Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:563 - Medicaid covered services appeals and hearings unrelated to managed care

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS Chapter 13B, 194A.025, 205.231, 205.237,
				205.520, 205.8451, 210.270
				42
				C.F.R. 431.233,
				431.244, Part
				475,
				475.101,
				483.2,
				483.12,
				431 Subpart E, 483 Subpart E,
				42 U.S.C.
				1396n(c)
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services has responsibility to administer the Medicaid Program.
				KRS
				205.520(3) authorizes the
				cabinet, by administrative regulation, to comply with a requirement that may be
				imposed or opportunity presented by federal law to qualify for federal Medicaid
				funds. This administrative regulation establishes policies and requirements
				relating to an adverse action, an appeal, or a hearing regarding Medicaid
				covered services that are not the responsibility of a managed care
				organization.
Section 1. Definitions.
(1) "1915(c) home and community based waiver
			 service" means a service available or provided via a 1915(c) home and community
			 based waiver services program.
(2)
			 "1915(c) home and community based waiver services program" means a Kentucky
			 Medicaid program established pursuant to and in accordance with
			 42 U.S.C.
			 1396n(c).
(3) "Administrative hearing" is defined by
			 KRS
			 13B.010(2).
(4) "Appeal board" means the entity or
			 individual designated by the secretary of the Cabinet for Health and Family
			 Services to hear appeals of recommended orders or final orders following a
			 decision by a representative of the designated hearing agency or hearing
			 officer.
(5) "Applicant" means an
			 individual who has applied for Medicaid covered services.
(6) "Authorized representative" means:
(a) For a recipient or applicant who is
			 authorized by Kentucky law to provide written consent, an individual or entity
			 acting on behalf of, and with written consent from, the recipient or the
			 applicant; or
(b) A legal
			 guardian.
(7) "Cabinet"
			 means the Cabinet for Health and Family Services.
(8) "Department" means the Department for
			 Medicaid Services or its designee.
(9) "Designated hearing agency" means the
			 entity designated by the secretary of the Cabinet for Health and Family
			 Services to adjudicate administrative hearings.
(10) "Enrollee" means a recipient who is
			 enrolled with a managed care organization for the purpose of receiving Medicaid
			 or Kentucky Children's Health Insurance Program covered services.
(11) "Final order" is defined by
			 KRS
			 13B.010(6).
(12) "Hearing officer" is defined by
			 KRS
			 13B.010(7), and includes a
			 representative from a designated hearing agency.
(13) "ICF IID" means intermediate care
			 facility for an individual with an intellectual disability.
(14) "Managed care organization" or "MCO"
			 means an entity for which the Department for Medicaid Services has contracted
			 to serve as a managed care organization as defined in
			 42
			 C.F.R. 438.2.
(15) "Medicaid covered services" means items
			 or services a Medicaid recipient may receive through the Medicaid
			 Program.
(16) "Party" is defined by
			 KRS
			 13B.010(3).
(17) "PASRR" means preadmission screening and
			 resident review.
(18) "Patient
			 liability" means the financial obligation of a recipient towards the cost of
			 the recipient's nursing facility services or services provided pursuant to a
			 1915(c) waiver.
(19) "Provider" is
			 defined by
			 KRS
			 205.8451(7).
(20) "QIO" or "quality improvement
			 organization" means an entity that meets the requirements established in
			 42 C.F.R.
			 475.101.
(21) "Recipient" is defined by
			 KRS
			 205.8451(9).
(22) "Recommended order" is defined by
			 KRS
			 13B.010(5).
(23) "Time-limited benefits" means Medicaid
			 coverage which is restricted to a specified period in time.