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 nonwaiver 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 129-8-7.

(B) The appeal involves the termination, suspension, or reduction of previously authorized covered services.

(C) The covered services were ordered by an authorized provider.

(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.

(C) The department determines that the request for a state fair hearing concerns a discontinued program or service.

(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 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 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.

Notes

Kan. Admin. Regs. § 129-8-5

Authorized by and implementing K.S.A. 65-1,254 and 75-7403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.