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. 60-127 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 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.
757409.
(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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.