization schedule reflecting the expense, including the construction-in-progress subsidiary ledger;

(ii) the loan agreement;

(iii) the amortization schedule for interest;

(iv) invoices;

(v) receipts for contractor fees; and

(vi) receipts for other costs associated with the capital expenditure.

(6) Invoices or contractor statements dated more than two years before the date the rebase request is received shall not be allowed.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-26 Interest expense

(a) Only necessary interest on working capital or personal property loans shall be an allowable expense. Interest on real estate or personal property covered by the real and personal property fee in accordance with K.A.R. 129-10-25 shall not be included.

(b) The interest expense shall be incurred on indebtedness established with either of the following:

(1) Lenders or lending organizations not related to the borrower; or

(2) partners, stockholders, home office organizations, or related parties, if the following requirements are met:

(A) The terms and conditions of payment of the loans shall resemble terms and conditions of an arm's-length transaction by a prudent borrower with a recognized, local lending institution with the capability of entering into a transaction of the required magnitude. Allowable interest expense shall be limited to the annual expense submitted on the loan amortization schedule, unless the loan principal is retired before the end of the amortization period, or working capital loans if the period is one year or less; and

(B) the provider shall demonstrate, to the satisfaction of the agency, a primary business purpose for the loan other than increasing the per diem rate.

(c) If the general fund of a nursing facility borrows from a donor-restricted fund, this interest expense shall be an allowable cost. In addition, if a nursing facility operated by members of a religious order borrows from the order, interest paid to the order shall be an allowable cost.

(d) The interest expense shall be reduced by the investment income from restricted or unrestricted idle funds or funded reserve accounts, unless that income is from gifts and grants, whether restricted or unrestricted, that are held in a separate account and not commingled with other funds. Income from the provider's qualified pension fund shall not be used to reduce interest expense.

(e) Interest earned on restricted or unrestricted reserve accounts of industrial revenue bonds or sinking fund accounts shall be offset against interest expense and limited to the interest expense on the related debt.

(f) Loans made to finance that portion of the cost of acquisition of a facility that exceeds historical cost or the cost basis recognized for program purposes shall not be considered to be reasonably related to resident care.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-27 Central office costs

(a) Allocation of costs. Allocation of central office costs shall be reasonable, conform to general accounting rules, and allowed only to the extent that the central office is providing a service normally available in the nursing facility. Central office costs shall not be recognized or allowed to the extent that they are unreasonably in excess of the central office costs of similar nursing facilities in the program. The burden of furnishing sufficient evidence to establish a reasonable level of costs shall be on the provider. All expenses reported as central office costs shall be limited to the actual resident-related costs of the central office.

(1) The provider shall report cost of ownership or the arm's-length lease expense, utilities, maintenance, property taxes, insurance, and other plant operating costs of the central or regional office space for resident-related activities report as central office costs.

(2) The provider shall report all administrative expenses incurred by central and regional offices as central office costs. These may include the following:

(A) Salaries;

(B) benefits;

(D) printing, management, and consultant fees;

(E) telephones and other forms of communications;

(F) travel and vehicle expenses;

(G) allowable advertising;

(H) licenses and dues; and

(I) legal, accounting, data processing, insurance, and interest expenses.

The administrative expenses reported as central office costs shall not be directed to individual facilities operated by the provider or reported on any other line of the cost report.

(3) Nonreimbursable costs in K.A.R. 129-10-23a, costs allowed with limitations in K.A.R. 129-10-23b, and the revenue offsets in K.A.R. 30-10-23c shall apply to central office costs.

(4) Estimates of central office costs shall not be allowable.

(b) Central office salary and other limitations.

(1) Salaries of employees performing the duties for which they are professionally qualified shall be allocated to the direct health care cost center or the indirect health care cost center as appropriate for the duties performed. Professionally qualified employees shall include licensed and registered nurses, dietitians, and others that may be designated by the agency.

(2) Salaries of chief executives, corporate officers, department heads, and other employees with ownership interests of five percent or more shall be deemed owner's compensation, and the provider shall report these salaries as owner's compensation in the operating cost center.

(3) The provider shall include the salary of an owner or related party performing a resident-related service for which the person is professionally qualified in the appropriate cost center for that service, subject to the salary limitations for the owner or related party.

(4) The provider shall report salaries of all other central office personnel performing resident-related administrative functions in the operating cost center.

(5) Each provider operating a central office shall complete and submit detailed schedules of all salaries and expenses incurred in each fiscal year. Failure to submit detailed central office expenses and allocation methods shall result in an incomplete cost report. The provider shall submit methods for allocating costs to all facilities in this and any other states.

(6) A central office cost limit may be established by the agency within the overall operating cost center upper payment limit.

(7) The provider may allocate and report bulk purchases by the central office staff in the appropriate cost center of each facility if sufficiently documented. Questionable allocations shall be transferred to the central office cost line within the operating cost center.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-31 Responsibilities of, assessment of, and disbursements for the nursing facility quality care assessment program

(a) In addition to the terms defined in K.S.A. 75-7435 and amendments thereto, each of the following terms shall have the meaning specified in this subsection, unless the context requires otherwise:

(1) "High medicaid volume skilled nursing care facility" means any facility that provided more than 25,000 days of nursing facility care to medicaid recipients during the most recent calendar year cost-reporting period.

(2) "Kansas homes and services for the aging," as used in K.S.A. 75-7435 and amendments thereto, means leadingage Kansas.

(3) "Nursing facility quality care assessment program" means the determination, imposition, assessment, collection, and management of an annual assessment imposed on each licensed bed in a skilled nursing care facility required by K.S.A. 75-7435, and amendments thereto.

(4) "Skilled nursing care facility that is part of a continuing care retirement facility" means a provider who is certified as such by the Kansas insurance department before the start of the state's fiscal year in which the assessment process is occurring.

(5) "Small skilled nursing care facility" means any facility with fewer than 46 licensed nursing facility beds.

(b) The assessment shall be based on a state fiscal year. Each skilled nursing facility shall pay the annual assessment as follows:

(1) The assessment amount shall be $818 annually per licensed bed for the following:

(A) Each skilled nursing care facility that is part of a continuing care retirement facility;

(B) each small skilled nursing care facility; and

(2) The assessment amount for each skilled nursing care facility other than those identified in paragraphs (c)(1)(A) through (C) shall be $4,908 annually per licensed bed.

(3) The assessment amount shall be paid according to the method of payment designated by the secretary of the Kansas department of health and environment. Any skilled nursing care facility may be allowed by the secretary of the Kansas department of health and environment to have an extension to complete the payment of the assessment, but no such extension shall exceed 90 days.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 75-7435; effective Feb. 18, 2011; amended Dec. 27, 2013; amended June 26, 2020.)

Kan. Admin. Regs. § 129-10-200 Definitions for intermediate care facility for mentally retarded (ICF-MR)

(a) "Accrual basis of accounting" means that the revenue of the provider is reported in the period when the revenue is earned, regardless of when it is collected, and expenses are reported in the period in which the expenses are incurred, regardless of when the expenses are paid.

(b) "Adequate cost and other accounting information" means that the data, including source documentation, is accurate, current, and in sufficient detail to accomplish the purposes for which the data is intended. Source documentation, including petty cash payout memoranda and original payout invoices, shall be valid only if the documentation originated at the time and near the place of the transaction. In order to provide the required costs data, financial and statistical records shall be maintained in a manner that is consistent from one period to another. This requirement shall not preclude a beneficial change in accounting procedures if there is a compelling reason to effect a change of procedures.

(d) "Ancillary services and other medically necessary services" mean those special services or supplies for which charges are made in addition to those for routine services.

(e) "Approved staff educational activities" means formally organized or planned programs of study usually engaged in by providers in order to enhance the quality of client care in an ICF-MR. These activities shall be licensed when required by state law.

(f) A "client day" means that period of service rendered to a client between the census-taking hours on two successive days and all other days for which the provider receives payment, either full or partial, for any Kansas medical assistance program or non-Kansas medical assistance program client who was not in the home. The census-taking hours consist of 24 hours beginning at midnight.

(g) "Common ownership" means that any individual or an organization holds five percent or more ownership or equity of the ICF-MR and of the facility or organization serving the ICF-MR.

(h) "Control" means that an individual or organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization or facility.

(i) "Cost finding" means the process of recasting the data derived from the accounts ordinarily kept by a provider to ascertain costs of the various types of services rendered.

(j) "Costs related to client care" means all necessary and proper costs, arising from arm's-length transactions in accordance with general accounting rules, that are appropriate and helpful in developing and maintaining the operation of client care facilities and activities. Specific items of expense shall be limited pursuant to K.A.R. 30-10-218, K.A.R. 30-10-219, K.A.R. 30-10-220, K.A.R. 30-10-221, K.A.R. 30-10-222, K.A.R. 30-10-223, K.A.R. 30-10-224, and K.A.R. 30-10-225.

(k) "Costs not related to client care" means costs that are not appropriate or not necessary and proper in developing and maintaining the ICF-MR operation and activities. These costs shall not be allowable in computing reimbursable costs.

(l) "Extra care" means temporary care required by a client that takes more time, services, and supplies than the care provided an average ICF-MR client. Extra care shall require prior authorization before reimbursement.

(m) "General accounting rules" mean the generally accepted accounting principles as established by the American institute of certified public accountants except as otherwise specifically indicated by ICF-MR program policies and regulations. Adoption of any of these principles shall not supersede any specific regulations and policies of the ICF-MR program.

(n) "Inadequate care" means any act or failure to take action that potentially could be physically or emotionally harmful to a recipient.

(o) "Inspection of care review of intermediate care facilities for the mentally retarded" means a yearly, client-oriented review of only Kansas medical assistance program clients, conducted by a team from the Kansas department on aging consisting of a nurse, a social worker, and a medical doctor, to determine whether those clients' needs are being met.

(p) "Intermediate care facility for the mentally retarded" and "ICF-MR" mean a facility that has met state licensure standards and meets the following conditions:

(1) Is primarily for the diagnosis, treatment, or habilitation of the mentally retarded or persons with related conditions; and

(2) provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or habilitative services to help each individual function at that person's greatest ability.

(q) "Levels-of-care model" means a residential model with five residential facility levels established by service-intensity categories and size of facilities, according to the following:

(1) Small facility: four through eight beds;

(2) medium facility: nine through 16 beds; and

(3) large facility: more than 16 beds.

(r) "Mental retardation" means subaverage general intellectual functioning that originates in the developmental period and is associated with impairment in adaptive behavior, as defined by the 1983 revision of "classification in mental retardation," authored by the American association of mental deficiency.

(s) "Net cost of educational activities" means the cost of approved educational activities less any grants, specific donations, or reimbursements of tuition.

(t) "Nonworking owners" means any individual or organization who has an interest of at least five percent in the provider and does not perform a client-related function for the ICF-MR.

(u) "Nonworking related party" means any related party, as defined in this regulation, who does not perform a client-related function for the ICF-MR.

(v) "Organization costs" mean those costs directly incidental to the creation of the corporation or other form of business. These costs are intangible assets in that they represent expenditures for rights and privileges that have value to the enterprise. The services inherent in organization costs extend over more than one accounting period and shall be amortized over a period of not less than 60 months from the date of incorporation.

(w) "Owner-related party compensation" means salaries, drawings, consulting fees, or other payments paid to or on behalf of any owner with an interest of at least five percent in the provider or any related party, as defined in this regulation, whether the payment is from a sole proprietorship, partnership, corporation, or nonprofit organization.

(x) "Persons with related conditions" means individuals who have a severe, chronic disability that meets all of the following conditions:

(1) Is attributable to either of the following:

(A) Cerebral palsy or epilepsy; or

(B) any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons and requires treatment or services similar to those required for these persons;

(2) is manifested before the person attains the age of 22;

(3) is likely to continue indefinitely; and

(4) results in substantial functional limitations in three or more of the following areas of major life activity:

(A) Self-care;

(B) understanding and use of language;

(D) mobility;

(E) self-direction; and

(F) capacity for independent living.

(y) "Physician extender" means a person who is registered as a physician's assistant or licensed advanced registered nurse practitioner in the jurisdiction where the service is provided and who is working under supervision as required by law or state regulation.

(z) "Plan of care" means a document that states the need for care, the estimated length of the program, the methodology to be used, and the expected results.

(aa) "Projected cost report" means a cost report submitted to the agency by a provider prospectively for a 12-month period. The projected cost report is based on an estimate of the costs, revenues, resident days, and other financial data for the 12-month period.

(bb) "Projection status" means that a provider has been assigned a previous provider's rate for a set period or is allowed to submit a projected cost report. The provider shall submit a historic cost report at the end of the projection period to be used for a settlement of the interim rates and to determine a prospective rate.

(cc) "Provider" means the operator of the ICF-MR specified in the provider agreement.

(dd) "Psychological evaluations or reevaluations in intermediate care facilities for the mentally retarded" means a review of the previous pertinent psychological material to determine if the evaluation is consistent with the client's present status.

(ee) "Related parties" means two or more parties with a relationship in which one party has the ability to influence another party to the transaction such that one or more of the transacting parties might fail to pursue its own separate interests fully. This term shall include parties related by family, business, or financial association or by common ownership or control. Transactions between related parties shall not be considered to have arisen through arm's-length negotiations. Transactions or agreements that are illusory or a sham shall not be recognized.

(ff) "Related to the ICF-MR" means that the facility, to a significant extent, is associated or affiliated with, has control of, or is controlled by, the organization furnishing the services, facilities, or supplies.

(gg) "Representative" means legal guardian, conservator, or representative payee as designated by the social security administration, or any person who is designated in writing by the client to manage the client's personal funds and is willing to accept the designation.

(hh) "Routine services and supplies" mean services and supplies that are commonly stocked for use by or provided to any client. These services and supplies shall be included in the provider's cost report.

(1) Routine services and supplies may include the following:

(A) All general nursing services;

(B) items that are furnished routinely to all clients;

(C) items stocked at nursing stations in large quantities and either distributed or utilized individually in small quantities;

(D) routine items covered by the pharmacy program if ordered by a physician for occasional use; and

(E) items that are used by individual clients but are reusable and expected to be available in a facility.

(2) Routine services and supplies shall be distinguished from nonroutine services and supplies that are ordered or prescribed by a physician on an individual or scheduled basis. Medication ordered may be considered nonroutine if either of the following conditions is met:

(A) The medication is not a stock item of the facility.

(B) The medication is a stock item with unusually high usage by the individual for whom prior authorization may be required.

(3) Routine services and supplies shall not include ancillary services and other medically necessary services as defined in subsection (d) and also shall not include those services and supplies the client must provide.

(4) Reasonable transportation expenses necessary to secure routine and nonemergency medical services shall be considered reimbursable through the medicaid per diem rate.

(ii) "Working trial balance" means the summary from the provider's general ledger that was used in completing the cost report. This summary shall contain the account number, a description of the account, the amount of the account, and the line of the cost report specifying the account.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Kan. Admin. Regs. § 129-10-210 ICF-MR reimbursement

(a) (1) Each provider with a current signed provider agreement shall be paid a per diem rate for services furnished to eligible Kansas medical assistance program clients. Payment shall be for the type of medical or health care required by the beneficiary as determined by either of the following:

(A) The attending physician's or physician extender's certification upon admission; or

(B) inspection of care and utilization review teams, as specified in K.A.R. 30-10-207.

(2) Payment for services shall not exceed the type of care the provider is certified to provide under the Kansas medical assistance program. The type of care required by the beneficiary may be verified by the agency before and after payment. No payment shall be made for care or services determined to be the result of unnecessary utilization.

(A) Initial eligibility for ICF-MR level services shall be determined based on a screening completed by the agency or its designee.

(B) Continued eligibility for ICF-MR level services shall be determined by a professional review of the client by the utilization review team of the Kansas department on aging.

(b) Payment for routine services and supplies, pursuant to K.A.R. 129-10-200, shall be included in the per diem reimbursement. No provider shall bill or be reimbursed for these services and supplies.

(1) The following durable medical equipment, medical supplies, and other items and services shall be considered routine:

(A) Alternating pressure pads and pumps;

(B) armboards;

(D) bed rails, beds, mattresses, and mattress covers;

(E) canes;

(F) commodes;

(G) crutches;

(H) denture cups;

(I) dressing items, including applicators, tongue blades, tape, gauze, bandages, adhesive bandages, pads and compresses, elasticized bandages, petroleum jelly gauze, cotton balls, slings, triangle bandages, and pressure pads;

(J) emesis basins and bath basins;

(K) enemas and enema equipment;

(L) facial tissues and toilet paper;

(M) footboards;

(N) foot cradles;

(O) gel pads or cushions;

(P) geriatric chairs;

(Q) gloves, rubber or plastic;

(R) heating pads;

(S) heat lamps and examination lights;

(T) humidifiers;

(U) ice bags and hot water bottles;

(V) intermittent positive-pressure breathing (IPPB) machines;

(W) IV stands and clamps;

(X) laundry, including personal laundry;

(Y) lifts;

(Z) nebulizers;

(AA) occupational therapy that exceeds the quantity of services covered by the Kansas medical assistance program;

(BB) oxygen masks, stands, tubing, regulators, hoses, catheters, cannulae, and humidifiers;

(CC) parenteral and enteral infusion pumps;

(DD) patient gowns and bed linens;

(EE) physical therapy that exceeds the quantity of services covered by the Kansas medical assistance program;

(FF) restraints;

(GG) sheepskins and foam pads;

(HH) speech therapy that exceeds the quantity of services covered by the Kansas medical assistance program;

(II) sphygmomanometers, stethoscopes, and other examination equipment;

(JJ) stretchers;

(KK) suction pumps and tubing;

(LL) syringes and needles;

(MM) thermometers;

(NN) traction apparatus and equipment;

(OO) underpads and adult diapers, disposable and nondisposable;

(PP) walkers;

(QQ) water pitchers, glasses, and straws;

(RR) weighing scales;

(SS) wheelchairs;

(TT) irrigation solution, including water and normal saline;

(UU) lotions, creams, and powders, including baby lotion, oil and powders;

(VV) first aid-type ointments;

(WW) skin antiseptics, including alcohol;

(XX) antacids;

(YY) mouthwash;

(ZZ) over-the-counter analgesics;

(AAA) two types of laxatives;

(BBB) two types of stool softeners;

(CCC) nutritional supplements;

(DDD) blood glucose monitors and supplies;

(EEE) urinary supplies; and

(FFF) nutritional therapy.

(c) Payment for ancillary services, as defined in K.A.R. 129-10-200, shall be billed separately when the services are required.

(d) Payment for a day service program for clients of an ICF-MR shall be included in the per diem reimbursement. Each provider shall allow the client or the client's guardian to select a day service program offered by another agency. The other agency shall be licensed and unencumbered by documented service deficiencies that would prevent the provider from becoming certified or remaining certified as a medicaid provider. The provider shall pay the actual cost of the service provided by the other agency, which shall not exceed 24 percent of the provider's approved per diem rate. Expenses incurred by the provider for this service shall be allowable expenses and may be reported on the provider's financial and statistical report.

(e) Payment shall be limited to providers who accept, as payment in full, the amount paid in accordance with the fee structure established by the Kansas medical assistance program.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2007 Supp. 75-7403 and 75-7412; implementing K.S.A. 2007 Supp. 75-7405 and 75-7408; effective Sept. 19, 2008.)

Article 14 Children's Health Insurance Program

Kan. Admin. Regs. § 129-14-2 Definitions

The terms defined in K.A.R. 129-1-1 shall be applicable to this article. In addition and for purposes of this article, each of the following terms shall have the meaning specified in this regulation, unless the context clearly indicates otherwise:

(a) "Capitated managed care" means health care services provided by a contracted provider for which payment is made on an approved contracted rate for each enrolled person assigned to the provider, regardless of the number or nature of the services provided.

(b) "Caretaker" means the person who is assigned the primary responsibility for the care and control of the child and who is any of the following persons:

(1) Parent, including parent of an unborn child;

(2) guardian, conservator, legal custodian, or person claiming the child as a tax dependent;

(3) sibling;

(4) nephew;

(5) niece;

(6) aunt;

(7) uncle;

(8) person of a preceding generation who is denoted by a term that includes any of the following prefixes: "grand," "great-," "great-great-," or "great-great-great-";

(9) stepfather, stepmother, stepbrother, or stepsister;

(10) legally adoptive parent or another relative of adoptive parents as listed in this subsection; or

(11) spouse of any person listed in this subsection or former spouse of any of those persons, if marriage is terminated by death or divorce.

(d) "Earned income" means all income, in cash or in kind, that an applicant or recipient currently earns through the receipt of wages, salary, or profit from activities in which the individual engages as an employer or as an employee.

(e) "Family group" means the applicant or recipient and all individuals living together in which there is a relationship of legal responsibility or a caretaker relationship.

(f) "Household size" means the number of persons counted as members of an individual's tax household in accordance with K.A.R. 129-14-33. For each pregnant woman in the household, the household size shall include the woman and the number of children she is expected to deliver.

(g) "Legally responsible relative" means the person who has the legal responsibility to provide support for the person in the assistance plan.

(h) "Modified adjusted gross income" and "MAGI" mean income as defined in 26 U.S.C. 36B(d).

(i) "Parent" means natural or biological parent, adoptive parent, or stepparent.

(j) "Sibling" means natural or biological sibling, adopted sibling, half sibling, or stepsibling.

(k) "Tax dependent" means a dependent under 26 U.S.C. 152 for whom another individual claims a deduction for a personal exemption under 26 U.S.C. 151 for a taxable year.

(l) "Unearned income" means all income that is not earned income.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-3 Providers

(a) Subject to provider availability, any recipient may be required to be enrolled in a managed care option in order to access covered program services.

(b) Managed care contractors shall be selected by the secretary from willing providers, as determined by the secretary or designees.

(c) Before signing a contract to provide services, each provider of capitated managed care shall demonstrate the ability to meet contract requirements, including providing or maintaining the following:

(1) Financial solvency;

(2) a panel of service providers, who shall meet the following requirements:

(A) Have professional credentials required by the state in which the services are provided;

(B) be in active practice;

(D) be able to provide services sensitive to the needs of a diverse population, including individuals of any race, ethnicity, or disability;

(3) a quality management process under 42 C.F.R. Part 438; and

(4) any other relevant requirements as determined by the secretary.

(d) Penalties for failure to abide by the contract provisions shall be imposed by the secretary, or other appropriate actions, as specified in the contract, may be taken.

(e) Each capitated managed care contractor shall be reimbursed at a rate agreed to by the secretary.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-20 Application process

(a) An application for kancare-CHIP shall be made by an applicant or by another person authorized to act on the applicant's behalf.

(b) An application for kancare-CHIP shall be made using a department-approved form. The applicant or person authorized to act on behalf of the applicant shall sign the application. Electronic signatures, including telephonically recorded signatures, and handwritten signatures transmitted by any other electronic transmission shall be acceptable. If any person signs by mark, the names and addresses of two witnesses shall be required.

Each application shall be submitted on the state application web site or the federally facilitated exchange web site, by telephone, in person, by mail, by electronic mail, or by fax.

(c) If the department denies an application within 45 days of receipt of the application and the applicant reapplies or provides required information within this 45-day period, the application shall be reactivated.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-21 Reenrollment process

(a) Each recipient shall reenroll for the program by providing the department with information on the recipient's current situation and having an opportunity to review the eligibility factors so that the department can redetermine the recipient's eligibility for coverage under the program.

(b) Each recipient shall complete the reenrollment process by either of the following:

(2) completing and returning information on the recipient's current situation requested by the department.

(c) Each recipient shall reenroll for coverage at least once each 12 months or as often as a need for review is indicated. Coverage under the program shall not be provided for more than 12 months, unless the recipient completes the required reenrollment process.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-22 Revoked

Publisher status: INEFFECTIVE (not currently effective).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by K.S.A. 2005 Supp. 75-7412; implementing K.S.A. 2005 Supp. 75-7412 and 75-7413, as amended by L. 2006, ch. 4, § 2; effective Aug. 11, 2006; revoked, T-129-10-31-13, Nov. 1, 2013; revoked Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-23 Responsibilities of applicants and recipients

Each applicant or recipient shall meet the following requirements:

(b) supply information essential to the determination of initial and continuing eligibility, insofar as the applicant or recipient is able to do so;

(d) report each change in circumstances that could affect eligibility within 10 calendar days of the change or as otherwise required by the program. Changes to be reported shall include changes to income, living arrangement, household size, family group members, residency, alienage status, health insurance coverage, and employment;

(e) take all necessary action to obtain any income due the person; and

(f) except for children for whom a determination under presumptive medical assistance as defined in K.A.R. 129-14-51 has been made, request a fair hearing in writing if the individual is dissatisfied with any department decision or lack of action in regard to the application for or the receipt of assistance.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-25 Act on own behalf

(a) For purposes of this regulation, each of the following terms shall have the meaning specified in this subsection:

(1) "Emancipated minor" means either of the following:

(A) A person who is aged 16 or 17 and who is or has been married; or

(B) a person who is under the age of 18 and who has been given or has acquired the rights of majority through court action.

(b) Each applicant or recipient shall be legally capable of acting on that individual's own behalf.

(1) An incapacitated person aged 18 for whom a court has named a guardian or conservator shall not be eligible for kancare-CHIP, unless the named legal guardian or conservator applies for assistance on the person's behalf.

(2) An incapacitated person aged 18 for whom a court has not named a guardian or conservator shall not be eligible for kancare-CHIP, unless a representative payee for the person's social security benefits, a person with durable power of attorney for financial decisions for the individual, or a medical representative applies for assistance on the person's behalf.

(3) Each emancipated minor shall be eligible to apply for and receive assistance under kancare-CHIP on that individual's own behalf.

(4) An unemancipated minor shall not be deemed capable of acting on that individual's own behalf and shall not be eligible to apply for or receive assistance under kancare-CHIP on that individual's own behalf, except as specified in this paragraph. An unemancipated minor shall not be eligible unless a caretaker, representative payee for social security benefits, or other nonrelated responsible adult who is approved by the parent or legal guardian and who resides with the child applies for assistance on the minor's behalf. However, an unemancipated minor may apply for or receive assistance on that individual's own behalf if one of the following conditions exists:

(A) The parents of the minor are institutionalized.

(B) The minor has no parent who is living or whose whereabouts are known, and there is no other caretaker who is willing to assume parental control of the minor.

(C) The health and safety of the minor has been or would be jeopardized by remaining in the household with the minor's parents or other caretakers.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-26 Residence

Each applicant or recipient shall be a resident of Kansas. Temporary absence from a state with subsequent return to the state, or intent to return when the purposes of the absence have been accomplished, shall not be considered to interrupt continuity of residence. Residence shall be considered to be retained until abandoned or established in another state. Residency shall be established as follows:

(a) For each individual who is not residing in an institution, capable of stating intent, and either is emancipated from the individual's parents or is married, the individual shall choose the state of residence based on either of the following:

(1) The state in which the individual is living and intends to reside, including without a permanent address; or

(2) the state that the individual has entered with a job commitment or for seeking employment, whether or not the individual is currently employed.

(b) For each individual who is not residing in an institution and who does not meet the conditions of subsection (a), the state of residence shall be either of the following:

(1) The state in which the individual is residing, including without a permanent address; or

(2) the state in which the individual's parent or caretaker resides, if the individual is living with the parent or caretaker.

(c) For each individual residing in an institution, the state of residence shall be one of the following, whether or not the individual is capable of stating intent:

(1) The state in which the individual's parent or guardian resides, if the individual became incapable of stating intent before the age of 21;

(2) the state that placed the individual in an out-of-state institution; or

(3) for any other institutionalized individual, the state in which the individual is living and intends to reside.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-27 Citizenship and alienage

(a) Each applicant or recipient shall be a citizen of the United States or shall be a noncitizen who meets either of the following conditions:

(1) The individual entered the United States before August 22, 1996 and meets one of the following conditions:

(B) is granted asylum, pursuant to 8 U.S.C. 1158;

(D) is a lawful, permanent resident;

(E) is an honorably discharged veteran or is on active duty in the armed forces or is the spouse or unmarried dependent child of the veteran or the person on active duty;

(F) has been paroled into the United States for at least one year under 8 U.S.C. 1182(d)(5);

(G) has been granted conditional entry under 8 U.S.C. 1157;

(H) has been battered or subjected to extreme cruelty by a United States citizen or lawful permanent spouse or parent and has a pending or approved violence against women act (VAWA) case or petition before the department of homeland security pursuant to 8 U.S.C. 1641(c); or

(I) is a certified victim of severe forms of trafficking, as defined in 22 U.S.C. 7105; or the individual entered the United States on or after August 22, 1996 and meets one of the following conditions:

(B) is granted asylum, pursuant to 8 U.S.C. 1158;

(D) is an honorably discharged veteran or is on active duty in the armed forces or is the spouse or unmarried dependent child of the veteran or the person on active duty;

(E) is an Iraqi or Afghani special immigrant under the 2006 national defense authorization act, public law 109-163;

(F) is a certified victim of severe forms of trafficking, as defined in 22 U.S.C. 7105;

(G) is a lawful, permanent resident who has resided in the United States for at least five years;

(H) has been paroled into the United States under 8 U.S.C. 1182(d)(5) for at least one year and has resided in the United States for at least five years;

(I) has been granted conditional entry under 8 U.S.C. 1157 and has resided in the United States for at least five years; or

(J) has been battered or subjected to extreme cruelty by a United States citizen or lawful permanent spouse or parent, has a pending or approved violence against women act (VAWA) case or petition before the department of homeland security pursuant to 8 U.S.C. 1641(c), and has resided in the United States for at least five years.

(b) Each applicant or recipient declaring to be a citizen or national of the United States shall present evidence of citizenship or nationality in accordance with the department's policy memo titled "KDHE-DHCF policy no. 2013-10-01," dated October 4, 2013 and hereby adopted by reference. This requirement shall not apply to any of the following:

(1) Newborn children who meet the provisions of K.A.R. 129-6-65(e);

(2) individuals receiving SSI benefits;

(3) individuals entitled to or enrolled in any part of medicare;

(4) individuals receiving disability insurance benefits under 42 U.S.C. 423 or monthly benefits under 42 U.S.C. 402, based on the individual's disability; or

(5) individuals who are in foster care and who are assisted under title IV-B of the social security act as amended by public law 109-288 and individuals who are recipients of foster care maintenance or adoption assistance payments under title IV-E.

(c) Each individual declaring to be a noncitizen shall present evidence of that individual's status in accordance with "KDHE-DHCF policy no. 2013-10-01," which is adopted by reference in subsection (b). Each noncitizen who has provided evidence of qualified noncitizen status that has been verified with the department of homeland security shall be eligible for medical assistance.

(d) Each applicant or recipient shall have 90 days from the date the application is approved to supply the evidence described in subsections (b) and (c).

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2013 Supp. 65-1,254 and 75-7403; effective June 30, 2006; amended, T-129-10-31-13, Nov. 1, 2013; amended Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-28 Cooperation

(a) Establishment of eligibility. Each applicant or recipient shall cooperate with the department in the establishment of the applicant's or recipient's eligibility by providing all information necessary to determine eligibility as provided in K.A.R. 129-14-23. Failure to provide all information necessary shall render the members of the assistance plan, as defined in K.A.R. 129-14-33, ineligible for medical assistance.

(b) Social security number. Except as noted in this subsection, each applicant or recipient shall cooperate by providing the department with the applicant's or recipient's social security number. Failure to provide the number, or failure to apply for a number if the applicant or recipient has not previously been issued a social security number, shall render the applicant or recipient ineligible for medical assistance. The following individuals shall be exempt from this requirement:

(1) Any individual who is not eligible to receive a social security number;

(2) any individual who does not have a social security number and can be issued a number only for a valid non-work reason; and

(3) any individual who refuses to obtain a social security number because of well-established religious objections.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-30 Public institution

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this subsection:

(1) "Institution" means an establishment that furnishes food, shelter, and some form of treatment or services to four or more persons who are unrelated to the proprietor.

(2) "Public institution" means any institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

(b) Living arrangement. Each applicant or recipient meeting one of the following conditions shall be ineligible for assistance:

(1) Lives in a public institution, unless one of the following conditions is met:

(A) The individual is in a public educational or vocational training institution for purposes of completing education or vocational training; or

(B) the individual is in the public institution for a temporary period not to exceed the month of entrance and the following two months;

(2) resides in a state intermediate care facility for diagnosis, treatment, or rehabilitation of persons with intellectual disabilities or related conditions that has been approved for medicaid coverage of inpatient services;

(3) receives inpatient care in either of the following:

(A) A state psychiatric hospital that has been approved for medicaid coverage of inpatient services; or

(B) a nursing facility for mental health that has been approved for medicaid coverage of inpatient services;

(4) receives inpatient care in a psychiatric residential treatment facility as defined in K.A.R. 28-4-1200;

(5) resides in a correctional facility; or

(6) is in the custody of the department of corrections as an accused or convicted criminal and does not meet any of the following conditions:

(A) Is on probation, parole, bail, or bond;

(B) has been released on the individual's own recognizance; or

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-31 Insurance coverage

(a) An applicant or recipient shall not currently be covered under a "group health plan" or under "health insurance coverage" as defined in 42 U.S.C. 300gg-91. The applicant or recipient shall not be considered covered if the applicant or recipient does not have reasonable geographic access to care under that plan or coverage. Reasonable geographic access to care shall mean that the applicant or recipient routinely does not have to travel more than 50 miles to reach providers participating in the group health plan or health insurance coverage.

(b) For family groups with income over 200 percent of the official federal poverty-level income guidelines, the applicant or recipient shall not have had health insurance coverage in the three-month period before the effective date of coverage and terminated this coverage without good cause.

(c) For family groups with income less than or equal to 200 percent of the official federal poverty-level income guidelines, the applicant or recipient shall not have had health insurance coverage in the prior three months and terminated this coverage without good cause.

(d) An applicant or recipient shall not be eligible for enrollment in the Kansas state employee health plan.

(e) The standards for good cause shall include the loss of health insurance due to the involuntary loss of employment, the death of the policy holder, and the elimination of coverage by the applicant's or recipient's employer.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-32 Premium payment requirement

(a) If the total monthly applicable income in a family group exceeds 166 percent of the official federal poverty-level income guidelines, the family shall pay a monthly premium for coverage in kancare-CHIP.

(b) Each family who fails to pay the monthly premium for two consecutive months shall be considered delinquent, which shall result in the ineligibility of that family. The period of ineligibility shall not exceed 90 days.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-33 Assistance plan

(a) The assistance plan shall consist of those persons in the household as determined in subsections (b) through (f).

(c) For each person claimed as a tax dependent by another taxpayer, the household shall consist of that taxpayer and the taxpayer's dependents, except as noted in subsection (e).

(d) For each person who neither files a tax return nor is claimed as a tax dependent, the household shall consist of the person and, if living with the person, the following:

(1) The person's spouse;

(2) the person's natural children, adopted children, and stepchildren under the age of 21;

(3) the person's natural parents, adopted parents, and stepparents, if the person is under the age of 21; and

(4) the person's natural siblings, adopted siblings, and stepsiblings under the age of 21, if the person is under the age of 21.

(e) For each person who is claimed as a tax dependent by another taxpayer, the household shall be determined in accordance with subsection (d) if the person meets the following conditions:

(1) Is not a spouse of the taxpayer and is not a biological child, an adopted child, or a stepchild of the taxpayer;

(2) is claimed by one parent as a tax dependent and is living with both parents who do not expect to file a joint tax return; or

(3) is under the age of 21 and expected to be claimed as a tax dependent by a noncustodial parent.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-34 Financial eligibility

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this subsection:

(2) "MAGI-based income" means income calculated using the same financial methodologies used to determine MAGI as defined in 26 U.S.C. 36B(d)(2), with the following exceptions:

(A) Each amount received as a lump sum shall be counted as income only in the month received;

(B) scholarships, awards, and fellowship grants used for education purposes and not for living expenses shall be excluded from income; and

(i) Distributions from Alaska native corporations and settlement trusts;

(iv) distributions either resulting from real property ownership interests related to natural resources and improvements located on or near a reservation or within the most recent boundaries of a prior federal reservation or resulting from the exercise of federally protected rights relating to these real property ownership interests;

(vi) student financial assistance provided under the bureau of Indian affairs education programs.

(b) Determination of financial eligibility. Financial eligibility for families and children shall be based on household income, except for the following:

(1) The MAGI-based income of an individual who is included in the household of the individual's natural parent, adoptive parent, or stepparent and is not expected to be required to file a tax return under 26 U.S.C. 6012(a)(1) for the taxable year in which eligibility is being determined shall not be included in household income whether or not the individual files a tax return.

(2) The MAGI-based income of a tax dependent described in K.A.R. 129-14-33(e)(1) who is not expected to be required to file a tax return under 26 U.S.C. 6012(a)(1) for the taxable year in which eligibility is being determined shall not be included in household income whether or not the tax dependent files a tax return.

(d) Budget periods. Each household's financial eligibility shall be based on the current monthly income and family size of the household, unless a change in circumstances is expected. In these instances, financial eligibility shall be based on the projected monthly income and family size of the household.

(e) Exclusion of resources. The value of the household's resources shall not be taken into consideration in determining financial eligibility.

(f) Poverty-level determination. The total monthly income limits for the poverty-level determination shall be established by the secretary and converted to MAGI-equivalent numbers in accordance with 42 C.F.R. 457.300 et seq. If the department determines that the program funds appropriated are insufficient to fund up to this income level, a lower income level shall be implemented by the department, and the notice of the lower income level shall be published by the department in the Kansas register.

(g) Continuous eligibility. Except for children determined eligible for presumptive medical assistance as specified in K.A.R. 129-14-51, each child under the age of 19 who becomes eligible for kancare-CHIP shall continue to be eligible for assistance for 12 months beginning with the month of enrollment or reenrollment regardless of any changes in circumstances, unless one of the following conditions is met:

(1) The child reaches the age of 19.

(2) Assistance is voluntarily terminated for the child.

(3) The child no longer resides in the state.

(4) The state determines that eligibility was granted erroneously because of fraud or agency error.

(5) The child dies.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2013 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-35 Treatment of income

(a) For purposes of this regulation, "prospective monthly amount" shall mean an amount that is projected for purposes of determining an applicant's or recipient's monthly income. All earned income and unearned income received or expected to be received in the month of application shall be used to determine a prospective monthly amount.

(b) For changes in earned income and unearned income, an estimate of those changes shall be used to determine a prospective monthly amount.

(c) For self-employment income, a prospective monthly amount shall be determined based on annual federal tax information from the most recent tax year. In the absence of federal tax information from the most recent tax year, an estimate shall be used to determine a prospective monthly amount.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-36 Applicable income

For pur poses of this regulation, "applicable income" shall mean the amount of earned income and unearned income that is compared with the appropriate income standard to establish financial eligibility. All earned income and unearned income shall be considered applicable income, unless exempted in accordance with K.A.R. 129-14-34(a)(2), and shall be determined as follows:

(a) Applicable income shall be based on the methodologies used to determine modified adjusted gross income, as specified in K.A.R. 129-14-34(a)(2), for persons in the household, as specified in K.A.R. 129-14-34(b).

(b) An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted from the combined household income, for purposes of determining the individual's eligibility under the highest income standard for which the individual is eligible, in accordance with K.A.R. 129-14-34(a)(1).

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History

History: (Authorized by and implementing K.S.A. 2013 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-37 Overpayments

Each recipient who receives an overpayment, whether caused by the department or the individual, shall repay the amount of the overpayment, either by voluntary action or through administrative processes including recoupment and legal action.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-40 Discontinuance of assistance

A recipient's participation in kancare-CHIP shall be discontinued if the recipient no longer meets one or more of the applicable eligibility requirements.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-50 Scope of services

The services provided to children enrolled in kancare-CHIP shall be Kansas medicaid services as specified in K.A.R. 30-5-58 through 30-5-310 and K.A.R. 129-5-1 through 129-5-118b.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-51 Presumptive eligibility

(a) Each child, as defined in K.A.R. 129-14-2, shall be eligible for a presumptive period if a qualified entity, as specified in K.A.R. 129-14-52, designated by the department determines that the child meets the presumptive eligibility requirements.

(b) Each child shall meet the following requirements:

(1) The child shall be under the age of 19.

(2) The child shall meet the general eligibility requirements of K.A.R. 129-14-25, 129-14-26, 129-14-27, and 129-14-28.

(3) The child shall be financially eligible according to K.A.R. 129-14-34.

(4) The child shall be uninsured as specified in K.A.R. 129-14-31.

(5) The child shall not be living in a public institution, as specified in K.A.R. 129-14-30.

(c) The presumptive period shall begin on the date on which the qualified entity makes an eligibility determination. The presumptive period shall end on the last day of the month following the month in which the determination is made, unless an application for medical assistance is received. If an application is filed in accordance with K.A.R. 129-14-20 before this date, the presumptive period shall end on the last day of the month in which a full determination is made.

(d) Each child shall be eligible for only one period of presumptive eligibility within a 12-month period under this regulation or under K.A.R. 129-6-151. The 12-month period shall begin on the first day of presumptive eligibility under either of these regulations.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective June 30, 2006; amended, T-129-10-31-13, Nov. 1, 2013; amended Feb. 28, 2014.)

Kan. Admin. Regs. § 129-14-52 Presumptive eligibility to be determined by qualified entities

(a) Each qualified entity shall be designated by the department to make determinations of presumptive eligibility as specified in K.A.R. 129-14-51.

(b) Each qualified entity shall meet the requirements of 42 C.F.R. 435.1100.

(1) Make a finding of presumptive eligibility pursuant to K.A.R. 129-14-51 or 129-6-151;

(2) notify the child's parent or caretaker, by written or electronic means, of the results of the determination at the time of the determination;

(3) provide the child's parent or caretaker with an application for regular medical assistance. For a child determined to be presumptively eligible, the qualified entity shall notify the child's parents or caretaker that, unless a regular medical assistance application is submitted before the last day of the month following the month of the presumptive determination, eligibility shall end on that date;

(4) assist the child's parent or caretaker in completing and filing a regular medical assistance application; and

(5) notify the department of the presumptive determination within five working days after the determination.

***** Authenticated Kansas Administrative Regulation *****

History

History: (Authorized by and implementing K.S.A. 2012 Supp. 65-1,254 and 75-7403; effective June 30, 2006; amended, T-129-10-31-13, Nov. 1, 2013; amended Feb. 28, 2014.)