CABINET FOR HEALTH AND FAMILY SERVICES

Department for Medicaid Services

Division of Policy and Operations

(As Amended at ARRS, February 10, 2014)

 

††††† 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 to qualify for federal Medicaid funds[for the provision of medical assistance to Kentucky's indigent citizenry]. This administrative regulation establishes[sets forth] the conditions under which an application is denied or medical assistance is decreased or discontinued and establishes the 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) For an individual:

††††† (a) Whose eligibility standard is not a modified adjusted gross income or who is not a former foster care individual, an application for Medicaid eligibility shall be denied if:

††††† 1. The individualís[(a)] income exceeds[or resources exceed] the standards as established in 907 KAR 20:020[set forth in 907 KAR 1:004];

††††† 2. The individualís resources exceed the standards[standard] established in 907 KAR 20:025;

††††† 3.[(b)] The applicant does not meet technical eligibility criteria or fails to comply with a technical requirement as established in 907 KAR 20:005[set forth in 907 KAR 1:011];

††††† 4.[(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;

††††† 5.[(d)] The applicant fails to keep the appointment for an interview without good cause;

††††† 6.[(e)] The applicant requests, in writing, voluntary withdrawal of the application without good cause;

††††† 7.[(f)] Staff are unable to locate the applicant; or

††††† 8.[(g)] The applicant is no longer domiciled in Kentucky;

††††† (b) Whose eligibility standard is a modified adjusted gross income pursuant to 907 KAR 20:100, the application for Medicaid eligibility shall be denied if:

††††† 1. Income exceeds the standards as established in 907 KAR 20:100;

††††† 2. The applicant does not meet the citizenship, residency, and other technical requirements established in 907 KAR 20:100;

††††† 3. 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;

††††† 4. The applicant fails to keep the appointment for an interview without good cause;

††††† 5. The applicant requests, in writing, voluntary withdrawal of the application without good cause;

††††† 6. Staff are unable to locate the applicant; or

††††† 7. The applicant is no longer domiciled in Kentucky; or

††††† (c) Who is a former foster care individual between the age[ages] of nineteen (19) and twenty-six (26) who aged out of foster care while receiving Medicaid coverage, an application for Medicaid shall be denied if:

††††† 1. The applicant does not meet the citizenship, residency, and other technical requirements established in 907 KAR 20:075;

††††† 2. 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;

††††† 3. The applicant fails to keep the appointment for an interview without good cause;

††††† 4. The applicant requests, in writing, voluntary withdrawal of the application without good cause;

††††† 5. Staff are unable to locate the applicant; or

††††† 6. The applicant is no longer domiciled in Kentucky.

††††† (2) Medicaid eligibility shall be discontinued:

††††† (a) For a recipient whose Medicaid eligibility income standard is not a modified adjusted gross income if:

††††† 1.[(a)] Income[or resources] of the recipient exceeds[exceed] the standards established in 907 KAR 20:020[set forth in 907 KAR 1:004];

††††† 2. Resources of the recipient exceed the standards[standard] established in 907 KAR 20:025;

††††† 3.[(b)] Deductions decrease[decease] resulting in income exceeding the standards established in 907 KAR 20:020[set forth in 907 KAR 1:004];

††††† 4.[(c)] The recipient does not meet technical eligibility criteria or fails to comply with a technical requirement as established in 907 KAR 20:005[set forth in 907 KAR 1:011];

††††† 5.[(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;

††††† 6.[(e)] The recipient fails to keep the appointment for an interview;

††††† 7.[(f)] Staff are unable to locate the recipient;

††††† 8.(g)] The recipient is no longer domiciled in Kentucky; or

††††† 9.(h)] A change in program policy that adversely affects the recipient has occurred;

††††† (b) For a recipient whose Medicaid eligibility income standard is a modified adjusted gross income if:

††††† 1. Income of the recipient exceeds the standards established in 907 KAR 20:100;

††††† 2. The applicant does not meet the citizenship, residency, and other technical requirements established in 907 KAR 20:100;

††††† 3. 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;

††††† 4. The recipient fails to keep the appointment for an interview;

††††† 5. Staff are unable to locate the recipient;

††††† 6. The recipient is no longer domiciled in Kentucky; or

††††† 7. A change in program policy that adversely affects the recipient has occurred; or

††††† (c) For a former foster care individual between the ages of nineteen (19) and twenty-six (26) who aged out of foster care while receiving Medicaid coverage if:

††††† 1. The applicant does not meet the citizenship, residency, and other technical requirements established in 907 KAR 20:075;

††††† 2. 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;

††††† 3. The recipient fails to keep the appointment for an interview;

††††† 4. Staff are unable to locate the recipient;

††††† 5. The recipient is no longer domiciled in Kentucky; or

††††† 6. A change in program policy that adversely affects the recipient has occurred.

††††† (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 for an individual whose income eligibility standard is:

††††† (a) Not a modified adjusted gross income, if:

††††† 1.[(a)] Income exceeds[or resources exceed] the standards established[as set forth] in 907 KAR 20:020[1:004]; or

††††† 2. The individual[(b) The recipient] does not meet technical eligibility requirements established in 907 KAR 20:005; or

††††† (b) A modified adjusted gross income, if:

††††† 1. Income exceeds the standards established in 907 KAR 20:100; or

††††† 2. The individual does not meet the citizenship, residency, and other technical eligibility requirements established in 907 KAR 20:100[as set forth in 907 KAR 1:011].

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

 

††††† Section 2.[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 an administrative[a fair] hearing as established in 907 KAR 20:065[set forth in 907 KAR 1:560].

 

††††† Section 3.[4.] Advance Notice of a Discontinuance, Increase in Patient Liability, or a Reduction of Medicaid Coverage. (1) A[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) A[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 an administrative[a fair] hearing;

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

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

††††† (4) An administrative[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 established in 907 KAR 20:065[set forth in 907 KAR 1:560].

 

††††† Section 4.[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 signed[signs] a waiver of the notice requirement indicating that the recipient understood[understanding of] the consequences;

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

††††† (3) The receipt of factual information indicating[is received] that the recipient has died;

††††† (4) The whereabouts of the recipient being[are] unknown and mail addressed to the recipient being[him][is] returned indicating no known forwarding address;

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

††††† (6) The recipient entering[enters]:

††††† (a) A penal institution; or

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

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

 

††††† Section 5. Expiration of Hospital or Psychiatric Residential Treatment Facility Stay.[6.] Expiration of an approved time-limited hospital or psychiatric residential treatment facility stay shall not constitute a termination, suspension, or reduction of benefits.

 

††††† Section 6. Individuals Whose Income Eligibility Standard is a Modified Adjusted Gross Income. An individual whose Medicaid eligibility is determined using a modified adjusted gross income as the eligibility standard shall be as established in 907 KAR 20:100[ an individual who is:

††††† (1) A child under the age of nineteen (19) years, excluding children in foster care;

††††† (2) A caretaker relative with income up to 133 percent of the federal poverty level;

††††† (3) A pregnant woman, with income up to 185 percent of the federal poverty level, including the postpartum period up to sixty (60) days after delivery;

††††† (4) An adult under age sixty-five (65) with income up to 133 percent of the federal poverty level who:

††††† (a) Does not have a dependent child under the age of nineteen (19) years; and

††††† (b) Is not otherwise eligible for Medicaid benefits; or

††††† (5) A targeted low income child with income up to 150 percent of the federal poverty level][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].

 

LAWRENCE KISSNER, Commissioner

AUDREY TAYSE HAYNES, Secretary

††††† APPROVED BY AGENCY: January 13, 2014

††††† FILED WITH LRC: January 14, 2014 at 1 p.m.

††††† CONTACT PERSON: Tricia Orme, Office of Legal Services, 275 East Main Street 5 W-B, Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573, email tricia.orme@ky.gov.