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
NECESSITY, FUNCTION, AND CONFORMITY: 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. This administrative regulation establishes
the conditions under which an application is denied or medical assistance is
decreased or discontinued and establishes the advance notice requirements.
Section 1. 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 individual’s income exceeds the
standards as established in 907 KAR 20:020;
2. The individual’s resources exceed the standards
established in 907 KAR 20:025;
3. The applicant does not meet technical
eligibility criteria or fails to comply with a technical requirement as established
in 907 KAR 20:005;
4. 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. The applicant fails to keep the
appointment for an interview without good cause;
6. The applicant requests, in writing,
voluntary withdrawal of the application without good cause;
7. Staff are unable to locate the applicant;
or
8. 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 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. Income of the recipient exceeds the
standards established in 907 KAR 20:020;
2. Resources of the recipient exceed the standards
established in 907 KAR 20:025;
3. Deductions decrease resulting in
income exceeding the standards established in 907 KAR 20:020;
4. The recipient does not meet technical
eligibility criteria or fails to comply with a technical requirement as established
in 907 KAR 20:005;
5. 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. The recipient fails to keep the appointment
for an interview;
7. Staff are unable to locate the recipient;
8. The recipient is no longer domiciled
in Kentucky; or
9. 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. Income exceeds the standards established
in 907 KAR 20:020; or
2. The individual 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.
(5) Medicaid coverage may be reduced due
to a change in Medicaid coverage policy.
Section 2. 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
hearing as established in 907 KAR 20:065.
Section 3. Advance Notice of a
Discontinuance, Increase in Patient Liability, or a Reduction of Medicaid
Coverage. (1) A 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 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 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 hearing;
(e) Provide an explanation of the
circumstances under which Medicaid is continued if an administrative 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 so desires.
(4) An administrative 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.
Section 4. 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 a waiver of the notice requirement indicating that the
recipient understood the consequences;
(2) A clear written statement, signed by
the recipient, that the recipient no longer wishes to receive Medicaid;
(3) The receipt of factual information indicating
that the recipient has died;
(4) The whereabouts of the recipient being
unknown and mail addressed to the recipient being returned indicating no known
forwarding address;
(5) Establishment by the agency that
Medicaid has been accepted in another state;
(6) The recipient entering:
(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 prescribed by the recipient's physician.
Section 5. Expiration of Hospital or
Psychiatric Residential Treatment Facility Stay. 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. (21
Ky.R. 2878; Am. 22 Ky.R. 293; eff. 6-21-1995; Recodified from 907 KAR 1:600, 9-30-2013; 40 Ky.R. 1193;
1797; 2176; eff. 4-4-2014.)