Kan. Admin. Regs. § 129-1-1

Current through Register Vol. 44, No. 2, January 9, 2025

Section 129-1-1 - Definitions

Each of the following terms, when used in the division's Regulations, shall have the meaning specified in this regulation, unless the context clearly indicates otherwise:

(a) "Acknowledgement and order" means the initial documentation from the presiding officer that acknowledges the filing of an administrative hearing case and that includes an order from the presiding officer requiring the department to submit a department summary by the designated due date.

(b) "Activities of daily living" and "ADL" mean basic daily activities involving bathing, dressing, eating, ambulating, toileting, and personal hygiene.

(c) "Affordable care act" and "ACA" mean the patient protection and affordable care act of 2010, public law 111-148, as amended by the health care and education reconciliation act of 2010, public law 111-152, and any subsequent amendments.

(d) "Appellant" means an applicant, a beneficiary, an enrollee, or a provider who has received an adverse benefit determination or adverse action, the real party in interest as defined in K.S.A. 60-127 and amendments thereto, or the department if the department is the losing party of an external independent third-party review and requests a state fair hearing.

(e) "Applicant" means any individual who is seeking an eligibility determination for that individual through the submission of an application for medical assistance.

(f) "Beneficiary" means an individual who is eligible to receive covered services. This term shall include a recipient or consumer who is eligible to receive covered services. This term shall include a beneficiary's authorized representative.

(g) "Business day" means any day that is not a Saturday, Sunday, or legal holiday. "Legal holiday" shall include any day designated as a holiday by any Kansas statute or regulation. If a department is inaccessible on the last day of any period of time prescribed by the division's regulations, the time period shall be extended until the next business day on which the department is open for business.

(h) "CMS" means the centers for medicare and medicaid services, a division within the U.S. department of health and human services.

(i) "Computing period of time" means that, in computing any period of time prescribed by K.S.A. 77-503, the day from which the designated period of time begins to run shall not be included.

(j) "Continuation of benefits" and "continuation of services" means the continuation of previously authorized covered services.

(k) "Covered services" means medical services or other care for which reimbursement will be made, directly or indirectly, by KMAP. Coverage may be limited by the secretary through prior authorization requirements.

(l) "Department" means Kansas department of health and environment and its designees authorized to administer the medicaid program and kancare-CHIP.

(m) "Division" means division of health care finance in the Kansas department of health and environment.

(n) "Durable medical equipment" and "DME" mean equipment that meets the following conditions:

(1) Withstands repeated use;

(2) is not generally useful to a person in the absence of an illness or injury;

(3) is primarily and customarily used to serve a medical purpose;

(4) is appropriate for use in the home; and

(5) is rented or purchased as determined by the secretary or the secretary's designee.

(o) "Effective date of action" means the date on which the action, as defined in 129-7-1, becomes effective.

(p) "Election statement" means the revocable statement signed by a beneficiary that is filed with a particular hospice and that consists of the following:

(1) Identification of the hospice selected to provide care;

(2) acknowledgement that the beneficiary has been given a full explanation of hospice care;

(3) acknowledgement by the beneficiary that other medicaid services are waived;

(4) the effective date of the election period; and

(5) the beneficiary's signature or the signature of the beneficiary's legal representative.

(q) "Eligibility" means qualification for or access to medical assistance.

(r) "Emergency services" means medical care provided promptly after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(1) Serious jeopardy to the patient's health;

(2) serious impairment to bodily functions; or

(3) serious dysfunction of any bodily organ or part.

(s) "Enrollee" means an individual who has been assigned to and has enrolled with a KanCare MCE and is entitled to receive covered services provided by a KanCare MCE. This term shall include a recipient, consumer, or beneficiary who is entitled to receive covered services provided by a KanCare MCE and who has been assigned to and enrolled with a KanCare MCE. This term shall include an enrollee's authorized representative.

(t) "Evidentiary standard" means the responsibility to establish a proposition in a state fair hearing by a preponderance of the evidence.

(u) "Federally facilitated exchange" and "FFE" mean an insurance exchange operated by the federal government as established under the patient protection and affordable care act, public law 111-148.

(v) "Fee-for-service" and "FFS" mean a system of health insurance payment in which a doctor or other health care provider is paid a fee for each service rendered.

(w) "Final administrative action" as used in 42 C.F.R. 431.244 means a decision rendered by a presiding officer pursuant to K.S.A. 77-526(b), and amendments thereto, that determines the legal rights, duties, privileges, immunities, or other legal interest of one or more specific persons. For the purpose of interpreting 42 C.F.R. 431.244, an initial order shall be a final administrative action. This term shall include a proposed default order that has become effective.

(x) "Final order" means an initial order decision by a presiding officer that becomes a final order pursuant to KAPA, and amendments thereto, an initial order reviewed by the secretary or the state appeals committee pursuant to K.S.A. 77-527, and amendments thereto, or a final order reconsidered by the secretary pursuant to K.S.A. 77-529, and amendments thereto.

(y) "Home- and community-based services" and "HCBS" mean a program of covered services operated under the authority of section 1915(c) of the social security act that permits a state to waive certain medicaid requirements in order to furnish an array of home- and community-based services that promote community living for medicaid beneficiaries to avoid institutionalization. Waiver-based covered services complement and supplement the covered services that are available through the medicaid state plan or other federal, state, and local public programs, as well as the supports that families and communities provide to individuals.

(z) "Initial order" means a decision rendered by a presiding officer pursuant to K.S.A. 77-526(b), and amendments thereto, that determines the legal rights, duties, privileges, immunities, or other legal interest of one or more specific persons. This term shall include a proposed default order that has become effective. For the purpose of interpreting 42 C.F.R. 431.244, an initial order shall be a final administrative action.

(aa) "Instrumental activities of daily living" and "IADL" mean activities involving shopping, housekeeping, paying bills, food preparation, medicine regimens, communication, transportation, and resting.

(bb) "Kan be healthy program participant" means an individual under the age of 21 who is eligible for medicaid and who has undergone a kan be healthy medical screening in accordance with a specified screening schedule. The medical screening shall be performed for the following purposes:

(1) To ascertain physical and mental defects; and

(2) to provide treatment that corrects or ameliorates defects and chronic conditions that are found.

(cc) "Kancare-CHIP" means the health insurance program for children administered by the department and authorized under title XXI of the social security act.

(dd) "KAPA" means the Kansas administrative procedure act, K.S.A. 77-501 et seq. and amendments thereto.

(ee) "KDHE" means the Kansas department of health and environment, which is the single state medicaid agency.

(ff) "KJRA" means the Kansas judicial review act, K.S.A. 77-601 et seq. and amendments thereto.

(gg) "KMAP" means the Kansas medical assistance program.

(hh) "Local evidentiary hearing" as used in 42 C.F.R. 431.201 means a hearing held on the local or county level serving a specified portion of the state. Local evidentiary hearings are not available in Kansas.

(ii) "Long-term services and supports" and "LTSS" mean covered services and supports provided to beneficiaries of all ages with functional limitations or chronic illnesses that have the primary purpose of supporting the ability of the beneficiary to live or work in the setting of the individual's choice, which may include the individual's home, a worksite, a provider-owned or provider-controlled residential setting, a nursing facility, or other institutional setting.

(jj) "Managed care" means a system of managing and financing health care delivery to ensure that covered services provided to managed care plan members are necessary, efficiently provided, and appropriately priced.

(kk) "MCE" means a managed care entity, including an MCO, a PAHP, or a PIHP.

(ll) "MCO" means a managed care organization that has a comprehensive risk contract with the Kansas medical assistance program to provide covered services to enrollees of the MCO. The contract shall have the approval of the U.S. department of health and human services or its designee. An MCO shall provide a grievance, appeal, and state fair hearing process to its enrollees.

(mm) "Medicaid" means the federal medical assistance program authorized under title XIX of the social security act.

(nn) "Medical assistance" means assistance that covers all or part of the cost of medical care for eligible persons paid through joint federal and state funding, federal-only funding, and state-only funding, including Kansas medicaid, kancare-CHIP, and medikan. This assistance is administered under KMAP.

(oo)

(1) "Medical necessity" means that a health intervention is an otherwise covered category of service, is not specifically excluded from coverage, and is medically necessary, according to all of the following criteria:

(A) Authority. The health intervention is recommended by the treating physician and is determined to be necessary by the secretary or the secretary's designee.

(B) Purpose. The health intervention has the purpose of treating a medical condition.

(C) Scope. The health intervention provides the most appropriate supply or level of service, considering potential benefits and harms to the patient.

(D) Evidence. The health intervention is known to be effective in improving health outcomes.

(i) For new interventions, effectiveness shall be determined by scientific evidence as described in paragraph (oo)(3).

(ii) For existing interventions, effectiveness shall be determined by scientific evidence as described in paragraph (oo)(4).

(E) Value. The health intervention is cost-effective for this condition compared to alternative interventions, including no intervention. Cost-effective shall not necessarily be construed to mean lowest-priced. An intervention may be medically indicated and yet not be a covered service or benefit or meet the definition of medical necessity in this subsection. Interventions that do not meet this regulation's definition of medical necessity may be covered at the discretion of the secretary or the secretary's designee. An intervention shall be considered cost-effective if the benefits and harms relative to the costs represent an economically efficient use of resources for patients with this condition. In the application of this criterion to an individual case, the condition of the individual patient shall be determinative.

(2) The following definitions shall apply to these terms only as they are used in this subsection:

(A) "Effective," when used to describe an intervention, means that the intervention can be reasonably expected to produce the intended results and to have expected benefits that outweigh potential harmful effects.

(B) "Health intervention" means an item or covered service delivered or undertaken primarily to treat a medical condition or to maintain or restore functional ability. For the definition of medical necessity in this subsection, a health intervention shall be determined not only by the intervention itself, but also by the medical condition and patient indications for which the health intervention is being applied.

(C) "Health outcomes" means treatment results that affect health status as measured by the length or quality of a person's life.

(D) "Medical condition" means a disease, illness, injury, genetic or congenital defect, pregnancy, or biological or psychological condition that lies outside the range of normal, age-appropriate human variation.

(E) "New intervention" means an intervention that is not yet in widespread use for the medical condition and patient indications under consideration.

(F) "Scientific evidence" means controlled clinical trials that either directly or indirectly demonstrate the effect of the intervention on health outcomes. However, if controlled clinical trials are not available, observational studies that demonstrate a causal relationship between the intervention and health outcomes may be used. Partially controlled observational studies and uncontrolled clinical series may be considered to be suggestive, but shall not by themselves be considered to demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or by potential experimental biases.

(G) "Secretary's designee" means a person or persons designated by the secretary to assist in the medical necessity decision-making process.

(H) "Treat" means to prevent, diagnose, detect, or palliate a medical condition.

(I) "Treating physician" means a physician who has personally evaluated the patient.

(3) Each new intervention for which clinical trials have not been conducted because of epidemiological reasons, including rare or new diseases or orphan populations, shall be evaluated on the basis of professional standards of care or expert opinion as described in paragraph (oo)(4).

(4) The scientific evidence for each existing intervention shall be considered first and, to the greatest extent possible, shall be the basis for determinations of medical necessity. If no scientific evidence is available, professional standards of care shall be considered. If professional standards of care do not exist or are outdated or contradictory, decisions about existing interventions shall be based on expert opinion. Coverage of existing interventions shall not be denied solely on the basis that there is an absence of conclusive scientific evidence. Existing interventions may be deemed to meet the definition of medical necessity in this subsection in the absence of scientific evidence if there is a strong consensus of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or, in the absence of those standards, convincing expert opinion.

(pp) "Medical necessity in psychiatric situations" means that there is medical documentation indicating either of the following:

(1) The person could be harmful to that individual or others if not under psychiatric treatment.

(2) The person is disoriented in time, place, or person.

(qq) "Medikan" means a totally state-funded program covering all or part of the cost of medical care for disabled individuals who do not qualify for medicaid but who are eligible for covered services and benefits under K.A.R. 129-6-95.

(rr) "Non-covered services" means services for which KMAP will not provide direct or indirect reimbursement, including services that have been denied due to the lack of medical necessity.

(ss) "PACE" means a program of all-inclusive care for the elderly under K.A.R. 129-6-34.

(tt) "Plan of care" and "POC" mean a plan prepared and authorized by the secretary or the secretary's designee that identifies the following:

(1) The medical and LTSS needs of a KMAP beneficiary or enrollee for a specified period of time;

(2) the treatment and covered services, including LTSS, to be used in meeting the needs of the KMAP beneficiary or enrollee during that time period;

(3) the expected result of the treatment and covered services, including LTSS;

(4) the provider or providers of the treatment and covered services, including LTSS; and

(5) the cost of the treatment and covered services, including LTSS.

(uu) "Prepaid ambulatory health plan" and "PAHP" mean an entity that meets the following conditions:

(1) Provides covered services to enrollees under contract with the state and on the basis of capitation payments or other payment arrangements that do not use state plan payment rates;

(2) does not provide or arrange for, and is not otherwise responsible for the provision of, any inpatient hospital or institutional services for its enrollees; and

(3) does not have a comprehensive risk contract.

(vv) "Prepaid inpatient health plan" and "PIHP" mean an entity that meets the following conditions:

(1) Provides covered services to enrollees under contract with the state and on the basis of capitation payments or other payment arrangements that do not use state plan payment rates;

(2) provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and

(3) does not have a comprehensive risk contract.

(ww) "Preponderance of the evidence" means a standard of evidence in which the evidence presented demonstrates a fact to be more likely true than not true.

(xx) "Presiding officer" means the secretary, one or more members of the department, or an administrative law judge assigned by the secretary's state fair hearing designee for the purposes of conducting an initial adjudicative hearing.

(yy) "Primary care" means all health care and laboratory services customarily furnished through a general medical practitioner, family physician, internal medicine physician, obstetrician, gynecologist, or pediatrician.

(zz) "Primary diagnosis" means the most significant diagnosis related to the medical care rendered.

(aaa) "Prior authorization" means a KMAP beneficiary's or a managed care enrollee's request for the provision of a covered service before the covered service is rendered. This term is also known as a covered service authorization.

(bbb) "Provider" means a person or entity who provides covered services to eligible beneficiaries and enrollees and receives payment, directly or indirectly, from KMAP. This term shall include a provider's authorized representative.

(ccc) "Recipient" means any individual who has been determined eligible and is receiving medical assistance. This term shall include a consumer who has been determined eligible and is receiving medical assistance.

(ddd) "Respondent" means the department, which appears at the state fair hearing; the skilled nursing facility or nursing facility in a discharge or transfer of a resident; the real party in interest as defined in K.S.A. 60-217, and amendments thereto; or a provider, if the provider was the winning party of the external independent third-party review and the department requests a state fair hearing.

(eee) "Secretary" means secretary of the Kansas department of health and environment. This term shall include the secretary's designee.

(fff) "Secretary's designee" means a designee of the secretary, whether an individual or an entity, who has been delegated authority as specified in a contract between the secretary and the individual or entity.

(ggg) "Secretary's reconsideration" means a response by the secretary to a petition for reconsideration of the orders pursuant to K.S.A. 77-529, and amendments thereto.

(hhh) "Send" or "Sent" means deliver by mail, facsimile, or in electronic format.

(iii) "Service of order or notice" means the delivery of the order or the notice by U.S. mail or in electronic format. Delivery of a copy of an order or notice means handing the order or notice to the person or leaving the order or notice at the person's principal place of business or residence with a person of suitable age and discretion who works or resides there. Service of order or notice by mail shall be complete upon mailing. Service of order or notice by electronic means shall be complete upon transmission. Service includes delivery of a copy of an order or notice to the person's authorized representative.

(jjj) "Single state agency" and "single state medicaid agency" mean the Kansas executive agency that has been designated as the agency responsible for the overall administration and supervision of the medicaid program in Kansas. The single state agency may delegate part of the administration of the Kansas medicaid program to another state, a local agency, or a contractor. The overall authority of the single state agency for the Kansas medicaid program shall not be impaired.

(kkk) "State appeals committee" and "SAC" mean the committee appointed by the secretary as the secretary's designee to respond to petitions for review of the initial orders pursuant to K.S.A. 77-527, and amendments thereto.

(lll) "State fair hearing" means a proceeding during which evidence is presented to the secretary or the secretary's designee by an appellant and a respondent. This term is also known as a fair hearing, an evidentiary hearing, or an administrative hearing under KAPA.

(mmm) "State medicaid agency" means the single state agency for the medicaid program pursuant to K.S.A. 757409.

(nnn) "State plan" means the agreement between Kansas and federal authorities allowing Kansas to participate in certain federal programs.

(ooo) "Swing bed" means a hospital bed that can be used interchangeably as a hospital, skilled nursing facility, or intermediate care facility bed, with reimbursement based on the specific type of care provided.

(ppp) "Targeted case management services" means a set of covered services that will assist an enrollee in gaining access to medical, social, educational, or other needed covered services. This term shall include the following:

(1) Assessment of an enrollee to determine covered service needs;

(2) development of a specific care plan;

(3) referral and related activities; and

(4) monitoring and follow-up activities.

(qqq) "Waiver" means an amendment to the state plan in which some part of federal medicaid requirements are no longer applied to a specific applicant or enrollee seeking medical assistance. A waiver shall require agreement between KDHE and federal medicaid authorities before the waiver can be effective for KMAP. HCBS programs shall be established by waivers.

Kan. Admin. Regs. § 129-1-1

Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014; amended by Kansas Register Volume 43, No. 50; effective 12/27/2024.