1310 Prudent Person

1310 Prudent Person 

The local worker shall use the prudent person concept in administering the medical assistance programs. The phrase, "prudent person" applies to the particular situation that indicates further verification of information is needed. It also applies to the reasonableness of judgments made by an individual in a given situation based on that individual's experience and knowledge of the program.

It is the responsibility of staff to be prudent when the circumstances of a particular case indicate the need for further inquiry. Additional substantiation or verification should be obtained whenever the information provided by the applicant or recipient is incomplete, unclear, or contradictory.

Circumstances that require a more thorough analysis of a case include:

1. Real or personal property holdings that are very near or equal to the resource limitation.
2. An individual who is living at a higher standard of living than known resources or income would permit.
3. An individual who appears to qualify for potential resources such as Social Security, unemployment benefits, veterans' benefits, medical insurance, etc. (See 2124 and subsections)
4. An individual who appears to be confused.
5. An individual who has a history of providing conflicting or incomplete information.
6. Documents (birth certificates, Social Security cards, etc.) that appear to have been altered.
7. Information obtained from non-medical assistance programs (Cash Assistance – TANF, Food Assistance, Child Care) through KEES according to the following guidelines:
   1. Earned income that is currently budgeted on an open or pending program; or was included on a non-active program if the income started within the past three months.
   2. Unearned income that is currently budgeted on another program in any status, except for expired time-limited unearned income.
   3. Non-exempt resources that are currently included on an open or pending program.
   4. Other information currently used for another open or pending program that, if were validated, would result in a different eligibility outcome.

      NOTE: Staff should not research non-medical cases unless there is cause, such as a discrepancy or red flag identified.

8. Documents provided by the applicant (pay stubs, employer statement, tax returns, etc.) that appear to be incomplete due to missing required information (i.e., pay dates, frequency, or tax form Schedule 1 or 1040).

1310.1 Resolving Conflicting Information

When conflicting or contradictory information is discovered, the eligibility staff person shall research the medical case file and other sources, such as interfaces, to determine if a reasonable explanation exists.

If the discrepancy is not resolved, contact with the consumer is required. First, phone contact must be attempted. If the issue remains unresolved a written request for information is issued, as per 1321(3) below. Eligibility cannot be denied or terminated solely based on the discrepant information until the consumer has been given the opportunity to explain the discrepancy. Unless the consumer consents to negative action based upon their request, a written request for information must be issued prior to any negative action.

Staff are responsible for updating the case file (e.g. journal) with information regarding the discrepancy as well as the resolution. If the staff person made a judgement call regarding a specific situation, an explanation of the facts of the case as well as the factors that lead to the decision are also included in the journal. As each situation is unique, the extent and content of the necessary journal entry will depend upon the circumstance of the case.