RELATES TO:
KRS
205.520
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:
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 redetermi-nation, 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 redetermi-nation, 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 redetermi-nation, 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
Med-icaid coverage for an individual whose income eligibility standard is:
(a) Not a modified adjusted gross income, if:
2. The individual does not meet technical
eligibility requirements established in
907
KAR 20:005; or
(b) A modified adjusted gross income, if:
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.