907 KAR 20:060. Medicaid adverse action and conditions for recipients.

 

      RELATES TO: KRS 205.520

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 C.F.R. 431.210, 431.211, 431.213, 431.214, 42 U.S.C. 1396a, b, d, EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services has responsibility to administer the Medicaid Program. KRS 205.520(3) empowers the cabinet, by administrative regulation, to comply with any requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation sets forth the conditions under which an application is denied or assistance is decreased or discontinued and advance notice requirements.

 

      Section 1. Definitions. (1) "Applicant" means an individual applying for Medicaid.

      (2) "Application" means the process set forth in 907 KAR 1:610.

      (3) "Medicaid coverage" means items or services a Medicaid recipient may receive through the Medicaid Program.

      (4) "Recipient" means an individual who receives Medicaid.

 

      Section 2. Reasons for Adverse Action. (1) An application for Medicaid eligibility shall be denied if:

      (a) Income or resources exceed the standards as set forth in 907 KAR 1:004;

      (b) The applicant does not meet technical eligibility criteria or fails to comply with a technical requirement as set forth in 907 KAR 1:011;

      (c) Despite receipt of written notice detailing the additional information needed for a determination, the applicant fails to provide sufficient information or clarify conflicting information necessary for a determination of eligibility;

      (d) The applicant fails to keep the appointment for an interview without good cause;

      (e) The applicant requests in writing voluntary withdrawal of the application without good cause;

      (f) Staff are unable to locate the applicant; or

      (g) The applicant is no longer domiciled in Kentucky.

      (2) Medicaid eligibility shall be discontinued if:

      (a) Income or resources of the recipient exceed the standards set forth in 907 KAR 1:004;

      (b) Deductions decease resulting in income exceeding the standards set forth in 907 KAR 1:004;

      (c) The recipient does not meet technical eligibility criteria or fails to comply with a technical requirement as set forth in 907 KAR 1:011;

      (d) Despite receipt of written notice detailing the additional information needed for a redetermination, the recipient fails to provide sufficient information or clarify conflicting information necessary for a redetermination of eligibility;

      (e) The recipient fails to keep the appointment for an interview;

      (f) Staff are unable to locate the recipient;

      (g) The recipient is no longer domiciled in Kentucky; or

      (h) A change in program policy that adversely affects the recipient.

      (3) Patient liability shall be increased if:

      (a) Income of the recipient increases; or

      (b) Deductions decrease.

      (4) Medicaid eligibility may be redetermined in another category resulting in a reduction of Medicaid coverage if:

      (a) Income or resources exceed the standards as set forth in 907 KAR 1:004; or

      (b) The recipient does not meet technical eligibility requirements as set forth in 907 KAR 1:011.

      (5) Medicaid coverage may be reduced due to a change in Medicaid coverage policy.

 

      Section 3. Notification of Denial of Applications. If a Medicaid application is denied, the applicant shall be given written notification of the denial which shall include:

      (1) The reason for the denial;

      (2) The cites of the applicable state administrative regulation; and

      (3) The right to a fair hearing as set forth in 907 KAR 1:560.

 

      Section 4. Advance Notice of a Discontinuance, Increase in Patient Liability or a Reduction of Medicaid Coverage. (1) The recipient shall be given ten (10) days advance notice of the proposed action if a change in circumstances indicates:

      (a) A discontinuance of Medicaid coverage;

      (b) An increase in patient liability; or

      (c) A reduction of Medicaid coverage.

      (2) The recipient shall be given five (5) days advance notice of the proposed action if a change in circumstance indicates:

      (a) Facts that action should be taken because of probable fraud by the recipient; and

      (b) The facts have been verified through secondary sources.

      (3) The ten (10) days advance notice and the five (5) days advance notice of proposed action shall:

      (a) Be in writing;

      (b) Explain the reason for the proposed action;

      (c) Cite the applicable state administrative regulation;

      (d) Explain the individual's right to request a fair hearing;

      (e) Provide an explanation of the circumstances under which Medicaid is continued if a hearing is requested; and

      (f) Include that the applicant or recipient may be represented by an attorney or other if he so desires.

      (4) A hearing request received during the advance notice period may result in a delay of the discontinuance of Medicaid coverage, a delay in an increase in patient liability or delay of a reduction of Medicaid coverage pending the hearing officer's decision, as set forth in 907 KAR 1:560.

 

      Section 5. Exceptions to the Advance Notice Requirement. An advance notice of proposed action shall not be required, but written notice of action taken shall be given, if discontinuance of Medicaid coverage or an increase in patient liability resulted from:

      (1) Information reported by the recipient if the recipient signs a waiver of the notice requirement indicating understanding of the consequences;

      (2) A clear written statement, signed by the recipient, that he no longer wishes to receive Medicaid;

      (3) Factual information is received that the recipient has died;

      (4) Whereabouts of the recipient are unknown and mail addressed to him is returned indicating no known forwarding address;

      (5) Establishment by the agency that Medicaid has been accepted in another state;

      (6) The recipient enters:

      (a) A penal institution; or

      (b) If between twenty-one (21) and sixty-five (65), a mental hospital or an institution for mental disease (IMD); or

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

 

      Section 6. Expiration of an approved time-limited hospital or psychiatric residential treatment facility stay shall not constitute termination, suspension, or reduction of benefits.

 

      Section 7. Material Incorporated by Reference. (1) The forms necessary for adverse action in the Medicaid Program are being incorporated effective April 1, 1995. These forms include the MA 105, revised July 1992 and the KIM 105, revised September 1992.

      (2) Material incorporated by reference may be reviewed at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621. Office hours are 8 a.m. to 4:30 p.m. Copies may be obtained from that office upon payment of the appropriate fee allowed by 200 KAR 1:020. (21 Ky.R. 2878; Am. 22 Ky.R. 293; eff. 6-21-1995; Recodified from 907 KAR 1:600, 9-30-2013.)