Presenter outlines appeals, grievances and fair hearings under Kansas Community Support Waiver

A presenter in a Kansas Department for Aging & Disability Services (KDADS) training video summarized the appeals, grievance and fair hearing rights for participants in the Community Support Waiver (CSW), including key deadlines and contact points.

The presenter said the CSW, developed after Kansas House Bill 2184, supports Kansans with intellectual or developmental disabilities ages 5 and older who do not require continuous 24-hour paid support. “The CSW provides a per person annual budget of up to $20,000,” the presenter said.

Why it matters: the CSW gives participants a formal process to challenge eligibility and service decisions. The presenter outlined who decides different eligibility elements: KDADS makes final functional eligibility determinations, and the Kansas Department of Health and Environment (KDHE) makes final financial eligibility determinations.

Appeals and fair hearings: People determined not eligible for the CSW will receive a notice of action that explains the reason and their right to request a fair hearing. The presenter defined a fair hearing as one heard by an administrative law judge or an official with equivalent authority and said requests for a fair hearing must be received within 33 calendar days of the notice of action. The presenter gave the Office of Administrative Hearings mailing address (1020 South Kansas Avenue, Topeka, KS 66612-1327) and a fax number ((785) 296-4848) for written requests.

MCO and FFS differences: The presenter explained that most KanCare participants are enrolled with a managed care organization (MCO). When an MCO issues an adverse benefit determination — examples include denying, limiting, reducing, suspending or terminating a service — the notice of action must include appeal instructions and participants generally must exhaust the MCO’s appeal process before requesting a state fair hearing. Participants must request an MCO appeal within 63 calendar days of the notice of adverse benefit determination; if they do so within 63 days, their current CSW services will continue until the MCO issues the notice of appeal resolution.

If the MCO continues to issue an adverse determination after the appeal, participants may request a state fair hearing. The presenter said requests for a state fair hearing must be submitted within 123 calendar days from the date of the notice of appeal resolution; MCOs automatically continue services during that 123-day period but services may end after 123 days if no hearing is requested.

Tribal and fee-for-service participants: Tribal members may opt out of KDHE’s managed care program and be served under KDHE’s fee-for-service (FFS) Medicaid program. FFS participants also have the right to request a fair hearing when KDHE denies, suspends, reduces or terminates FFS waiver services.

Grievances: The presenter described the grievance process as a way to express dissatisfaction about non-adverse matters (examples provided: poor employee behavior, concerns about dignity or rights, poor customer service, or quality of care). Grievances may be submitted by phone, in writing or in person. MCOs and the FFS fiscal agent must log and track grievances; both KDHE and KDADS have access to grievance logs and the KanCare website has detailed procedures.

Resources and next steps: The presenter repeatedly directed viewers to KanCare’s online appeals and grievances pages for full procedures, phone numbers and addresses. The training included contact instructions for requesting fair hearings and appeals and emphasized timelines for filing (33 days for initial fair hearing requests tied to notice of action; 63 days to request an MCO appeal; 123 days to request a state fair hearing after an appeal resolution).

The presenter closed by noting additional information is available on the KanCare website’s appeals and fair hearings pages.