This section sets forth eligibility guidelines related to other groups of persons who may qualify for medical assistance.
See Policy Memo, PM2000-12-01 (revised 05/01/06), Access to Benefits for Qualifying and Non-qualifying Aliens and Their Families. Non-citizens who are not documented or do not meet the qualifying categories specified in 2140, may receive medical coverage for an emergency if provided they would otherwise qualify for any Medicaid program (including those found in the Kansas Family Medical Assistance Manual, see 2600), except for alienage status. Persons admitted in the country for temporary purposes, such as foreign students, visitors, tourists and diplomats may meet state residency requirements if they intend to reside within the state. See 2150.
Eligibility exists under this section only if a person has experienced an approved emergency medical condition. The emergency service must be required after the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
When determining if the emergency criteria are met, an analysis of the medical condition as well as the location in which treatment was provided are completed. Only the SOBRA program manager at KDHE-DHCF or designated fiscal agent staff may determine if an allowable emergency has occurred. The MS-2156 , Medical Review of Emergency Services for SOBRA form, shall be used to capture information pertaining to the condition in order to make this determination. The MS-2156 and required supporting documentation, obtained from the provider shall be sent to the fiscal agent for a decision. An MS-2156 that is received from the provider must be submitted to the Fiscal Agent/SOBRA Program Manager for every alleged emergency, except labor and delivery. For women requesting assistance only for labor and delivery, eligibility may be determined without an MS-2156.
Payment for services other than labor and delivery requires a completed MS-2156 with information regarding the medical reason for the services. Where an MS-2156 is required, action to approve or deny eligibility is not taken until a medical determination is rendered. An MS-2156 is not required for persons who fail to meet other eligibility criteria. Eligibility can be granted for more than one emergency. Coverage is limited for individuals eligible under the SOBRA coverage group to only the emergency service. No other services shall be covered.
NOTE: If a subsequent emergency occurs, a new MS-2156 must be obtained and evaluated as described above. It must be sent to the fiscal agent for review as well. This is true even if the emergencies occur in the same month.
The general eligibility requirements of 2100 and subsections must be met except for the SSN requirements of 2130 and the alienage provisions of 2140. In addition, eligibility shall be based on the appropriate medical program (e.g., poverty level for children and pregnant woman meeting poverty guidelines, Medically Needy for dependent children, Spenddown for disabled persons, Family Medical, etc.). Although coverage is restricted to meeting a specific emergency and no further ongoing medical eligibility will be permitted, eligibility shall be determined under normal procedures including the appropriate base period rules. See 7330. In addition, the spenddown provisions of 7530(2) are also applicable except for poverty level eligibles. Care must be taken to ensure eligibility is properly displayed in MMIS.
The case is to be closed as rapidly as possible due to the time-limited nature of the coverage and is not to remain open through the entire base period. Should eligibility be determined under a 6-months base period and the client again requires emergency services later in that base period, eligibility is to be redetermined using the same 6-months base period. If spenddown was met with the previous emergency and there are no other changes in circumstances, the client would be eligible.
Individuals diagnosed as tubercular and are found in need of treatment for this condition by the Tuberculosis Control and Prevention staff at the Kansas Department of Health and Environment (KDHE) are eligible for limited medical assistance coverage. Coverage is limited to inpatient hospital care or necessary alternative community-based care as approved KDHE. Only those services deemed necessary on the care plan developed by KDHE and approved by KDHE-DHCF policy staff are covered. KDHE and local health department staff are responsible for ensuring the care plan is cost effective. No other services or items, such as prescription and physician services are covered.
Eligibility is solely based on a TB diagnosis and an approved care plan from KDHE. No further eligibility requirements must be met including financial, SSN and citizenship/alienage. TB-Only coverage may be approved presumptively while being screened for Medicaid coverage. If eligible for full coverage Medicaid, persons must enroll in Medicaid. Persons receiving Medically Needy coverage may receive TB coverage in addition to Medically Needy. See 1411.3 (3) for application process. TB-Only coverage shall not be affected by a denial of Medicaid eligibility for any reason and shall only be discontinued if approved for Medicaid coverage or once determined appropriate by KDHE TB Program staff.
Medical coverage shall be authorized for the period approved by KDHE only. If coverage is authorized for a period exceeding 6 months, a new application is not necessary but the continued need for coverage must be confirmed with KDHE TB program staff.
All applications for TB coverage are processed by the TB Eligibility staff at the KanCare Clearinghouse. Persons requesting coverage are referred to KDHE.
FFP is not available for any services provided under the TB only program. A monthly medical card will be issued to each participant, but coverage is limited as explained above.
Medicaid coverage is available to persons diagnosed with breast or cervical cancer through the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program if the requirements specified in this section are met. The general eligibility criteria of residency (2150), citizenship and alienage (2140), cooperation (2120) and SSN (2130) must be met. There are no financial criteria. Persons are eligible for the entire scope of Medicaid services, not just those related to treatment of the cancer.
In order to be eligible under this category, a screening by the specific CDC program indicated above must be completed. Currently, Early Detection Works, with the Kansas Department of Health and Environment is the only CDC entity in Kansas. Regional case managers located in the county health departments are responsible for enrollment into Early Detection Works. Screening by an approved CDC entity in another state will also meet this requirement. The Early Detection Works program applies certain eligibility requirements for entrance into the program. In 2006, only women ages 40-65 with incomes under 250% of poverty were eligible for Early Detection Works. Men are not eligible for the CDC screening. The case manager with the local health department is responsible for verifying enrollment into Early Detection Works by providing the eligibility worker with a copy of the approved Intake and Visit Summary document.
The Early Detection Works case manager is responsible for assisting the woman in the application process. The Application for Medical Coverage – BCC has been developed for this purpose. Elements needed for the eligibility determination not available on the application (e.g., date of birth) shall be obtained from the Intake and Visit Summary.
It is expected that all applications shall be processed within 10 calendar days of receipt. Except for required verification (i.e., citizenship, identity or proof of alienage status) it is not necessary to verify the information reported on the application unless it appears questionable.
Eligibility is processed under the Medically Needy program. A one month base period is used.
Three month prior eligibility (see 7330 (2)) may be provided if all eligibility criteria are met, including the necessary screening referral from FREE to Know. In no event can coverage under this category begin prior to the first of the month in which the screening occurred.
The individual must be uninsured and she cannot be otherwise covered under any other form of creditable coverage, as defined by the Health Insurance Portability and Accountability Act, for treatment of breast or cervical cancer. Persons who have such coverage, including Medicare, are not eligible. If a person has coverage but is in a period of exclusion, such as a preexisting condition waiting period, or has exhausted the lifetime limit for treatment, creditable coverage for cancer is considered unavailable and the person may be eligible. A plan which covers cancer treatment but requires a high deductible be met IS considered available and would render the woman ineligible.
Persons eligible under other Medicaid groups are not eligible for coverage under this category, with the exception of spenddown coverage. A person meeting the criteria for another group must be placed in the other group and would not be eligible for coverage under this category until such eligibility ceased. A screening by the worker is required at the time of application. Persons may be eligible under this group while a disability decision is pending. If approved for SSI, coverage shall be switched given adequate notice requirements.
Eligibility continues as long as the person is receiving treatment for breast or cervical cancer. The case manager is responsible for monitoring ongoing treatment with the individual’s physician or other medical provider(s) and notifying the eligibility worker when the course of treatment ends.
Cooperation with the review requirements of 9310 is required. Individuals in this group will be mailed a Targeted Review form. Twelve month review periods shall be established for this group. The KC-1400 Notice of Review – Medical Assistance – BCC Program is used for the redetermination. Ongoing cancer treatment must be verified at review. The review form informs the beneficiary of the review and the requirement regarding ongoing cancer treatment. The beneficiary is responsible for obtaining verification of ongoing cancer treatment from the treating physician. The Statement of Continuing Cancer Treatment Medical Assistance - BCC Program is used to obtain information regarding treatment and care. Because the determination of ongoing cancer treatment is made by evaluating information on the form, the physician may submit additional information if necessary. The KDHE-DHCF Nurse/Program Manager for the BCC program makes the determination of ongoing cancer treatment.
Eligibility ends no later than the month following the month any of these requirements cease to be met, including reaching age 65, obtaining creditable coverage or the cessation of treatment. Eligibility may be established in another category if requirements are met. A new application will generally be required for this determination.
A BCC recipient who reports a pregnancy is continuously eligible per KFMAM 2300.
Limited coverage is available for persons diagnosed with AIDS. Coverage is limited to payment of prescription drugs related to treatment of AIDS as provided in an ongoing formulary. KDHE has ultimate responsibility for the program, including budget, claims payments and case processing. KDHE-DHCF eligibility staff are not responsible for the eligibility determination or case maintenance of these cases.
Eligibility information is entered into KEES and then sent to the fiscal agent and is displayed on MMIS. Providers bill the MMIS for medications provided to the ADAP eligible client. Persons may be eligible for Medicaid or MediKan coverage as well as ADAP. Payment for claims is generally drawn from Medicaid funds, except when noted.
Persons may be eligible for one of three separate ADAP coverage groups: