Member Appeals, Hearings & Grievances

Current Medicaid beneficiaries may request that their eligibility continue while they wait for a state fair hearing decision. Coverage will be continued if they ask for a hearing either before the effective date of the eligibility decision or within 15 calendar days from the date of the notice, whichever is later.

*The additional submission time allowed during the COVID-19 public health emergency for member appeals and state fair hearings ended effective with Notices of Adverse Benefit Determination dated on or after September 17, 2022.

Eligibility

The grievance process is for people who are applying for or renewing Medicaid eligibility and have a complaint about some part of the eligibility process.

The eligibility state fair hearing is processed by the Office of Administrative Hearings (OAH). It is an opportunity for the applicant/member to speak about the eligibility decision made by the Medicaid agency.  Eligibility state fair hearings include the opportunity to speak about the HCBS waiver eligibility decision made by the Department on Aging and Disability (KDADS). The member and either the Medicaid agency or KDADS meet before an impartial administrative law judge. He or she will issue an initial order based upon what is presented by you and the Medicaid agency or by you and KDADS at the hearing. An eligibility state fair hearing can be requested regarding any negative eligibility decision or if the application process is delayed.

 

KanCare Managed Care Organization (MCO)

If you are a KanCare member currently receiving services and have a managed care organization (MCO) such as Aetna, Sunflower or UnitedHealthcare, this applies to you.

Grievance

A managed care grievance is an expression of dissatisfaction about any matter other than an adverse decision. The grievance process is for KanCare members who are currently receiving services from an MCO.


Appeal

An appeal is your request for a review by your MCO of an adverse decision about your services. The appeal process is for KanCare members currently receiving services from a MCO.

State Fair Hearing

The KanCare state fair hearing is processed by the Office of Administrative Hearings (OAH). It is an opportunity for the member to speak about the healthcare service decision made by one of the Medicaid agency’s managed care organizations (MCO), Aetna, Sunflower, or United Healthcare. The member, representatives from Aetna, Sunflower or United Healthcare, and a representative from the Medicaid agency or KDADS meet before an impartial administrative law judge. He or she will issue an initial order based upon what is presented by you and the Medicaid agency or by you and KDADS at the hearing. This process is for KanCare members who have already completed the appeal process with Aetna, Sunflower, or United Healthcare.

Fee for Service (FFS)

If you receive Medicaid and do not have a managed care organization (MCO) such as Aetna, Sunflower or UnitedHealthcare, this applies to you (e.g., MediKan, QMB, SOBRA, Early Detection Works, PACE, etc.).

Grievance

A grievance is defined as an expression of dissatisfaction about any Fee For Service matter including an adverse decision. 

State Fair Hearing

The FFS state fair hearing is processed by the Office of Administrative Hearings (OAH). It is an opportunity for the FFS member to speak about the healthcare service decision made by the Medicaid agency. The member and the Medicaid agency meet before an impartial administrative law judge. He or she will issue an initial order based upon what is presented by you and the Medicaid agency at the hearing. The fair hearing process is for members currently receiving services.

KanCare Ombudsman

The KanCare Ombudsman Office helps people who are having problems with KanCare and have not been able to get the problem resolved. The office serves KanCare members and applicants in fixing problems about their services, coverage, access and rights.


Contact:

Phone: 1-855-643-8180
Relay: 711
Email: KanCare.Ombudsman@ks.gov

Helpful Forms

State Fair Hearing Forms

Withdrawal of State Fair Hearing Request
Withdrawal of State Fair Hearing Request Large Print 

KDADS Complaint Grievance and Appeals Process