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

Link to law: http://www.lrc.ky.gov/kar/907/020/060.htm
Published: 2015

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      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.)