KanCare State Fair Hearings

Managed Care State Fair Hearing Process

• What is a managed care 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.

• How do I submit a managed care state fair hearing request regarding a managed care decision?

  The member or member’s authorized representative’s state fair hearing request must be submitted in writing.

  • To submit a managed care state fair hearing by fax send to:
    • (785) 296-4848 (Requests greater than 20 pages cannot be faxed)
  • To submit a managed care state fair hearing by mail send to:
    •  Office of Administrative Hearings 1020 S. Kansas Ave. Topeka, KS 66612

   A managed care State fair hearing request form: KanCare Member_Request for Medicaid Fair Hearing 
  
  Notice of Withdrawal of Appeal

• Is there a deadline for filing a managed care state fair hearing?

  Yes, the member or member’s representative must submit a request for a state fair hearing within 123 calendar days from the date of the notice of the appeal resolution determination.

  The member has another opportunity to submit a request for a state fair hearing if the healthcare service decision was reviewed by the External Independent Third-Party Reviewer.  The member must submit the request for a state fair hearing within 33 calendar days of the date of the notice containing the decision by the external independent third-party reviewer.

• What happens once a managed care state fair hearing request has been submitted?

  The MCO will submit documents related to the decision about your services to OAH prior to the state fair hearing. You may also submit documents to OAH prior to the state fair hearing. OAH will schedule a state fair hearing about the MCO's decision within one or two months of the date of your state fair hearing request. OAH must reach its decision usually within 30 calendar days of the state fair hearing date.
  
  

  If you asked for an expedited (fast) appeal with the MCO, and the MCO approved the request and made a decision about your appeal within 72 hours, then you may ask for a fast state fair hearing due to an urgent medical need. OAH will schedule a state fair hearing and make a decision within 3 business days following receipt of your request for a fast state fair hearing.

• What documents do I need to submit for my managed care state fair hearing?

  Send in your state fair hearing request form as soon as possible saying you want a hearing. Provide an explanation of why you believe the MCO's decision is wrong. Include a copy of the notice and include an explanation of: 

  • the change that has been determined by the managed care organization
  • why this should not be done and the problem it will cause
  • the effect it will have short and long-term on the physical, mental and emotional well-being of the member.
  • For HCBS members, include a copy of the current Integrated Service Plan (ISP) (plan of care) and the new plan.

• What happens to my services during the managed care state fair hearing process?

  Non-HCBS Services:

  • If the MCO did not change their decision when you appealed you may ask for a state fair hearing. You must ask for the state fair hearing within 123 calendar days from the date of the appeal resolution notice. 
  • If you want your services to continue during the state fair hearing process, you must ask the MCO within 10 calendar days from the mailing date of the appeal resolution notice.
  • If the state fair hearing officer changes the MCO's decision, and the Member received the services while the state fair hearing was pending, the MCO must pay for those services.  
  • Please keep in mind that you may have to pay for the continued services if you lose the state fair hearing.

  Home and Community Based Services (HCBS):

  • If the MCO did not change their decision when you appealed, you may ask for a state fair hearing.  The MCO will automatically continue your current HCBS services for 123 calendar days from the date of the appeal resolution notice to allow you time to ask for a state fair hearing. If you do not ask for a state fair hearing, the current level of HCBS services will change.
  • If you ask for a state fair hearing within 123 calendar days from the date of the appeal resolution notice, the MCO will continue your current level of HCBS services until the hearing decision.
  • If the state fair hearing officer changes the MCO's decision, and the Member received the HCBS services while the state fair hearing was pending, the MCO must pay for those services.  
  • You will not have to pay for the continued services if the state fair hearing decision is not in your favor unless fraud is present.

• Other managed care 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 Kansas.

  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 state fair hearing process. The notices and documents will have deadlines. Read everything you receive very carefully.

• How do I withdraw my request for a state fair hearing?

  Withdrawal of State Fair Hearing Request