8110 Types of Institutional Arrangements and Care

 

8111 Non-Medicaid Approved Institutions - This category applies to those institutional arrangements in which Medicaid cannot make payments on behalf of eligible individuals' care in that institution.

 

This includes not only care received in nonmedical facilities (e.g., penal institutions, elderly high rises, etc.) but also nonapproved care or ineligibility for payment of care in medical facilities (e.g., inappropriate ACH placements, non-Medicaid certified facilities, persons assessed or reassessed as not in need of nursing facility care through the CARE assessment or resident status review process or persons who are ineligible for payment due to transfer of property provisions.)

 

8111.1 Penal Institutions - See PM2012-09-01 Policy Memo:  Inpatient Hospital Coverage for Inmates of State Correctional Institutions and  PM-1999-10-02  Law Enforcement Custody and State Psychiatric Hospital Admissions      

 

The following provisions apply to an individual in a penal institution:

  1. There is no eligibility for medical assistance [except as indicated in subsection (2) below] for an individual who is:

 

    1. Physically residing in a jail or penitentiary.
       
    2. An accused person or convicted criminal under the custody of the juvenile or adult criminal justice system.
       

      A person can receive assistance if there is no indication of custody, or if in a status of:

      1. Pardoned;

      2. Released on his or her own recognizance;

      3. On probation, parole, bail or bond; or

      4. Participating in a prison diversion program which is operated by a privately supported facility (i.e., a facility which operates without financial or administrative support from the State).

        In rare instances a person considered in custody could also be in one of the statuses referenced in this paragraph. Such person could receive assistance. Either the court record or a document in the possession of the client should be available to clearly establish any of these statuses.
         

        NOTE: Since "house arrest" is a term used across the state for a variety of situations, this status cannot be used to confirm eligibility requirements. It is only an indication to look for another status in determining eligibility. It is recognized that many clients considered in house arrest will be eligible for assistance as there will be no actual custody indication.


    3. Placed in a detention facility. Except as indicated in subsection (2) below, an individual in a detention facility cannot attain status as an inpatient of a medical facility for purposes of medical eligibility.
      1. Visits to physicians and other medical practitioners outside a penal institution, or transfers to public or private medical facilities do not in any way affect the person's ineligibility for medical coverage. However, if the individual was not actually living in the penal institution prior to transfer to a medical facility, he or she could obtain medical eligibility for the medical stay.

      2. Even if the inmate has not been transferred from a prison or other correctional institution (e.g., for a mental examination or because he has been found mentally incompetent to stand trial), he is not considered a patient therein for purposes of medical coverage. However, if the court commitment to a mental institution were to allow a verdict of "not guilty by reason of 'insanity'," the individual is not in custody as an accused person nor as a convicted criminal and so may be entitled to medical coverage (if he is otherwise eligible).

  2. An inmate of a correctional facility administered by the Kansas Department of Corrections (KDOC) or the Kansas Juvenile Justice Authority (JJA) may be eligible for medical assistance to cover inpatient hospital services. No other medical services are covered under this exception. The following provisions apply to this group.
    1. An inmate otherwise qualifying for medical assistance to cover inpatient hospital services must meet all non-financial and financial eligibility criteria for the appropriate medical program.
      1. For purposes of this provision, an inmate is defined as an individual serving time for a criminal offense or confined involuntarily in a state correctional facility managed by the Kansas Department of Corrections (KDOC) or the Kansas Juvenile Justice Authority (JJA). Inmates in other correctional facilities within the state, such as county or city jails, are not eligible under this policy [see subsection (1) above].

      2. Only inpatient hospital services, known as a qualifying event, are covered under this policy. There is no coverage for outpatient care provided outside of the correctional facility or for medical services provided on the premises of the correctional facility.

      3. An application shall be filed by the inmate with designated correctional facility staff indicated as “facilitator”. All applications will be processed by KDHE-DHCF staff at a central clearinghouse. A supplemental form (ES- 3100.1a – Qualifying Event) shall be attached to the initial application for assistance and also submitted any time there is an additional qualifying event within an established 12 month eligibility period [see subsection (c) below]. The application and/or qualifying event form shall be filed only after the inmate has been treated and released from the hospital. An application received prior to release shall be held for processing until the date of discharge has been verified.

    2. Since these individuals are incarcerated in a non-Medicaid approved correctional facility, eligibility shall be determined using independent living budgeting methodologies.
      1. Eligibility shall be determined under the poverty level MP (Title 19) or MA programs for children (under age 19) and pregnant women, and under the Medically Needy MS program for adults (over age 18). There is no eligibility for this group under either the state funded MediKan or the MP (Title 21) programs.

      2. For budgeting purposes, each inmate shall be treated as a household of one. Neither the income nor resources of the parent(s) or spouse of the inmate shall be included in the eligibility determination.

    3. Since only the qualifying event is covered, the case shall only be approved for the month(s) of the event. However, once approved for coverage, a 12 month eligibility period shall be established beginning with the month of approval. The case will not be open during the eligibility period, but any new qualifying event which occurs during the eligibility period may be approved without a new application by submitting a completed ES-3100.1a (Qualifying Event) form.

    4. Eligibility for the Medicare Savings Programs (QMB, LMB, Expanded LMB) shall not be determined for this population. Nor will the state assume responsibility for the Medicare Part B premium through the normal buy-in process. In addition, pursuit of either SSA/SSI disability or of Medicare Part B is not an eligibility requirement.

    5. Inmates eligible under this policy will not receive a medical card. If approved for coverage, the medical ID number will be included on the approval notice with instructions to present the notice to the medical provider for billing. Due to the limited coverage package for this special population, qualifying inmates are not subject to managed care. The covered inpatient hospital services will be paid for under the fee for service plan.

8111.2 Other Non-approved Institutions - Medical eligibility may be determined for persons residing in other non-Medicaid approved institutional settings provided the individual is eligible under the MA, Medicaid poverty level, or MS program criteria. Eligibility shall be determined using independent living procedures and guidelines set forth in 4300 and subsections, 7240, 7330, and 7530. See also 8171.