KanCare: Reinventing Medicaid for Kansas

Consumers

KanCare Ombudsman


To contact the KanCare Ombudsman

Kerrie Bacon
Toll Free: (855) 643-8180
TTY:  711
Fax:  (785) 296-0256
KanCare.Ombudsman@kdads.ks.gov


Resource Information

Resources



KanCare/Medicaid Contact Information



MCO Contact Information
For general assistance for your managed care companies call these main numbers:

  • Amerigroup (1-800-600-4441)
  • Sunflower (1-877-644-4623)
  • United Healthcare (877-542-9238)


Frequently Asked Questions



Grievance

A grievance is an expression of dissatisfaction. 

If you have a problem with an MCO’s or network providers services concerning such things as quality of care, access to care, your rights and dignity, or poor behavior of a provider or an MCO associate, you may:
      •  Call or write to the MCO about it; or
      •  Ask a representative of your choice to call or write to the MCO
If you ask a provider or other person to call or write to the MCO, you will need to include written approval for them to represent you.

Possible subjects or examples of a grievance might be:

  • You are unhappy with the quality of your care or services provide
  • Poor behavior by an employee of the MCO or their provider
  • The failure to respect a member’s rights and dignity
  • You received a bill from a provider that should be covered by KanCare (your MCO) and the MCO said they are not covering it

Members must file a grievance within 180 days of the action taken by the MCO. The MCO must acknowledge in writing the grievance was received within 10 business days; 98% of all grievances must be resolved in 30 business days.  If the MCO believes an additional 30 business days may be needed to resolve the grievance, this request must be made to KDHE/HDCF two business days in advance of the 30 business day deadline.  100% of grievances must be resolved in 60 business days.


For grievance/complaint process for your managed care companies call these main numbers.

  • AmerigroupToll Free:(1-800-600-4441) (TTY: 711); Direct: 913-749-5955 (TTY 711)
          Mail to:
          Administrative Review and Grievance Department
          Amerigroup Kansas, Inc.
          9225 Indian Creek Parkway, Building #32
          Overland Park, KS 66210
          Visit us in person at:
          Amerigroup Kansas, Inc., Administrative Review and Grievance Department
          9225 Indian Creek Parkway, Building #32
          Overland Park, KS 66210
  • Sunflower   Toll Free:  (1-877-644-4623)  (TTY: 1-888-282-6428)
          Fax:  1-888-453-4755
          Mail to:
          Sunflower Health Plan Quality Department
          8325 Lenexa Dr., Suite 200
          Lenexa, KS  66214
  • '
  • United Healthcare (1-877-542-9238) (TTY: 711)
          Mail to:
          United Healthcare
          Grievance and Appeals
          P.O. Box 31364
          Salt Lake City, UT 84131-0364


Appeals

What is an appeal? 
An appeal is your request for a review of an Adverse Action. An Action is when a managed care organization (MCO) such as Amerigroup, Sunflower or Unitedor a state agency such as Kansas Department of Children and Families, Kansas Department of Aging and Disability Services or Kansas Department of Health and Environment :

  • Denies or limits a service you want;
  • Reduces, suspends or terminates  payment for a service you are getting ;
  • Fails to authorize a service in the required time; or
  • Fails to respond to a grievance or appeal in the required time.

-Portions taken from United 2015 Member Handbook, p.43

With an MCO appeal, the Managed Care Organization (Amerigroup, Sunflower or Untied) team will review your case information and any new documentation you send to determine if they agree with you or with the original decision.

A “notice of action” or “notice of adverse action or determination” letter is mailed to tell a KanCare member that there has been a change in the KanCare services.  It will tell the member that there is an option to appeal the action.  The appeal must be filed within a 30 days plus 3 days if the notice was mailed. 

Basics

  • You should not be treated differently by your MCO or MCO Care Coordinator if you file an appeal.
  • DO NOT WAIT.  Turn in the appeal right away.  You can always dismiss the action if you decide not to go forward with the appeal.  They do not make exceptions for missed deadlines. 
  • What documentation do I need?
    • Send in your appeal letter as soon as possible saying you want to appeal.  It does not have to state your case yet.  Follow up with documentation showing why you are appealing the case and disagree with the decision.
  • Filing an MCO appeal:
    • Sunflower   Toll Free:  (1-877-644-4623)  (TTY: 1-888-282-6428)
            Fax:  1-888-453-4755
            Mail to:
            Sunflower Health Plan Quality Department
            8325 Lenexa Dr., Suite 200
            Lenexa, KS  66214
       
    • Amerigroup  Toll Free:(1-800-600-4441) (TTY: 711); Direct: 913-749-5955 (TTY 711)
            Mail to:
            Central Appeals Processing
            Amerigroup Kansas, Inc.
            PO Box 62429
            Virginia Beach, VA  23466-2429
            Visit us in person at:
            Amerigroup Kansas, Inc., Administrative Review and Grievance Department
            9225 Indian Creek Parkway, Building #32
            Overland Park, KS 66210
       
    • United Healthcare (1-877-542-9238) (TTY: 711)
            Mail to:
            United Healthcare
            Grievance and Appeals
            P.O. Box 31364
            Salt Lake City, UT 84131-0364
       
  • What happens to my services while I am appealing?
    • Non Home and Community Based Services - If you file an appeal related to services that are not provided as a Home and Community Based Service (HCBS), you may ask to keep getting those services while the appeal is in progress. 
    • The request must be made within 10 days of the mailing of the letter noting the action.  You may ask for services to continue within your request for an appeal. Some of the MCO’s may have the member pay for the care if the decision in not in your favor.  
    • Home and Community Based Services (HCBS) – If you file an appeal related to services that are provided as Home and Community Based Services (HCBS), you will keep getting those services while the appeal is being decided.  You will not have to pay for this care if the appeal decision in not in your favor unless fraud is present.

-Portions taken from Sunflower 2015 Member Handbook, p.52

Which appeal should I file first?
If you want to file both appeals, there are two options:

  • File the MCO appeal, see if you are accepted or denied.  If denied, then file a state fair hearing after you receive the denial letter from the MCO.  You have 30 days to appeal after receiving the denial letter from the MCO.
  • File the MCO appeal and the state fair hearing appeal at the same time. 


Expdited Appeals – for an appeal related to services that put your health at immediate risk, you may file an expedited appeal with your MCO.  The appeal will be reviewed within 3 working days of the request.  They can be submitted in writing or verbally (by phone).  A member may not file a state fair hearing at the same time as an expedited appeal.



State Fair Hearing

What is a State Fair Hearing?
The state fair hearing is done through the Office of Administrative Hearings (OAH) with the State of Kansas.  It is an opportunity for the member to speak about his/her issue.  The member and MCO meet before a Presiding Officer that is an administrative law judge, who is an impartial individual.  He or she will enter an initial order based upon what is presented by the agency and by you at the hearing.

It is usually done on the phone as a conference call, but a member can request to have the hearing in person.  There is no expense for this. 

A “notice of action” or “notice of adverse action or determination” letter is mailed to tell a KanCare member that there has been a change in the KanCare services.  It will tell the member that there is an option to appeal the action.  The appeal must be filed within a 30 days plus 3 days if the notice was mailed. 

Basics

  • You should not be treated differently by your MCO or MCO Care Coordinator if you file a state fair hearing.
  • DO NOT WAIT.  Turn in the state fair hearing right away.  You can always dismiss the action if you decide not to go forward with the state fair hearing.  They do not make exceptions for missed deadlines. 
  • What is the timing of the state fair hearing?
    You have 30 days (plus three if it was mailed) from the date on the “Notice of Action” letter to turn in a state fair hearing.
    • If you wish to ask for a State Fair Hearing instead of an MCO appeal or at the same time as an MCO appeal, the Kansas Office of Administrative Hearings must receive your state fair hearing request within 33 days of the date of the Notice of Adverse Action.
    • If you wish to ask for a state fair hearing after an MCO appeal has decided your appeal, the Kansas Office of Administrative Hearing must receive your request for a state fair hearing within 33 days after the date of the MCO’s response letter advising you of the outcome of your MCO’s appeal.
       
      • Filing a state fair hearing:
        • State fair hearing; by mail or fax
          • Office of Administrative Hearings
            1020 S. Kansas Ave.
            Topeka, Kansas 66612
          • Fax:  785-296-4848
          • Phone: 785-296-2433

What happens to my services while I am filing a state fair hearing?

  • Non Home and Community Based Services - If you file a state fair hearing related to services that are not provided as a Home and Community Based Service (HCBS), you may ask to keep getting those services while the state fair hearing is in progress. 
  • The request must be made within 10 days of the mailing of the letter noting the action.  You may ask for services to continue within your request for a state fair hearing. Some of the MCO’s may have the member pay for the care if the decision in not in your favor.  
  • Home and Community Based Services (HCBS) – If you file a state fair hearing related to services that are provided as Home and Community Based Services (HCBS), you will keep getting those services while the state fair hearing is being decided (This is called continuation of care).  You will not have to pay for this care if the state fair hearing decision in not in your favor unless fraud is present.

-Portions taken from Sunflower 2015 Member Handbook, p.52

What documentation do I need?
For a State fair hearing:

  • Send in your state fair hearing letter as soon as possible saying you want to appeal.  It does not have to state your case yet.   Follow up with a letter and documentation from yourself and other professionals.  It can identify:
    1. the change that has been determined by the managed care organization
    2. why this should not be done and the problems it will cause
    3. the effect it will have short and long-term on the physical well-being of the member. 
  • For HCBS member, get a copy of the plan of care (current) and the new one with the changes and compare them by line and state the case based on the changes (line by line.)  For example, decreasing meal preparation from 8 hours/wk. to 4 hours/wk.; decreasing bathing from 6 hours wk. to 3 hours/wk.).  How will this impact the member short and long term?  Have the professionals write something as well as the member. It would probably be helpful if the medical provider knows the specific things that are being denied and why. If it is not the plan of care hours being reduced, ask for the detail and note what services specifically so the provider can help explain why those services are needed based on your issues. 

Other State Fair Hearing Information:

  • You may have an attorney represent you at the hearing.  The attorney will be at your expense.  If you hire an attorney, he or she must be licensed in the State of Kansas and enter their appearance on your behalf prior to the hearing.  If you choose Kansas Legal Services or Disability Rights Center of Kansas, they do not charge a fee.  The Ombudsman’s office recommends members consider having a lawyer assist with preparing for the state fair hearing and come to the state fair hearing with them. 
  • Deadlines for this information will come by letter from the Office of Administrative Hearing.  Be sure to read every letter from them thoroughly.
  • The most frequent mistake made by individuals during the process of preparing is failing to read the notices and documents issued as part of the hearing process.  Read everything you receive very carefully.
  • Most state fair hearings are done by phone on conference call.  If you prefer to meet in person, you can request it.


Legal Services

The Disability Rights Center of Kansas
The Disability Rights Center of Kansas (DRC) is a public interest legal advocacy agency empowered by federal law to advocate for the civil and legal rights of Kansans with disabilities. DRC is the Official Protection and Advocacy System for Kansas and is a part of the national network of federally mandated and funded protection and advocacy systems.

Contact Information
214 SW 6th St., Suite 100 
Topeka, KS 66603
Voice: (785) 273-9661
Toll Free Voice: (877) 776-1541

Kansas Legal Services
Kansas Legal Services is a statewide non-profit organization dedicated to helping low-income Kansans meet their basic needs through the provision of essential legal, mediation and employment training services. Kansas Legal Services can assist individuals with cases involving health issues, housing, employment, juvenile issues (delinquent, termination of parental rights), income maintenance, Indian laws, family issues, individual rights and consumer issues.
Legal Assistance Toll Free Central Intake Line 
Phone: (800) 723-6953 
Main Office: (785) 233-2068 (voice)



Managed Care Organization (MCO) Handbook Information
on Grievances, Appeals and State Fair Hearings


KanCare Ombudsman Volunteer Program

The KanCare Ombudsman Volunteer Program is designed to help serve KanCare members in resolving problems regarding their services, coverage, access and rights. The program is training volunteers in the Kansas City Metro and Wichita areas in 2015. Further expansion of the volunteer program will begin in 2016.

To contact the Ombudsman or a volunteer near you call 1-855-643-8180.


Reports

Quarterly/Annual Reports


Ombudsman Lunch and Learn Conference Call Series

Information for KanCare members that includes community providers, state agencies, Managed Care Organizations, connected providers, and advocacy groups. These calls share information that may relate to members interests and/or current situations. The option for asking questions is offered at the end of each session.

   1st Quarter 2016

   4th Quarter 2015

   3rd Quarter 2015

   2nd Quarter 2015

   1st Quarter 2015


Meet the KanCare Ombudsman

Dear KanCare Consumer,

I am the new KanCare Ombudsman.  My name is Kerrie Bacon and I live in Topeka, Kansas.  I have helped people with disabilities for many years. I worked for the Kansas Commission on Disability Concerns for more than 10 years, as Interim Executive Director for eight months at the Kansas Council on Developmental Disabilities and in KDADS’ Money Follows the Person program for nine months. 

A great deal of the work I have done in the past has been to help people with resources, answer questions and resolve the issues they have. Those skills will be very helpful when working with consumers in the Ombudsman’s office.

Treating people with respect and dignity is a core value in the Ombudsman’s office.  The primary role of the Ombudsman’s office is to help people understand how to navigate the KanCare system and to assist them in solving problems.

Kerrie Bacon, KanCare Ombudsman

Please call me to talk about concerns you may have.

Sincerely,
James Bart Signature
Kerrie Bacon
KanCare Ombudsman