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 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 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
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 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 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 129-7-4.
Notes
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No prior version found.