Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 12/26/2024
01000: Administrative Information -
01100 Health Benefit Programs - Several health benefit programs are provided to low-income Kansans to help cover the cost of health care.
1101 Medicaid - The Medicaid program is a joint federal/state-funded program that covers a majority of low-income persons in the State including children and pregnant women. Policies for family related medical coverage are in this manual while policies for other medical programs are located in the KDHE MKEESM Manual.
1102 Children's Health Insurance Program (CHIP) - The CHIP program is based on a federal block grant program and is intended to serve children under the age of 19 who are uninsured and who are not otherwise eligible for Medicaid.
01120 Basis of Programs and Policies - The Kansas Department of Health and Environment - Division of Health Care Finance (KDHE-DHCF) has the responsibility to develop state plans for furnishing assistance and services to eligible individuals and to determine the general policies relating to the medical assistance programs. The Kansas programs are independent from programs administered in other states unless otherwise stated in this manual. An application for assistance in Kansas shall be treated as a new application.
Therefore, a new determination of eligibility rendered by another state shall not, in and of itself, affect eligibility in Kansas.
Policies set forth in this manual are based upon various federal and state statutes and administrative regulations. The following citations provide an overview of the primary statutory and regulatory references on which the programs are based.
Medicaid
-42 United States Code Annotated (U.S.C.A.), Subsection 1396a et seq.
-42 Code of Federal Regulations (C.F.R.), Parts 430 - 456
-Kansas Statutes Annotated (K.S.A.), 39-708c, 39-209(e)
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Article 6 and Chapter 129, Article 7
CHIP
-Section 2103 of Public Law 105-32
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Article 14
Fair Hearings
-42 Code of Federal Regulations (C.F.R.), Part 205
-Kansas Statutes Annotated (K.S.A.), 75-3306
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Article 7 and Chapter 129, Article 7
Confidentiality Policies
-Kansas Statutes Annotated (K.S.A.), 39-709b
-Kansas Administrative Regulations (K.A.R.), Chapter 30, Articles 2-11
This manual has been developed to implement the policies set forth in the above-mentioned statutes and administrative regulations. Thus, the provisions of the manual are to be followed by program staff when determining eligibility of applicants or recipients for assistance in accordance with K.A.R. Chapter 30, Article 2.
Providing assistance is a continuing and comprehensive process, embracing all parts of the administration of the welfare program. All of the steps or parts of the process are interrelated and must be planned for, and ultimately judged, in terms of the effectiveness of the complete administration.
1131 Volunteers - May be used in related activities such as outreach or assisting applicants in completing the application, other prescreening activities, and securing needed verification. Individuals and organizations who are parties to a strike or lockout and their facilities may not be used in the certification process except as a source of verification for information supplied by the applicant.
1132 Data Collection of Racial/Ethnic Categories - The Case Manager may request applicants to voluntarily identify their racial or ethnic status on the application form and shall inform the applicant(s) that this designation shall not affect their eligibility.
The Case Manager may ask the applicant to identify his racial/ethnic origin during a telephone contact. However, there are certain stipulations that are necessary when the self-identification process is used in either the application process or a telephone contact.
1132.01 - Applicants shall be assured by the Case Manager that information is used for statistical purposes only in determining if the program is administered without discrimination. Racial/ethnic data shall have no effect on an applicant's eligibility to participate and it will not be used for discriminatory purposes.
1132.02 - The applicant shall be advised that the information is used to ensure that benefits are available to all eligible persons regardless of race, color, or national origin.
1132.03 - Applicants shall be advised that the information given will be confidential and, should they decide not to provide this information, such a decision will not have an adverse effect on determining their eligibility.
01200 Rights and Responsibilities -
01210 Availability and Confidentiality of Information -
1210 Rights of Applicant/Recipient -
1210.01 Right to Make Application - An individual shall have the right to make application regardless of any question of eligibility or agency responsibility. The right of an individual to make application may not be abridged.
1210.02 Right to Information - A client has the right to be provided with information concerning the types of assistance, which are provided by the agency. Upon request, the agency shall furnish the client with informational pamphlets and will explain to him/her the categories of assistance for which he/she may be eligible and the eligibility factors for each.
1210.03 Right to a Private Interview - A client has the right to a private interview whenever he/she is discussing his/her individual situation with the agency.
1210.04 Right to Receive a Prompt Decision - A client has the right to have a timely decision rendered on his/her application. See 1405. A recipient has the right to a decision rendered on any other formal request (such as a request for information) within 30 days of its receipt by the agency.
1210.05 Right to Restored Benefits - If the client has been wrongfully delayed, denied, or terminated, he/she is due restored benefits.
1210.06 Right to Correct Amount of Assistance - The client, if eligible, shall be entitled to the correct determination of benefits based upon budgetary standards or allowances in accordance with agency policies.
1210.07 Right to Equal Treatment - All clients have a right to equal treatment in similar circumstances and no person shall be denied benefits or be subject to discrimination on the basis of race, color, or national origin, gender, religion, age, disability, political beliefs, sexual orientation, or marital or family status.
The client has the right to file a discrimination complaint with either the Federal or the State agency.
1210.08 Right to a Fair Hearing - A client has the right to request a fair hearing on any agency decision or lack of action in regard to his application for or receipt of assistance.
1210.09 Right to Withdraw from the Program - An applicant has the right to withdraw his application at any time between the date the application is signed and the date the notice of the agency decision is mailed. A recipient may withdraw from a program at any time.
1210.10 Right to an Individual Determination of Eligibility for Assistance - A client shall be given an opportunity to present his request and to explain his situation.
1210.11 Right to Written Notification of Action - A client has the right to a written notification of agency action concerning his eligibility for assistance.
1211 Responsibilities of Applicant/Recipient -
1211.01 Responsibility to Submit Identifiable Application - The applicant shall submit an application containing a legible name and address (unless homeless), and which has been signed.
1211.02 Responsibility to Supply Information - A client has the responsibility to supply, insofar as able, information essential to the establishment of eligibility.
Information, which is "time-sensitive" and received in the office through a drop box, mail slot or other such manner at the opening of the business day shall be considered as received that business day. This policy does not apply to verification/information that has a time and date stamp, such as e-mails and faxes. Those items are generally considered received the day of the date and time stamp. Information, which is received as a fax or copy, but is required in original form, shall be considered as received when the fax/copy arrives in the office provided the original document arrives in a timely manner as determined at the local level. In general, a fax or copy of a document shall be acceptable without requiring an original (including an application form or monthly report form). However, an original document shall be required for establishing age, identity and citizenship and alienage status, and when determined to be necessary based on prudent person judgment.
1211.03 Responsibility to Provide Verification - The client has primary responsibility for providing verification (certain exceptions to these requirements are specified in the verification section). See 1330.
1211.04 Responsibility to Authorize Release of Information - A client has the responsibility to give written permission for release of information when needed.
1211.05 Responsibility to Report Changes - Persons have the responsibility to report changes in circumstances within 10 calendar days from the date the change is known. See 7120 for specific changes that change reporting persons are required to report.
1211.06 Responsibility to Cooperate - The client shall cooperate with all program requirements and in supplying required information.
1211.07 Responsibility to Provide Social Security Numbers - Each applicant/recipient shall provide his/her Social Security number. See 2031.
1211.08 Responsibility to Meet Needs - A client has the responsibility to meet his/her own needs insofar as he/she are capable.
1212 Responsibilities of the Agency - Upon request, the agency must explain the rights and responsibilities of clients and the following requirements placed on the agency.
1212.01 Periodic Reviews - The agency is required to make periodic reviews of eligibility if the application is approved.
When a formal review is required, the agency shall notify the client of the expiration of the review period and shall send the client a renewal form prior to the last month of the review period.
1212.02 Fraud - The agency is required to investigate and refer for legal action any alleged fraud related to the receipt of assistance.
1212.03 Responsibility to Accept an Identifiable Application - The agency shall accept an application containing a legible name and address (unless homeless) and which has been signed. See 1401.
1212.04 Responsibility to Review Recipients Timely - The agency has the responsibility to process all subsequent applications timely so there will be no break in the benefits the client is eligible to receive.
1212.05 Responsibility to Establish Claims of Overpayment - The agency is responsible for establishing claims for overpayment (either fraud, client, or agency error).
1212.06 Responsibility to Restore Lost Benefits - The agency shall restore benefits to the client if benefits were wrongfully denied, delayed, or terminated.
1212.07 Responsibility for Giving Notice of Action - The agency is responsible for giving adequate and/or timely notice of action when appropriate.
1212.08 Case File Documentation - The agency has the responsibility to ensure that case file documentation supports the decision to provide, deny or change eligibility, benefits, or services.
1212.09 Cost-Effective Service Provision - Services shall be provided in the most cost-effective manner in order to provide the client with the appropriate services within the resources allowed.
1221 Confidentiality of Information Concerning Applicants or Recipients - Information concerning applicants or recipients (present and past) is confidential and may not be disclosed to another DCF employee, the client, or any other nonagency personnel except as set forth in this section.
Information concerning clients or providers who have been referred for investigation is confidential and may not be released unless the Fraud Unit or the prosecuting attorney to whom the case has been referred for legal action authorizes such disclosure.
1222 Disclosure of Confidential Information - The agency may disclose confidential information when the purpose of such disclosure is directly related to: (1) the administration of the KDHE-DHCF program; (2) an investigation, prosecution, or criminal or civil proceeding conducted in connection with the administration of the KDHE-DHCF program or the SSI program; or (3) the administration of any federal or federally assisted program which provides assistance (in cash or in kind) or services directly to individuals on the basis of need. For exceptions see 1225 and 1226.
Throughout this material related to confidentiality of case records, the term KDHE-DHCF and DCF employees includes contracted employees (e.g., contractor employees responsible for CHIP determinations).
1223 Nature of Information to be Safeguarded - The confidential nature of the following information must be safeguarded:
1223.01 - Names and addresses, including lists of applicants or recipients.
1223.02 - Information contained in applications, reports of investigations, reports of medical examinations, correspondence, and other records concerning the condition or circumstances of any person for whom or about whom information is obtained, and including all such information whether or not it is recorded; and
1223.03 - Records of agency evaluations of such information. General information, not identified with particular individuals, such as total expenditures made, number of recipients, and other statistical information and social data contained in general studies, reports, or surveys of welfare problems, does not fall within the class of material to be safeguarded.
1224 Disclosure of Information to Client - Information entered in the case record is to be made available to the client upon request, for inspection at a time mutually agreeable to the agency and the client, except as set forth below.
1224.01 Information Provided by Other Agency Programs - Information provided by other agency programs is not to be made available to the client unless the respective program regulations authorize such disclosure. This includes programs such as Prevention and Protection Services, Rehabilitation Services, Food Assistance, and Cash Assistance that are managed by DCF and Substance Abuse, Mental Health and Developmental Disabilities that are managed by KDADS.
1224.02 Medical and Psychiatric Reports - Medical and psychiatric reports are not to be made available to the client unless signed, written consent is obtained from the medical practitioner who rendered such report.
1224.03 Names and Addresses of Complainants - The names and addresses of complainants are not to be made available to the client.
1224.04 Investigative Reports - Investigative reports concerning welfare fraud or other types of overpayments are not to be made available to the client during the course of the investigation or during the time period in which the case has been referred for legal action unless the Fraud Unit, Legal Division or the prosecuting attorney to whom the case has been referred for legal action authorizes such disclosure.
NOTE: With the exception of 1224.03, all documents and records to be used by the agency at a fair hearing are to be made available, upon request, to the appellant or his representative for inspection and/or copying at a reasonable time mutually agreeable to the agency and the client or his representative prior to the date of the hearing.
1225 Disclosure of Information to Agency Personnel - Information is not to be disclosed to another KDHE-DHCF, DCF, or KDADS employee unless the employee has a need for the information in the performance of his official duties. The client's signature on the application form authorizes the disclosure of information concerning a Caretaker Medical, Extended Medical, TransMed, Child Care, Medicaid, CHIP, and/or Food Assistance client if the purpose of such disclosure is connected with the administration of any of the aforementioned programs, the Child Welfare or Child Support programs (under titles IV-B, IV-D, and XX), or any other federal or federally assisted program which provides assistance, in cash or in kind, or services directly to individuals on the basis of need. (Example: SSI, LIEAP.)
1226 Disclosure of Information to Nonagency Personnel and the Public - Information is not to be disclosed to nonagency personnel such as courts, school boards, legislators, prosecuting attorneys, policemen, FBI agents, doctors, social service agencies, state employment offices, public housing authorities, landlords, creditors, relatives, etc., except as set forth below.
1226.01 Information Available to the Public - Information Available to the Public - Regulations, Plans of Operation, state manuals, and federal procedures, which affect the public, shall be maintained in the office of the KDHE-DHCF for examination by members of the public on regular workdays during the regular office hours.
1226.02 Directly Related to the Administration of KDHE-DHCF Programs - Information may be disclosed to nonagency personnel when the purpose of such disclosure is directly related to the administration of KDHE-DHCF programs or assisting DCF or KDADS in the administration of their programs. The information concerning a cash, medical, childcare, or food stamp client is not to be disclosed without the signed written consent of the client unless the purpose of such disclosure is directly related to one of those programs. Any information disclosed is to be limited to that which is reasonably necessary to accomplish the purpose of such disclosure. Such purposes include establishing eligibility, determining amount of assistance, and providing services to applicants or recipients.
In the course of providing services to clients, disclosure of information should be made to representatives of other welfare agencies or programs only when they can give assurance that:
(1) - the confidential nature of the information will be preserved;
(2) - the information will be used only for the purposes for which it is made available (such purposes should be reasonably related to the purposes of the KDHE-DHCF program and the functioning of the inquiring agencies); and
(3) - the standards of protection established by the agency to which the information is disclosed are equal to those established by KDHE-DHCF itself, both with regard to the use of information by staff and the provision of protective office procedures.
1226.03 Federal or Federally Assisted Programs - Information concerning clients is to be disclosed to federal or federally assisted programs which provide assistance (in cash or in kind) or services directly to individuals on the basis of financial need if the requesting agency certifies in writing that the information so requested is necessary to the administration of its program. Example: SSI.
1226.04 Officials Conducting an Investigation, Prosecution, or Criminal/ Civil Proceeding - Information is to be disclosed to the official conducting an investigation, prosecution or criminal or civil proceeding in connection with the administration of the KDHE-DHCF program if such information is reasonably necessary to the investigation, prosecution or criminal or civil proceeding. This includes welfare fraud investigations and prosecutions. The client's signature on the application/redetermination form authorizes the disclosure of information from the case record necessary to conduct an investigation, prosecution, criminal or civil proceeding related to eligibility for medical assistance.
Information concerning clients is to be disclosed to the official conducting an investigation, prosecution or criminal or civil proceeding in conjunction with the administration of the SSI program if such information is reasonably necessary to the investigation, prosecution, or criminal or civil proceeding.
Information disclosed pursuant to the above paragraphs shall be provided the appropriate official in the following manner:
(1) - The official requesting such information shall be allowed to review pertinent case record material in the agency office during normal working hours.
(2) - Such official, upon request, shall be furnished with copies, or authenticated copies, or originals of pertinent case record materials as necessary at no cost. Prior to the release of an original document, a copy of the document shall be placed in the case record with a notation as to the disposition of the original.
If a question arises as to the pertinency of any requested material, consult the Office of the Medicaid Inspector General.
1226.05 Intention to Commit Crimes - Information concerning the intention of a client to commit a crime and the information necessary to prevent the crime shall be disclosed to the appropriate authorities.
1226.07 Information Not Otherwise Authorized to be Disclosed - Information not otherwise authorized to be disclosed by this provision may only be disclosed if the client has the authority to disclose such information and the agency has a signed, written consent on file authorizing the agency to disclose the information to the specific person requesting such information, excepting that such information may be disclosed without signed, written consent in an emergency situation such as death or other serious crises to an appropriate person if the agency deems such unauthorized disclosure to be in the best interest of the client. If such information is disclosed without signed, written consent, the client shall be notified of such disclosure as soon thereafter as possible.
1227 Subpoenas and Testifying in Court Concerning Information Not Otherwise Authorized to be Disclosed - Since all information relative to a client is by law confidential and since clients are advised that any information they reveal is held confidential, any information received by the Case Manager or other person connected with the agency, is by statute, in the nature of a privileged communication just as is the information received by an attorney or physician from his client, or received by a minister in the performance of his function as a spiritual advisor.
The Legal Division must be notified immediately of a subpoena to produce records or of a court order to testify; such notice should be in writing whenever time permits. A staff member who is subpoenaed or whose records are subpoenaed, unless otherwise instructed by the Legal Division, should make appearance at the time and place stated in the subpoena, and should bring the records subpoenaed with him, if any.
After being sworn in he should make the following statement to the court in response to the first material question:
"I am attending the court's hearing as a result of a subpoena. The law and KDHE-DHCF policy require that I call the court's attention to the laws and regulations limiting use and disclosure of information concerning public assistance. K.S.A. 39-709b limits the use or disclosure of information concerning applicants and recipients of assistance to purposes directly connected with the administration of the assistance program, unless there is written consent given by the consumer. These federal laws and regulations also similarly limit use and disclosure":
1227.01 - Section 1902(a)(7) of the Social Security Act, codified at 42 U.S.C. Sec. 1936a(a)(7), and 42 C.F.R. Sec. 431.300, et seq. (the Medicaid Program);
The witness will submit the above statement in its entirety to the court and a copy to the attorney and will testify further according to the ruling and instructions of the court. Testifying and releasing confidential information when ordered to do so directly by a judge in an in-court setting is not considered unauthorized disclosure of information. See 1229.
1228 Questions Concerning Disclosure of Information - When there is some question as to the disclosure of information to another KDHE-DHCF, DCF, or KDADS employee, the client or other non-agency personnel, the question is to be referred to the legal division for clearance.
1229 Unauthorized Disclosure of Confidential Information - A KDHE-DHCF employee who discloses confidential information concerning an applicant or recipient (present and past) in violation of the provisions set forth in 1220 and subsections shall be subject to appropriate disciplinary action (official reprimand, suspension, demotion, dismissal, etc.).
Further, any individual who discloses confidential information concerning an applicant or recipient (present, past) in violation of the provisions set forth in 1220 and subsections shall be subject to criminal prosecution, and if convicted, may be fined up to $1,000 and/or sentenced to the county jail for a period not to exceed six months.
01300 Prudent Person - Eligibility staff shall use the prudent person concept in administering the Medical 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.
01310 Staff Responsibility - Staff must be prudent when the circumstances of a particular case indicate the need for further clarification. Additional confirmation or verification should be obtained whenever the information provided by the applicant or recipient is incomplete, unclear, or contradictory.
Circumstances that may require a more thorough analysis of a case include:
1310.01 - An individual who appears to be confused.
1310.02 - An individual who has a history of providing conflicting or incomplete information.
1310.03 - Documents (birth certificates, Social Security cards, etc.) that appear to have been altered.
1310.04 - Information obtained from non-medical through KEES according to the following guidelines:
a. Earned income that is currently budgeted on an open or pending case; or was included on a non-active case if the income started within the past three months.
b. Unearned income that is currently budgeted on another case in any status, except for expired time-limited unearned income.
c. Other information currently used for another open or pending case that, if were validated, would result in a different eligibility outcome.
1310.05 - 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).
01320 Simplified Eligibility - The applicant is the primary source of information used by the agency for purposes of determining eligibility. For some factors of eligibility, additional information will have to be obtained. The agency shall use, to the greatest extent possible, the information on the application/redetermination as provided by the individual applicant/recipient, for purposes of determining eligibility and extent of entitlement.
1320.01 - Carefully review the application for completeness, clarity, consistency, and lack of error or questionable statement.
1320.02 - Consider additional information from agency records.
1320.03 - Advise the applicant/recipient when it is necessary for the agency to go to other sources, and when necessary, obtain his consent on the information release form. If he does not consent to the necessary contacts, it may not be possible to determine that initial or continuing eligibility exists. Each applicant and recipient give consent to a full field investigation when he signs the application/redetermination form, but a signed informational release form may be necessary to obtain the needed information. See 1211.04.
1320.04 - Give the applicant/recipient the opportunity to present additional clarification when information on the form is incomplete, unclear, or inconsistent, or where other circumstances in the particular case indicate to a prudent person that further inquiry needs to be made. Negative action as a result of failure to provide the information can be taken only when written notice was given allowing at least 12 calendar days from the date the notice is initiated to return the information.
1321 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 1332.01 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.
1330 Verification - A four-tiered approach is used to verify information needed to determine eligibility. Federal law requires that information available through interfaces and other sources are used prior to contacting the consumer. The verification process will proceed in order from Tier 1 through Tier 4 and is not limited only to verification of income. When a Reasonable Compatibility test has been previously run and it has been determined that an administrative error was made or a new self-attestation is received, it is acceptable to return to a prior tier to verify the information (including running a new RC test with the updated information).
The four tiers apply to all family medical assistance programs. See also 1333.04(3) (Earned Income), 6125 (Pre-tax and Federal Deductions), 6122 (Reasonable Compatibility) and 6120 (Budgeting Method). See 2040 for requirements regarding citizenship/identity verification.
1330.01 Tier 1: Payer Interfaces - Reported information is verified through the use of a payer source interface (Federal Hub, Social Security, Unemployment Compensation, KPERS). Since this data comes directly from the source of the reported information, it is considered verified.
Note: If there is a difference between the reported SSA or SSI amount and the amount verified through the Federal HUB, the Social Security interface (EATSS) may be accessed to resolve the discrepancy. If reported SSA or SSI is not showing on the EATSS record, a collateral contact with SSA may be needed.
Reported unearned income not verifiable through a payer source interface shall be verified as indicated in 1330.04(2).
Also included as a payer source for purposes of this section are paystubs, or other comparable documentation voluntarily provided by the employee or employer at the time of application or request for assistance, which are sufficient to determine the countable amount of earned income without request for further verification. To be considered sufficient, the information provided must meet one of the following:
a. All paystubs received in the 30 days immediately preceding the date of application or request for assistance;
b. Paystubs which allow calculation via year-to-date totals of gross earnings received in the 30 days immediately preceding the date of application or request for assistance;
c. A written statement from the employer attesting to the employee’s gross earnings received in the 30 days immediately preceding the date of application or request for assistance, including the date(s) and frequency of payment; or
d. Any other document or documents from either the employee or employer which verifies the total amount of gross earnings received by the employee in the 30 days immediately preceding the date of application or request for assistance.
If the information voluntarily provided is sufficient to verify earned income, no further verification is required. The information voluntarily provided shall be used to determine the amount of earnings. If insufficient to verify the earned income, the information voluntarily provided is not considered a payer source.
Note: If sufficient information as described above is not voluntarily provided at the time of application or request for assistance, eligibility staff shall not request paystubs or additional information as part of the Tier 1 process. Verification shall proceed through the remaining Tiers 2 through 4, in order.
1330.02 Tier 2: Automatic Interfaces - Reported information is verified through the use of a secondary non-payer source interface. Tier 2 interfaces include wage verification from either The Work Number (TALX) or Kansas Department of Labor (KDOL) wages. All resources used to verify citizenship and identity are also included in Tier 2, such as Kansas VRV and KSWebIZ.
The Reasonable Compatibility test is used in Tier 2. See 6122 for Reasonable Compatibility. When income is not determined to be Reasonably Compatible and the Both Below is not applicable, the following Tier 3 sources are used in the order presented and should always be used prior to requesting verification from the applicant.
1330.03 Tier 3: Research - Manual research by the eligibility worker is required. This may include review of the case file, reconciling information received from Tier 2 interfaces, checking other available program information, and making collateral contacts. Any decision to verify reported information at this level must be thoroughly documented.
When an IBU for an applicant/recipient meets the Household RC test for ‘Both Below’ (see 6122.02) and all other factors of eligibility have been satisfied, additional verification is not required. The individual is eligible for Medicaid. It is not appropriate to continue to Tier 3 verification for this applicant or to delay approval of coverage while pending for information for other household members.
Manual research shall progress through the following steps in the order listed:
a. The Work Number (TALX) - When the Work Number (TALX) data is not successful in establishing reasonable compatibility in Tier 2, the income details may be used to verify income reported. Staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. If Work Number (TALX) data is not available, proceed to researching the case file.
b. Case File - The medical case file record shall be searched for hard copy verification of the reported information. This includes the images located in the medical case. The date of wage verification must be within the three months prior to the month of application when processing a new application. When processing a review or case change, the income must be from the three months prior to when the initial RC test was run. If no hard copy information is found in the case file, proceed to the DCF images.
c. Department for Children and Families (DCF) Images - A manual search of the DCF case records shall be completed for usable images to satisfy verification requirements if a consumer was part of a DCF case for a relevant time period. If verification cannot be obtained from DCF images, proceed to collateral contact.
d. Collateral Contact – Collateral contact may be made to verify the reported information, when deemed appropriate. If verification cannot be made via collateral contact, proceed to Tier 4 level verification.
1330.04 Tier 4: Request for Information - If the earnings cannot be verified using the above methods, Tier 4 verification is used, and the information is requested from the consumer. See also 6122 (Reasonable Compatibility) and 6120 (Budgeting Method).
(1) Self-employment Income - Self-employment income must be verified through Tier 3 or Tier 4 as there is not a data-source for this information. It is verified through either the tax return or the KC-5150 Self-Employment worksheet as indicated below.
When the applicant indicates they have filed taxes, a copy of their tax return is required. If it is after the IRS mandated filing deadline (typically April 15th) and the applicant has not filed their tax return, the prior year’s return may be used if they have filed an extension with the IRS. Verification of the extension is not required.
The KC-5150 Self-Employment Worksheet is used to request income and expenses for the 12 months prior to the month of application. This form is generated through KEES by staff and mailed locally. It is used in the following circumstances:
a) It is a new business and a tax return has not yet been filed.
b) It is an existing business, but the applicant has not (or will not) file a tax return.
c) A change in the amount of self-employment income is reported.
d) The tax return is no longer representative of the self-employment income. The reason for the discrepancy must be clearly documented and is only allowed when there is a definitive change in the amount or type of business. When the applicant indicates their tax return is not representative of the existing self-employment income, both the tax return and the KC-5150 Self-Employment Worksheet are required.
(2) Unearned Income - Tier 1 payer interfaces are used to verify SSA income and Unemployment Compensation. Because this information is directly from the source, the amount verified through the interface shall be used regardless of what has been reported by the applicant.
For unearned income types not verifiable through Tier 1, self-attestation is accepted as verification of all unearned income with the exception of the following types which will need to be requested from the consumer as Tier 4 verification:
a) Annuity Income
b) Trust Income
c) Contract Sales
d) Insurance Payments
e) Oil Royalties and Mineral Rights
f) Railroad Retirement
(3) Earned Income – Verification of earned income is required for all individuals. A request for information is sent to the applicant and "the last 30 days of income" is requested as proof. Proof of income is acceptable as long as the date of paystubs or employer statement falls within the three months prior to the month of application. If partial income is received from within this timeframe, it may be budgeted using the Partial Month Budgeting Method, see 6124.
1330.05 Verification of Pre-Tax Income and Federal Deductions - When total reported pre-tax or federal deductions is over $300.00 per month, verification of deductions will be required for them to be used in the income determination. If proof is not received, processing may be completed without them, and the applicant advised by notice that the amount was not used. Eligibility may not be denied due to failure to provide proof of deductions.
Verification of pre-tax income and/or federal deductions will follow the tiered approach of earned income in 1330. Information on hand, such as the case file and the Work Number (TALX) records must be used if available prior to requesting the information from the consumer. Paystubs must be no older than three months prior to the month of application to be used. Collateral contact with the employer may also be used but is not required. If there is no available information on file, the information must be requested from the consumer as noted below:
a) Pre-tax income deductions – Paystubs from the last 30 days or a statement from the employer
b) Federal/IRS deductions – Corresponding tax form or most recent tax return
Note: If based on the consumer’s self-attestation of both wages and deductions, the income will exceed guidelines for all programs, it is not necessary to request proof of the deductions.
1331 Sources of Verification - Once it has been determined that Tier 4: Request for Information is the only method of verification, the following information applies:
1331.01 Documentary Evidence - Documentary evidence consists of a written confirmation of a household's circumstances. Examples are wage stubs, tax returns, and school enrollment records. Acceptable verification shall not be limited to any single type of document and may be obtained through the household or other sources.
1331.02 Collateral Contacts - A collateral contact is a verbal confirmation of a household's circumstances made by a person outside of the household. The collateral contact may be made either by mail or over the telephone. The acceptability of a collateral contact shall not be restricted to a particular individual but may be anyone who can be expected to give an accurate third-party verification of the household's statements. Examples of acceptable collateral contacts are employers, landlords, social service agencies, migrant service agencies, and neighbors of the household.
1331.03 Self Attestation - Self-attestation or Client Statement is sufficient as verification for several elements. Although it is acceptable to verify those items with a Tier 1 or Tier 2 interface, the individual is never asked to provide verification. An exception exists if the information reported is discrepant or inconsistent. The test for this varies dependent upon the context of the information in question as well as the other information in the case.
A declaration of income is used when determining Reasonable Compatibility of Income as defined in 6122. Declaration of income may be taken from the application form, written correspondence, or through verbal contact with the applicant.
A request for coverage is denied when the self-declared income exceeds the income guidelines for the program and does not require verification. When this occurs, the notice of action shall contain detailed information of what income was used.
1332 Responsibility for Obtaining Verification - The household has the primary responsibility for providing verification to support its statements and to resolve any questionable information. Information may be provided in writing or verbally. Any reasonable evidence provided by the household shall be accepted. Staff shall be primarily concerned with how adequately the verification proves the statements on the application. If it would be difficult or impossible for the household to obtain documentary evidence in a timely manner, staff shall offer assistance to the household in obtaining documentary evidence in a phone call and/or send a notice that includes the offer of assistance to all households. The household shall not be held responsible when a person outside of the household fails to cooperate with a request for verification.
As it relates to income, where all attempts to verify the income have been unsuccessful because the person or organization providing the income has failed to cooperate with the household and the Agency, and all other sources of verification are unavailable, the Eligibility staff shall determine an amount to be used based on the best available information.
1332.01 Discrepancies - Where information from another source contradicts statements made by the household; the household shall be afforded a reasonable opportunity to resolve the discrepancy prior to an eligibility determination. Information needed to resolve the discrepancy shall be requested from the household, however, if the household fails to provide the necessary information, staff may elect to verify the information directly. Households are to be given 12 days to provide necessary verification. If the client does not or refuses to provide adequate verification to resolve the discrepancy, the case may then be closed, or the application denied if that is the appropriate case action.
1333 Mandatory Verification - Eligibility staff shall verify the following information prior to approval for initial applicants, when processing a review, or a reported change.
1333.01 SSN - An applicant is required to supply their Social Security Number or verification of application for the required SSN prior to approval of coverage unless the individual claims good cause or qualifies for exemption. See 2033. The reported SSN is then verified using either the Federal HUB or SVES in Tier 1, or through EATSS-SSA in Tier 2. Verification of the SSN does not include a copy of the paper SSN card. Verification of the SSN is a once-in-a-lifetime requirement. For persons without an SSN, they must apply for an SSN and provide proof of application. The requirement to supply and verify an SSN does not apply to non-citizens who would only qualify for a non-work SSN, such as refugees, asylees, and special immigrants.
When an applicant fails to provide an SSN or proof of application for an SSN, he or she may qualify for a Good Cause exception, see 2033.
1333.02 Citizenship and Identity - Persons applying for medical assistance attesting to be a citizen must have citizenship and identity verified as described in 2045. Unless otherwise exempt, this applies to all applicants. This is a once-in-a-lifetime requirement. Information is not requested from the client once citizenship and identity are verified.
This requirement does not apply to the following individuals:
- Current or former SSI recipients
- Current or former Medicare beneficiaries
- Current or former recipients of Social Security Disability benefits
- Children currently in foster care or recipients of foster care maintenance. (See 2045 to address verification once released from DCF custody)
- Children who are recipients of adoption support payments
- Children born on or after July 1, 2006 to a Medicaid recipient as outlined in 2320.
Tier 1 verification includes the Federal HUB.
Tier 2 verification includes Web-IZ. When the Web-IZ is from Vital Statistics, it can be used as proof of both citizenship and identity. Otherwise, it is only proof of identity.
Note: For verification of citizenship and identity, it is acceptable to access the file in Tier 3 to determine if documentation has previously been provided before accessing the Tier 2 sources. Both Tier 2 and Tier 3 must be followed before proceeding to Tier 4.
Tier 3 and 4 verification can include birth certificates and other paper documents. See KDHE Eligibility Policy-Appendix Item A-12 and 2045.
1333.03 Non-Citizenship Status - Qualified non-citizenship status must be verified for persons applying for coverage. Verification is not required for SOBRA but may be necessary to establish the individual is not a qualified non-citizen. Verification is accomplished through the Department of Homeland Security and additional verification steps may be necessary. The SAVE process is used to obtain the information. Verification is not requested for non-applicants.
Tier 1 verification includes the Non-Citizen VLP through the Federal HUB, including subsequent SAVE processes.
Tier 2 includes the manual SAVE process.
Tier 3 includes information available in the case file.
A Reasonable Opportunity period may be granted for persons who fall to Tier 4. The Reasonable Opportunity period is granted only if the individual reports a non-citizenship status that would qualify him/her for medical assistance. See 2047.01.
1333.04 Income - Unless otherwise indicated, income must be verified. See also 6122 (Reasonable Compatibility) and 6120 (Budgeting Method).
(1) Self-employment Income - Self-employment income must be verified. It is verified through either the tax return or the KC5150 Self-Employment worksheet as indicated below.
When the applicant indicates they have filed taxes, a copy of their tax return is required. If it is after April 15th and the applicant has not filed their tax return, the prior year's return may be used if they have filed an extension with the IRS. Verification of the extension is not required.
The KC5150 Self-Employment Worksheet is used to request income and expenses for the 12 months prior to the month of application. This form is generated off-system by staff and mailed locally. It is used in the following circumstances:
a) It is a new business and a tax return has not yet been filed
b) It is an existing business, but the applicant has not (or will not) file a tax return.
c) A change in the amount of self-employment income is reported.
d) The tax return is no longer representative of the self-employment income. The reason for the discrepancy must be clearly documented and is only allowed when there is a definitive change in the amount or type of business. When the applicant indicates their tax return is not representative of the existing self-employment income, both the tax return and the KC5150 Self-Employment Worksheet are required.
(2) Unearned Income - Tier One payer interfaces are used to verify SSA income and Unemployment Compensation. Because this information is directly from the source, the amount verified through the interface shall be used regardless of what has been reported by the applicant.
For unearned income types not verifiable through Tier One, self-attestation is accepted as verification of all unearned income with the exception of the following types:
a) Annuity Income
b) Trust Income
c) Contract Sales
d) Insurance Payments
e) Oil Royalties and Mineral Rights
f) Railroad Retirement
(3) Earned Income – Verification of earned income is required for all individuals. When earnings have not been reported, they are verified against available earned income data sources, as outlined below in section (4).
The Reasonable Compatibility test is used in Tier Two. See 6122 for Reasonable Compatibility. When income is not determined to be Reasonably Compatible and the Both Below is not applicable, the following Tier Three sources are used in the order presented and should always be used prior to requesting verification from the applicant.
a.) Work Number (TALX) - When the Work Number/TALX data is not successful in establishing reasonable compatibility, the income details may be used to verify income reported. Staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. Note: Usually TALX will provide a prospective amount for this purpose, but in some instances, it will use an actual amount (i.e. a sum vs. an average) depending on information provided by the employer, see note on 6122.
b) Hard-copy Wage Verifications - Staff shall review the medical case file to determine if hard copy verification has been submitted by the applicant. This could be in the form of paystubs or a statement from an employer. The date of wage verification must be within the three months prior to the month of application when processing a new application. When processing a review or case change, the income must be from the three months prior to when the initial RC test was run.
c) DCF Images - A manual search of the DCF case records shall be completed for usable images to satisfy verification requirements if a consumer was part of a DCF case for a relevant time period. If verification cannot be obtained from DCF images, proceed to collateral contact.
d) Collateral Contact – Collateral contact shall be made to verify the reported information, when deemed appropriate. If verification cannot be made via collateral contact, proceed to Tier 4 level verification.
e) Request Information - If the earnings cannot be verified using the above methods, Tier 4 verification is used. A request for information is sent to the applicant and "the last 30 days of income" is requested as proof.
(4) Zero Earnings – It is necessary to verify the absence of earnings for all individuals. This is applicable to all individuals who do not report earnings, report non-wage income only, such as self-employment or unearned income, or fail to answer questions about their income. Earned income sources are also checked for children. Even though most children will not have earnings found, this income test is a necessary element of the Both Below Reasonable Compatibility test as outlined in 6122. System interfaces will be checked to verify that no earnings exist. The Reasonable Compatibility Test will be used in Tier 2 to verify that no earnings exist. If no earnings are found in both TALX and KDOL (BASI) the zero earnings are considered verified.
When data sources are not able to confirm the absence of earnings, it is necessary to evaluate if proof of the income is going to be required prior to proceeding. When an applicant’s IBU meets the Household RC test for Both Below and there is no other information, other than income, that is still pending, the applicant is eligible and should be approved for Medicaid without further verifying the IBU income. When Both Below is not applicable, continue to Tier 3 sources and use in the order presented:
a) The Work Number/TALX – When Work Number/TALX returns wage information, staff will evaluate the check dates returned on the Reasonable Compatibility Detail page. If the latest check date is older than 30 days, this is indicative that there has been a change in income. The lack of reported earnings is accepted and considered verified. If the latest TALX check date is within the last 30 days, staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. It is considered current and countable income. If the consumer later contests the use of this income, proof of the end of the income would be required and the eligibility will be redetermined if appropriate.
b) Case File – When KDOL (BASI) wages are returned for the quarter prior to the current quarter, staff shall research the case file for information that may indicate the recent loss of employment. If an explanation is found that substantiates the report of no income, then further research into the KDOL (BASI) wages are not required. The zero earnings are considered verified.
(5) Proof of End of Income
Self-attestation of the end or absence of income is acceptable, with the exception of the following:
a) Individual is a CHIP premium-payer and reports a reduction/elimination of income.
b) TransMed (TMD) or Extended Medical (EXT) recipient reports a reduction/elimination of income.
c) The consumer contests to the use of income found in a data source.
1333.05 Medical Expenses - The amount of any medical expenses used to meet a spenddown must be verified in order to allow it against the spenddown. Failure to verify expenses doesn't disqualify the individual, as eligibility is determined without allowing the expense. Medical expenses for Spenddown submitted through Provider Billing protocols in the MMIS are considered verified if proper procedures are followed.
1334 Information Known to the Agency - The agency is required to act on information when it becomes known. The phrase’ Known to the Agency’ establishes the point in time that the agency is made aware of information in order to act upon such information for purposes of eligibility determination/redetermination. These policies do not negate the consumer’s responsibility to report information (see 7100), but are meant to provide required parameters when reacting to new information.
See 7140 for processing changes.
1334.01 Definition of Agency - Agency means the single state Medicaid/CHIP agency as well as any contractors or other state agency units authorized to determine eligibility for medical assistance or provide direct support of the medical assistance eligibility determination process. Currently, this means the KanCare Clearinghouse, KDHE Outstationed Workers, KDHE Central Office – Eligibility Unit and DCF PPS workers who make medical determinations. It also includes automated systems that determine medical assistance eligibility to the extent the information is used in the medical assistance determination.
1334.02 Date Information is Known - The date information is considered known to the Agency establishes the date by which information must be acted upon. This date is determined by the source/channel of the information:
1. Information reported directly to the Agency by a consumer or third party, by any channel, is considered known on the date it is reported. Examples:
• The date of a phone call from the consumer reporting a change in income
• The date of receipt of written correspondence
• The date a Nursing Home reports a change in living arrangement
• The date a new application is received, whether for a new household or an existing household reporting a change or a new member
2. Information that originally becomes known to another state agency but is communicated to the Agency as part of an approved business process is considered known on the date the information was reported to the Agency. Examples:
• The date DCF creates a task notifying KDHE of a new medical condition that a mutual client originally reported to DCF
• The date DCF creates a task notifying KDHE of a change in health insurance premium amount
3. Information obtained through an interface used by the medical assistance programs which populates information directly into KEES is considered known on the date the information is added to KEES. Examples:
• The date a TBQ adds new Medicare entitlement to the Medicare Information page
• The date an SDX task is created from a Social Security interface telling KDHE that SSI has ended.
4. Information originally obtained through another program through any channel that was not directly reported to the Agency, is considered known based on the type of information received.
a. Information received through a shared data field in KEES and is immediately used for case processing through an automated process is known on the date the information is added to KEES. Example:
• The date DCF updates an address in KEES for a mutual client.
b. Information received through a shared data field in KEES is considered known on the earlier of the date the information is used for processing or the date it is viewed by a person considered part of the Agency. Example:
• DCF updates health insurance premium at the end of the day. The review batch runs that evening and uses the health insurance premium in the new determination. DCF notifies KDHE of the change the following day. The information is considered known on the date of the review batch, because the information was used to redetermine medical benefits.
c. Information available only through a non-shared data field in KEES is considered known on the date it is viewed by someone considered part of the Agency. Example:
• The date a KDHE staff person views a DCF income record
01340 Discrepancies and Questionable Information - A discrepancy and/or Questionable Information is identified when information from one source contradicts statements from another source. To be considered questionable, the information on the application must be inconsistent with other information on the application or previous applications or inconsistent with information received by the agency. When determining if information is questionable, the decision shall be based on each household's individual circumstances. Also see 1310 and 1320.
Eligibility staff shall verify factors of eligibility prior to approval only if they are questionable and affect the household's eligibility.
01350 Documentation - Case files must contain documentation to support the determination to approve or deny program benefits. Documentation means that a written statement regarding the type of verification and a summary of the information obtained has been entered in the case record. Such statements must be in sufficient detail so that a reviewer would be able to determine the reasonableness of the determination. The results of the Reasonable Compatibility Test along with the Verification Tier used shall be included in the documentation. For example, when income is verified by the presentation of pay stubs, the gross amount of income on each pay stub, and the frequency of receipt of income are included on a copy of the pay stub in the case record or are recorded by the Eligibility Staff elsewhere.
Where verification was required to resolve questionable information, the Eligibility Staff shall document why the information was considered questionable and how the questionable information was resolved. The Eligibility Staff shall also document why any alternate sources of verification were needed and, if a collateral contact was rejected, the case file shall contain documentation of why the collateral contact was rejected and an alternate chosen.
01400 Application Process/General Information -
1401 General Information - An application is defined as a request for medical assistance. Individuals can apply for medical assistance in one of the following ways:
a) Online application submitted through the Self Service Portal (SSP)
b) Paper application form submitted by mail or in person at the KanCare Clearinghouse
c) Telephone application
d) Transfer of a request from the Federally Facilitated Marketplace (FFM)
e) Request by phone for individuals in households with already open medical programs (see 1402)
Based on the provisions of 3000, an application shall include all required persons. Required persons are as follows:
- The individual,
- The individual's spouse,
- The individual's children under age 21 living with them,
- The individual's partner who lives with them when they have mutual children,
- Any other individual who is on the individual's tax return (whether or not they live with them), and
- Anyone else under age 21 who lives with the individual and they care for.
The application, together with the agency records (if any), the necessary forms (budgets, notices of action, narratives, etc.), and any required verification must substantiate eligibility or ineligibility.
At the time of application processing, each month shall be viewed separately in determining eligibility or ineligibility. For example, if an application is filed in July but processed in August, ineligibility in August shall not affect the eligibility determination for the month of July.
1402 How to Apply - Each household has the right to file an application on the same day it contacts with the agency. Application forms can be requested from any local DCF office, KanCare Clearinghouse, or KDHE-DHCF Outstationed Worker. All requests for medical assistance must be made on KDHE-DHCF forms as follows:
KC1100 - Medical Assistance Application for Families with Children
KC1500 - Medical Assistance for the Elderly and Persons with Disabilities
Such applications are to be submitted to the KanCare Clearinghouse; a central operation established to determine eligibility for all medical programs. A contractor is currently used to manage the Clearinghouse. Applications provided to the local DCF office are immediately transferred to the Clearinghouse for processing.
Note: Online applications are received through the KDHE-DHCF Customer Self-Service Portal (CSSP).
When an application is requested in person, the household shall be encouraged to file the application that same day. When an application is requested over the telephone or in writing, it shall be mailed the same day, when possible, or the following business day.
NOTE: If the applicant household is homeless and they have no street address to list, the application shall be so noted and accepted by the agency.
Neither an application form nor signature is required to add additional household members to an existing medical program unless the medical program has remained active beyond the review period due to timeliness factors. If the medical program has remained active past the required review period, only submittal of a signed application form will constitute a request for coverage.
1403 Application Date - The date of receipt by the agency of a validly signed application is considered the application date for establishing initial eligibility and for processing purposes.
1403.01 Paper Applications - The date a paper application is received by the agency shall be considered the application date. All signed paper applications shall be date-stamped the date physically received at the KanCare Clearinghouse, an Outstation Worker site, or other location designated by the agency.
A paper application that is received through the mail or physically delivered to agency personnel on agency premises shall be considered received that date. An application that is received through a drop box, mail slot or other such manner at the opening of the business day shall be considered received that day, even if the application was deposited prior to that date.
An application received by the agency via email or fax is deemed an original application and is considered received on the date on the time stamp if received by 5:00 pm on a business day. If the application is received after 5:00 pm on a business day or on the weekend or a holiday, the application date is the next following business day.
When an applicant files an application form that is not intended for the medical coverage requested, additional information may be requested, but the application date is the date the application is received by the agency. Completion of the appropriate form is not required to establish the application date for the coverage requested.
Note: Date-stamping of a paper application by someone other than agency or agency contracted personnel does not constitute a date of receipt for application purposes.
1403.02 Online Applications - The date an electronically signed online application is received by the agency shall be considered the application date if received by 5:00PM on a business day. If the application is received after 5:00PM on a business day or on the weekend or holiday, the application date is the following business day.
1403.03 Other Electronic Applications - The application date for other electronic applications received by the agency is described below. MIPPA and FFM applications both have two (2) application dates – one for processing purposes and one for eligibility purposes.
FFM Applications - The date the electronic data file is received by the agency from the federally facilitated health insurance marketplace exchange is the application date for processing purposes and establishes the 45-day processing timeline. The date the original health insurance exchange subsidy application was filed with the Federally Facilitated Marketplace (FFM) is considered the date of request for medical assistance and therefore is the start date for eligibility purposes.
MIPPA Applications - The date the electronic data file is received by the agency from social security is the application date for processing purposes and establishes the 45-day processing timeline. The date the original Low-Income Subsidy (LIS) application was filed with Social Security is considered the date of request for MSP and therefore is the start date for eligibility purposes. Note: Since the original LIS applications on which these applications are based do not include a request for prior medical assistance, there is no MSP eligibility for months prior to the request month of these applications.
PE Application – The date the PE Application is received by the agency shall be considered the application date.
1403.04 Telephonic Applications - The application date for a telephonic application is the date the applicant answers all the questions and telephonically signs the application by certifying, under penalty of perjury, that they understand the questions and statements read to them and his/her answers are correct and complete to the best of their knowledge.
1403.05 Unsigned Applications - An unsigned application received by the agency is not considered an application for processing purposes. All unsigned applications shall be promptly returned to the applicant for signature.
The entire application shall be returned to allow the applicant to review his/her answers prior to certifying under penalty of perjury that all answers are correct and complete to the best of their knowledge. A cover letter must be attached to the returned application explaining the need to sign the application and return to the agency for processing.
If the originally unsigned application is returned with a valid signature, the application date for processing purposes is the date the returned application is received by the agency if received on a business day. If the application is received on the weekend or a holiday, the application date is the next following business day.
Note: An online application may not be submitted without a signature. Therefore, there should never be an online application received without a signature. The signature may be invalid (see subsection 1403.06), but there should always be a signature.
1403.06 Invalid Signature - An application received by the agency with an invalid signature is considered an application for processing purposes. An invalid signature is one in which the person who signed the application has no authority to act on behalf of the applicant (see 2110 and subsections).
When an application with an invalid signature has been received by the agency, the application (or a copy of the application for online applications) shall be returned to the applicant with instructions to either verify the authority of the person who signed the application or to sign the application in their own name (if legally competent to do so).
If verification of authority to sign the application or if the application with the applicant’s own signature is timely received by the agency, the application date for this application is determined by the following:
a. If verification is provided documenting that the person who signed the application was authorized to apply on behalf of the applicant at the time the application was received by the agency, the application date is the date the application was originally received by the agency.
Note: If the application indicates that the person signing the application has authority to apply on behalf of the applicant (such as a person holding a Durable Power of Attorney or is a guardian or conservator of the applicant), but no verification has been provided at the time of application, the process described in this section does not apply. In that instance, the signature is initially considered valid, and the agency shall send a request for information to provide verification of the authority.
b. If the applicant responds by formally designating the person who signed the application as his/her medical representative according to 2010.02, the application date is the date documentation of the medical representative authorization is received by the agency if received on a business day. If the medical representative authorization is received on the weekend or a holiday, the application date is the next following business day.
c. If the application is returned with the applicant’s own signature, and the applicant is legally competent to apply on their own behalf, the application date is the date the returned application with the valid signature is received by the agency if received on a business day. If the returned application is received on the weekend or a holiday, the application date is the next following business day.
This provision also applies where someone other than the applicant, who is verified to act on behalf of the applicant according to 2010 and subsections, signs and timely returns the application to the agency.
If verification of authority to sign the application or if the application with the applicant’s own signature (or of someone who can act on behalf of the applicant) is not timely received, the application shall be denied due to an invalid signature based on the date the application was originally received.
1403.07 No Program Request - The application date for an application received with no program request is the date the application is physically received at the KanCare Clearinghouse, an Outstation Worker site, or other location designated by the agency. Immediate contact with the applicant shall be made to determine which programs are being requested.
The program(s) requested shall be registered using the date of receipt of the application as the application date for those programs only. Any subsequent request for other programs by the applicant shall be registered with an application date based on the date of request for the additional program(s).
Note: An online application may not be submitted without a program request. Therefore, there should never be an online application received without a program request.
1404 Who May File - An application for assistance shall be made by the individual in need or by another person able to act in the individual's behalf. See 2010. If the applicant or his representative signs by mark, the names and addresses of two witnesses are required. Obtaining the signatures of all persons in the family group who are requesting assistance and able to act in their own behalf per 2010 is encouraged, but cannot be required.
1404.01 Filing on Behalf of a Deceased Person - An application shall be made on behalf of a deceased person in the month of death or within the three following months by the following individuals:
• A parent of the decedent where the decedent is a minor;
• The surviving spouse of the decedent;
• An adult child of the decedent;
• An adult in the decedent’s tax household; or
• An executor or administrator (including temporary) of the decedent’s estate.
1404.02 Filing for Institutionalized Individuals - When possible, all necessary information and signed forms will be obtained by institutional personnel. Parents, spouses, guardians/conservators and others who may apply on behalf of the individual per 2010 must always be given the opportunity to apply on behalf of an institutionalized person not able to act in his own behalf. If institutionalized personnel are unable to obtain the required forms from the patient or any of the above individuals, the administrator of a licensed facility may apply on behalf of the patient. General hospitals are not regarded as a licensed facility for this purpose.
Complete applications will be forwarded to the DCF office or KanCare Clearinghouse for processing.
All information pertinent to eligibility and known by institutional staff will be communicated to the local office. When the institution acts as an employer to the patient, institutional personnel will be responsible for reporting all earnings to the local DCF office.
Generally the local DCF office where the institution is located will process new applications. However, when appropriate, the local office or KanCare Clearinghouse shall determine whether the individual is currently included on an open medical case before processing. If the individual is included on a currently open case, the application shall be denied. The referral and a copy of the application shall be sent to the current county or CH where the appropriate case action will be taken to certify eligibility to the institution. (See 7300.)
For individuals who currently have an unmet spenddown, the institution should be notified as no FFP can be claimed until the spenddown is met. Medical expenses incurred at the institution shall be considered toward the unmet spenddown and eligibility certified when the spenddown is met.
1404.03 Filing for Individuals through the Federal Health Insurance Marketplace - Individuals may apply for medical assistance through the Federal Health Insurance Marketplace. The Marketplace application allows any adult member of the tax household to apply for any and all other members of the tax household. Should the agency receive an application via file transfer from the Marketplace, it shall be accepted and processed even if the individual filing the application does not meet the requirements of 2110 and subsections. The application shall be registered following standard procedures, establishing the correct individual as the primary applicant.
1405 Withdrawing the Application - The household may voluntarily withdraw its application at any time. The agency shall document in the case file the reason for withdrawal, if any was stated by the household, and that contact was made with the household to confirm the withdrawal. The household shall be advised of its right to reapply at any time subsequent to withdrawal.
1406 Universal Access - An individual or family can apply for medical assistance at either a DCF office or the KanCare Clearinghouse. DCF accepts these applications but does not process them. Applications are gathered and transferred to the KanCare Clearinghouse several times a week. The DCF Service Center where the application is filed shall inform the consumer about the transfer to the KanCare Clearinghouse. The application date is not based on when the application is received by DCF. See 1403.
1407 Time in Which Application is to be Processed and Case Disposition - All applications shall be approved or denied on a timely basis except when a determination of eligibility cannot be made within the required period due to the failure of the applicant or collateral to provide required information. Written notice must be given to the applicant by the end of the required period giving the reason(s) for the delay. The approval of an application from an alien who is otherwise eligible may not be delayed beyond the timely processing time frame due solely to the fact that no USCIS response to a request for verification of immigration status has been received.
Timely action is defined as follows:
1407.02 All Other Medical Applications - Within 45 days of the agency's receipt of a signed application. For management purposes the agency shall strive to process applications within 30 days.
1408 Presumptive Eligibility - (PE) is a process that allows qualified hospitals and qualified entities to determine if an individual is eligible for temporary short-term medical assistance. The PE determination is a simplified process based on information provided by the applicant. Standard application procedures, such as obtaining hard copy documentation, are not required for a presumptive decision. PE grants immediate temporary medical coverage to persons pending their formal application for KanCare. The PE Program is designed for uninsured low-income persons in the following populations:
• Children
• Pregnant Women
January 1, 2014 the Affordable Care Act (ACA) implemented the options for hospitals to self-elect to determine presumptive eligibility and expanded the group for which hospitals could determine. This group includes adults in one of the following groups:
• Low-income Caretakers
• Former Foster Care
• Breast or Cervical Cancer recipients diagnosed through Early Detection Works (EDW)
Presumptive Eligibility for Pregnant Women only covers outpatient ambulatory services related to pregnancy. All other presumptive eligibility groups receive full Medicaid coverage.
Qualified Entities (QEs) eligible to complete PE determinations for the above adult population include all clinics and hospitals. The Presumptive Eligibility determination is final. The applicant household does not have appeal rights regarding the outcome of their presumptive determination.
1408.01 Qualified Hospitals and Qualified Entities - KDHE-DHCF is responsible for certifying all entities qualified to make Presumptive Eligibility decisions. Certain Medicaid enrolled hospitals and Safety Net Clinics have been designated Qualified Entities allowed to make presumptive eligibility decisions.
All entities must complete training and receive certification by KDHE-DHCF prior to making any determinations.
Presumptive Eligibility is determined through the Presumptive Eligibility (PE) Portal. Once entity staff have received training and are deemed certified, they will gain access to the PE Portal.
Qualified Hospital
A qualified hospital is a hospital that
(1) Participates as a Kansas Medicaid provider, notifies KDHE of its election to make presumptive eligibility determinations, and agrees to make presumptive eligibility determinations consistent with Kansas policies and procedures,
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements, and
(3) Has not been disqualified by KDHE.
Qualified Entity
A qualified entity is
(1) Healthcare providers, community-based organizations, schools, head start programs authorized by the state to screen for Medicaid and CHIP eligibility and immediately enroll adults, children, and pregnant women who appear to be eligible,
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements,
(3) Has not been disqualified by KDHE.
1408.02 Qualified Hospital/Entity Responsibilities - Staff at each Qualified Entity/Hospital are responsible for identifying adults, children, and pregnant women who could benefit from the Presumptive Eligibility Program.
Staff will make presumptive decisions as well as inform families of the program. They will also assist families who wish to apply for coverage with completing the KanCare application. This assistance shall include completion and submission of the application, assistance in obtaining supporting documentation, and follow-up with the family to provide support through the application process.
The following processes must be completed by the Qualified Entity when making a presumptive determination:
1. Complete the training program provided by DHCF upon becoming a QE and ensure that new employees are trained.
2. Attend recertification training if mandated by DHCF.
3. Follow all policies and procedures outlined in the PE Resource Manual and training material.
4. Offer PE to uninsured persons accessing services.
5. Confirm through the KMMS that prospective PE recipients are not currently covered.
6. Determine PE based on the information in the PE Portal in accordance with the instructions in the PE Resource Manual and training material and instructions in the PE Portal itself.
7. Assist families in the completion of a KanCare application, which includes providing assistance in obtaining required verifications for application processing; families denied PE should still receive assistance in completion of the KanCare application.
8. Provide the parent/guardian or adult applicant the signed Approval or Denial determination letter Notice and a copy of their application following their PE determination.
9. Provide each parent/guardian or adult applicant determined eligible verification of the coverage start date. This eligibility verification is in the form of an approval letter which includes the approved individual’s name, date of birth, and the date coverage begins. The approval letter is proof of coverage until the individual has their medical card and uses this as proof of eligibility, or the provider must verify eligibility through the KMMS.
10. Inform families in writing and verbally of the reason the applicant(s) was found ineligible for PE coverage and assists the household in completing the formal application process even though the applicant was not presumptively eligible. A presumptive determination is based on household statements and a simplified process which may not have the same outcome as the formal eligibility determination completed by KDHE-DHCF.
11. Educate the parent/guardian or adult that future communication on their KanCare application will be from the KanCare Clearinghouse and provide the parent/guardian or adult with the KanCare Clearinghouse contact information.
12. Provide the family with comprehensive assistance to ensure a successful completion of their KanCare application. This may include contacts with families prior to appointments to encourage them to bring necessary documentation at the time of service, follow-up contacts with the family, assistance in obtaining documentation, and agreeing to photocopy and fax documents to the KanCare Clearinghouse.
13. Meet the performance standards outlined below:
a. 95% of PE determinations are completed accurately,
b. 90% of individuals are offered help from PE staff to complete the full Medicaid application.
c. 85% of approved PE applicants ultimately achieve eligibility through the KanCare process.
14. Maintain a record of PE determinations for 5 years.
15. Maintain client confidentiality.
1408.03 KanCare Clearinghouse Responsibilities - Staff at the KanCare Clearinghouse record the results of each Presumptive Eligibility determination and enter presumptive coverage in the Kansas Eligibility Enforcement System (KEES).
Presumptive Eligibility is determined in the Presumptive Eligibility Portal (PE Portal) and then entered into KEES. The following individual medical subtypes are recorded in KEES:
• PEN/CH – Medicaid Child
• PET/CH – CHIP Child
• PEN/PW – Pregnant Women
• PEN/CT – Adult Caretaker
• PEN/BC – Breast or Cervical Cancer
• PEN/AO – Foster Care Aged Out
The KanCare Clearinghouse is responsible for completing the determination of ongoing eligibility under MAGI programs.
1408.04 Applicant Responsibilities in the Presumptive Eligibility Process - The adult applicant household member is responsible for providing the Qualified Entity staff with household information to be used in making the Presumptive Eligibility determination, see 1211.02. Information provided to each entity for purposes of making a presumptive eligibility determination must be true and correct, see 8410.
1408.05 Period of Presumptive Eligibility - Presumptive Eligibility coverage begins on the date the determination is completed. The approval letter provided to the family by the Qualified Entity shall reflect this date as when the applicant’s coverage begins. Coverage is not provided for days prior to the date on the presumptive eligibility approval letter. The family must complete the KanCare application (and request assistance with unpaid medical bills, if applicable) in order to be determined for potential eligibility for the time prior to the period of presumptive coverage.
Presumptive Eligibility coverage ends the month following the presumptive eligibility determination if a KanCare application is not received.
If the application is received during the presumptive eligibility period, an applicant may continue to receive presumptive coverage until the formal application is processed and a determination of the applicant’s formal eligibility is made.
Children and Adults may only be provided with one Presumptive Eligibility coverage period within a twelve-month period. The applicant must self-declare any prior Presumptive Eligibility coverage to the entity at the time of application. Entities shall check their records to verify Presumptive Eligibility has not been received at their facility. The twelve-month period begins with the month the child or adult is determined eligible for presumptive coverage. For example, Billy is approved for presumptive eligibility on July 10th, 2007. July is the first month of the twelve-month period. Billy cannot receive additional presumptive coverage until July 1, 2008.
Pregnant Women may only be provided one Presumptive Eligibility coverage period per pregnancy.
Presumptive eligibility coverage periods have no impact on continuous eligibility provisions. Continuous eligibility is not applicable until the formal application is processed, see 2310.
The household does not have a right to continuation of benefits upon pending an appeal of the termination of presumptive benefits because the receipt of these benefits is time-limited.
1409 Signature Requirement - As noted in 1403, an application or review form must be signed to be considered a valid request for assistance. The signature must be both valid (see 1403.06) and acceptable. An acceptable signature is one which meets the following requirements.
1409.01 Paper Applications and Review Forms - Any mark or sign made by the person signing the application with the intent to represent the identity of that person is acceptable. This includes handwritten (wet), typed (mechanical), stamped, and scanned signatures. A handwritten signature does not have to be legible to be acceptable. If the person is marking the application with an “X” (or other symbol) because they are unable to sign their name due to illiteracy or disability, the signature of two (2) witnesses to validate the identity of the person making the mark is required.
A signature provided in the wrong place in most instances shall not disqualify the application as long as the signature is both valid and acceptable. This applies to signatures provided on either the signature page or the medical representative authorization page of the application.
Note: While it is not required that the signature be on the correct signature line, it does need to indicate an agreement/authorization of the items preceding the signature section on the signature page, i.e., the rights and responsibilities section of the application or review form.
1409.02 Online Applications - In general the applicant (or applicant’s representative authorized to act on behalf of the applicant) should type his/her full name on the application, which constitutes a valid and acceptable signature. However, when less than the applicant’s (or authorized representative’s) full name appears, the following provisions apply.
1. Acceptable – Using the prudent person concept described in 1300, if the signature submitted on the application provides enough evidence to reasonably identify the signer as the applicant (or authorized representative), the signature is considered acceptable. Examples of acceptable signatures include (but are not limited to) the use of initials, nicknames, or partial names associated with that person instead of his/her legal name, if as long as the identity of the signer can reasonably be discerned from the signature.
2. Not Acceptable – If the signature provided on the application does not provide enough evidence to reasonably identify the signer as the applicant (or authorized representative), the signature is considered unacceptable. Examples of unacceptable signatures include (but are not limited to) partial names or nicknames not normally associated with the person’s formal name, an indecipherable combination of letters and/or numbers, or a name totally disassociated from the applicant.
When the signature has been determined to be unacceptable, an attempt to contact the applicant should be made to confirm the identity of the person who signed the application. If it is confirmed that the applicant (or authorized representative) signed the application, the signature shall be considered acceptable.
1409.03 Telephonic Applications - A person applying telephonically shall be required to verbally certify, under penalty of perjury, that they understand the questions and statements read to them, and that the answers are correct and complete to the best of their knowledge. To complete the telephonic signature, the applicant will be required to state their full legal name. That statement will be recorded and attached to the case as a permanent record.
Based on this process, the verbal signature shall always be deemed to be acceptable. However, if it is later verified that the person who provided the verbal signature was not the applicant (or authorized representative), the signature is considered to be a forgery, and thus an invalid signature (see 1403.06).
1409.04 Unacceptable Application - If the application does not contain an acceptable signature, follow the process described in 1403.06 for invalid signatures.
Note: While the applicant (or authorized representative) is directed to both sign and date the application, failure to date the application (or provide an incorrect date) does not invalid the signature or the application. As long as an acceptable signature has been provided, the signature requirement has been met. See also 1409.
01410 Disposition of Applications - The purpose of this section is to provide instructions regarding the procedures that follow the determination of eligibility or ineligibility for assistance. Eligibility/ineligibility is certified using KEES procedures. A copy of the Notice of Action is to be sent to medical providers to certify eligibility/ineligibility on medical cases when required.
One of the following case actions must occur within the established time period outlined in 1407.
1410.01 Approval - A notice of approval shall be sent for all programs determined eligible.
(1) Approved - The application will be approved for medical, if automatically eligible, or if determined eligible with respect to all factors including financial.
(2) - Approved - Suspended - If the applicant is eligible with respect to all factors other than financial but there is a spenddown (see 6500), the application will be approved in a spenddown status if there appears to be a likelihood that the spenddown will be met within the 6 month eligibility base period using evidence provided by the client and known to the agency. This is an administrative procedure to meet the application disposition time requirements and to preserve the original application date. However, there is no eligibility until the spenddown is met. See 1412 concerning suspension. The individual will however be enrolled with a KanCare managed care organization (MCO). They will be eligible for any value-added services the MCO provides. A medical card will be issued by the MCO, and claims billed will be applied to the spenddown.
For all individuals enrolled in KanCare, the MCO, will issue a medical ID card. For non-KanCare recipients, medical cards are issued by the fiscal agent.
1410.02 Denial - A denial shall be processed to assure that the applicant is provided with his/her denial notice in a timely manner. A notice of denial shall be sent at the time of denial, clearly explaining the reason for the denial.
(1) - Found Ineligible - A denied application may be reinstated without a new application at any time within the original 45-day processing timeline. In no case does the denial of the application abridge that individual's right to reapply at any time.
(2) - Failure to Provide Required Information/Cooperation - An application shall be denied after a period of 12 days from the date of a written request for information, but no later than 45 -days from the date of application when the applicant has failed to provide required information or cooperate with eligibility requirements. The applicant must be informed in writing of the 12-day standard and the date by which the verification /cooperation must be received.
If the information is subsequently received or the household cooperates within the 45-day application processing time period, the application shall be reactivated and, if eligible, benefits prorated from the date of application. If the information/ cooperation is not received within the above time frames, then the client must re-apply.
(3) - Spenddown - When a spenddown is established for a minor who would otherwise be eligible for CHIP coverage, eligibility staff must ascertain the likelihood that the spenddown will be met. In order to make this determination and prevent delaying CHIP approval, contact with the applicant must be made as quickly as possible. The applicant must be informed of the spenddown amount and given a 12- day notice to respond to the likelihood that the spenddown will be met within the 6-month eligibility base period. If the applicant fails to respond or it does not appear that the spenddown will be met, the application will be denied (or case closed for failure to meet the spenddown) and CHIP coverage will be authorized. In spenddown cases where there is no possibility of CHIP eligibility, the spenddown is established, and the case remains open throughout the base period. At the end of the base period, staff determines if there is a need for further spenddown coverage.
(4) - Another Agency Assumes Responsibility - The agency may dispose of the application if another agency assumes complete responsibility for meeting the applicant's need.
(5) - Cannot be Located - The agency may dispose of the application if the applicant has moved and cannot be located. The agency shall not send a notice of decision.
1410.03 Pending - If a decision cannot be made on an application within the applicable timely processing period because of agency delay, the application shall not be denied. Eligibility staff shall notify the applicant(s) that the application is still pending, and what action must be taken to complete the application process and what date the action must be taken by, or the request will be denied.
1411 Provisions Specific to Medical Eligibility - Suspension of medical benefits does not shorten an established medical eligibility base period and a new application is not required to reinstate assistance within the period. Regardless of the procedure used, medical eligibility shall not be suspended without meeting notice requirements related to adverse action. Benefits shall not be suspended for more than 6 months except in rare cases where there is clear documentation that circumstances have changed so that medical eligibility can reasonably be expected within the next 6 month period. If the case is not to be closed, medical eligibility on a medical only case will be suspended.
1412 Termination of Assistance - Case closures will always be effective the last day of a given month. To protect credibility with medical providers, the termination date may not be changed after issuance of a medical card. However, the date of death will be used for a deceased individual since there are no eligible services after that date.
1413 Reinstatement of Assistance - Medical assistance can be reinstated in the month following the month of closure or suspension if the reason for the closure has been cured by the end of the month following the month of the closure/suspension and all other eligibility requirements are met. The exception to this is if medical assistance was discontinued due to whereabouts unknown (see 7230). If the individual was discontinued due to whereabouts unknown and confirms their whereabouts prior to the end of their review period, coverage shall be reinstated back to the date of termination, unless the consumer reports a change in circumstances that will impact eligibility. If this information becomes known, the agency will be required to act on the information. See 1334.
A new application is not required for reinstatement purposes unless the current review period has expired. However, if the review form is returned within the three month reconsideration period (see 7431), the form can be used to redetermine eligibility.
01420 Written Notice of Case Action - An applicant or recipient of assistance shall be notified promptly of the action taken on his case. The recipient of assistance shall also be notified of other changes such as an increase or decrease in the spenddown, cost share, suspension, or reinstatement after suspension.
1421 Notice of Action - Shall be sent promptly to the applicant or recipient with a copy of any manually prepared notices filed in the case record. Specialized notice forms are required for all cases involving a spenddown, and for all cases in which the medical program will assume at least partial payment for care situations.
Notices shall indicate clearly the action taken, the effective date, and such other information as the situation may require. For all medical approvals, notices must include the beginning date of the review period. If an application is denied, the applicant shall be informed of the basis for this action. A similar procedure shall be followed for all other changes.
1422 Timely and Adequate Notice - The agency shall give timely and adequate notice of agency actions to terminate, suspend, or reduce assistance except as provided for in 1422.01 regarding dispensing with timely notice and in 1425 regarding negative actions resulting from information obtained through federal match data. See 7420 for further information on notice provisions for reviews.
1422.01 Adequate Notice - Adequate means a written notice that includes a statement of what action the agency is taking, the reasons for the intended agency action, the specific manual references supporting such action, an explanation of the individual's right to request a fair hearing, and the circumstances under which assistance may be continued if a fair hearing request is made. All notices must be adequate.
1422.02 Timely Notice - Timely means that the notice is mailed at least 10 clear days before the effective date of action. Neither the effective date of action nor the mailing date shall be considered in determining this 10-day period. For closures, the consumer must receive the notice prior to the last day of eligibility. For increases in premium, the consumer must receive the notice prior to the 1st of the month for which the change is effective. The Processing Deadlines Code Card Chart on the KEES Repository shall be used to identify the last day in which action can be taken in order for timely notice to be provided for the various scenarios.
An increase in an unmet spenddown does not require timely notice; however, a change which results in the spenddown changing from met to unmet does require timely notice. When a spenddown for a base period changes from met to unmet, the consumer is notified both by the KanCare Clearinghouse and by MMIS. The MMIS notification must be received before the first day they return to having an unmet spenddown.
1423 Adequate Notice Only - When only adequate notice is required, such notice may be received by the household at the time reduced benefits are received or if benefits are terminated, at the time benefits would have been received if they had not been terminated. The agency is not required to send timely notice but must send adequate notice no later than the date of action when:
1423.01 - The agency denies an application for assistance. However, denials resulting from information obtained through federal match data shall be subject to the provisions of 1425.
1423.02 - The agency has factual information confirming the death of a client or of the payee when there is no relative available to serve as new payee.
1423.03 - The agency receives a clear written statement signed by a client indicating that he no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the client has indicated, in writing, that he understands that this must be the consequence of supplying such information.
1423.04 - The client has been admitted to an institution and further medical assistance will not be provided to that individual.
1423.05 - The client has been placed in a Medicaid approved institution for long term care or begins HCBS and will receive Medicaid payment for the cost of care.
1423.06 - The client's whereabouts are unknown and agency mail directed to him has been returned by the post office indicating no known forwarding address.
1423.07 - A client has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance.
1423.08 - A child is removed from the home as a result of a judicial determination, or voluntarily placed in foster care by his legal guardian.
1423.09 - Assistance is approved and negative case action such as a closure is incorporated into the initial notice of action to the client. However, negative action resulting from information obtained through federal match data shall be subject to the provisions of 1425.
NOTE: Timely and adequate notice must be given for any termination in benefits resulting from information obtained by the consumer or other sources.
1423.10 - A client is disqualified for fraud through a court of appropriate jurisdiction.
1423.11 - A premium requirement is established or increased for a CHIP case per 2440.
1423.12 - The agency receives a request to end coverage on the basis of the cost of the CHIP premium obligation.
1424 Automatic Benefit Adjustments for Classes of Clients - When changes in either state or federal law require automatic adjustment for classes of clients, timely notice of such adjustments shall be given which shall be adequate if it includes a statement of the intended action, the reasons for such intended action, a statement of the specific change in the law requiring such action, and a statement of the circumstances under which a hearing may be obtained and assistance continued.
1425 Notice of Actions Resulting from Federal Match Data - Based on the provisions of the Computer Matching and Privacy Protection Act, no immediate action to suspend, terminate, reduce, or deny assistance in the medical program may be taken as a result of information obtained through federal match data which has not been determined to be accurate and reliable by the federal agency producing the data. When the federal information has not been determined to be accurate and reliable, the individual must be given 30 days from the date the notice of action is received to verify or contest the match data. This means that such notice must be sent at least 35 days prior to the effective date of action for recipients or the date the application is to be processed for applicants.
Federal matches currently affected by these provisions include the PARIS, SIEVS (IRS and BEER data) match and VA match. It does not include BENDEX, SDX, SAVE information from INS, and third- party queries obtained through SSA as all of these data exchanges are either considered to be accurate and reliable or involve a computer match process between state and federal records. It also does not include Employment Security matches as this is not a direct federal-state match.
1501 Request for a Hearing - A request for a fair hearing is defined as a clear expression, oral or written, to appeal a decision or final action of any agency or employee of the KDHE-DHCF. The Office of Administrative Hearings in the Department of Administration administers the agency's fair hearing program pursuant to the Kansas Administrative Procedure Act (K.S.A. 77-501 et seq.).
The request may be made orally (either in person or by telephone), in writing (either in person or by mail), by fax, or by email.
The rights, responsibilities, and procedures for fair hearings for other interested persons are similar to those applicants/recipients as explained in this section except that hearings for other interested persons shall be held in Topeka.
The following persons may request a fair hearing:
1501.01 - Any person who is an applicant, recipient, or is authorized to represent the applicant/recipient may request a fair hearing for the individual. This includes the applicant/recipient’s attorney, or an individual appointed as a Medical Representative. Form KC6100 Medical Representative Authorization Form or medical representative section on the application form is required to authorize a representative as stated above. This authorization must be signed prior to the date the request for fair hearing is filed.
In addition, the applicant/recipient can provide a written authorization allowing an attorney, or other individual, to request a fair hearing on his/her behalf. For deceased individuals, only persons specifically authorized by a court or appropriate jurisdiction may request a fair hearing or represent the decedent in a fair hearing action.
1502 Time Period for Requesting a Hearing - The date of request shall be the date the agency received the request. The date of request for oral requests is the day the person requests a fair hearing in person or by telephone. The date of receipt of a fair hearing request submitted after business hours by telephone, fax, or email shall be the next business day.
1502.01 - Unless preempted by federal law, a request for a fair hearing shall be in writing and received by the agency within 33 days from the date the notice of action is mailed. When a request for a fair hearing is received prior to the effective date of action as prescribed in 1503, assistance may be continued.
Such request may relate to an applicant's request for assistance, which is denied, or is not acted upon with reasonable promptness, and to any recipient who is aggrieved by any agency action resulting in suspension, discontinuance, or termination of assistance.
1503 Continuation of Benefits - - If a written or oral request for a fair hearing is received on a Medicaid only program (excludes CHIP) prior to the effective date of action, the notice of adverse action is mailed, and the review period has not expired, assistance shall not be suspended, discontinued, or terminated until a decision is rendered after a hearing, unless:
1503.01 - A determination is made at the hearing by the hearing officer that the sole issue is one of state or federal law or regulation or change in state or federal law and not one of incorrect application of a policy (when appropriate KanCare Clearinghouse staff should raise this issue in the hearing in order for the referee to render a decision).
1503.02 - A change (except the matter under appeal) affecting the recipient's assistance occurs while the fair hearing decision is pending and the recipient fails to request a hearing after notice of the change.
1503.03 - The request for a fair hearing concerns a discontinued program or service.
1503.04 - The review period expires. The household may reapply and may be determined eligible for a new review period with assistance as determined by the agency.
1503.05 - A mass change affecting the household's eligibility or level of coverage or share of cost occurs while the hearing decision is pending.
Assistance shall also be continued at its prior level if the client or agency submits a timely request for review by the State Appeals Committee. See 1507.
NOTE: In any case where action was taken without timely notice, if the recipient requests a hearing within 10 days of the mailing of the notice of action, and the agency determines that the action resulted from other than the application of state or federal law or policy or a change in state or federal law, assistance shall be reinstated and continued until a decision is rendered in the matter as set forth above.
The agency shall promptly inform the household in writing if assistance is reduced or terminated pending the hearing decision. See 1505.05.
1504 Client's Rights Related to a Fair Hearing - The client or the client's representative shall have adequate opportunity to:
1504.01 - Submit a request for a fair hearing (including a request to expedite as described in 1505.06), which may be on the Request for Administrative Hearing form, regarding any agency action. However, a hearing need not be granted if the request concerns only the validity of federal or state law or regulation. In addition, a hearing need not be granted when either state or federal law requires automatic adjustments for classes of recipients unless the reason for an individual appeal is incorrect computation. See 1503.01.
1504.02 - Examine the contents of his case file and all documents and records to be used by the agency at the hearing at a reasonable time before the date of the hearing as well as during the hearing. See 1224 and subsections regarding confidential case file information.
1504.03 - At his option, present his case himself, or with the aid of an authorized representative, and bring witnesses.
1504.04 - Establish all pertinent facts and circumstances and advance any pertinent arguments without undue interference.
1504.05 - Question or refute any testimony or evidence, including opportunity to confront and cross-examine adverse witnesses.
1504.06 - Submit evidence to establish all pertinent facts and circumstances in the case.
1505 Responsibilities of the KanCare Clearinghouse - Every applicant/recipient shall be informed in writing at the time of application and at the time of any subsequent action affecting medical assistance of the right to a fair hearing, the method of obtaining such hearing, and that representation may be by an authorized representative such as legal counsel, relative, friend, or other spokesperson. In addition, the applicant/recipient shall be informed of the circumstances under which eligibility may be continued or reinstated during the appeal as well as an explanation that an appeal decision for one household member may result in a change in eligibility for other household members. Information printed on the application/redetermination form and notices of action will provide this information.
Agency hearing procedures shall be uniform, clearly written, and available to any interested party. At a minimum, the procedures shall include time limits for filing requests for appeals, advance notice requirements, hearing timeliness standards, and the rights and responsibilities of persons requesting a hearing. The Office of Administrative Hearings (OAH) has created a Q&A document describing the Medicaid fair hearing process. That document (OAH Frequently Asked Questions) can be found in the Miscellaneous Section of the Appendix.
1505.01 Standard Procedures - The procedures set forth below shall be followed whenever a client makes an inquiry concerning a fair hearing, asks for fair hearing forms, or files a request for a fair hearing.
(1) The eligibility staff or supervisor should find out why the client is questioning the agency action.
(2) If the client is only disagreeing with a federal or state law or policy, the reason for such policy should be discussed with the client.
(3) If a client appears to be questioning the application of a federal or state law or policy to his individual situation (incorrect eligibility determination or use of incorrect facts), an administrative review shall be conducted to determine if the agency action was correct. Upon reconsideration, the agency may amend or change its decision at any time before or during the hearing. The hearing shall not be delayed or canceled because of this preliminary review.
If a satisfactory adjustment is reached prior to the hearing, the agency shall submit a written report to the hearing officer but the appeal shall remain pending until the client submits a signed written statement withdrawing the request for a fair hearing.
(4) If the client is questioning the decision regarding disability and the decision was made related to an SSI or SSA application for benefits, the client is to be referred to the SSA office to file an appeal. See MKEESM 2636.
(5) If the client is questioning the decision regarding disability and the decision was made by Disability Determination Services (DDS) based on an KDHE request via the DD-1104 and DD-1105, the appeal will be processed through DDS as specified in MKEESM 1614.6(1).
(6) When a household member or representative makes an oral request for a fair hearing to the KanCare Clearinghouse or to the Office of Administrative Hearings by telephone or in person, the agency shall document the request by using the Request for Administrative Hearing form. The date of the request shall be the date the oral communication was made to the agency and that date shall appear on the form. Lack of signature by the household member on the form used to document an oral request shall not invalidate the request.
1505.02 Agency Contact - Once a fair hearing has been received, the KanCare Clearinghouse shall attempt to contact the client, or the client’s representative, by telephone to explain the agency action and the effective date of the action taken.
(1) Unable to Contact - The KanCare Clearinghouse shall make at least two (2) attempts to contact the client by telephone to explain the agency action taken on the case. All unsuccessful attempts to contact the client shall be thoroughly documented in the case file. If the agency is unable to contact the client by telephone to discuss the agency action, the KanCare Clearinghouse shall complete an Agency Summary as described in 1505.04.
(2) Contact Completed - If the KanCare Clearinghouse is able to contact the client by telephone to explain the agency action and the client is satisfied with the agency explanation, the client should be asked if he/she is willing to withdraw the fair hearing request. Whether or not the client is willing to voluntarily withdraw the fair hearing request will determine the next action taken by the agency.
(a) Client Agrees to Withdraw - If the client agrees to withdraw the fair hearing request, the KanCare Clearinghouse shall complete a Motion to Dismiss based on the client’s decision to withdraw the fair hearing request. There is no need to complete an Agency Summary at this point. See. 1505.03.
(b) Client Does Not Withdraw- If the client does not agree to withdraw the fair hearing request and states an intent to continue the appeal, the KanCare Clearinghouse shall complete an Agency summary as described in 1505.04. See also 1505.06 concerning dismissal of fair hearing.
1505.03 Withdrawal of Request - The client may withdraw the request for fair hearing at any stage of the appeal process, up to and including the day of the fair hearing. The request must be in writing and signed by the client or the client’s representative. A special form, Notice of Withdrawal of Appeal, is available for this purpose. The agency may offer this form to the client for completion, but any writing evidencing the intent to withdraw shall be accepted.
The request may be submitted to either the KanCare Clearinghouse or directly to the Office of Administrative Hearings (OAH). The request may be delivered by mail, fax, or in person. The appeal process will continue until the written withdrawal request has been formally received by OAH.
1505.04 Completion of Summary - Within 15 days after the appellant has filed a request for a fair hearing, the KanCare Clearinghouse shall furnish the appellant and the Office of Administrative Hearings (OAH) with a summary. One copy of the summary shall be sent electronically to OAH. Another copy shall be mailed to the appellant or representative. The summary shall include the following information:
(1) Name and address of the appellant;
(2) A summary statement concerning why the appellant is filing a request for a fair hearing;
(3) A brief chronological summary of the agency action which led to the appeal and the agency's action after receiving the request for fair hearing;
(4) A statement of the basis for the agency's decision;
(5) A citation of the applicable policies relied upon by the agency;
(6) A copy of the notice which notified the appellant of the decision in question;
(7) Applicable correspondence; and
(8) The name and title of the person or persons who will represent the agency at the hearing.
When the request for a fair hearing involves a Disability Determination Services (DDS) disability determination, the process described in MKEESM 1614.6(1)(c) shall be followed.
If, through an agency contact as discussed in 1505.02, the appellant has withdrawn the appeal, see 1505.03, completion of the summary is not necessary. The Request for Administrative Hearing form should then be submitted, along with the Notice of Withdrawal of Appeal, to OAH within 7 days of the date of the request for a fair hearing.
1505.05 Informing the Client of Termination of Assistance - The KanCare Clearinghouse shall promptly inform the client in writing if assistance is to be terminated pending the fair hearing decision. See 1503 concerning continuation of assistance.
1505.06 Expedited Fair Hearing - A request to expedite the fair hearing process may be granted for an appellant who demonstrates an urgent medical need. The request may be made either at the time the fair hearing is filed or any time thereafter up to the actual date of the scheduled hearing. If granted, the hearing will be scheduled as soon as possible. If the expedited request is denied, the hearing process will proceed on a normal schedule.
The following additional provisions apply:
(1) Request - As indicated above, a request to expedite the fair hearing process may be made at the time of the request for fair hearing or at any time prior to the scheduled hearing. If the expedited request is received after the original fair hearing is filed, it is important to note that this is not a separate hearing request, but rather simply a request to expedite the process for the previously filed hearing request. Therefore, to avoid duplicating appeals, whenever an expedited request is received, staff should ascertain whether or not there is already an existing active appeal.
(2) Documentation - An expedited request cannot be granted without documentation supporting a claim of urgent medical need. The documentation must be provided at the time of the expedited request. The supporting documentation should be based on medical records and/or the written opinion of a medical professional familiar with the appellant’s condition and circumstances. A simple statement of medical need is not sufficient proof of an urgent medical need, nor are self-serving statements provided by the appellant or by family and friends lacking medical credentials.
Note: Refusal or failure to supply supporting documentation with the expedited processing request will result in an automatic denial of the request.
(3) Evaluation - The documentation provided shall be reviewed by KDHE-DHCF clinical staff to determine if the appellant has an urgent medical need which necessitates the need to expedite the fair hearing. An urgent medical need means that the appellant’s life, health, or ability to attain, maintain, or regain maximum function is in jeopardy if the hearing is not expedited.
As indicated above, the determination will be based on the documentation (i.e.: medical records and/or medical professional statement) provided at the time of the expedited request. That determination is then forwarded to the Fair Hearings Manager.
Please note that this evaluation is not the same as a disability determination for eligibility purposes. The purpose of the review is to determine if an urgent medical need exists which warrants expediting the fair hearing process. The review is not intended to determine if the appellant meets the disability criteria for disability-related medical assistance programs.
(4) Decision- Based on the evaluation completed by the clinical team reported to the Fair Hearings Manager, the expedited request shall be either denied or approved.
(a) Denied - If the expedited request is approved, the Fair Hearings Manager will contact the Office of Administrative Hearings to schedule the hearing as expeditiously as possible, but no later than 7 working days after the date the expedited request is received. The KanCare Clearinghouse shall also complete the Appeal Summary and forward to the Office of Administrative Hearings as expeditiously as possible, but no later than 15 days from the date the fair hearing request is received ,see 1505.04.
1505.07 Federally Facilitated Exchange (FFE) Fair Hearing - An applicant may appeal a decision made by the Federally Facilitated Exchange (FFE) concerning his/her application for coverage and/or eligibility for the subsidy through the Health Insurance Marketplace. That appeal request will be sent to the Marketplace Appeals Center for adjudication. During the appeal process the Marketplace Appeals Center may determine that the appellant is potentially eligible for Medicaid or CHIP coverage.
In that instance, the Marketplace Appeals Center will submit an electronic appeal package to the agency containing consumer account information. The package of information will include not only information provided directly by the applicant when he/she completed the Health Insurance Marketplace application, but also data obtained from the result of any verifications performed by the Federally Facilitated Exchange (FFE). Also included in the package is the appeal request submitted by the appellant. This information shall be used by the KanCare Clearinghouse to review the individual’s eligibility for medical assistance.
Note: the agency should only receive an appeal package for individuals who have already applied for and been denied Medicaid and/or CHIP coverage by the KanCare Clearinghouse.
Upon receipt of the appeal package, the KanCare Clearinghouse shall conduct an administrative review of the case based on the information provided and redetermine eligibility for Medicaid and/or CHIP. If the applicant is determined eligible based on the review, coverage shall be promptly approved with notification provided to the applicant. If the KanCare Clearinghouse determines that the applicant is not eligible, the application shall remain denied. The applicant shall be notified of the decision with the right to appeal. Whatever decision is made, the KanCare Clearinghouse shall also notify the FFE of the outcome of the redetermination.
1505.08 Dismissal of Fair Hearings - By Kansas statute, the agency has no jurisdiction to determine the facial validity of a state or federal statute. Nor does an administrative law judge from the Office of Administrative Hearings have jurisdiction to determine the facial validity of an agency rule and regulation. So, clients have no right to a fair hearing if they simply disagree with a regulation that results in a loss of eligibility. However, clients may have a hearing if they believe that the agency incorrectly applied such regulation to the client's individual situation (use of incorrect facts). The issue is whether the client is only challenging the validity of the regulation or really presenting a factual dispute. If there is no dispute between the client and the agency as to the facts involved, the client's request for a fair hearing in most instances will be dismissed by the hearing officer before the hearing.
As such, if the client is only disagreeing with a federal or state law or regulation (whether a current regulation or one that is changing) and, after following the procedures set forth in 1505.01, wishes to file a request for a fair hearing (or fails to withdraw a request previously filed), the agency should complete a Motion to Dismiss form. The form is to be submitted to the Office of Administrative Hearings within 10 days of the request for a hearing. A copy of the appropriate Notice of Action and the Request for Administrative Hearing form should be attached to the motion. Do not submit an appeal summary unless the motion is denied. KDHE-DHCF must mail a copy of the Motion to Dismiss to the appellant. Staff should complete the Certificate of Service and sign it. Write the actual mailing date on the certificate, as well as the appellant's name and address. On the Motion to Dismiss, the line "Such action is based on" should reflect the appropriate law or regulation. (Contact Eligibility Policy as needed for this information.) For dismissal requests regarding major program changes or cutbacks, specific citations will be provided from the Eligibility Policy Section.
Fair hearings shall also be dismissed if the request is not received within the time periods specified in 1502, or the household or its representative fails, without good cause, to appear at the scheduled hearing, or is received from an individual who is not authorized to represent the applicant/recipient in a fair hearing as indicated in 1501.01.
Assistance shall continue as noted in 1503 until a decision is rendered concerning the dismissal. If the dismissal request is approved, assistance shall be terminated unless the appellant requests State Appeals Committee review within the 15 days allowed. If the dismissal request is denied, assistance must continue until the presiding officer issues an initial order affirming the agency action, unless there is a State Appeals Committee review request.
1506 Place and Conduct of Fair Hearings - Fair hearings for applicants or recipients shall be held in the Social and Rehabilitation Services' administrative area in which the applicant or recipient resides unless another site has been designated by the hearing officer. At least 10 days prior to the hearing, advance written notice shall be mailed to all parties involved to permit adequate preparation of the case.
The hearing officer may conduct the fair hearing or any prehearing by telephone or other electronic means if each participant in the hearing or prehearing has an opportunity to participate in the entire proceeding while the proceeding is taking place. A party may be granted a face-to-face hearing or prehearing if good cause can be shown that a fair and impartial hearing or prehearing could not be conducted by telephone or other electronic means.
At a hearing, the hearing officer shall regulate the course of the proceedings. To the extent necessary for full disclosure of all relevant facts and issues, the hearing officer shall provide all parties the opportunity to respond, present evidence and argument, conduct cross-examination and submit rebuttal evidence, except as restricted by a limited grant of intervention or by a prehearing order.
The hearing officer may, and when required by statute shall, give nonparties an opportunity to present oral or written statements. If the hearing officer proposes to consider a statement by a nonparty, the hearing officer shall give all parties an opportunity to challenge or rebut it and, on motion of any party, the hearing officer shall require the statement to be given under oath or affirmation.
A hearing officer need not be bound by technical rules of evidence but shall give the parties reasonable opportunity to be heard and to present evidence. Evidence need not be excluded solely because it is hearsay.
All testimony of parties and witnesses shall be made under oath or affirmation. Statements of nonparties may be received as evidence.
Any part of the evidence may be received in written form if doing so will expedite the hearing without substantial prejudice to the interests of any party. Documentary evidence may be received in the form of a copy or excerpt. Upon request, parties shall be given an opportunity to compare the copy with the original if available.
The hearing officer may not communicate, directly or indirectly, regarding any issue in the proceeding while the proceeding is pending, with any party or participant, with any person who has a direct or indirect interest in the outcome of the proceeding or with any person who presided at a previous stage of the proceeding, without notice and opportunity for all parties to participate in the communication.
1507 Fair Hearing Decision and Request for Review - A fair hearing decision shall be rendered by the hearing officer no later than 90 days after receipt of the request on a Request for Administrative Hearing form or similar document and the decision shall be sent to the client and the KanCare Clearinghouse.
The client/respondent shall be informed of his right to have the State Appeals Committee review the decision of the hearing officer and also his right to petition to the District Court. A request to the State Appeals Committee must be made within 18 days of the date of the fair hearing decision. The client/respondent may also have the right to request a re-hearing in order to submit additional information or evidence. This request must also be made within 18 days of the date of the fair hearing decision.
Assistance shall be continued at its prior level if the client or the agency requests a review by the State Appeals Committee. Assistance shall continue until a decision is rendered by the State Appeals Committee.
The decision of the Appeals Committee is final and binding upon the client and the agency on the date of the decision. This is true even if one of the parties should appeal the matter to the District Court. Assistance shall not continue at its prior level following the decision of the State Appeals Committee unless there is a court order to the contrary.
1508 Agency Actions Following Fair Hearing Decisions - The decision of the hearing officer shall be implemented immediately upon receipt (including decisions related to disability) if the decision is favorable to the client and the agency does not intend to request a review by the State Appeals Committee. A report of such action shall be submitted to the Administrative Hearings Section. If the agency requests such a review, the decision shall not be implemented until a final decision by the State Appeals Committee has been rendered. Also, if the decision is unfavorable to the client, the decision shall not be implemented until the 18th day following the date of the mailing of the initial decision to allow the client the opportunity to request a review by the State Appeals Committee. If a request is made within the 18-day period, the decision shall not be implemented.
1508.01 Retroactive Payments - When the hearing decision is favorable to the client, or when the agency decides in favor of the client prior to the hearing, the agency shall promptly make corrective coverage.
1508.02 Recovery of Overpayments - When the hearing decision upholds agency action, any overpayment made during the fair hearing process is subject to recovery, except in situations where the action being appealed is the application of a CSS penalty.
1521 Complaint Procedures - A complaint is a verbal or written grievance concerning an agency action or program policy. Any person who is an applicant, recipient, or is authorized to represent the applicant/recipient per 2010.01, 2010.02, 2010.04, 2011, and 2011.01 may file a complaint with the agency.
1521.01 Complaints Received in the KanCare Clearinghouse - Upon receipt of a complaint, the KanCare Clearinghouse shall:
(1) - Review the situation and determine if corrective action is indicated. The determination should be made by the Eligibility Supervisor or Program Administrator after consulting with the Eligibility Specialist.
(2) - Explain the action or policy to the complainant in writing or verbally. If corrective action is necessary, it should be initiated immediately. If corrective action is not indicated, inform the complainant of his right to request a fair hearing and the request procedure.
1521.02 Complaints Received in KDHE-DHCF Administration - Complaints received in KDHE-DHCF Administration will be referred to Eligibility Policy Section for a response. If the response requires KanCare Clearinghouse input, a telephone call or e-mail message outlining the nature of the complaint will be made to the Eligibility Program Administrator or their designee. This person will review the case and determine the appropriateness of the agency's action. If the agency is in error, the Eligibility Program Administrator or their designee will mandate that corrective action be initiated immediately.
Once the determination is completed, the Eligibility Program Administrator or designee will telephone or e-mail the Eligibility Policy Section and provide details of the agency's actions as well as any corrective measures taken. The Eligibility Policy Section will then answer the verbal or written complaint. If the Eligibility Program Administrator wishes to respond to a telephone complaint directly, the Eligibility Policy Section will notify the complainant to expect a telephone call from the Eligibility Program Administrator or designee within a pre-determined time period.
Complaints filed through the above system shall not include complaints alleging discrimination. Refer to 1530 for discussion of Civil Rights complaints. This system shall also not include complaints that should be pursued through the fair hearing process.
01530 Civil Rights Complaints -
1530 Civil Rights Complaints - Kansas shall maintain a system to ensure that no person in Kansas shall, on the grounds of race, color, national origin, gender, age, sex, disability, political belief, religion, sexual orientation, marital or family status, be excluded from participation in, or be denied the benefits of any Family Medical Program or be otherwise subjected to discrimination. This applies to all Family Medical programs.
1530.01 - Public Notification, Data Collection, Maintenance, Reporting, and Training
(1) - All applicants and participants shall be informed of the following:
(a) Rights and responsibilities;
(b) KDHE’s policy of nondiscrimination;
(c) Procedures for filing a complaint; and
(d) Procedures for filing for a fair hearing.
(2) – Regarding race and identity questions on the application, the applicant is encouraged to complete all questions regarding race or identity on the application. The applicant shall be informed that the information will be used for statistical purposes and will have no effect on his/her eligibility. However, if the applicant fails to provide this information, it is acceptable for the staff person to complete the questions by observation.
(3) KDHE, either directly or through contacted services, will provide bilingual services as needed.
(4) Local service centers, including contractors, shall complete and mail the Civil Rights Complaint Form, KC-6501, to KDHE Policy according to the procedures of this section.
(5) Local service centers, including contractors, shall cooperate with Personnel Services in the investigation and resolution of the complaint;
(6) Local service centers, including contractors, shall take any corrective action indicated by the investigation; and
(7) Local service centers, including contractors, are to insure that medical assistance staff receive training on the civil rights of applicants/recipients as well as procedures for handling civil rights complaints on a regular basis. This includes staff who answer the phones and staff who deal with the public in reception areas.
1530.02 Civil Rights Complaint Processing System – Discrimination Complaints or Allegations - Upon receiving an oral or written complaint alleging discrimination or other civil rights issue, the entity receiving the complaint shall:
(1) Log the complaint on the KC-6501, provide a clear summary of the complaint.
(2) Send a copy of the KC-6501 to KDHE Eligibility Policy. Retain the original in the case file. The referral must be made within 2 days of the complaint.
(3) KDHE Policy will consult with KDHE Legal, Personnel Services, and, if necessary, Senior Leadership to determine corrective action.
(4) KDHE Policy will communicate the recommended corrective action approach to the entity receiving the complaint.
(5) The local entity is responsible for carrying out the corrective action. This may include oral or written explanation, interview, change in agency action, or assisting the complainant to either file for a fair hearing, or another action.
(6) If the complaint cannot be settled within 10 days to the satisfaction of the complainant, inform the complainants that the issued will referred for additional consideration.
(7) Local staff shall contact KDHE Policy for additional remedies. These may include contacting HHS, consultation with KDHE Legal or other agency division to resolve the complaint.
(8) As part of the corrective action, contact with Personnel Services may be necessary.
(9) Staff must cooperate with Personnel Services in investigation and resolution of the complaint, to include taking the necessary actions indicated by the investigation.
(10) Retain a copy of the completed form KC-6501 in the case file.
01600 General Information about Other Programs and Miscellaneous -
1601 Case Records - Case records are required for all assistance cases and are to be separate from social service records. The eligibility record shall include required forms to establish eligibility for assistance and additional information and decisions reached regarding eligibility, the type of assistance, notices to the client, and authorization forms.
The case record includes all information about all individuals on a case. The case record is comprised of three (3) main components: 1) All information input into KEES, 2) The eligibility record held on KEES, and 3) information and documentation in the case file.
The eligibility record is the output of KEES which is transferred to the MMIS for claims payment and MCO assignment. All data input is a part of the eligibility and case record.
The case file is the collection of documents that support the information contained in the state eligibility system as well as all other documentation that relates to the case. Any information received, in any format, in relation to a case must be in the case file. The case file contains all documentation supporting the case processing activities, such as application forms, income verification and worksheets, correspondence, legal documents, requests for case maintenance, a log of case actions and customer contacts, and previous eligibility information for the household.
1601.01 Correspondence - Notices affecting the eligibility shall become a permanent part of the agency's record. Notices sent through KEES are maintained in KEES. Off-system notices are imaged to the case file.
(1) - Content of Notices - All notices should contain sufficient information to make clear their purpose, the information desired, and how the information is to be used. The wording should be clear, direct, and adequate to cover the subject. Care should be taken to avoid misunderstanding or misinterpretation.
(2) - Filing - Letters from clients are to be retained if they contain significant material.
(3) - Letters, newspaper clippings, and other material, should be dated and properly identified.
1602 Disposition of Obsolete Case Record Material - Destroy any material which is older than 36 months and is not currently in effect on active cases with the following exceptions:
(1) - The last application which opened the case;
(2) - For AABD cases converted to SSI (whether open for medical or not), the application and budget in effect for December 1973 must be retained indefinitely;
(3) - Retain indefinitely all documentation needed to establish current eligibility such as income verification, tax filing status, etc.;
(4) - Retain indefinitely a copy of the individual's Social Security card when it has been provided. In addition, the PA-3120.4 (Welfare Enumeration) form and copies of all documents used for enumeration purposes shall also be maintained indefinitely;
(5) - Retain indefinitely all material pertaining to unrecovered overpayments, including all documentation for the amount and cause of the overpayment;
(6) - Retain indefinitely all material pertaining to verification of the immigration status of aliens;
(7) - Retain indefinitely all materials pertaining to documentation of common-law marriages or paternity;
(8) - Retain indefinitely all documents used to verify citizenship and identity of the individual, including the ES-3850.
1602.01 Disposition of Closed Cases - Closed medical cases may be destroyed after they have been closed for 36 months except for (1) all material pertaining to unrecovered overpayments, or (2) cases that have a designated period of ineligibility which exceeds the retention period (e.g., first time conviction of fraud, etc.)
1603 Voter Registration - The National Voter Registration Act of 1995 requires voter registration to be available in public assistance offices. The Act also requires that anyone applying for or receiving public assistance, including Medicaid, be offered the opportunity to register to vote at the time of initial application, each eligibility review, and each report of a change of address. Each individual must be informed of this registration service and offered assistance in completing the voter registration form or declining the registration activity. The KC1100, Medical Assistance Application for Families with Children and the KC1500, Medical Assistance Application for the Elderly and Persons with Disabilities offers everyone the opportunity to register to vote or to decline to register. Completion of the voter registration question is not a condition of eligibility for assistance. If an individual does not complete this section of the application, it is considered an indication of voter registration. An answer of “Yes”, “No” or blank in the Voter Registration section has no bearing on case processing or eligibility. Those applying on-line are offered the opportunity to link to the Secretary of State's voter registration site. All those who answer "yes" are to be handed or mailed a voter registration application. Voter Registration forms can be returned to KanCare and will be sent to the corresponding Secretary of State’s Office within five (5) days of receipt.
1604 Estate Recovery - The estate recovery program has been established as a means to recover medical care costs from the estates and property of certain medical assistance recipients. See MKEESM 1725
1700 Delivery of Medical Cards - All medical cards are issued by the assigned Managed Care Organization (MCO). For individuals not enrolled in managed care, the medical care is issued by the Fiscal Agent. Cards are delivered by mail to the address of the Primary Applicant unless otherwise requested. If the individual requests a different mode of delivery, the agency shall consider the appropriateness of the request. When deemed appropriate the agency may use other modes of delivery including P.O. Boxes, General Deliveries, addresses of friends or relatives, or the address of the agency when it is necessary to hand deliver the medical card to the client, particularly for situations involving a homeless client.
02000: General Eligibility Requirements -
02010 Act in Own Behalf - The client must be legally capable of acting in his or her own behalf.
2010.01 Legally Incapacitated Persons - Legally incapacitated persons are not eligible to receive assistance unless such assistance is applied for by one of the following:
a. Guardian or conservator.
b. Medical Representative
c. Representative Payee for Social Security
d. Tax filer who claims (or intends to claim) the adult as a dependent on his or her federal tax return
A legally incapacitated adult shall be defined as any adult who is impaired both physically and mentally by reason of mental illness, mental deficiency, physical illness or disability to the extent that he or she is unable to understand or communicate responsible decisions concerning his or her person, or to the extent the adult cannot effectively manage or apply his or her estate to necessary ends for whom a guardian or conservator has been appointed by the court.
2010.02 Not Legally Incapacitated - A competent adult may apply for assistance for himself or herself. Any adult who has not been determined to be legally incapacitated is presumed to be able to act in their own behalf. Act in own behalf is further defined as being able to perform all activities that a consumer would perform for themselves, including the ability to appoint an additional Medical Representative or Facilitator.
For medical applications, the following individuals may apply on behalf of an adult who has not been determined legally incapacitated:
- Spouse,
- Opposite sex partner with whom there is a mutual child,
- Tax filer - a tax filer may apply for anyone they claim or intend to claim as a dependent,
- Durable power of attorney (for financial decisions), or
- Representative payee for Social Security benefits may apply on behalf of an adult who has not been determined legally incapacitated.
For any other individual to apply, they must be appointed by the applicant as a Medical Representative. A signed written authorization from the person for whom they are applying must be obtained. The KC6100 Medical Representative Authorization Form or medical representative section on the application form may be used for this purpose and must be signed by the adult. Two witness signatures are required if the applicant/recipient signs with a mark. Attorneys representing the consumer must provide a statement on the attorney’s letterhead indicating they are representing the consumer in their Kansas Medicaid matter. The designated medical representative shall act in the place of the individual for whom they are applying. The medical representative shall receive copies of all notices and is responsible for completing the review and reporting changes.
Once appointed, the Medical Representative(s) shall have authority to act on behalf of the consumer until revoked or the Medical Representative passes away.
The medical representative(s) should be someone who is trusted and knowledgeable about the individual's circumstances and needs, including their income, resources, and household situation. Except in very limited circumstances, it would not be appropriate to appoint or accept a medical representative who has little or no prior experience with the individual. This would include those whose primary interest is in collecting on outstanding medical bills rather than in fully representing the interests and needs of the applicant for medical assistance.
In rare instances where the individual is unable to file their own application and obtaining written consent is not possible, the application shall be accepted and a referral completed to Adult Protective Services (APS) to have a guardian or conservator appointed if appropriate. For example, an individual may have been in an automobile accident and is in a coma. The application would not be denied or delayed because an appropriate person is not available to file.
When someone other than the individual is acting in their behalf, all notices must still be sent to the applicant/recipient in addition to the authorized representative.
2010.03 Facilitators - An individual may grant limited authority to a person who is assisting in the medical application process. This individual would not be a medical representative and may not apply on behalf, sign an application for the adult, nor request a fair hearing on behalf of the individual. They may share and receive information concerning the case depending on the scope of authority granted. This individual would not be responsible for completing review forms or reporting changes. Their role would be confined to helping the individual with the application process.
A signed written authorization from the person for whom they are assisting must be obtained. The KC6200 Facilitator Authorization Form or Facilitator authorization section on the paper application form may be used for this purpose and must be signed by the adult. Two witness signatures are required if the applicant/recipient signs with a mark.
For Facilitators, the length of appointment is dependent on the form used to appoint. The appointment of a community organization, medical provider or staff cannot exceed 12 months.
a. KC6200 form – Six months from date of signature or through the application period, whichever is later, unless a specific date of expiration is provided by the individual. If a specific date of expiration is listed which exceeds six months, the appointment shall last through the date specified or twelve months from the date the form is signed, whichever is shorter.
b. Facilitator form within the KanCare paper application – Through the end of the application period.
Note: The application period is the month following the month of eligibility determination.
2010.04 Applicants for Pregnant Woman Coverage - In addition to what is outlined in 2010.02 above, the following additional individuals are permitted to act on behalf of a pregnant woman applying for medical assistance.
a) The adult father of the unborn child of an adult pregnant woman
b) The adult father of the unborn child of a pregnant minor may apply on her behalf when residing with the minor and there is not another caretaker in the home.
c) When a minor pregnant woman is residing with the minor father of the unborn child, his caretaker may apply on behalf of the pregnant woman. This could be his parents or other another person who meets the caretaker definition of 2011.
2010.05 Release of Protected Health Information - An individual may grant a specific person or organization to share and receive information concerning the case. This does not give authority to act on behalf of the individual or request a fair hearing on behalf of the individual.
A signed written authorization from the person for whom they are requesting to share or receive information must be obtained. The Release of Protected Health Information form may be used for this purpose and must be signed by the adult. The length of appointment shall be the date entered on line 8 of the form, or 12 months, whichever is shorter.
2011 Minors - Minors who are unable to act in their own behalf are not eligible to receive assistance unless such assistance is applied for by a person meeting one of the following criteria:
a) A court-appointed legal guardian, custodian, or conservator.
b) A representative payee for the minor's Social Security benefits.
c) A responsible adult with whom the child resides, who meets the definition of a caretaker according to 2110.
d) An individual, with whom the child resides, who claims the minor child, or intends to claim the minor child on his/her federal income taxes.
e) A responsible adult, with whom the child resides, who does not meet any of the above criteria can apply for the minor child if they are appointed as the authorized agent by the minor's parent or legal guardian. This authorization is only for purposes of application and maintenance of the minor child's medical assistance case with the KDHE-DHCF and DCF. A completed Required Authorization for Medical Agent for Minor must be on record. This form is generated in KEES as Form # V075.
If the child's parent or legal guardian cannot be located to assign an authorized agent, the relationship of the responsible adult to the child must be confirmed or substantiated. An individual's statement and two corroborative pieces of evidence shall meet the burden of proof unless there is an independent reasonable basis to doubt the veracity of the statement. Corroborative evidence may include but is not limited to a written statement from a public or private licensed social agency, clergy, attorney, school official, medical provider, or other professional.
f) An individual who meets one of the above criteria to apply on behalf of a child may also request prior medical coverage for the child. This is true even if the individual did not meet the criteria or was not living with the child during the prior medical period. However, eligibility shall be determined based upon the child's situation in the month, see3100 – MAGI Budgeting Units. Refer to 2110 to determine who is eligible to receive medical assistance on the basis of being a caretaker of a child.
Note: Anytime a minor's health, safety, or current medical condition is judged to be at risk, a referral to the Protection and Prevention Services' (PPS) Report Center is appropriate.
2011.01 - Minors can act in their own behalf and receive assistance under the following circumstances:
(1) - The minor is determined to be emancipated. An emancipated minor is a person who is:
(a) Age 16 or 17 and is or has been married; or
(b) Under the age of 18 and who has had the rights of majority conferred upon him or her by court action; or
(2) The minor is unemancipated (i.e., does not meet the criteria in (1)(a) or (b) above), there is no adult or emancipated minor exercising parental control over the child, and one of the following circumstances exist:
(a) The parents of the minor are institutionalized per MKEESM 8113 or the minor has no parent who is living or whose whereabouts is known, and there is no other caretaker who is willing to assume parental control of the minor; or
(b) The health and safety of the minor has or would be jeopardized by remaining in the household with the minor's parents or other caretakers. Such status must be documented by an independent source such as social services, law enforcement, religious authorities, or a battered person's shelter.
If local arrangements are made between the Division of Health Care Finance and Prevention and Protection Services (PPS), a referral may be made to PPS for assistance in determining the status of the minor's parents or other caretakers and any health and safety issues that would exist in such living arrangements. The determination of a minor's ability to act in own behalf under this provision must be approved by the KanCare Clearinghouse Manager, the Eligibility Policy Manager or his or her designee.
The determination must be documented in the case record. Minors able to act in their own behalf are eligible for medical benefits and can qualify under any family medical program (e.g., Medicaid poverty level or CHIP).
(3) The minor is placed into independent living by DCF. In situations where the minor's needs are being met by PPS or a foster care contractor, the minor cannot apply for his/her own needs but may apply on behalf of his/her child providing the child resides with the minor and is not in DCF custody.
02020 Cooperation - The client must cooperate with all program requirements. In addition, the client (including an ineligible caretaker) shall cooperate with the agency in the establishment of eligibility including providing necessary information, reporting changes as required, cooperating in the application process, and cooperating in obtaining resources.
2020.01 Supplying Information - The client (or ineligible caretaker) shall supply information essential to the establishment of eligibility; give written permission on prescribed forms for release of information regarding resources when needed; and report changes in circumstances in accordance with 7100 as appropriate.
Failure to provide information necessary to determine eligibility shall result in ineligibility. A case which has been closed for failure to provide information is to be reinstated when the required information is provided by the end of the month following the effective date of closure and all other eligibility requirements are met.
2020.02 Application and Review Process - To determine eligibility, the application form must be completed and signed; certain information on the application must be verified. If denied or terminated for refusal to cooperate, the client may reapply but shall not be determined eligible until he or she cooperates.
The client shall also be determined ineligible if he or she refuses to cooperate in any subsequent review of its eligibility, including reviews generated by reported changes and recertification. For medical, the formal review requirement does not apply to individuals under the SI program or anyone within a CE period. In instances where a pre-populated review is sent for an individual with a passive review type, return of the review is not a requirement for the individual with the passive review type.
2020.03 Potential Resources - For medical purposes, a client shall cooperate with the agency to obtain potential resources. The client is required to take action to:
(1) identify and provide information to assist the agency in pursuing any third party who may be liable to pay for medical services under the medical programs.
2022 Requirements - The client is required to take any necessary action to acquire potential resources. In many instances, legal action may be necessary. In general, any source must be considered. It is the responsibility of the client to demonstrate all required actions have been taken to make the resource available. The special situations listed below are applicable:
2022.01 - The client must cooperate with the Medical Subrogation Unit as well as cooperate with the requirements of the Health Insurance Premium Payment System (HIPPS) including enrollment in the employer health insurance plan if cost effective. (See 2540.)
2022.02 - Persons may not be rendered ineligible for failure to apply for or receive SSI benefits.
2023 Failure to Comply - Failure to meet these requirements without good cause shall: For medical assistance, render the client ineligible for assistance. However, minor children will not be impacted by a caretaker's failure to meet these requirements on behalf of himself or the minor. If the client is cooperating in obtaining the identified potential resource, assistance shall continue.
02030 Social Security Numbers -
2031 Social Security Numbers - As a condition of eligibility, a Social Security number must be provided for each applicant (with the exception of newborns and certain qualifying non-citizens - see 2032), or an application filed for one before assistance is approved.
For those individuals who provide an SSN prior to approval or during any contact, the specialist shall record the SSN and verify it according to 2031.01(1). For those individuals required to provide an SSN who do not have one, an application for a Social Security number must be completed. The SSN application must be made at the local SSA office and verification of that application from SSA must be provided before approval.
Individuals who do not know if they have an SSN or who are unable to find their SSN shall be referred to the local SSA office to obtain their SSN.
An SSN may be applied for a newborn child through the SSA's Enumeration at Birth process. If individuals have more than one number, all numbers shall be provided. The specialist shall explain to clients that refusal or failure without good cause to provide or apply for an SSN will result in exclusion of the individual for whom an SSN is not provided. The individual that has applied for an SSN shall be allowed to participate pending receipt of an SSN.
2031.01 Verification of SSN - 1) – Social Security number(s) reported by the client requesting coverage shall be verified by an automated match with the Social Security Administration through the Federal Hub. If unable to verify SSN through the Federal Data Hub, staff should navigate to EATSS to determine if SSNs are verified by using the F10 (pop-up) function as explained in the KAECSES AE User Manual. In addition, either BENDEX or SDX will provide a verified SSN for those individuals receiving either SSA or SSI benefits.
(2) - If the individual's SSN is not verified in the above- mentioned process, the individual may provide proof of their SSN by supplying a copy of their Social Security card or other official document containing the SSN. Often, an SSN may be unverified due to a name or date of birth difference between our records and those owned by SSA.
(3) - If the individual's SSN has not been verified as described in item (1) and they have no Social Security card or other official document containing the SSN an application for a replacement Social Security card must be requested. The person should be referred to the appropriate SSA office. Refer to 2036. Proof from SSA that the individual has applied for the replacement Social Security card shall meet the SSN verification provision pending receipt of further documentation.
(4) - When a copy of the individual's Social Security card has been provided, it shall be maintained in the case file indefinitely. If applicable, a copy of the SSN-1 or any Enumeration at Birth documents should be included.
(5) - A verified SSN shall be reverified only if the identity of the individual or the SSN becomes questionable.
2032 Participation Without an SSN - If any client is unable to provide an SSN, that individual must apply for one prior to approval. The individual must apply for the required SSN at the Social Security Office and verification of application for the number is required. The individual who is unable to provide an SSN but has applied for one may receive assistance pending receipt of the required Social Security number. When the client submits proof of application for an SSN, the individual may participate throughout the duration of the review period. (This includes SSNs applied for through the SSA's Enumeration at Birth process.) If the SSN has not been reported by the time of the next review, it should be requested at that time. If the client has the SSN but fails or refuses to provide it, the individual is ineligible per 2034. If the client claims they did not receive an SSN, or that they received the number but have subsequently lost it, they must begin the process again by applying for a replacement card at the district SSA office. Once the client reapplies for a number and provides documentation, they may receive assistance until the next review.
Qualifying non-citizens under 2043 are exempt from providing or applying for an SSN prior to approval.
If proof of application for an SSN for a newborn cannot be provided, the SSN or proof of application must be provided at the next review or within 6 months following the month the child is born, whichever is later. If an SSN or proof of application for an SSN cannot be provided at the next review or within 6 months following the baby's birth, the State agency shall determine if the good cause provisions of 2033 are applicable.
NOTE: Based on SSA's Enumeration at Birth process, a parent can apply for an SSN for a newborn child through the process of initiating a birth certificate at the hospital. If he or she does so, documentation that an SSN has been applied for can be acquired from the hospital in one of the two ways. For hospitals submitting birth registration information to the Kansas Office of Vital Statistics electronically (through the Electronic Birth Certificates or EBC process), a letter on the hospital stationery is acceptable. This letter must be titled "Birth Confirmation Letter," contain information about the birth and a statement confirming the SSN application and be signed and dated by an authorized hospital official. For hospitals which do not use the electronic process, a copy of form SSA-2853 which is given to the parent is acceptable. The SSA-2853 form must contain the name of the newborn as well as the date and signature of an authorized hospital official to be considered valid documentation. A copy of the letter or form is to be included in the case file. If the letter or form is not available, a copy of the child's certified birth certificate showing that the Enumeration process was elected is also acceptable documentation.
2033 Good Cause for Participation Without a Social Security Number (SSN) - The client who establishes good cause for failure to apply for an SSN shall be allowed to receive assistance for 1 month in addition to the month of application. For benefits to continue past these 2 months, good cause for failure to apply must be shown and documented on a monthly basis.
In determining if good cause exists for failure to comply with the requirement to apply for or provide an SSN, the specialist shall consider information from the individual, SSA, and any other appropriate sources. Documentary evidence or collateral information that the individual has applied for an SSN or made every effort to supply the necessary documents to complete an application for an SSN shall be considered good cause for not complying timely with this requirement. Good cause does not include delays due to illness, lack of transportation, or temporary absences because SSA makes provisions for mailing applications in lieu of applying in person. If the individual can show good cause why an application for an SSN has not been completed in a timely manner, that person shall be eligible for assistance for 1 month in addition to the month of application. Good cause for failure to apply must be shown monthly after the initial 2 months for such an individual to continue to participate. Good cause must be documented to support the decision to allow the individual to receive assistance pending application for an SSN.
Non-citizen applicants who qualify for a non-work SSN (see those under 2043) only are not required to apply for or provide an SSN to the agency as a condition of eligibility. They may be approved without an SSN under the good cause provision.
2034 Refusal or Failure to Provide or Apply for SSN - An individual who has without good cause refused or failed to provide an SSN or to apply for one shall be ineligible for assistance. The eligibility and amount of benefits for any remaining family or household members shall be determined. The income of the excluded individual shall be considered.
The individual excluded for failure or refusal to provide or to apply for an SSN may become eligible upon providing the agency with an SSN or proof of application for the required number. The report of this number or proof of application for such number shall be treated as a reported change and benefits affected as outlined in 7140.
2035 Use of SSN - The agency is authorized to use SSNs in the administration of the medical program. The SSN shall be used in accessing KSES records of wages and benefits. To the extent determined by Health and Human Services, the agency shall have access to information regarding individual clients who receive benefits under Titles II, XVI, and XVIII of the Social Security Act to determine eligibility to receive assistance and the amount of assistance or to verify information related to the benefits of these clients. The specialist should use the BENDEX and SDX to the greatest extent possible. Social Security numbers also should be used to prevent duplicate participation and to determine the accuracy and/or reliability of information given by the client or household.
2036 Referral Procedure for Applying for an SSN - The following referral procedure shall be used for persons who must apply for an SSN.
2036.02 - The client is to take the referral form along with the necessary supporting documentation to the SSA office when he or she applies. Sufficient time should be given for the client to accomplish this.
2036.03 - Once the client has applied, SSA will return the referral indicating the action taken. If the application process was completed, the client meets the SSN requirement and can be approved for assistance. If the individual could not, without good cause, complete the process, he or she is ineligible for assistance per 2034.
2036.04 - A copy of the completed referral form is to be kept in the case file as proof of application for an SSN.
2036.05 - If the person is unable to apply in person at the SSA office (e.g., transportation problems, accessibility to office, physical limitations, etc.) this same procedure can be used on a mail-in-basis or as directed by the SSA office.
Staff should inform the client of the necessary documentation needed and direct the client to contact the SSA office for any additional information.
In certain instances, a client may have previously applied for a number prior to the request for assistance. A receipt from SSA acknowledging the application is still acceptable proof for meeting the SSN requirement.
02040 Citizenship and Alien Status - Eligibility for assistance shall be limited to those individuals who are citizens or who meet qualified non-citizen status as specified in 2043.
Non-citizens who are not described in 2043, including persons not lawfully admitted to the United States and persons admitted for temporary purposes, shall not be eligible for benefits, except for emergency medical benefits as described in MKEESM 2691. This is true even though the non-citizen may be receiving other government benefits such as Medicare. Other examples of non-eligible persons include those who are granted stays of deportation, persons admitted under the Family Unity provision, foreign visitors, tourists, diplomats, or students who enter the United States temporarily with no intention of abandoning their residence in a foreign country. A non-citizen who enters the United States for a limited period of time and subsequently decides to remain in the United States must go back to USCIS and obtain appropriate documentation before his or her eligibility can be established.
At the time of application, the client who signs the application form certifies under penalty of perjury the truth of the information concerning citizenship and non-citizen status of all household members for whom assistance is requested.
NOTE: For cases in which assistance is provided on behalf of a child, such as CHIP, only the citizenship or non-citizen status of the child who is the primary beneficiary is relevant for eligibility purposes. Citizenship or non-citizen status should never be requested or newly verified through the Federal Data Hub for a non-applicant.
2041 Citizens - Citizens of the United States of America include persons born in any of the 50 states, the District of Columbia, Puerto Rico, Guam, the United States Virgin Islands, American Samoa, Swains Island, and the Northern Mariana Islands. Persons born in the Panama Canal Zone from 1904 to October 1, 1979 received citizenship at birth if one or both parents were a U.S. citizen. In addition, based on the provisions of the Child Citizenship Act, children born outside of the United States who are under 18, admitted to the U.S. as a lawful permanent resident, and in the legal and physical custody of a citizen parent are considered citizens at birth per 2041.01 and meet citizenship criteria automatically.
Note: Citizens of Micronesia, Palau, and the Marshall Islands have the right to enter, work, and establish residence as a non-immigrant in the United States. They are not considered citizens of the United States and must meet the qualifications of 2042 to receive medical. See additional details for this group under 2043.12.
2041.01 Citizens at Birth - With the exception of individuals born in the U.S. to foreign sovereigns or diplomatic officers, all individuals born in the United States are U.S. citizens. Most other individuals born outside the U.S. must become citizens through Naturalization. However, certain children born outside the United States establish citizenship at birth without completing the naturalization process. These individuals are also considered citizens at birth. Although individuals who meet the criteria were issued immigration documents in order to enter the United States, some may not have obtained a Certificate of Citizenship from the Department of Homeland Security (formerly INS).
Foreign-born individuals born to or adopted by at least one citizen parent are potentially considered citizens at birth. The following rules shall be considered when determining if a foreign-born individual is a citizen at birth.
(1) For persons born on or before January 31, 1941 - At least one parent is a citizen who lived in the U.S. prior to the child's birth.
(2) For persons born between January 14, 1941 and November 13, 1986 - If both parents are citizens, at least one resided in the U.S. prior to the child's birth. If one parent is a U.S. citizen, the citizen parent must have lived in the U.S. for at least 10 years.
(3) For persons born after November 14, 1986 who are over the age of 18 - If both parents are citizens, at least one resided in the U.S. prior to the child's birth. If one parent is a U.S. citizen, the citizen parent must have lived in the U.S. for at least 5 years.
(4) For children under age 18 - The Child Citizenship Act of 2000 went into effect on February 27, 2001 and provides automatic citizenship to certain foreign-born children. Automatic citizenship occurs on the date the following criteria have all been met:
- The child has at least one U.S. citizen parent (by birth or naturalization);
- The child is currently residing permanently in the United States in the legal and physical custody of the U.S. citizen parent; and
- The child is a lawful permanent resident.
This includes both natural and adopted children. These children generally enter the country with an IR-3 visa. It is not a requirement that the above criteria are achieved in a specified order, rather that the automatic citizenship is conferred upon the child on the date when all criteria have been achieved.
Individuals who were under 18 and living in the U.S. on February 27, 2001 and met the new criteria also became citizens on that date.
See 2046 for citizenship documentation requirements
2042 Qualified Non-Citizen Status - Eligibility for medical (including Medicaid and CHIP) benefits is limited to the following groups of qualifying non-citizens who also meet state residency requirements. Documentation requirements are specified in KDHE Policy Eligibility Appendix Item A-1, Non-Citizen Qualification Chart. The 5 year ban on receipt of assistance described in 2044 does NOT apply to the following non-citizens.
2043 Eligible Non-Citizens - The following non-citizens are eligible for medical benefits:
2043.01 - Refugees admitted under 207 of the Immigration and Nationality Act (INA).
NOTE: Effective December 19, 2009, Iraqi and Afghan Special Immigrants (SIVs) are eligible for medical benefits to the same extent and for the same time periods as refugees. Iraqi and Afghan aliens and family members who claim special immigrant status must provide verification that they have been admitted under section 101(a)(27) of the INA. See 2048 for a list of documents that will confirm Iraqi and Afghan Special Immigrant status.
2043.02 - Asylees granted asylum under 208 of the INA;
2043.03 - Aliens whose deportation has been withheld under Section 243 (h) of the INA;
2043.04 - Cuban or Haitian entrants as defined in section 501 of the Refugee Education Assistance Act of 1980;
2043.05 - Persons admitted as an Amerasian Immigrant pursuant to section 584 of the Foreign Operational Export Financing, and Related Programs Appropriations Act of 1988;
2043.06 - Persons who are honorably discharged veterans or are on active duty in the United States armed forces. In addition, the spouse and/or dependent children of such persons would also be deemed as meeting qualified non-citizen status. (Includes individuals who served in the Philippine Commonwealth Army during WW II or as Philippine Scouts following the war. This change is pursuant to the Balanced Budget Act of 1997.);
2043.07 - Persons who have obtained lawful permanent residence status and who entered the U.S. on or before August 22, 1996. This includes persons who did not obtain lawful permanent resident status until after August 22, 1996. Also see 2047;
2043.08 - Persons granted parole or conditional entry status and who entered the U.S. on or before August 22, 1996. This includes persons who did not obtain such status until after August 22, 1996; and
2043.09 - Persons who do not meet one of the other qualifying statuses, but who have been battered or subject to extreme cruelty by a U.S. citizen or lawful permanent resident spouse or parent and who entered the U.S. on or before August 22, 1996. Such persons must have a pending or approved Violence Against Women Act (VAWA) case or family-based petition before USCIS. This also includes the person's children who have also been battered or subject to extreme cruelty.
2043.10 - American Indians born in Canada to whom the provisions of Section 289 of the USCIS apply and members of an Indian Tribe as defined in Section 4(e) of the Indian Self-Determination and Education Assistance Act. This provision is intended to cover Native Americans who are entitled to cross the U.S. border into Canada. This includes among others, the St. Regis Band of the Mohawk in New York State, the Micmac in Maine, and the Abanaki in Vermont.
2043.11 - Non-citizens who are certified victims of severe forms of trafficking, and some family members, who are admitted to the U.S. as refugees under section 207 of the INA. See MKEESM 2144
2043.12 - Citizens of the Freely Associated States, also referred to as Compact of Free Association (COFA) migrants, of the Federated States of Micronesia, Republic of the Marshall Islands, or the Republic of Palau as of December 27, 2020 (Medicaid only – does not apply to CHIP coverage).
2043.13 - Afghan Humanitarian Parolees with an arrival date in the United States between July 31, 2021, and September 30, 2023 or who were paroled after September 30, 2023 whose parole status has not been terminated by the Department of Homeland Security (DHS), as well as their qualifying family members, including those admitted after September 30, 2023. Afghan Humanitarian Parolees who do not meet these criteria are subject to the 5-year waiting period for Medicaid and CHIP.
2043.14 - Afghans with a Special Immigrant Visa (SIV) and Afghan Special Immigrant Parolees (SI/SQ).
2043.15 - Ukrainian Humanitarian Parolees who paroled into the U.S. between February 24, 2022, and September 30, 2023.
2044 Non-Citizens Who Qualify After 5 Years From the Date of Entry or the Date Status Was Granted - The following non-citizens who entered the U.S. after August 22, 1996 qualify for medical benefits (if otherwise eligible) after they have been in the country for 5 years from the date of entry, or have had the listed statuses for five years.
If they have not been in the country for five years from date of entry, they do not meet non-citizen criteria and are ineligible.
The date of entry for persons who entered the country on or after August 22, 1996 is the date the individual attained one of the qualifying statuses listed below. The date the immigrant actually entered the country is not relevant unless it is prior to August 22, 1996. The five-year bar begins to run from the date the immigrant obtains a qualified status.
2044.01 - Persons lawfully admitted for permanent residence;
2044.02 - Persons granted parole or conditional entry status;
2044.03 - Persons who do not meet one of the statuses listed in 2044.01 or 2044.02 above, but who have been battered or subject to extreme cruelty by a U.S. citizen or lawful permanent resident spouse or parent with pending or approved Violence Against Women Act (VAWA) cases or family-based petitions before USCIS. This also includes the person's children who have also been battered or subject to extreme cruelty.
2045 Documentation of U.S. Citizenship and Identity - When verification of citizenship and identity cannot be obtained via the Federal Data Hub, documentation of U.S. citizenship and identity must be obtained for individuals claiming to be U.S. citizens who are otherwise eligible for Medicaid or CHIP. This requirement does not apply to the following individuals:
(1) - Current or former SSI recipients
(2) - Current or former Medicare beneficiaries
(3) - Current or former recipients of Social Security Disability benefits
(4) - Children currently in foster care or recipients of foster care maintenance
(5) - Children who are recipients of adoption support payments
(6) - Children born on or after July 1, 2006 to a Medicaid recipient as outlined in 2320.
2045.01 Primary Documents - A document that verifies both citizenship and identity as defined in KDHE Eligibility Policy Appendix Item A-12. The availability of a Primary Document shall be explored prior to using a secondary or other document. Persons born outside of the United States who were not citizens at birth per 2040 must submit a Primary Document.
2045.02 Secondary Documents - If a primary document is not used, two different documents must be used to establish citizenship and identity. The statement of the applicant/recipient that a Primary Document is not available is sufficient to seek a secondary or other document. In addition, the receipt of a secondary or other document indicates that a primary document is not available.
2045.03 Third and Fourth Level Documents - These may only be used if primary or secondary documents are not available. The document provided for citizenship must show a place of birth and it must match the place of birth reported by the applicant/recipient. A second document verifying identity is also needed.
If a second, third, or fourth level document is received this is accepted as a statement from the consumer that no other primary document was available.
2045.04 Written Declaration of Citizenship - A written declaration may be used as verification of citizenship if no other documents are available. The EES Program Administrator/KanCare Clearinghouse Manager or designee must approve the declaration in order for it to be considered acceptable verification.
Declarations must be provided by at least two individuals, one of whom is not related to the individual, who have personal knowledge of the event(s) establishing the claim of citizenship. KDHE Eligibility Policy Appendix P-8, Third Party Declaration of Citizenship, may be used for this purpose. The person(s) making the declaration must:
(a) provide proof of his/her own citizenship and identity,
(b) provide information regarding why documentary evidence establishing the individual's claim of citizenship does not exist or cannot be readily obtained as part of the declaration, and
(c) sign the declaration under penalty of perjury in the presence of a witness.
When a declaration is used to document citizenship, the original must be retained in the case file indefinitely.
2045.05 Written Declaration of Identity - A written declaration may be used to establish identity for children under age 16 or disabled adults if no other documents are available. If a declaration is used to establish citizenship it cannot also be used to establish identity. KDHE Eligibility Policy External forms item P-7, Declaration of Identity for Children and item P-9, Declaration of Identity for Disabled Adults, must be used for this purpose. The EES Program Administrator/KanCare Clearinghouse manager must approve the declaration in order for it to be considered acceptable verification.
The person making the declaration must:
(a) be a United States citizen,
(b) sign the declaration under penalty of perjury in the presence of a witness, and
(c) for children, must be the parent, legal guardian, or caretaker relative of the child;
(d) for disabled adults, must be the director or administrator of a residential care facility where the individual resides.
When a declaration is used to document identity, the original must be retained in the case file indefinitely.
2045.06 Multiple Documents - When none of the above items of identity are available, a consumer may submit three or more of the following documents as verification of identity:
(a) employer identification cards
(b) high school or college diplomas, including GED
(c) marriage certificates
(d) divorce decrees
(e) property deeds/titles
Multiple documents can only be used for identity if a second or third level of citizenship has been provided.
2045.07 Reasonable Opportunity Period to Provide Documentation (ROP) - The following provisions apply when an applicant or recipient declares U.S. citizenship or an eligible alien status but is unable to provide verification. For information pertaining to qualifying non-citizens, see 2040.
The agency may not request verification of citizenship and identity or alien status from the applicant or recipient if that information is available through an available resource. The agency shall make every effort to verify citizenship and identity or alien status through those resources. The following automated and manual verification resources shall be utilized:
Tier 1 – The Federal Data Services Hub. The Hub accesses the Social Security Administration (SSA) database in real-time to verify citizenship and identity status.
The Electronic Access to Social Security (EATSS) database. If the Hub is not available, EATSS may be accessed to verify citizenship and identity status for those individuals who are current or former recipients of SSI, Medicare, or Social Security disability benefits (2045). EATSS may not be used to verify citizenship or identity of individuals who do not meet those criteria.
Tier 2 - The Kansas Immunization Register (KSWebIZ) database. The KSWebIZ interface is a statewide database that includes immunization records for all Kansas residents that may be used to verify identity only for children.
The Kansas Department of Revenue (Driver’s License) database. The Driver’s License interface may be accessed to verify identity only of an individual with a valid Kansas license.
Tier 3 – Research by the agency. If the agency has been unable to verify citizenship and identity or alien status through the available automated and manual interfaces, staff shall review the case file and imaged documents to determine whether a hard copy verification has already been provided.
Tier 4 – Contact with the applicant or recipient. If the agency is unable to verify citizenship and identity via any of the means above, verification shall initially be waived, and a reasonable opportunity period applied as described below. The individual shall be contacted to provide verification and notified of the reasonable opportunity period.
An application shall not be delayed or denied because the agency was unable to verify citizenship or identity or eligible alien status. If otherwise eligible, the application shall be processed and approved granting a reasonable opportunity period to the individual to provide the verification. The reasonable opportunity period shall be three (3) calendar months commencing from the date the case is authorized. If the individual fails to provide verification (or the agency is unable to independently verify) by the end of the reasonable opportunity period, coverage shall end allowing for timely notification. If verification is provided within the month after the month coverage ends, eligibility may be reinstated without a new application/request. The following examples illustrate:
Example: The agency is unable to verify citizenship or identity for an applicant for medical assistance. Since the individual is otherwise eligible, assistance is approved on 03/11 with notification that verification must be provided by 06/11. Verification is provided within the reasonable opportunity period on 04/23. Eligibility continues without interruption.
If the individual failed to provide verification (and the agency was unable to independently verify) by 06/11, coverage would end effective 06/30 (assuming action was taken by timely notice deadline).
Example 2: The agency is unable to verify a qualifying non-citizen status for an applicant for medical assistance. Since the individual has attested to a qualifying non-citizen status and is otherwise eligible, assistance is approved on 09/29 with notification that verification must be provided by 12/29. The recipient fails to provide verification within the reasonable opportunity period. Coverage ends effective 01/31.
If the individual provides verification by 02/28 (the month after the month coverage ends) eligibility may be reinstated without a new application/request for assistance. If verification is provided after 02/28, a new application/request is required.
Note: An extension of the ROP will be provided if the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation, or if the agency needs more time to complete the verification process through the Federal Data Hub or Verification of Lawful Presence (VLP) interfaces. A decision to extend the period must be thoroughly documented and supported in the case file.
2046 Documentation for Citizens at Birth - For most foreign born individuals attesting to be U.S. citizens, primary documentation as established in 2045 is necessary. However, secondary, or subsequent documents may be used to verify citizenship and identity for person considered citizens at birth.
2047 Documentation of Legal Status - Applicants/recipients who are identified as non-citizens on their application shall be required to verify their non-citizens status. The agency shall determine if the person is a non-citizen who may be eligible to receive assistance. Only those non-citizens who are residents and meet one of the categories of qualifying non-citizens status described in 2044 may participate.
The agency may not request verification of legal non-citizen status from the applicant or recipient if that information is available through an available resource. The agency shall make every effort to verify the legal non-citizen status through those resources. Verification is accomplished through the Department of Homeland Security and additional verification steps may be necessary. The KEES system and the SAVE process is used to obtain the information. Verification is not requested for non-applicants.
The following automated and manual verification resources shall be utilized:
Tier 1 – The Non-Citizen VLP (Verify Lawful Presence) through the Federal HUB (including subsequent SAVE processes).
Tier 2 – The Manual SAVE process. Should the agency be unable to verify non-citizen status in this manner, additional research is required. Detailed instructions on primary and secondary verification procedures are contained in the SAVE User Manual. (See KDHE Eligibility Policy Appendix A-10) No action to deny, reduce, or terminate benefits may be taken based solely on information obtained from DHS through the SAVE primary verification system.
NOTE: Secondary verification should be requested when the person's entrance date is in question. For persons adjusting status to legal permanent resident, the primary web-based verification system will communicate the date of adjustment rather than the original date of entrance. The secondary system will always provide the original date of entrance.
Tier 3 – Research by the agency. If the agency has been unable to verify legal non- citizen status through the available automated and manual interfaces, staff shall review the case file and imaged documents to determine whether a hard copy has already been provided. Verification through the automated systems may be attempted again if additional information is found in the file that will assist in the process.
Tier 4 – Contact with the applicant or recipient. If the agency is unable to verify legal non-citizen status via any of the means above, verification shall initially be waived and a reasonable opportunity period applied as described in 2047.01. The individual shall be contacted to provide verification and notified of the reasonable opportunity period.
2047.01 Reasonable Opportunity Period (ROP) for Non-Citizens - An application shall not be delayed or denied because the agency was unable to verify the non-citizen status of an individual declaring to be a qualifying non-citizen. If otherwise eligible, the application shall be processed and approved granting a reasonable opportunity period (ROP). The ROP shall be three (3) calendar months commencing from the date of approval. If proof of qualifying non-citizen status is provided, the ROP ends and additional information is not necessary. If prior medical assistance has been requested and the individual is otherwise eligible, coverage shall be approved for these prior months as well.
The following processes shall be utilized:
a. Research by the agency - Staff shall review the application, case file and imaged documents to determine if the applicant has previously declared they meet a qualifying non-citizen statuses.
b. Contact with the applicant or recipient – If there is not enough information available to determine if the applicant is a qualifying non-citizen, phone contact is required to obtain additional information necessary to confirm whether or not the individual meets a qualifying non-citizen status. Staff shall attempt to obtain document types, immigration ID numbers and other details during this contact. If unable to reach the applicant, the individual is not provided with an ROP and a request for information is generated.
c. Verify Lawful Presence (VLP) – The Tier 1 and Tier 2 processes are completed as indicated in 2047. If VLP does not provide the information needed to complete a full determination of eligible status, then an ROP is provided for those who declare/attest to an eligible status. If more time is needed to verify status after the initial 3-month period, the ROP will be extended to allow additional time.
NOTE: Manual SAVE may be used only if the VLP interface is failing when first initiated from KEES.
2047.02 Non-Citizens Unable to Provide Documentation - If the alien is unable to provide any documentation of their status, the agency shall advise the person to contact the nearest USCIS office for verification.
2047.03 Documentation Obtained Later - If documentation of qualifying status is received at a later date, the specialist shall act on the information as a reported change in accordance with timeliness standards for these changes. See 7130 as appropriate.
2047.04 Unable to Verify Through KEES - If unable to verify through the non-citizenship status or if conflicting information is received, an inquiry shall be sent to the Eligibility Policy Unit for guidance.
2048 Verification of Iraqi and Afghan Special Immigrant Status - Iraqi and Afghan aliens and family members who claim special immigrant status must provide verification that they have been admitted under section 101(a)(27) of the Immigration and Nationality Act (INA). The following documents will confirm both status and date of entry for Iraqi and Afghan special immigrants.
1. Iraq Special Immigrants
a. Principal Applicant Iraqi Special Immigrant - Iraqi passport with an immigrant visa stamp noting that the individual has been admitted under IV (Immigrant Visa) Category SI1 or SQ1 and DHS stamp or notation on passport of I-94 showing date of entry.
b. Spouse of Principal Applicant Iraqi Special Immigrant: Iraqi passport with an immigrant visa stamp noting that the individual has been admitted under IV (Immigrant Visa) Category SI2 or SQ2 and DHS stamp or notation on passport or 1-94 showing date of entry.
c. Unmarried Child Under 21 Years of Age of Iraqi Special Immigrant: Iraqi passport with an immigrant visa stamp noting that the individual has been admitted under IV (Immigrant Visa) Category SI3 or SQ3 and DHS stamp or notation on passport of I-94 showing date of entry.
d. Principal Applicant Iraqi Special Immigrant Adjusting Status in the U.S.: DHS Form I-551 (“green card”) showing Iraqi nationality (or Iraqi passport), with an IV (immigrant visa) code for this category SI6 or SQ6.
e. Spouse of Principal Applicant Iraqi Special Immigrant Adjusting Status in the U.S.: DHS Form I-551 (“green card”) showing Iraqi nationality (or Iraqi passport), with an IV (immigrant visa) code for this category SI7 or SQ7.
f. Unmarried Child Under 21 of Principal Applicant Iraqi Special Immigrant h. Adjusting Status in the U.S.: DHS Form I-551 (“green card”) showing Iraqi nationality (or Iraqi passport), with an IV (immigrant visa) code for this category SI9 or SQ9.
2. Afghan Special Immigrants
a. Principal Applicant Afghan Special Immigrant: Afghan passport with an immigrant visa stamp noting that the individual has been admitted under IV (Immigrant Visa) Category SI1 and DHS stamp or notation on passport of I-94 showing date of entry.
b. Spouse of Principal Applicant Afghan Special Immigrant: Afghan passport with an immigrant visa stamp noting that the individual has been admitted under IV (Immigrant Visa) Category SI2 and DHS stamp or notation on passport of I-94 showing date of entry.
c. Unmarried Child Under 21 Years of Age of Afghan Special Immigrant: Afghan passport with an immigrant visa stamp noting that the individual has been admitted under IV (Immigrant Visa) Category SI3 and DHS stamp or notation on passport of I-94 showing date of entry.
d. Principal Applicant Afghan Special Immigrant Adjusting Status in the U.S.: DHS Form I-551 (“green card”) showing Afghan nationality (or Afghani passport), with an IV (immigrant visa) code for this category SI6.
e. Spouse of Principal Applicant Afghani Special Immigrant Adjusting Status in the U.S.: DHS Form I-551 (“green card”) showing Afghan nationality (or Afghan passport), with an IV (immigrant visa) code for this category SI7.
f. Unmarried Child Under 21 of Principal Applicant Afghan Special Immigrant Adjusting Status in the U.S.: DHS Form I-551 (“green card”) showing Afghan nationality (or Afghan passport), with an IV (immigrant visa) code for this category SI9.
02050 Residence - A client must be a resident of the state.
For all medical programs, a resident is one who is living in the state voluntarily and not for a temporary purpose (i.e., with no intention of leaving). Temporary absence from the state, with subsequent returns to the state, or intent to return when the purpose of the absence has been accomplished shall not interrupt continuity of residence. See also 02140 regarding temporary absence of children or parents. In addition, individuals who continue to receive a Kansas state supplementary payment while living out-of-state are regarded as Kansas residents.
For medical programs, residence can be established for persons who are living in the state with a job commitment or who are seeking employment in the state, including temporary stays. This would include migrant workers (both farm and construction) and their family members living with them in the state. The following provisions apply to a non-institutionalized individual:
1) An individual who is legally competent and capable of acting in his or her own behalf shall choose his or her state of residence as either the state the individual is living with the intent to reside (including without a permanent address), or the state the individual entered with a job commitment or for seeking employment (even if not currently employed).
2) The state of residence for each individual who is not legally competent or capable of acting in their behalf shall be either the state in which the individual is living (including without a permanent address) or the state in which the individual's parent or caretaker resides (if living with a parent or caretaker).
For individuals residing in an institution, see MKEESM 2152.
2051 Duplicate Benefits - Residence can be established in a month regardless of whether the person has received benefits from another state in that month.
Persons who move from another state can receive medical benefits in Kansas in the month he or she moves from that state. For medical, the person must be otherwise eligible for Medicaid or CHIP.
2052 Institutionalization - For medical assistance, the following criteria apply to persons who are institutionalized:
2052.01 - An individual who is placed by a state agency into an out-of-state institution retains residence in the state making the placement. Thus, individuals who are placed in care facilities outside of Kansas by DCF retain their Kansas residence.
Providing basic information to individuals about another state's Medicaid program or about the availability of health care services and facilities in another state does not constitute a placement action. This would also include assisting an individual in locating an institution in another state provided the individual was capable of intent and independently decided to move.
2052.02 - For individuals who become incapable of intent before the age of 21 or who are under the age of 21, the state of residence is the state in which their parents or legal guardian reside for applicants or in which they did reside at the time of institutional placement for recipients. If the parents live in different states, the state of residence of the parent making application shall be applicable.
Individuals are considered incapable of intent if: their IQ is 49 or less; or they have a mental age of 7 or less based on reliable tests; or they are judged legally incompetent; or there is medical and social documentation to support a finding that they are incapable of intent.
2052.03 - For individuals who become incapable of intent on or after age 21, the state of residence is the state in which they are physically residing.
2052.04 - For all other institutionalized individuals, the state of residence is the state in which the individual is living with the intention to remain there permanently or for an indefinite period.
NOTE: In addition, Kansas has entered into interstate residence agreements with the following states: California, Florida, Kentucky, New Mexico, Ohio, Pennsylvania, South Dakota, Tennessee, Texas, and Wisconsin. The agreement states that individuals residing in a Medicaid approved institution for long term care in one of the above-named states who would be Kansas residents under (2) or (3) shall be deemed residents of that state for purposes of medical assistance unless the person was placed there by Kansas state or local government personnel. The reciprocal situation is also covered in the agreement. Refer to MKEESM 8112 for definition of a Medicaid approved institution.
2052.05 Incarcerated Minors (Medicaid) - Federal regulations prohibit states from fully terminating Medicaid coverage for children under the age of 21 and Aged Out Foster Care (AGO) recipients who become inmates of public institutions, i.e., correctional facilities, on or after October 24, 2019. When a Medicaid recipient in this category becomes institutionalized in this manner, coverage is suspended vs. terminated, meaning that while coverage is inaccessible while they are in a detained/incarcerated status, it will be reinstated upon their release without a new application being required as long as they remain eligible based on current circumstances. Likewise, applications received on behalf of individuals in this category who are currently in a detention placement must be accepted and determined for Medicaid eligibility; if determined eligible while incarcerated, a new application will not be required for redetermination upon release.
2052.06 Incarcerated Minors (CHIP) - - A new CHIP eligible applicant cannot be enrolled while in an incarcerated setting. When an application is received requesting coverage for an incarcerated child, and the child is found to be otherwise CHIP eligible, the application must be denied due to incarcerated status. The exception to this rule is when a child is currently receiving coverage on the CHIP program and enters a correctional facility during a CE period. Incarceration is not an exception to CE, so in this case, coverage may not be terminated on the basis of incarceration; rather, coverage will temporarily end (i.e., be suspended) until the agency is notified of the child’s release at which point the child would be reinstated for the remainder of the existing CE period.
NOTE: If the child was not released prior to the expiration of the CE/review period, coverage would not be reinstated without a new application or review form.
2052.07 Incarcerated Adults - Medicaid funds are excluded from the payment of medical claims for individuals residing in a correctional facility except for certain emergency qualifying events under the Inmate Program. For this reason, when a Medicaid recipient enters a correctional facility (i.e., prison, jail, or other non-Medicaid eligible public institution) coverage must be deactivated or suspended upon entry. Likewise, when an application is received on behalf of a Medicaid-eligible incarcerated individual, coverage must be delayed until the release date.
While incarceration disallows Medicaid payment of medical claims, it does not impact a person’s eligibility. This means a person will maintain eligibility for Medicaid while residing in a correctional facility and upon release may have benefits reinstated without a new application as long as they continue to meet categorical program requirements (age, residency, etc.). This also means that an application may not be denied solely due to a person’s incarceration status. An incarcerated individual must be determined based on eligibility related factors, and if eligible, coverage will begin upon release. If the person is in a current continuous eligibility (CE) or review period, they may be reinstated for the remainder of that period, or a new CE period may begin, depending on program eligibility. If ineligible for another program, they may be reinstated or approved for MediKan Reintegration (MKN/RI) when criteria is met.
Note: See MKEESM 2640 for information related to MediKan.
02060 Cooperation with Child Support Services (CSS) - As a condition of eligibility in the Caretaker Medical program, the caretaker who is receiving assistance shall cooperate with the Child Support Services division of the DCF agency. At the time of initial application, it is assumed that the Caretaker will cooperate with CSS. See 2066 for information about applicants who were previously discontinued for failing to cooperate with CSS.
See 2064 for effect on eligibility for failure to cooperate with CSS.
2061 Referral to Child Support Services - Eligibility Staff are responsible for referring cases to CSS where there is one or more parents absent from the household (including a deceased parent). Only participating adults who are receiving coverage on the Caretaker Medical program shall be referred. Families requesting medical coverage only for children may elect to participate with CSS but are not required to be referred. See 2068 for voluntary referrals.
It is the function of the eligibility staff to determine continued parental absence and the function of the CSS staff to obtain support on behalf of the spouse and/or child(ren). Parental absence is based on self-attestation of household members.
For Family Medical, the referral is an automatic process in KEES following completion of the non-custodial referral and authorization of the program. Referrals are not made when there is no absent parent or when parental rights have been severed. See the KEES User Manual for further information on system processing.
2062 Cooperation - Cooperation involves providing information to CSS to establish the paternity of a child born out-of-wedlock and in obtaining medical support payments for such caretaker and for the respective child. For purposes of establishing paternity, the legal parent is presumed to be the biological parent.
For Medicaid there is no requirement that paternity be formally established. Self-attestation is accepted as to the paternity of a child. If DCF determines paternity for a child that differs from what was previously self-attested, KDHE will accept the verified paternity status.
CSS is responsible for determining whether the caretaker has cooperated in establishing paternity and/or in obtaining support. Cooperation is defined as:
2062.01 - Appearing at the local CSS office or the Court Trustee Office as necessary to provide information or documentation relative to establishing paternity of a child born out-of-wedlock, identifying and locating the absent parent, and obtaining support payments;
2062.02 - Appearing as a witness at court or other proceedings necessary to achieve the CSS objectives; and
2062.03 - Providing information, or attesting to the lack of information, under the penalty of perjury.
2063 Good Cause for Failure to Cooperate - In rare instances the caretaker may be deemed to have good cause for refusing to cooperate in establishing paternity and securing support payments. Examples of such cases would be those in which it has been determined that pursuing paternity/support is against the best interest of the child or the caretaker. Eligibility Staff have the ultimate responsibility for determining the validity of good cause claims; however, CSS and Protection and Prevention Services (PPS) staff may alert the Eligibility Staff of the need to evaluate for good cause.
The caretaker has the primary responsibility for providing documentary evidence required to substantiate a good cause claim. When necessary, the agency shall assist the client in securing any evidence that the client cannot reasonably obtain.
Good cause for failure to cooperate must relate to one of the following criteria:
2063.01 - The child was conceived as a result of incest or rape;
2063.02 - There are legal proceedings for adoption of the child pending before a court;
2063.03 - The caretaker is currently being assisted by a public or licensed private social agency to resolve the issue of whether to keep the child or relinquish the child for adoption;
2063.04 - The caretaker was a victim of domestic violence whereby compliance with program requirements would increase risk of harm for the individual or any children in the individual's case. Domestic violence includes acts on the part of perpetrators that result in:
(1) - physical acts resulting in, or threatening to result in, physical injury;
(2) - sexual abuse, sexual activity involving dependent children, or threats of or attempts at sexual abuse;
(3) - mental abuse, including threats, intimidation, acts designed to induce terror, or restraints on liberty, or;
(4) - deprivation of medical care, housing, food or other necessities of life.
2063.05 - Good cause claims must be confirmed or substantiated. Uncorroborated statements of the caretaker do not constitute documentary evidence; the mere belief that pursuing paternity or support is not in the client's or the child's best interest is not sufficient evidence. An individual's statement and one corroborating piece of evidence shall meet the burden of proof unless there is an independent reasonable basis to doubt the veracity of the statement. Evidence may include, but is not limited to:
(1) - Police or court records,
(2) - Court documents which indicate that legal proceedings for adoption of the child are pending,
(3) - Protection from abuse (PFA) or Protection from stalking (PFS) orders (filed for and/or obtained),
(4) - Written statement from a public or licensed private social agency substantiating the fact that the client is involved in resolving the issue of whether to keep or relinquish the child for adoption,
(5) - Documentation from a shelter worker, attorney, clergy, medical or other professional from whom the client has sought assistance,
(6) - Other corroborating evidence such as a statement from any other individual with knowledge of the circumstances which provide the basis for the claim, or physical evidence of domestic violence or any other evidence which supports the statement.
Exception: Regardless of the policy in this section regarding uncorroborated statements by caretakers, in extremely rare situations such as when an individual is in hiding and is afraid that there could be information disclosed that could reveal his/her whereabouts and where the Eligibility Staff do not doubt the veracity of the individual's statement, a written statement from the victim signed under penalty of perjury shall meet the burden of proof.
In most instances a good cause determination should be made within 60 days following the receipt of such claim. Exceptions to this would include such situations as when the evidence is extremely difficult to obtain.
The Eligibility Staff are responsible for notifying CSS of good cause determinations. A referral shall not be sent to CSS while a good cause claim is pending. Once a claim of good cause has been substantiated, a referral shall be sent to CSS with the good cause indicated. A good cause claim shall be reviewed as often as necessary and at each pre-populated review.
The Eligibility Staff shall not deny, delay, or discontinue assistance pending a good cause determination as long as the caretaker has complied or is in the process of complying with the requirement of providing evidence or other necessary information. If assistance is granted pending a determination of good cause and it is subsequently determined that the claim is invalid, the assistance granted shall not be considered an overpayment. A referral to CSS will be sent at the time the claim is determined to be invalid.
NOTE: Do not confuse cases that involve good cause with routine cases of noncooperation. A client's claim of good cause does not negate the requirement for the assignment of support rights.
2064 Failure to Cooperate - If the caretaker refuses to cooperate with CSS, Eligibility Staff will be notified by CSS via either a task in KEES or an email from the CSS staff. A penalty for failure to meet CSS requirements can be imposed only when the caretaker is referred to CSS and CSS determines the person has not cooperated.
Eligibility staff will discontinue medical assistance for the non-pregnant adult caretaker for failure to cooperate with CSS. However, medical coverage under all other categories shall be considered for such a caretaker at the time the penalty is applied. There is no penalty for other household members.
Pregnant caretakers or caretakers under the age of 19 will not be discontinued for failure to cooperate. Their cooperation status will be evaluated once they’ve reached the age of 19 or the end of the postpartum period.
Because penalties only affect coverage under the Caretaker Medical program, persons currently serving a penalty who later meet categorical requirements under another program shall have eligibility determined under the new medical program without regard to the penalty. Because penalties can result in a temporary hardship, penalties must be applied with much care and consideration. To ensure that penalties are applied uniformly and appropriately, the following guidelines must be applied in all instances of noncooperation:
2064.01 - There is documented evidence that the person was made aware of the cooperation requirement. Information provided in the approval notice fulfills this requirement.
2064.02 - There is documented evidence that the person was informed of the consequences for failing to cooperate. Information provided in the approval notice fulfills this requirement.
2065 Evaluating Cooperation of an Applicant - Previous non-cooperation does not impact future assistance. When processing a new request for medical assistance, and a caretaker is determined eligible for the Caretaker Medical program, it is assumed that the Caretaker will cooperate with CSS. In situations where the Caretaker was penalized for failing to cooperate with CSS in the six months prior to the month of application, the Caretaker must self-attest to cooperation prior to approval of Caretaker Medical coverage. Self-attestation of the agreement to cooperate with CSS in order to receive Caretaker Medical assistance may be provided verbally or in writing.
2066 Reestablishing Coverage Following Cooperation - After a non-cooperation penalty occurs, if the caretaker cooperates with CSS, Eligibility Staff will be notified by CSS via a task in KEES.
If cooperation occurs in the month of discontinuance or the month following, eligibility shall be reinstated without requiring a new application or request for coverage. Coverage shall be reinstated effective the first day of the month in which cooperation is established.
If more than a one-month break in assistance has occurred, a new application or request for coverage is required according to the policies outlined in 1402.
2067 Special Case Situations -
2067.01 Legal vs. Biological (Alleged) Father - In situations where the mother is currently or was married to a different person at the time, she was pregnant or during the child's birth, this establishes a legal father contrary to claims that the real (biological) father is in the home. When these circumstances are identified, both the mother and alleged father may volunteer for referral to CSS. CSS will be able to do a more in-depth analysis of the circumstances at the time of the child's birth and advise the clients of legal aspects of the situation. If CSS responds that a voluntary order is obtained, the Eligibility Staff will process the case considering paternity established with the father in the home. However, in most instances CSS's response may be that a legal father exists and a voluntary order is not possible. When this occurs, the alleged father is to be treated as a nonrelative to the child in question and the case is to be processed in that manner. In such instances, the non-custodial page should list the legal father as the absent parent. A penalty is applicable if she fails to cooperate with any CSS requirements following case approval.
2068 Voluntary Referral - All households which include a child whose parent(s) is absent may voluntarily request to be referred to CSS. CSS will help with establishing paternity if not already established and obtaining support. Clients requesting CSS services shall be given the name and phone number of the appropriate contact person in the local CSS office. No automated process is in place for referring voluntary CSS participants.
There is no penalty for failing to cooperate with CSS on a voluntary referral.
A previous finding of noncooperation by a voluntary household shall not impact future assistance under any program.
02100 Child in Family - There must be at least one child in the home or qualifying under temporary absence provisions of 2140. In order for any family member to qualify, a child must be included in the assistance plan for Caretaker Medical benefits unless the child is excluded as an SSI recipient or eligible under another medical program that is higher in the medical program hierarchy. See 3100 for more information about MAGI Budgeting Units.
A child must be under 19 years of age. The person may be considered a child the entire month he or she turns 19. A person acting in their own behalf per 2010 is not considered a child for Caretaker Medical purposes.
The statement of the applicant in regard to the month and day of the birth of the child will be accepted by the agency unless there is reason to question its authenticity or unless evidence establishes the month and day of birth as being different from that given by the applicant. This applies only to individuals that are exempt from providing verification of citizenship and identity, as those documents shall also provide a valid date of birth.
Eligibility cannot be approved when a child's date of birth cannot be accurately determined.
2110 Definition of a Caretaker - A child must be living in a home with a caretaker. Meeting the caretaker definition allows an individual to be considered for the Caretaker Medical program.
A person must have one of the following relationships to the child and have care and control of the child in order to be a caretaker under this provision.
2110.01 - Any blood relative (or one of half-blood) who is within the fifth degree of kinship to the dependent child. An appropriate relative is therefore a parent, (biological or adoptive) grandparent, sibling, great-grandparent, uncle, or aunt, nephew or niece, great-great grandparent, great uncle or aunt, first cousin, great-great-great grandparent, great-great uncle or aunt, or a first cousin once removed.
An example of a great uncle would be the brother of the grandparent of the dependent child. An example of the great-great uncle would be the brother of the great grandparent of the dependent child. An example of a first cousin once removed who would qualify as a caretaker would be an adult child of a first cousin of the dependent child. Another example of first cousins once removed would be in the relationship between a dependent child and the first cousin of that child's parent. Second cousins are not within the allowable degree of relationship. An example of second cousins would be two persons whose parents are first cousins.
2110.02 - A stepfather, stepmother, stepbrother, stepsister, step-grandparent, step-aunt, or step-uncle.
2110.03 - Legally adoptive parents and other relatives of adoptive parents as designated in groups (1) and (2).
2110.04 - A person who is court-appointed to be:
(1) - a guardian;
(2) - a conservator; or
(3) - the legal custodian.
2110.05 - In situations where multiple adults living in the home could qualify under the caretaker definition, the caretaker shall be determined using the following criteria:
(1) – When both a parent and another relative are residing in the home with the child, it is assumed that the parent has care and control unless specific information has been provided to the contrary. Self-attestation is accepted in these situations as to who has care and control, however, staff shall use prudent person as defined in 1300 when deemed appropriate.
(2) – When the court has designated an individual as a guardian of a child, this is the individual who has care and control, even when the parent is also residing in the home.
02120 Joint Custody - In situations of joint custody where a child resides with each parent within a calendar month, and both parents are applying for benefits, the parent who has the primary responsibility for exercising parental control may apply for and receive medical assistance for that child if otherwise eligible. This includes the ability to apply for and receive CTM for the caretaker if requested and otherwise eligible.
When both parents are applying for benefits, eligibility for the child or children in joint custody cannot be split between the separate parents; therefore, both parents cannot receive benefits for the same child for the same month. If neither parent can be shown to be the parent with whom the child resides a majority of the time (over 50%) and no other factor shows that one parent has the primary responsibility for the child, then the parents must designate which household will include the child.
If only one parent is applying for medical assistance, then the child(ren) are to be included in the assistance household with that parent.
02130 Minor Parent Not Living with Caretaker - A minor parent (including a minor expectant mother or father) who is not able to act in his/her own behalf per 2010 and not living with a caretaker as defined in this section may qualify for assistance if an application is filed by one of the following adult household members:
a) Parent of the minor's child, whether born or unborn (i.e. adult father applies for minor girlfriend and their child, or adult mother applies for minor boyfriend and their child)
b) Grandparent of minor parent's child, whether born or unborn (i.e. Mother applies for her son's minor pregnant girlfriend; Mother is grandparent of the unborn child)
NOTE: Anytime a minor's health or safety is judged to be at risk, a referral to Children and Family Services would be appropriate.
02140 Temporary Absence of a Child or Caretaker - A child who remains a part of the household, but is, or is expected to be, out of the home for 180 consecutive days or less, shall, if otherwise eligible, qualify to receive assistance. In addition, a caretaker who is out of the home for employment or to fulfill a work requirement, for the purpose of school attendance, or due to being in a Medicaid approved facility for a period not to exceed the month of entrance and two following months shall also qualify as a part of the household regardless of the length of time away.
A caretaker who is out of the home for any other reason, is no longer considered to have care and control of a minor child, therefore, no longer meets the definition of a Caretaker. Once it is determined an adult no longer meets the definition of a caretaker, negative action should be taken as soon as possible, allowing timely and adequate notice.
A child who is out of the home for a temporary visit with the non-custodial parent and who is expected to return within 180 days shall remain on the custodial parent's medical case and CSS (if CTM) shall be notified of the absence. A child out of the home attending school or in Job Corps remains a part of the household if he/she intends to return to the household, regardless of the expected length of absence. The determining factor in the case of a temporarily absent child shall be the caretaker's continued responsibility for the care and control of the absent child. The determining factor in the case of a temporarily absent caretaker shall be the caretaker's continued responsibility for the care and control of the children remaining in the home.
Note: A child may be out of the home for purposes such as visiting the absent parent or vacation. Even though the caretaker's responsibility for care and control is lost, if the absence is less than 180 days, they are still considered a caretaker.
02200 General Program Information for MAGI - Modified Adjusted Gross Income (MAGI) is a term that describes the budgeting methodology for all family medical programs. The term MAGI is also used to reference the group of medical programs that follow this methodology. MAGI medical categories include Parents and Caretaker Relatives, Pregnant Women, Children under age 19, and Medically Needy for pregnant women or children under age 19. Coverage is provided through both Medicaid and CHIP. See 2400 for additional information about CHIP.
Medicaid benefits are provided to help cover the cost of health care for an individual. Medicaid is a federally regulated and state administered program which is jointly funded by the federal and state government. It covers the majority of the state's medical recipients including children and pregnant women.
The Medicaid program provides payments for comprehensive medical care and services furnished through a managed care program, known as KanCare. Specific services for which payment can be made and the proper payment rate (including capitation rates for managed care) are established by the KDHE-DHCF and are reviewed and adjusted periodically.
KDHE-DHCF has contracts with three managed care organizations to provide care to all family medical programs. These organizations are Healthy Blue, Sunflower Health Plan and UnitedHealthcare of Kansas.
Information on covered services can normally be obtained by the provider. Each provider is given a policy and procedure manual providing instructions related to coverage and processing claims; additional information can be obtained by the provider from the fiscal agent or the KDHE-DHCF. The KanCare Clearinghouse has the responsibility of establishing eligibility/ineligibility of applicants/recipients based on the policies established within the limitations set forth by the Code of Federal Regulations (CFRs) and the Kansas Administrative Regulations (KARs).. Licensed or certified medical practitioners determine the necessity of specified medical services, subject to review by KDHE-DHCF. Capitation payments are made to the MCOs on a per-member, per-month (PMPM) basis. The MCOs are responsible for making direct service payments to the provider (vendor) of medical services rendered to individuals certified as eligible.
Not all consumers are included in KanCare. For those outside of the managed care program, payments are made to direct service providers on a fee-for-service basis. KDHE-DHCF contracts with a fiscal agent to process medical claims.
Medical programs are funded by the Kansas State Legislature through KDHE-DHCF. Title XIX of the Social Security Act authorizes federal financial participation (FFP) in medical payments for Medicaid covered individuals as well as specifies basic eligibility and service requirements. In addition, the income and resource methodologies of the SSI program affect the Medicaid eligibility in the aged and disabled categories. Financial eligibility rules are the same as those used in Medicaid program for nondisabled children.
02210 Medicaid - The Medicaid program is divided into two segments, the "categorically needy" and the "medically needy."
2211 Categorically Needy - Those persons who are eligible for a cash benefit under the SSI program or who meet Family Medical guidelines comprise a good portion of the categorically needy. Children and pregnant women who have incomes that fall below certain poverty level guidelines also are classified within this group.
The categorically needy receive medical assistance either because their income falls within poverty or Family Medical income guidelines or as a result of SSI eligibility. Within the categorically needy segment are also those persons who are "deemed" to be receiving an SSI cash benefit or Family Medical although ineligible for one due to certain financial or non-financial factors. For Family Medical, this would include persons who become ineligible due to increased earnings or hours of employment. For SSI, this would include persons qualifying based on the Pickle Amendment provisions and persons who qualify for 1619(b) status under the SSI program benefits because they are working but who retain disability.
Coverage of the categorically needy is largely mandated by federal law with some limited options.
2211.01 - The mandatory groups include:
(1) - Persons meeting Caretaker Medical criteria whose countable income does not exceed 38% of the federal poverty level.
(2) - SSI recipients, including those deemed to be receiving SSI.
(3) - Pregnant women and children under the age of 1 whose countable income does not exceed 171% of the federal poverty level.
(4) - Children ages 1 through 5 whose countable income does not exceed 149% of the federal poverty level.
(5) - Children ages 6 through 18 whose countable income does not exceed 133% of the federal poverty level.
(6) - Persons meeting TransMed and Extended Medical criteria.
2212 Medically Needy (Spenddown) - The medically needy segment is comprised of pregnant women and children who while meeting non-financial criteria do not qualify because their income exceeds the poverty level guidelines of either Medicaid or CHIP. Most persons in the medically needy group are obligated for a share of their medical costs through the "spenddown" process. Kansas provides coverage for the following groups:
(1) - Pregnant women (including the 12-month postpartum period if the spenddown becomes met during the pregnancy)
(2) - Children up to age 18
(3) - Persons 65 years of age and older
(4) - Persons who are disabled or blind under SSA standards. Medically needy coverage can also be provided to caretaker relatives of dependent children, but Kansas does not currently provide for this.
02220 Medical Coverage for Families -
2221 Medical Coverage for Families - Medical coverage is available to families with children under the Family Medical program if the requirements specified below are met. This includes those who lose eligibility under the Family Medical program and qualify under the extended medical provisions (TransMed and 4-Month Extended Medical.)
2222 Family Medical Coverage - Persons meeting the following criteria are eligible for medical coverage under the Family Medical program:
2222.01 General Eligibility Requirements - General eligibility requirements of act in own behalf (2010), cooperation (02020), not receiving SSI (MKEESM 2630), SSN (2031), citizenship and alienage (2040), citizenship and identity verification (2045), and residency (02050) must be met. In addition, the age and caretaker requirements of 2100 and 2110 must be met. The MAGI budgeting unit provisions of 3100 are also applicable.
2222.02 Financial Eligibility - Financial eligibility shall be determined based solely on income using the provisions of 5000 and subsections. Resources shall not be considered.
To be eligible, the total countable income must not exceed the monthly poverty level standards referenced in the KDHE Eligibility Policy Appendix F-8.
A one month base period shall be used in accordance with 6311.
2222.03 Coverage Limitation - Coverage shall not be provided under the Family Medical program to the following:
(1) - Persons convicted of medical fraud per 8420.
(2) - Persons who have a special spenddown per 8362.03.
(3) - Non-pregnant adult caretakers who fail to cooperate with child support services per 2061 and subsections. A period of ineligibility shall be imposed on such persons as per 2067. Medical coverage is not available to penalized individuals under the Family Medical program until the failure or refusal ceases. However, the possibility of medical eligibility under other determined medical programs shall be considered at the point the penalty is applied, based on ex parte guidelines and before medical coverage is terminated.
2222.04 Continuation of Coverage - Family medical coverage shall continue through the end of the established review period as outlined in 2310. The person must continue to meet nonfinancial criteria.
The Family Medical household is required to report applicable changes within ten days.
Once financial eligibility is established in the Family Medical program, the continuous eligibility provisions of 2301, 2310, 2311 and 2320 are applicable to all assistance plan members. Eligibility will continue to be provided to those individuals under the Family Medical program until the end of the individual's continuous eligibility period as established in these sections even if the household no longer meets financial criteria.
All Family Medical cases shall be reviewed once every twelve months (see 7441).
2223 Family Medical Programs Hierarchy - As the various medical programs have different rules and benefits, eligibility should be determined following the medical program hierarchy. This hierarchy is embedded in the eligibility system and is controlled by system rules. If the request for coverage is for children only, the hierarchy shall be applied beginning with level 5 unless eligible for SSI or AGO.
1) SSI – Eligibility for caretakers and children who are receiving SSI payments should first be determined for SSI.
2) AGO – If an individual is not otherwise eligible for SSI but reports being in foster-care in the month of their 18th birthday, eligibility should be determined for AGO.
3) CTM – If caretakers are not eligible for SSI or AGO, eligibility should be determined for CTM, as eligibility for this program can lead to TMD or EXT coverage.
4) TMD/EXT – If caretakers are not eligible for CTM, determine eligibility for TMD or EXT if 2230/2240 are met.
5) PLN – If pregnant women or children are not eligible for CTM, determine eligibility for PLN.
6) CHIP – If children are not eligible for PLN, determine eligibility for CHIP. For families with unpaid medical bills who are likely to meet a spenddown, eligibility should be determined for MDN prior to authorization of CHIP coverage due to CHIP authorization the date of approval.
7) MDN – A spenddown should be determined for pregnant women or children who exceed eligibility for the above medical programs. In addition, children eligible for CHIP might be better served by the MDN program if their medical bills occur prior to enrollment in a managed care plan.
02230 Transitional Medical Coverage (TransMed) - Medical coverage is available to caretakers and other individuals under the TransMed program for a period not to exceed 12 months when the provisions in this section are met.
Federal Financial Participation (FFP) is available for the medical coverage of all persons who qualify for TransMed.
2230.01 Eligibility Requirements - General eligibility requirements of act in own behalf (2010), cooperation (02020), not receiving SSI (MKEESM 2630), SSN requirements (2031), citizenship and alienage (2040), citizenship and identity verification (2045), residency (02050), and child in family (02100) must be met. If these requirements are not met, the individual is ineligible for TransMed.
CSS cooperation is not required for TransMed.
Eligibility for TransMed shall be established for twelve months when the following requirements are met:
- the individual meets the definition of a caretaker according to 2110.
- the individual is a recipient of Caretaker Medical coverage in the month prior to the month of the determination.
- the individual has experienced an increase in earnings (includes reported self-employment) resulting from increased hours of employment or monetary increase in the amount paid for hours of work since the last determination.
- the income of the individual's Individual Budget Unit exceeds Caretaker Medical financial standards. This is true even if other changes of income have occurred for either the individual or other IBU members.
If loss of coverage can be directly attributable to the above, TransMed eligibility must be established without regard to other reasons the case may have become ineligible for Caretaker Medical coverage.
2230.02 Establishing TransMed for Other Household Members - At the time of application, or when an individual loses coverage under other medical assistance programs, they shall be assessed for TransMed eligibility.
Household members of an individual approved for TransMed are also eligible for TransMed when the individual is not eligible for any other Medicaid program and the individual's IBU includes the caretaker originally qualifying for TransMed.
If this occurs at the time of the initial TransMed determination, a period of 12 months of coverage is provided.
If the household member is being added to an already established TransMed program, coverage is provided through the end of the already established period. However, such persons shall not be granted coverage for more than three months prior to the month of request and must have been a member of the IBU and residing in the household during the prior three months.
2230.03 Reacting to Changes During TransMed (TMD) - Individuals approved for TMD coverage are continuously eligible according to the 2310 with one exception. When a reduction of income is reported, eligibility shall be assessed to determine if the income is again with the limits of Caretaker Medical (CTM). If the individual meets eligibility requirements for CTM, the coverage shall be changed to CTM.
Individuals who leave the household do not automatically lose their continuous eligibility for TMD. Non-pregnant adults must continue to qualify as a caretaker for eligibility to continue. A new application may be required to reinstate the continuous eligibility. Policies in 2340 apply.
For a child, eligibility ceases when age requirements in 2100 are no longer met.
02240 Four-Month Extended Medical - Persons receiving Family Medical coverage are automatically eligible for medical coverage for a period not to exceed 4 months provided that the following criteria are met.
2240.01 Eligibility Requirements - General eligibility requirements of act in own behalf (2010), cooperation (02020), not receiving SSI (MKEESM 2630), SSN requirements (2031), citizenship and alienage (2040), citizenship and identity verification (2045), residency (02050), and 02100 child in family must be met. If these requirements are not met, the individual is ineligible for Extended Medical.
CSS cooperation is not required for Extended Medical.
Eligibility for Extended Medical shall be established for four months when the following requirements are met:
- the individual meets the definition of a caretaker according to2110.
- the individual is a recipient of Caretaker Medical coverage in the month prior to the month of the determination.
- the individual has experienced an increase in spousal support since the last determination that is the result of a divorce decree or agreement with an effective date prior to December 31, 2018. Spousal support or alimony effected from an agreement made or modified after that date is considered exempt and will have no effect on the MAGI determination.
- the income of the individual's Individual Budget Unit exceeds Caretaker Medical financial standards. This is true even if other changes of income have occurred for either the individual or other IBU members.
If loss of coverage can be directly attributable to the above, Extended Medical eligibility must be established without regard to other reasons the case may have become ineligible for Caretaker Medical coverage.
2240.02 Establishing Extended Medical for Other Household Members - At the time of application, or when an individual loses coverage under other medical assistance programs, they shall be assessed for Extended Medical eligibility.
Household members of an individual approved for Extended Medical are also eligible for Extended Medical when the individual is not eligible for any other Medicaid program and the individual's IBU includes the caretaker originally qualifying for Extended Medical.
If this occurs at the time of the initial Extended Medical determination, a period of 4 months of coverage is provided. If the household member is being added to an already established Extended Medical program, coverage is provided through the end of the already established period. However, such persons shall not be granted coverage for more than three months prior to the month of request and must have been a member of the IBU and residing in the household during the prior three months.
2240.03 Reacting to Changes During Extended Medical - Individuals approved for Extended Medical coverage are continuously eligible according to the 2310 with one exception. When a reduction of income is reported, eligibility shall be assessed to determine if the income is again with the limits of Caretaker Medical. If the individual meets eligibility requirements for Caretaker Medical, the coverage shall be changed to Caretaker Medical.
Individuals who leave the household do not automatically lose their continuous eligibility for Extended Medical. Non-pregnant adults must continue to qualify as a caretaker for eligibility to continue. A new application may be required to reinstate the continuous eligibility. Policies in 2340 apply.
For a child, eligibility ceases when age requirements in 2100 are no longer met.
02260 Aged Out Foster Care (AGO) - Individuals 18 up to age 26 who aged out of foster care in any state at the age of 18 or older and were receiving Medicaid shall be eligible for medical assistance under the Foster Care Aged Out Program.
Note: Prior to January 1, 2023, AGO was only considered for those who aged out of foster care in the State of Kansas. Effective January 1, 2023, AGO will be considered for those who aged out in another state on or after January 1, 2023.
To be eligible under the Foster Care Aged out program, the individual must meet the following criteria:
- Be in foster care and receiving Medicaid:
•The month of the individual’s 18th birthday or
•The month the individual aged out of foster care (for young adults leaving foster care after reaching age 18.)
- Foster Care youth not receiving Medicaid on the above dates solely because of living arrangement (such as incarceration, AWOL, or residing in detention facilities) are considered eligible for Medicaid for purposes of this group and may qualify for coverage under the new Foster Care Aged Out program.
- Foster care coverage is available for youth who were under the authority of DCF, KDOC-JS (previously JJA), KDOC or the Tribes.
- No income or resource test is applicable.
- When the individual is eligible for more than one coverage group, the Foster Care Aged Out program takes priority except in the following situations:
•SSI recipients – persons receiving SSI (or considered to be receiving SSI) shall be enrolled in SSI-related medical. See MKEESM 2630.
General Eligibility Requirements - The general eligibility requirements of acting in own behalf 2010, cooperation 2020, social security number2030, citizenship and alienage 2040, and residence contained in 2050 must be met.
An application is not required for these individuals as they are considered automatically eligible when they meet the above program requirements.
02270 Medicaid Poverty Level -
2271 Medicaid Poverty Level Eligibiles - Children under age 19 and pregnant women (including pregnant minors) shall be eligible for medical assistance without a spenddown if countable income (per 2280) does not exceed the following applicable limit:
2271.01 - For pregnant women and children under the age of 1, 171% of the appropriate federal Poverty Income Guidelines;
2271.02 - For children ages 1 through 5, 149% of the appropriate federal Poverty Income Guidelines; or
2271.03 - For children ages 6 through 18, 133% of the appropriate federal Poverty Income Guidelines. Children in this age group with an FPL between 113-133% without other health insurance are part of a special M-CHIP expansion group that follows Medicaid policies but receives CHIP funding. Children in this age group with an FPL between 113-133% with other health insurance are part of the special M-CHIP group that follows Medicaid policies and receives Medicaid funding.
However, persons convicted of medical assistance fraud shall not be eligible in accordance with 8420.
The poverty level programs are intended to cover children and pregnant women who are not financially eligible for SSI or Caretaker Medical, as eligibility is considered for these groups first. Persons ineligible under the financial criteria of these programs may meet the eligibility provisions of CHIP as well as the spenddown programs. See 2400 and 2350 and respectively.
NOTE: Persons under the age 19 who are pregnant shall first be determined under the Medicaid or CHIP program. If ineligible under these provisions, eligibility shall then be determined as a child under the pregnant woman provisions.
2272 General Eligibility Requirements - The general eligibility requirements of acting in own behalf 2010 (including the caretaker requirements), cooperation 2020, social security number 2030, citizenship and alienage 2040, and residence contained in 2050 must be met.
2273 Age/Pregnancy Determination - The child must be under the age of 19. Coverage may be provided through the end of the month of the individual's 19th birthday unless she is a pregnant woman. See 2300 for pregnant woman standards.
02280 Medicaid Financial Eligibility - Financial eligibility shall be determined based solely on income. Resources shall not be considered.
Eligibility is determined using the income of all persons in the Individual Budget Unit (IBU). See the Budgeting Unit rules contained in 3100.
To be eligible, the total countable income must not exceed the monthly poverty level standards referenced in the KDHE Eligibility Policy Appendix F-8.
A one month base period shall be used in accordance with 6311.
If countable income is in excess of the Medicaid poverty levels, the individual is not eligible under this provision but a child may then be considered for CHIP coverage. See 2400.
2311.01 - 2311.01 - a child turns age 19 (unless pregnant or in a postpartum period, see 02300 and 2301;
02300 Continuous Eligibility for Pregnant Women and Minors - Once eligibility for Medicaid or CHIP is established as of the date the case is processed, including Foster Care Medical (FCM), Adoption Support Medical (ASM), SSI Medical, Caretaker Medical (CTM), TransMed (TMD), Extended Medical (EXT), Breast and Cervical Cancer Medical (BCC), PLN or any Poverty Level Program (including prior medical), the pregnant woman or minor shall be automatically eligible throughout the pregnancy term and the postpartum period despite any changes in income. All general eligibility factors must be met during the continuous eligibility period. This includes pursuit of third-party resources per 2020.03, SSN requirements of 2031, citizenship and alienage requirements of 2040, and residence requirements of 2051. It does not include cooperation regarding countable income as changes in income do not affect continuous eligibility, loss of contact per 7230, or cooperation with reviews during the continuous eligibility period per 2020.02.
A pregnant woman or minor who initially qualifies for Medicaid or CHIP under another category shall continue to be eligible through the postpartum period even if she loses categorical eligibility under the program she was initially established under. When this occurs, eligibility shall be established under the Medicaid Poverty Level or CHIP program for the remainder of the continuous eligibility period. This would include pregnant persons turning 19 who are no longer eligible for child's poverty level coverage and SSI recipients who lose disability status.
When eligibility ends under one of the above-mentioned programs, and it is later discovered that a pregnancy existed during the CHIP or Medicaid eligibility period, the pregnant woman/minor shall be reinstated and provided with continuous eligibility through the postpartum period. The pregnancy must have existed within the eligibility period and must be reported within one calendar month following closure.
Continuous eligibility shall be provided if eligibility is established for any of the months in the prior medical period (Medicaid only). However, if there is a break in assistance of one or more months during the continuous eligibility period due to residency requirements or voluntary withdrawal, continuous eligibility shall end, and the woman would have to qualify under the poverty level program again or another medical program.
Only one continuous eligibility period is applicable per pregnancy. Thus, if one pregnancy ends during the continuous period and another begins shortly thereafter, the woman must requalify for regular poverty level eligibility for the second pregnancy before having access again to the continuous eligibility provisions. If coverage is approved for a new pregnancy during a previously established postpartum period, a new continuous eligibility period will be set based on the new pregnancy/postpartum dates. If the pregnant woman is not eligible for new pregnancy coverage, she will remain on the existing coverage for the previous pregnancy through the postpartum period at which time she will be reviewed for ongoing benefits.
For persons under the age of 19 eligible under these guidelines, a continuous eligibility period applies beginning the first month of determination and continuing through 12-months postpartum regardless of changes in circumstance.
Once continuous eligibility is established for a pregnant woman, she shall not switch between medical aid codes during her postpartum continuous eligibility period, with the exception of a change from Poverty Level Pregnant Woman to a Caretaker Medical Pregnant Woman category.
2301 Postpartum Period for Pregnant Women - Eligibility for pregnant adults/minors shall continue through the 12th calendar month following the month of birth of the child(ren) or termination of pregnancy provided the individual is or will be a Medicaid or CHIP recipient for the month of birth or pregnancy termination (including prior medical eligibility).
02310 Continuous Eligibility for MCD Adults and Children - Once financial eligibility is established as of the date the case is processed under a MAGI program, all eligible non-pregnant children and adults shall be eligible for a 12-month period (for pregnant adults and minors, see 2300 and 2301). This 12-month period establishes the review period for the family and the individual continuous eligibility dates for all approved members. However, if there is not eligibility in the application month, but eligibility does exist for one or more months of the prior period, continuous eligibility is established beginning with the first month of eligibility in the prior period.
Children and adults who subsequently enter a household, request assistance and are determined eligible for Medicaid shall also receive continuous eligibility for a 12-month period.
Newborns eligible under the provisions of 2320 and pregnant adults and minors eligible under the provisions of 2301 shall have continuous eligibility periods established independent of other household member's continuous eligibility periods, as the periods established for these groups take precedence for these individual family members.
When a family contains individuals eligible under any combination of Family Medical programs, individual continuous eligibility periods may differ. Continuous eligibility periods will not always align with other household members.
2311 Continuous Eligibility (CE) Period - Continuous eligibility begins with the first month of eligibility (see 2310 above) in the current review period and continues regardless of any changes in income. Such eligibility shall continue unless one of the following circumstances occurs:
2311.02 - an individual no longer meets residency requirements;
2311.04 - a recipient on a MAGI program (Medicaid or CHIP) becomes eligible for a non-MAGI program such as HCBS or SSI (including eligibility under the protected class, see MKEESM 2639), Foster Care Medical (FCM), or Adoption Support Medical (ASM) coverage.
2311.05 - the child no longer lives with a caretaker who meets the criteria of 2110. (Continuous eligibility ends for any non-pregnant adult caretakers in the home).
2311.06 - an individual is found to not have been initially eligible due to agency error or fraud;
2311.07 - a CHIP recipient (unless in a postpartum period) becomes eligible for Medicaid.
2311.08 - there is a voluntary request for case closure;
2311.09 - there is a loss of contact in which the individual and/or family's whereabouts are unknown. Continuous eligibility ends for any non-pregnant adults in the home in accordance with 7230;
2311.10 - there is not at least one child in the home or qualifying under temporary absence provisions of 2110. Continuous eligibility ends for any non-pregnant adults in the home;
2311.11 - a non-pregnant adult caretaker fails to cooperate with Child Support Services (CSS). (Continuous eligibility ends for any non-pregnant adult in the home).
In any of the above situations, coverage shall be terminated with the month the circumstances occur or a following month allowing for timely and adequate notice. Continuous eligibility can be reestablished if there is less than a calendar month break in assistance. Otherwise, the individual would have to reapply and qualify again.
Note: CE does not automatically end for recipients or applicants in an incarcerated status (i.e., individuals who become residents of a jail or prison). For eligibility rules related to incarceration, see 2052.05 for Medicaid minors and 2052.07 for adults.
2312 Changes in Coverage during a Continuous Eligibility Period -
2312.01 Extending Continuous Eligibility - The following situations will allow a change in coverage within the CE period and a new 12-month CE period will be set.
a. TransMed (TMD) to Caretaker Medical (CTM)
b. CHIP (PLT) to any Medicaid program (PLN, PLN/PW, CTM, SSI or LTC/HCBS programs)
c. Any MAGI category to any aid code that is higher in the hierarchy.
2312.02 - The following situations will allow a change in coverage within the CE period but will NOT extend the CE period.
a. Changes within aid code, such as PLT/C4 to PLT/C5
b. CHIP Pregnant Woman (PLT/PW) to PLN/PW (CE should remain 12 months postpartum)
c. SOBRA (PLN or CTM) 18-year-old – CE will only remain in place through the month of the SOBRA individual’s 19th birthday.
02320 Continuous Eligibility Medicaid Newborns - A child born to a woman who is eligible for and will receive medical benefits under one of the following categories is automatically eligible for Medicaid coverage and is continuously eligible through the month the child turns age 1 provided the requirements below are met. This includes children born to Medicaid eligible incarcerated individuals as well as children born to women who are only eligible for emergency services due to immigration status (SOBRA) but who are otherwise eligible for one of the named programs. (MKEESM 2691)
a. Foster Care (See 2320.01)
b. Adoption Support Medical
c. SSI Medical
d. Aged Out Foster Care
e. Breast and Cervical Cancer
f. Protected Medical Groups
g. Working Healthy
h. Caretaker Medical
i. Transitional Medical
j. Extended Medical
k. Poverty Level Title 19
The child's identifying information: name, date of birth, and gender must be known to provide continuous coverage. When this information has been provided by the last day of the month the child turns age 1, coverage will be provided beginning with the month of birth. When the birth has been reported, but identifying information is not known, only coverage for the month of birth is provided.
No other eligibility factors must be met except for the fact that the child must be a citizen and a resident of the state. Verification of citizenship and identity is not required for children born to a Medicaid recipient. A loss of contact per 7230 shall not affect ongoing eligibility. Cooperation regarding countable income is not a requirement since changes in income do not affect newborn eligibility.
Newborn eligibility shall be provided if eligibility for the mother is established for any of the months in the prior medical period. However, if there is a break in assistance of one or more months during the continuous eligibility period due to residency requirements or voluntary withdrawal, continuous eligibility shall end and the child would have to qualify under the poverty level program again or another medical program. In addition, if continuous eligibility is not established for the month following the month regular eligibility is lost, it cannot be provided and the child would once again have to qualify for poverty level coverage or another medical program, except as noted in 2230 regarding TransMed benefits.
2320.01 Providing Medicaid Coverage to Newborn Children of Mothers in Foster Care - Newborns of mothers currently receiving foster care medical benefits are eligible for medical benefits under the newborn provisions of 2320. Unless the newborn is also in foster care, it is the responsibility of eligibility staff to establish Medicaid coverage for the newborn child.
The newborn child is ALWAYS entitled to Medicaid in the month of birth. This is true even if the newborn does not physically reside with the mother in the month of birth or following months.
A new application is not required to be filed on behalf of the infant to provide either coverage in the month of birth or continuing coverage. Coverage may be verbally requested, or an application filed, by the mother or the mother's caretaker. If the coverage is requested verbally, sufficient information must be obtained to set up a new case. A new case must be opened with the foster care/minor mother as the Primary Applicant.
If the child is not living with the mother, the current caretaker of the newborn child must file an application for medical assistance to continue coverage for the newborn beyond the month of birth.
For children residing in a group home or residential care facility, the administrator of the facility (or designee) is viewed as a qualifying caretaker of the newborn child for medical assistance. The minor mother's foster parent is also viewed as a qualifying caretaker of the newborn child for medical assistance.
2320.02 Facility Birth Reporting Form for Medicaid Deemed Newborns - ES-4501 Facility Birth Reporting form for Medicaid Deemed Newborns, may be used by a medical facility to report the birth of an infant born to a Medicaid mother, if the child has been transferred to their medical facility due to a medical necessity after birth. The form will not be considered a valid request for coverage if all the fields are not filled out or the mother of the newborn did not receive Medicaid coverage in the month of birth. This form is not considered verification of Citizenship or Identity as it is not a birth confirmation letter.
02330 Inpatient Care for MCD Children - Eligibility for children may end in either the calendar month the child turns age 1 or age 6 based on the differing poverty level determinations. However, if the child is receiving inpatient services in the month, he or she turns age 1 or 6, Medicaid eligibility shall continue through the calendar month in which the inpatient care ends provided the child is or will be a Medicaid recipient in the month he or she turns such age (including prior eligibility). This provision would not be applicable to a child turning age 1 who continues to be eligible using the 133% poverty guideline for children ages 1 to 6 or turning age 6 who continue to be eligible using the 100% poverty guideline for children ages 6 and above. It also does not apply to long term care treatment and, thus, if the child's inpatient stay will exceed the month following the month of entrance, there is no continued poverty level eligibility beyond the month the client turns age 1 or 6. Instead, eligibility would be determined using long term care methodologies. The extended eligibility period is applicable not only to children who were poverty level program recipients in the month they turned age 1 or 6, but also to children who were eligible under another Medicaid program that month and lost that eligibility due to a change in circumstances (e.g., loss of cash eligibility). All general eligibility factors must continue to eligibility would continue to be determined based on the poverty level program rules.
02340 Changes in MCD Family Unit - The following provisions apply in determining the continuous eligibility period for children and adults when household composition changes. These policies are applicable to all family medical programs.
2340.01 Removing an Individual from an Existing Plan - When an eligible individual in a current continuous eligibility period leaves the household, the continuous eligibility period shall not be broken as long as a new request for coverage is received in the month following the month of closure (see 2311). To facilitate the process, the individual shall remain a participating member of the plan through the end of the month following the month the change is reported. This is not necessary if action is being taken immediately to add the individual to a new case so no break in assistance results. Follow the provisions of 2312 when removing an individual if the continuous eligibility period is broken.
2340.02 Adding an Individual to a Plan - An individual meeting the general eligibility requirements of the Medicaid Poverty Level program (2271, 2272 and 2273), the CHIP program (2401, 2402 and 2403), or Family Medical program (2221 and 2222) may be added to a plan effective the month the request is made for coverage. If needed, eligibility may also be determined for three months prior to the month of request. The addition of an individual to the plan will not affect the coverage of any family member that is continuously eligible. See also 3100 - Assistance Planning, 2010 - Act in Own Behalf, 2310 - Continuous Eligibility and 2100 - Child in family. The following guidelines shall be used when making such changes:
(1) - Adding an Individual to an Existing Plan - A new or recipient individual may be added to an existing family medical plan without a formal review. This includes individuals new to the household as well as those previously excluded from the plan because coverage was not requested (see 3120) and those previously ineligible due to nonfinancial criteria (e.g., non-cooperation penalty). A verbal request is sufficient to prompt such action as long as the individual was not previously discontinued due to failure to complete a review. See 1402.
(a) If the individual is already a recipient under a MAGI program and a request is made to add the individual to another existing MAGI program, the individual shall be added to the new program effective the month following termination on the previous program. A new determination of eligibility shall be completed based on the new family group's circumstances to determine the type of coverage the individual will have. Income in the amount already budgeted on the new case shall be used along with income of the individual being added and any new IBU members added to the plan because of the addition of the individual. If the family group cooperates with the application process and the individual is determined eligible using the new family group's income and circumstances, they will be approved for a new continuous eligibility period. No changes will be made to the family’s existing review period. Changes in the type of coverage (Medicaid or CHIP) may result. However, if the family does not cooperate (e.g., fails to provide information) or if the individual is no longer eligible, the individual remains eligible through the end of his/her initial continuous eligibility period under the type of coverage initially provided.
(b) If the individual is not a current MAGI recipient, they are added effective the month of request. Income currently being budgeted for individuals already included in the IBU shall be used to determine eligibility along with the income of the individual being added and any new IBU members added to the IBU due to the addition of the individual. This includes eligibility for months prior to the month of request. If retroactive coverage is requested, the individual may be added to a plan up to three months prior to the month of request.
In either situation, if the family reports a change in income at the time of the addition of the individual, that new income will be budgeted in the month of the application. Any positive changes that may occur for other individuals or to a premium obligation will be made effective the month the request is made for the new individual.
(2) - Adding an Individual to a New Plan - If a new request for coverage is received from a new caretaker or family group for an individual who is a current recipient under a MAGI program, and the family unit does not have an active case, an application shall be obtained. See 2460.01 for requirements to remove an individual from the previous case. If the family cooperates with the application process and the individual remains eligible, a new twelve-month continuous eligibility period is established. However, if the family does not cooperate (e.g., fails to provide income information) or if the individual is no longer eligible, the individual remains eligible through the end of his/her initial continuous eligibility period under the type of coverage initially provided. When processing such changes, it is imperative that action be taken as expeditiously as possible to ensure uninterrupted medical coverage.
Determinations for children impacted when two households combine shall also be treated according to these provisions.
02350 Medically Needy Coverage Related to Children and Pregnant Women - Medical assistance is available for children and pregnant women who are not financially eligible for Family Medical coverage and do not meet the Medicaid poverty level criteria. (See 2271.) Eligibility shall always be determined first for the Medicaid poverty level programs prior to Medically Needy.
2350.01 Age - The person must be under the age of 19 if not pregnant. If pregnant, age is not a factor.
2350.02 Income and Resource Methodologies - The income methodologies of 5000 are to be used in determining eligibility for this group. For a prior medical Spenddown, the prior medical income should be determined using the budgeting methods of 6130 and related sections. There is no resource requirement. The protected income level is based on the number of IBU members (see 3000). Expenses for medical services paid or incurred by the eligible persons or IBU members are allowable in determining eligibility. (See 6500)
2350.03 Medically Needy Spenddown Postpartum Medical Coverage - Eligibility as a pregnant woman ends 12 months following the month of birth of the child(ren) or termination of pregnancy provided that the woman was accurately receiving FFP medical the month of birth or pregnancy termination (including prior eligibility).
02360 Other Programs - Several other programs are available to low-income Kansans to help cover the cost of health care.
2360.01 SSI - Refer to MKEESM 2660
2360.02 Breast and Cervical Cancer (BCC) - Refer to MKEESM 2693
2360.03 Protected Medical Groups (PMG) - Refer to MKEESM 2680
2360.04 AIDS Drug Assistance Program (ADAP) - Refer to MKEESM 2694
2360.05 MediKan (MKN) - Refer to MKEESM 2640
2360.06 Tuberculosis (TB) - Refer to MKEESM2692
2360.07 Medicare Savings Program (MSP) - Refer to MKEESM 2670
2361 SOBRA - Refer to MKEESM 2691.
0245.07 Reasonable Opportunity Period to Provide Documentation (ROP) - The following provisions apply when an applicant or recipient declares U.S. citizenship or an eligible alien status but is unable to provide verification. For information pertaining to qualifying non-citizens, see 2040.
The agency may not request verification of citizenship and identity or alien status from the applicant or recipient if that information is available through an available resource. The agency shall make every effort to verify citizenship and identity or alien status through those resources. The following automated and manual verification resources shall be utilized:
Tier 1 – The Federal Data Services Hub. The Hub accesses the Social Security Administration (SSA) database in real-time to verify citizenship and identity status.
The Electronic Access to Social Security (EATSS) database. If the Hub is not available, EATSS may be accessed to verify citizenship and identity status for those individuals who are current or former recipients of SSI, Medicare, or Social Security disability benefits (2045). EATSS may not be used to verify citizenship or identity of individuals who do not meet those criteria.
Tier 2 - The Kansas Immunization Register (KSWebIZ) database. The KSWebIZ interface is a statewide database that includes immunization records for all Kansas residents that may be used to verify identity only for children.
The Kansas Department of Revenue (Driver’s License) database. The Driver’s License interface may be accessed to verify identity only of an individual with a valid Kansas license.
Tier 3 – Research by the agency. If the agency has been unable to verify citizenship and identity or alien status through the available automated and manual interfaces, staff shall review the case file and imaged documents to determine whether a hard copy verification has already been provided.
Tier 4 – Contact with the applicant or recipient. If the agency is unable to verify citizenship and identity via any of the means above, verification shall initially be waived, and a reasonable opportunity period applied as described below. The individual shall be contacted to provide verification and notified of the reasonable opportunity period.
An application shall not be delayed or denied because the agency was unable to verify citizenship or identity or eligible alien status. If otherwise eligible, the application shall be processed and approved granting a reasonable opportunity period to the individual to provide the verification. The reasonable opportunity period shall be three (3) calendar months commencing from the date the case is authorized. If the individual fails to provide verification (or the agency is unable to independently verify) by the end of the reasonable opportunity period, coverage shall end allowing for timely notification. If verification is provided within the month after the month coverage ends, eligibility may be reinstated without a new application/request. The following examples illustrate:
Example: The agency is unable to verify citizenship or identity for an applicant for medical assistance. Since the individual is otherwise eligible, assistance is approved on 03/11 with notification that verification must be provided by 06/11. Verification is provided within the reasonable opportunity period on 04/23. Eligibility continues without interruption.
If the individual failed to provide verification (and the agency was unable to independently verify) by 06/11, coverage would end effective 06/30 (assuming action was taken by timely notice deadline).
Example 2: The agency is unable to verify a qualifying non-citizen status for an applicant for medical assistance. Since the individual has attested to a qualifying non-citizen status and is otherwise eligible, assistance is approved on 09/29 with notification that verification must be provided by 12/29. The recipient fails to provide verification within the reasonable opportunity period. Coverage ends effective 01/31.
If the individual provides verification by 02/28 (the month after the month coverage ends), eligibility may be reinstated without a new application/request for assistance. If verification is provided after 02/28, a new application/request is required.
Note: An extension of the ROP will be provided if the individual is making a good faith effort to resolve any inconsistencies or obtain necessary documentation, or if the agency needs more time to complete the verification process through the Federal Data Hub or Verification of Lawful Presence (VLP) interfaces. A decision to extend the period must be thoroughly documented and supported in the case file.
02400 General Program Information for the Childrens Health Insurance Program (CHIP) - The CHIP program is designed to cover children up to age 19 who are not financially eligible for Medicaid and whose countable income does not exceed the maximum amount of the federal poverty level. The child must not be covered under current health insurance. If family income is equal to or greater than 167% of the federal poverty level, a monthly family premium is charged for coverage. See the F-8 Kansas Medical Assistance Standards.
CHIP is based on a federal block grant authorized under Title XXI of the Social Security Act. For the most part it is state controlled but is subject to federal funding allotments as well as state funding provided by the Kansas State Legislature.
The CHIP program provides health coverage through KanCare. A capitated payment rate is established by KDHE-DHCF on a per enrollee basis. The overall scope of services covered in the program is similar to those services provided in the Medicaid program. The KanCare Clearinghouse has the responsibility for establishing eligibility based on policies established within the limits set forth in state and federal statutes, the Code of Federal Regulations, and the Kansas Administrative Regulations.
Children who are eligible for Medicaid (SI, poverty level eligible, etc.) do not qualify for CHIP and thus a determination of Medicaid eligibility must be done prior to establishing coverage under CHIP. This includes a spenddown determination if beneficial to the child.
Coverage under the CHIP program is not effective until the day of authorization. See 2470. CHIP is not an entitlement program like Medicaid and coverage availability is subject to federal funding authorized for the program.
The following additional requirements and issues affect the CHIP program.
2401 General Eligibility Requirements - The general eligibility requirements of acting in own behalf 2010 (including the caretaker requirements in 2110), cooperation 2020, citizenship and alienage 2040, and residence 2050 must be met.
2402 Age - The child must be under the age of 19. Coverage may be provided through the end of the month of the individual's 19th birthday unless she is a pregnant woman. See 2300 for pregnant woman standards.
2403 State Psychiatric Hospitals - CHIP coverage continues throughout the month of entrance and the following month, regardless of the anticipated length of stay. CHIP coverage terminates at the end of this period and any continuing eligibility is determined under the Medicaid program. No patient liability is determined during this period; however, any premium obligation continues.
02410 Health Insurance Coverage for CHIP - Health insurance coverage can impact eligibility as noted below.
2411 Uninsured Status - Each child must not be covered by comprehensive health insurance which includes coverage of at least doctor visits and hospitalization. This is regardless of the extent of coverage for these benefits, the cost of the insurance, the amount of any deductibles or co-insurance, or whether the maximum level of benefits for a particular coverage year has been reached. Health insurance coverage shall be deemed not to exist if the lifetime maximum of benefits for the policy has been reached.
Health insurance providing only single types of coverage would be excluded from this definition. Examples of health insurance which would not disqualify a child include:
2411.01 - Dental or vision only coverage.
2411.02 - Prescription only coverage.
2411.03 Long term care insurance - In addition, comprehensive health insurance that is not reasonably accessible to a child because of the distance involved in traveling to participating providers shall also be excluded from this definition. These situations generally involve insurance coverage through an insurance plan that pays for services performed by a limited group of contracted providers. For example, a child is covered under a policy provided by an absent parent who lives in Florida. Although mail order prescription drugs are available and accessible to the child under the plan, the only participating doctors and hospitals are located in the state of Florida. Therefore, comprehensive coverage is not accessible and CHIP coverage would not be denied for this child due to insurance coverage. These situations shall be evaluated on a case-by-case basis however, any situation where routine travel exceeding 50 miles one-way may be evaluated for exclusion under this provision.
If health coverage is obtained while an application for CHIP is still pending, the insurance would be considered for eligibility purposes. If this is obtained after CHIP benefits have been approved, eligibility shall continue for the entire continuous eligibility period (see 2450 below) and then terminated at the time of review if health insurance is still in effect and the individuals remain eligible for CHIP. The same is true if the insurance was present at the time the CHIP benefits are approved but due to a waiting period, the private coverage had not yet begun.
2412 Medical Share Plans - Medical share plans are not considered comprehensive health insurance. These are not licensed medical insurance companies and any medical benefit reported by a consumer will not exclude them from CHIP eligibility. Two of the most common medical share plans are Christian Hospitalization Aid and Christian Care Medi-Share, although this policy does apply to other similar organizations.
02430 Ineligibility for Medicaid - The family does not have the choice between Medicaid and CHIP benefits. If the child is eligible for Medicaid, including coverage through the poverty level or Family Medical programs, coverage must be provided under that program. This also includes pregnant woman coverage if the child is pregnant. See 2510.
However, a spenddown determination is only required if the family requests such a determination for either the prior or current period.
For a child that would be otherwise eligible for CHIP, if there are expenses in the month of application as well as potentially past due and owing expenses which could be used to meet a current spenddown, the family can also be given the opportunity to qualify under the spenddown program (including both Family Medical Spenddowns and Disability-related Spenddowns). If requested, a full 6-month determination would be applicable. If the family can meet the spenddown and it is to their benefit to do so, Medicaid eligibility would be initially established on the case.
The family will need to be contacted to discern if there is a potential for spenddown coverage and the degree to which it will benefit the children. A final CHIP determination would not be made until the spenddown decision is made.
If spenddown coverage is not established, CHIP coverage shall then be initiated. If spenddown coverage is established for the current period, only one 6-month base should be established with a review set at the end of that period to redetermine CHIP eligibility and establish the 12- month continuous eligibility period. If spenddown can be met for more than 1 base period due to using older unpaid bills or current non-covered expenses, spenddown coverage is to be extended for as long as the family or child can meet the spenddown requirement.
Prior medical eligibility provisions currently in effect are applicable to any family seeking such coverage even though they may only be CHIP eligible in the month of application or are not currently eligible for either Medicaid or CHIP. Eligibility can be established either through a poverty level or spenddown determination for the prior 3 months.
02440 Premium Requirement for CHIP - A monthly family premium will be charged for CHIP coverage beginning at 167% of federal poverty. If the total countable income is less than this amount, there is no premium charge. If income is equal to or greater than 167% of poverty but less than 192% of poverty, a $20 monthly premium is charged. If income is greater than or equal to 192% of poverty but less than 218%, a $30 monthly premium is charged. If income is equal to or greater than 219% of poverty but less than 255% of poverty, a $50 monthly premium is charged.
Only one premium per family is charged regardless of the number of CHIP eligible children. The amount of premium shall be based on the highest poverty level percentage determined for the family.
Families that include participating American Indian/Alaska Native (AI/AN) children are not subject to the premium requirements. The classification of AI/AN is based on client statement and will require no further verification. The premium will be eliminated for the family unit in these situations. These families shall never be subject to a premium penalty for failing to pay premiums.
The premium obligation is determined through the eligibility process in KEES and is communicated to the premium billing vendor through an automated interface with the Premium Billing and Collection system which is operated by the premium billing vendor.
The Eligibility Specialist is responsible for providing notification to the family of their obligation, see 1423.
The premium billing vendor is responsible for premium billing, collection, and monitoring. Monthly premium notices will be sent to all families subject to a premium obligation. The initial premium statement will be mailed on either the 1st or 15th of the month, depending on when coverage is authorized. Subsequent monthly premiums will be mailed on the 1st business day of each month.
All premium payments are due on the last day of the month in which they are billed. Premium payments are sent to the following address: KanCare Premium Billing, P.O. Box 842195, Dallas, TX 75284-2195. Payments can also be made by phone by calling 1-866-688-5009. Information regarding premium status is available to staff in KEES and by accessing the premium billing system.
2441 Premium Delinquency - Payment of CHIP premiums is a requirement for CHIP eligibility with the exception of pregnant CHIP minors, see 02510. Failure to pay premiums at review results in the establishment of a three-month penalty period where CHIP coverage cannot be received. The penalty period is considered to be ‘Served’ on the first day of the month following the end of the premium penalty. Once a penalty has been served, that same amount and time periods cannot be used again to terminate or deny CHIP coverage.
An account meets the definition of delinquent when there are two invoices that have not been paid and not previously used in a penalty. These invoices do not have to be consecutive and may occur from two different eligibility periods. An account remains delinquent until the payment is made for the delinquent amount, the penalty is served, or the penalty is shortened. The Premium Billing and Collection (PB&C) system is responsible for determining when an account is delinquent and transmitting that information to KEES so it may be used in the eligibility determination.
A denial or discontinuance for delinquent premiums shall only be applied to individuals who are otherwise eligible for CHIP at the time of their review. For example, if an individual has existing health insurance, they shall be denied or discontinued for that reason. They are not considered otherwise eligible for CHIP, so the delinquency is not relevant to their denial or discontinuance
Penalties are applied at the case level, not the individual level. If there is a request to add a child to a CHIP program where there is a premium delinquency on the case, the child is ineligible for CHIP and a premium penalty would be established. If a penalty is already established and has begun, the child is ineligible for CHIP and will have the same penalty period that has already been established on the case.
2441.01 Penalties and Penalty Statuses - There are four penalty statuses, which will all be updated automatically by KEES depending upon the individual case situation. They are defined below:
- Active - Individuals outside a continuous eligibility period are not eligible for CHIP when there is an active penalty period. When a penalty is first applied to a case it starts in Active status. It will stay in this status until it moves into one of the following statuses. The penalty will be in an active status even prior to the start date of the penalty. The Active status begins from the moment the decision is made to discontinue or deny coverage.
- Negated - A penalty is cancelled before it actually begins. This occurs when the delinquent premiums are paid before the penalty start date.
- Shortened - A penalty is shortened if the consumer pays their delinquent premiums or becomes Medicaid eligible sometime DURING the penalty period.
- Served - A penalty is considered served once the penalty period has ended and no other status changes have occurred.
2442 Impact on Current Recipients - - When an ongoing CHIP recipient fails to pay their premium obligation for two invoices and the account becomes delinquent, coverage is discontinued and a three-month penalty is applied at the time of their next review.
The penalty is established beginning with the first month of ineligibility and is considered to be in an ‘Active’ status.
2442.01 Impact of Payments on the Penalty Period - If a payment is made of the delinquent amount before the penalty start date, the delinquency is resolved and the penalty is placed into a ‘Negated’ status. CHIP eligibility is reinstated without a new request for coverage being required.
If payment of the delinquent amount is made at some point during the penalty period, the penalty is ‘Shortened’. A new request for coverage is required and a new determination is made. If the request is received during the Reactivation period, a verbal request is allowed. After that time, a new application is required, which would include a verbal request for coverage as allowed per 1402.
2443 Impact on Eligibility for Former Recipients - For new applicants, a child who continues to live in the family unit upon which the premium was assigned (i.e., the case number in which the premium was assigned) cannot re-qualify for CHIP until all delinquent premiums are paid or a penalty has been served for the time period in question. This includes children who would be eligible for CHIP coverage without a premium obligation. However, as Medicaid eligibility is not affected by non-payment of premiums, any Medicaid eligible child in the family would still qualify even if there were premiums due and owing from a period in which they were CHIP eligible.
When processing a new request for CHIP, whether a new application or adding a person to an existing program, if the account meets the definition of delinquent, CHIP ineligibility exists. Prior to denial for a premium delinquency, staff must send a notice to the applicant informing them of the requirement to pay. The applicant is given the standard 12-day pending timeframe to pay the outstanding balance. If payment is not made, coverage is denied and a three-month penalty is applied. The penalty is established beginning with the month the application is processed.
2443.01 Impacts of Payments on the Penalty - If payment of the delinquent amount is made at some point during the penalty period, the penalty is ‘Shortened’. A new request for coverage is required and a new determination is made. If the request is received during the Reactivation period, per 1410.02 a verbal request is allowed. After that time, a new application is required, which would include a verbal request for coverage as allowed per 1402.
2444 Collection of Past Due Premiums - Although the penalty period for a past due premium may have been served, and another penalty will not occur for that same premium balance, the past due obligation is not forgiven. The obligation remains on the consumer’s account. Collection activities will continue to be made against the consumer until the balance is paid.
The premium billing vendor applies a special payment methodology to the accounts in such a way that will prevent the case from going into a delinquent status, solely on the basis of how the payments are applied. When the case is actively receiving CHIP, in an ACTIVE penalty or NEGATED penalty, payments are applied to the oldest invoice first. When the case has already SERVED or has a SHORTENED penalty, the payments are applied from the newest invoice to oldest invoice.
2444.01 Fees and Collections of Unpaid Premiums - If the agency incurs a fee associated with the collection of a premium obligation, such as a returned check fee, this fee will be assigned to the consumer and included as a past due amount.
Cases that have become six months past due may be referred to State Debt Set-Off for collection. Any fee charged for collections through State Debt Set-Off and will be assigned to the consumer.
2445 Premium Changes - If a change occurs during the 12-month continuous eligibility period that decreases the family's poverty level percentage (such as a change in countable income or household composition), action is to be taken to reduce or eliminate the premium as necessary.
- A premium reduction or removal is processed in the month after the month of report of the change when it is unrelated to a request for coverage for a household member.
- A premium reduction or removal is processed in the month of report when also processing a request for coverage for a household member.
- A premium shall not be increased for an individual during their continuous eligibility period, unless adding CHIP coverage for a new household member who requires a premium obligation.
A premium change notice is required.
2446 Premium Refunds and Adjustments -
Overstated Premiums - When the agency determines a premium has been overstated for a prior period, immediate action to correct future premiums shall be taken. In addition, a premium is adjusted for a prior period in the following situations:
- An agency error resulted in the incorrect premium; or
- A timely reported change was not acted upon timely and resulted in the incorrect premium.
Failure on the part of the client to report a change timely shall not result in an adjusted premium for a prior period.
To adjust the premium amount for the prior period, the Eligibility Specialist must reprocess eligibility in KEES for each month affected.
Understated Premiums - When the agency determines a premium has been understated for a current or prior period, immediate action to correct future premiums shall be taken. Only adequate notice is required when notifying of the new premium amount. If the client was initially given notice of the correct premium amount, a retroactive adjustment shall be made in KEES. If the client did not initially receive the correct notification, an overpayment shall be established for the prior period.
02450 Continuous Eligibility for CHIP -
2451 Continuous Eligibility for CHIP - Once financial eligibility is established as of the date the case is processed, all eligible CHIP children shall be eligible for a 12-month period, unless pregnant (see 02510). This 12-month period establishes the review period for the family and the individual continuous eligibility dates for all approved members.
Children who subsequently enter a household, request assistance and are determined eligible for CHIP shall also receive continuous eligibility for a 12-month period.
When a family contains individuals eligible under any combination of poverty level children, CHIP, Family Medical, newborn or pregnant women categories, individual continuous eligibility periods may differ. Continuous eligibility periods will not always align with other household members.
2452 Continuous Eligibility (CE) Period for CHIP - For CHIP, continuous eligibility begins with the first full month of eligibility, typically the month following authorization or the first month of a new review period. Coverage continues regardless of any changes in income. See 2311 for additional information regarding exceptions to CE.
CE does not automatically end for CHIP recipients who enter an incarcerated status (i.e., become residents of a jail or prison). For eligibility rules related to incarceration for CHIP minors, see 2052.06.
Beginning January 2024, CHIP coverage may not end during a CE period for non-payment of premiums.
2452.01 - the child turns age 19 (unless pregnant or in a postpartum period, see 02300 and 2301);
2452.02 - the child no longer meets residency requirements;
2452.05 - the child no longer lives with a caretaker who meets the criteria of 2110;
2452.06 - the child is found to not have been initially eligible due to agency error or fraud;
2452.07 - the child (unless in a postpartum period) becomes eligible for Medicaid, including PLN, CTM, HCBS, SSI (including eligibility under the protected class in MKEESM 2639), foster care, or adoption support assistance.
2452.08 - there is a voluntary request for case closure.
2452.09 - In any of the above situations, coverage shall be terminated no later than the month following the month the circumstances occur allowing for timely and adequate notice except as noted. Continuous eligibility can be reestablished if circumstances change and there has been less than a calendar month break in assistance. Otherwise, the child would have to qualify again for CHIP or coverage under another medical program.
Note: CE does not automatically end for CHIP recipients who enter an incarcerated status (i.e., become residents of a jail or prison). For eligibility rules related to incarceration for CHIP minors, see 2052.06. Additionally, beginning January 2024, CHIP coverage may not end during a CE period for non-payment of premiums.
2453 Changes in Coverage during a Continuous Eligibility Period - See 2312 for additional information that may impact the CE period of a CHIP child.
02460 Changes in the Family Unit for CHIP - The following provisions apply in determining the continuous eligibility period for children when household composition changes.
2460.01 Removing a Child From an Existing Plan - When an eligible child in a current continuous eligibility period leaves the household, the continuous eligibility period shall not be broken as long as the new family is cooperating with the agency in adding the child to the new plan (see 2460.02). To facilitate the process, the child shall remain a participating member of the plan through the end of the month following the month the change is reported. This is not necessary if action is being taken immediately to add the child to the new case so no break in assistance results. Follow the provisions of 2452 when removing a child if the continuous eligibility period for a child is broken.
2460.02 Adding a Child to a Plan - A child meeting the general eligibility requirements of 2272 and 2273 or 2402 and 2403 may be added to a plan effective the month the request is made for coverage. If needed, eligibility may also be determined for three months prior to the month of request. (See also 3100 - MAGI Budgeting Units and 2010 - Act in Own Behalf). The following guidelines shall be used when making such changes:
(1) - Adding a Child to an Existing Plan - A new or recipient child may be added to an existing plan without a formal review. This includes children new to the household as well as children previously excluded from the plan because coverage was not requested (see 3100) and children previously ineligible due to nonfinancial criteria. A verbal request is sufficient to prompt such action.
(a) If a child is already a recipient under a MAGI program and a request is made to add the child to another existing MAGI program, the child shall be added to the new program effective the month following termination on the previous program. A new determination of eligibility shall be completed based on the new family's circumstances to determine the type of coverage the child will have. Income in the amount already budgeted on the new case shall be used along with income of the individual being added and any new IBU members added to the plan because of the addition of this child. If the family cooperates with the application process and the individual is determined eligible using the new IBU income and circumstances, they will be approved for a new continuous eligibility period. No changes will be made to the family’s existing review period. Changes in the type of coverage (Medicaid or CHIP) may result. However, if the family does not cooperate (e.g., fails to provide information) or if the child is no longer eligible, the child remains eligible through the end of his/her initial continuous eligibility period under the type of coverage initially provided.
(b) If the child is not a current MAGI, the child is added effective the month of request. Income currently budgeted for individuals already included in the IBU shall be used to determine eligibility along with the income of the individual being added and any new IBU members added due to the addition of the child. If the child falls into the CHIP income range, the additional CHIP requirements of Health Insurance Coverage, 2411, must also be met. If retroactive coverage is requested, a child may be added to a plan up to three months prior to the month of request.
In either situation, if the family reports a change in income at the time of the addition of the individual, that new income will be budgeted in the month of application. Any positive changes that may occur for other individuals or to a premium obligation will be made effective the month the request is made for the new individual.
(2) - Adding a Child to a New Plan - If a request for coverage is made by a new caretaker for a child who is a current recipient under a MAGI program, and the family unit does not have an active case, a review application shall be obtained. See 2460.01 for requirements to remove a child from the previous case. If the family cooperates with the application process and the child remains eligible, a new twelve-month continuous eligibility period is established. However, if the family does not cooperate (e.g., fails to provide income information) or if the child is no longer eligible, the child remains eligible through the end of his/her initial continuous eligibility period under the same coverage initially provided. When processing such changes, it is imperative that action be taken as expeditiously as possible to ensure uninterrupted medical coverage.
Determinations for children impacted when two households combine because of the request for assistance of a mutual child shall also be treated according to these provisions.
02470 Other Issues - Other issues affecting CHIP include the following:
Effective Date of Coverage - In contrast to the Medicaid program where coverage generally begins as of the month of application, CHIP coverage begins on the date that coverage is approved. There is no prior medical eligibility in the CHIP program so any coverage for months prior to the effective date would have to be determined through the Medicaid program. Retroactive enrollment is allowed for certain newborns. See 2500.
A review submitted during the Review Reconsideration period will allow for continuation of coverage, including retroactive coverage in some instances.
02480 Financial Methodologies for CHIP - Financial eligibility shall be determined based solely on income. Resources shall not be considered. The income of all members of the IBU are to be considered. See the MAGI budgeting unit guidelines contained in 3100 and subsections.
Persons age 18 and under who are capable of acting in their own behalf per the guidelines of 2222 shall have eligibility determined in a separate plan. A separate case shall be established in these instances. However, for an ongoing child who turns 18, action to set up a separate plan for the child is not required until the time of the next scheduled review.
To be eligible, the total countable income must not exceed the maximum amount of the federal poverty level guidelines. See the current F-8 Kansas Medical Assistance Standards for these guidelines. A one-month base period shall be used in accordance with 6311.
02500 Other Newborn Issues - Newborn children who are not eligible under the provisions of 2320, shall have their eligibility determined in the following situations:
2501 - When an application is filed for a newborn within 30 days of the date of birth and the newborn is determined eligible for Medicaid or CHIP, coverage will backdate to the date of birth. For coverage requested more than 31 days from the date of birth, a formal prior medical determination would be required, and if CHIP eligible, a Medically Needy spenddown must be offered prior to CHIP approval.
2503 - An eligibility determination is required for all other newborns including newborns that have CHIP siblings. If the newborn is being added to a case with an open medical program, the child shall be added according to 2460.02. If the request for coverage is received within 30 days of the date of birth and the newborn is determined to be CHIP eligible, the child’s effective date of CHIP coverage shall be the date of birth. If adding the newborn to the case reduces or eliminates the premium, the change is effective the month of birth. A spenddown must be offered prior to CHIP approval if the newborn’s request for coverage is received more than 30 days after the date of birth. If there is no current open medical program for the family, a new application is needed.
2502 - If a CHIP eligible member has a child, the child is eligible for deemed CHIP coverage effective the date of birth. For coverage to go back to the date of birth the agency must be notified of the birth prior to the last day of the third month following the month of birth. A baby born to a CHIP beneficiary will have a continuous eligibility period matching that of the CHIP parent and be reviewed at that time. A new application and/or review form is not needed to add the newborn to the case. No verification of the birth is needed to add the newborn, and client statement is acceptable. Verification of citizenship and identity is not required to provide initial coverage. Proof of citizenship and identity will be required at the time of the next review. A loss of contact per 7230 will not affect ongoing eligibility. All other individuals already receiving medical coverage will remain enrolled in either CHIP or Medicaid according to the continuous eligibility provisions. If adding the newborn reduces or eliminates the premium, the change is effective the month of birth.
02510 Pregnant CHIP Minor - If a CHIP eligible child is pregnant, a Medicaid pregnant woman determination is required in accordance with 2271. If the child does not meet these guidelines, she shall then have eligibility determined under CHIP guidelines.
Whether the pregnant minor is approved under PLN or CHIP, eligibility will be established through the end of the postpartum period in accordance with 02300 and 2301 regardless of premium delinquency, aging out, or changes in circumstances other than Kansas residency.
For an ongoing CHIP eligible child who becomes pregnant, the child would continue to be covered under the CHIP program until the end of her 12-month postpartum period.
02520 Child Support Services - There is no requirement to refer a child eligible for CHIP to CSS or that the family cooperate in establishing paternity and support on behalf of the child. A family can voluntarily pursue paternity and support for any CHIP child where there are no Medicaid eligible siblings and should be directed to the local CSS staff if such a request is made. In these instances, a system generated referral shall not be used. There is no penalty for failing to cooperate with CSS on a voluntary referral.
02530 Third Party Resources - A third party is an individual, institution, corporation, public or private agency (other than the applicant/ recipient or the agency) who is or may be liable to pay all or part of the medical costs of a recipient that otherwise would be paid through the medical program.
Individuals eligible for medical assistance will be informed that they have the responsibility to utilize all available medical resources and to inform the agency of any third parties which may have a legal obligation to assume responsibility for payment of any or all medical expenses. (Examples are Medicare and other health insurance.) Refer to 2020 for the eligibility factor related to cooperation and 2540 regarding cooperation with HIPPS.
Third party liability can be considered a resource to the applicant/ recipient in the sense that it is or may be available to meet particular medical expenses, but is not considered against allowable non-exempt resource standards.
No one may be denied Medicaid because of an existing or potential third party resource or other medical resources. See 2400 regarding CHIP eligibility. Payment for a particular covered service may be withheld pending a determination of failure to utilize other medical resources or an existing liable third party (e.g., Medicare extended care benefits for payment of adult care home costs).
In addition, eligibility may be denied or terminated for failure to cooperate in identifying and pursuing third party resources in accordance with 2020 or in cooperation with the HIPPS process in accordance with 2540.
The Case Manager has the responsibility to:
2531 - Ascertain and document legal liabilities of third parties (e.g., private or group health insurance coverage, Medicare, VA, etc.) or of pending lawsuits which might establish such a liability. We cannot require an applicant/recipient provide the information as a condition of eligibility. If partial information is known at the time of the application approval, a partial referral shall be submitted. The MMIS fiscal agent will attempt to identify the needed TPL information in order to create an accurate record. If the fiscal agent is unable to locate the record using the information provided, it is the responsibility of the agency to obtain the information from the consumer. If the consumer either refuses the information or fails to contact the agency, coverage should be denied/closed due to failure to cooperate. Good cause shall apply in instances where the consumer is unable to provide the information but shows an attempt to cooperate.
Note: Condition of eligibility in this sense indicates that Medicaid cannot be denied due to the existence of TPL or for failure to provide full information up front. It does not exempt the consumer from cooperating with the agency in obtaining the information when needed.
All existing health insurance coverage must be notated in the MMIS system. Failure to do so can result in claims being paid incorrectly or in error. However, certain third-party coverage such as Indian Health Services, VA, and Kansas Health Insurance Association coverage are not to be included on the TPL file. Third Party Liability information is captured through the application process and entered KEES. A referral is automatically sent to the MMIS upon case approval. To generate the referral, the following fields must be complete: Case Number, Client ID, Policy Holder Name, Carrier Name, and Policy ID. For partial referrals, use ‘unknown’ in the fields that are unknown at the time of application approval.
2531.01 - Inform the Medical Subrogation Unit in writing of failure of Medicaid consumers to utilize such third-party liability or of pending lawsuits, insurance settlements, etc. which might establish such liability. This is not applicable to CHIP. The Medical Subrogation referral form (Injury) shall be used to notify the unit. (See the Forms.)
2531.02 - Request assistance from Medical Subrogation Unit in writing to help obtain third party resource information from non-cooperative sources such as birth mothers, adoption agencies, or adoptive parents when a Medicaid or MediKan consumer is adopted. This is not applicable to CHIP. The Medical Subrogation referral form (Adoption) shall be used for this purpose. (See KFMAM Forms.)
02540 Health Insurance Premium Payment System (HIPPS) - Based on federal law, States are permitted to purchase employer-sponsored health insurance (ESI) for all clients who have access to such coverage and if it is determined to be cost effective. This includes "COBRA" continuation coverage which allows for continued health insurance coverage through a person's former employer. If it is known such coverage exists for an individual, the case is to be referred as indicated in item 2550 below.
This optional provision has been adopted in Kansas and applies to Medicaid clients except those eligible only under SOBRA provisions. It is not applicable to CHIP. Thus, all employed medical recipients are impacted including those in the medical-only programs such as Caretaker (CTM), TransMed (TMD), and the Medicaid poverty level programs (PLN). Families with children receiving CHIP coverage are not to be referred. In addition, the requirement also affects persons who are legally responsible for a recipient but who are not eligible or for whom assistance is not requested (i.e., a non-eligible parent or spouse such as an excluded stepparent). It is not, however, applicable to absent parents currently providing coverage for their dependents. Establishment of medical coverage for these individuals is a function of CSS. However, if there is coverage available, but the absent parent is not currently providing such coverage, the case should be referred the HIPPS unit.
Coverage can be purchased for non-legally responsible family members (grandparents, aunts, uncles, etc.) if by doing so recipient family members can also be covered. This would be a voluntary action on the part of the person and is not an eligibility requirement. The individual does not need to be living in the same household as the recipient.
The purchase of group health insurance is to be determined as cost-effective if the cost of paying for such coverage is expected to be less than the person's or family's medical expenditures that would otherwise be paid by DHCF. Where cost-effectiveness is shown, the individual is required to enroll for such coverage if he or she is an applicant/ recipient and the State would be responsible for paying the cost of the insurance for the client and all Medicaid eligible family members, including the premiums, deductibles, co-insurance, and other cost-sharing obligations. In addition, when a non-eligible family member must be enrolled in the health plan in order for the client to receive coverage, the State must also pay the premiums for that member, but no other cost-sharing expenses would be covered. Persons for whom coverage is purchased will continue to receive medical assistance as long as they remain eligible. HIPPS only provides for the establishment of third-party resources.
HIPPS has been developed jointly by DHCF and the fiscal agent for Kansas. The fiscal agent has the primary responsibility for administering the project which includes gathering information from clients, employers, and insurance companies concerning availability and extent of health insurance coverage, determining cost-effectiveness, and payment of insurance costs.
This affects only employer-based plans and no other types of private or group insurance. The client must cooperate in providing information concerning potential health insurance coverage and in enrolling for such coverage if it is cost-effective. Failure to do so shall result in ineligibility as indicated below. The following is a description of the basic requirements:
Enrollment Process - Individuals eligible for HIPPS are part of the managed care population and will receive a HIPPS Information Form with the managed care enrollment packet. Individuals should fill out the form and return it to the address listed on the form to find out if they qualify for the program. Individuals may contact the HIPPS unit directly for more information about the program.
02550 HIPPS Referral - Referral Process - Staff should send HIPPS referrals in instances where DCF, DHCF, or contract staff become aware of a family where at least one family member is working (or eligible for COBRA coverage) and has high medical expenses, a serious illness, and/or has an employer who offers low-cost family coverage. In these instances, staff should fill out the Health Insurance Premium Payment Information Form and send it to the HIPPS Unit.
The form should be completed as thoroughly as possible by the Case Manager. It is not necessary to send the form to the client, but additional information not available on the Information Form may need to be obtained by the HIPPS unit, including information on pre-existing medical conditions. If information is known about such illnesses, a determination on the cost-effectiveness of the policy as described in item 2560 below can often be made quicker. The Specialist does not need to verify that coverage exists prior to sending in the HIPPS Information Form. The HIPPS unit will make a final determination on coverage availability. Referrals should be sent whenever an eligible individual or a legally responsible individual is employed. But no referral should be sent when it is known that coverage is not available (e.g., situations where the employment is part-time and the company only offers coverage to full-time employees.) Those persons whose only employment is in a sheltered workshop setting should not be referred unless it is known that health coverage may be available.
If the client is covered through a policy held by an absent parent, no referral should be sent. It is assumed that coverage for these children was established by CSS as part of a medical support order. However, if the health insurance is available through an absent parent, but the child is not enrolled, a HIPPS referral should be sent. The policy will be reviewed and, if determined cost-effective, eligible children will be enrolled. HIPPS staff will ensure that CSS has not established the policy as part of the medical support order by checking the TPL file prior to enrolling any child in coverage provided by an absent parent. If the agency is aware that the employed individual is not authorized to work in the country (according to INS) a referral shall not be made.
Failure to cooperate in providing information concerning the completion of the referral can lead to denial of eligibility as indicated in item 2560 below.
Once a completed referral is received by the fiscal agent from the individual or the Specialist and the availability of coverage is established, the fiscal agent contacts employers and insurance companies to determine cost, enrollment restrictions, restrictions on pre-existing conditions, etc. This information will be used to determine cost-effectiveness. Special forms have been developed to gather this information and it is likely that it could take a maximum of 90 days to complete. If any additional information is needed, local staff may be contacted. Otherwise, staff will receive no additional feedback.
NOTE: Those persons whose only employment is in a sheltered workshop setting should not be referred unless it is known that health coverage may be available.
02560 HIPPS Cost Effectiveness - Cost Effectiveness Determination - Upon receipt of all information from the client, employer, and insurance company, the fiscal agent will determine if there is a likelihood that paying for the coverage would be cost-effective to the agency. This will be based on specific criteria which will analyze such things as the type of coverage available, the total cost of that coverage including all cost-sharing requirements, and any waiting period restrictions along with limitations on pre-existing medical conditions. This will then be compared with the historical claims data on a sample group which have like characteristics such as age, sex, type of coverage, etc. In addition, any medical expenses associated with known pre-existing and chronic illnesses are factored in. Based on this analysis, including both automated and manual procedures conducted by the HIPPS Unit, the coverage will be either approved or denied for health insurance purchase.
The client as well as the Case Manager, will be informed of the results by the HIPPS Unit. A copy of the approval or denial letter to the client will be provided to the Case Manager to include in the case file. On-line screens in the MMIS system are also available to provide this information. (See the SRS/MMIS User Reference for Field Staff Manual.)
The employer will be notified of an approval only when enrollment needs to take place or payment will be made directly to the employer. The insurance company would also be notified of an approval if payment will be made directly to the company. If denied, the employer and/or insurance company will only be notified if there was a reevaluation of a policy currently being paid that will be discontinued.
Once cost-effectiveness has been determined it will not be reevaluated unless there are changes in circumstances. This would include such things as loss of eligibility, loss or change in employment, change in the health insurance plans offered or in the cost, and changes in family composition. The HIPPS Change Report Form should be used to communicate any such changes in insurance/employment status to the fiscal agent as they become known.
If a person does not initially meet cost-effectiveness guidelines and staff become aware of changes in his or her situations that might lead to a different decision, a new referral should be sent to the fiscal agent for a new determination. The form should indicate that is a redetermination and what the event was that changed in the specified section of this form.
02570 HIPPS Payment Process - As noted above, if the health insurance coverage is determined to be cost effective, the client will be notified of the decision along with the employer and/or insurance company. If the individual is not currently enrolled in the health plan, he or she is required to complete that process. As indicated previously, the client must enroll as a condition of eligibility. Failure to do so would result in ineligibility for only the affected client. See item 2560 below. The fiscal agent will inform field staff if the individual has failed to cooperate around the enrollment process so that negative action can be taken.
Once the enrollment process is complete, the payment process will be determined. Payment will only be made starting with the month of enrollment, not for any prior months. The primary payment issue will be concerning the premiums since all cost-sharing charges will be handled through the normal claims process. All coverage that is purchased for an individual or family will be automatically entered into the TPR files at by the fiscal agent.
2571 Payment of Premiums - Premiums will likely be paid directly to the employer or insurance company so that the client will not be directly involved. However, there will be some instances in which such an arrangement cannot be made, such as when the employer requires that coverage be paid for only through a payroll deduction. In these instances, the fiscal agent will have to arrange for a direct reimbursement check to the client. A process has been established to provide such payments. These would be made in a timely fashion as soon after the payment has been made by the client as possible. This should generally be within two weeks' time at most. Such reimbursement checks would be exempt as income per 5400.
Verification of any payroll deduction will usually not be required of field staff as the fiscal agent will have this information at the time of enrollment in order to begin making direct payments. Staff should reverify this information at the time of each review if there are no other changes in the interim. If the client must make other payment arrangements such as paying the insurance company directly, field staff will need to request verification from the client for reimbursement purposes. No reimbursement payment will be made without such verification.
Should the client discontinue the payroll deductions or other insurance payments; negative action would need to be taken to terminate eligibility for the individual. If the fiscal agent become aware of payments being discontinued or of enrollment being terminated, they will contact the Case Manager. If the Case Manager becomes aware of such instances, they are to refer the information to the fiscal agent immediately to stop reimbursement and take negative action as quickly as possible.
2572 Termination of Payments - As previously mentioned, there are a number of changes that could lead to the termination of premium payments. This would include changes in circumstances that result in loss of cost-effectiveness, elimination of coverage by the employer or insurance company, loss of eligibility or employment, change in employment, and disenrollment in the plan by the client. In all instances, payment will be stopped as soon as possible and the client will be notified of this by the HIPPS unit. Clients will be given as much advance notice as possible of the payment termination and they will be instructed to contact the employer or insurance company if they wish to retain coverage on their own.
Staff will receive copies of the termination notices sent for case file purposes. No further follow up action is required of staff other than to pursue any potential effects on eligibility as indicated in item 2590 below.
02580 HIPPS With a Spenddown - Treatment of Spenddown Cases. Coverage of health insurance cost under HIPPS will only be applicable to those persons who are eligible for medical assistance, other than the payment of premiums for non-eligible individuals as referred to earlier. As persons in spenddown status are not technically "eligible" for benefits until the spenddown is met, enrollment in and payment of employer insurance coverage under HIPPS would not be potentially applicable until the spenddown is met. In general, it is not expected that the majority of spenddown cases will meet cost-effectiveness criteria unless one or more of the family members has an ongoing chronic medical condition (such as AIDS, heart problems, cancer, etc.) and ongoing expenses arising from this condition that consistently meet spenddown.
If there is no indication of an ongoing condition or the likelihood of meeting spenddown, the information would not be referred. If, for instance, the only ongoing as well as projected medical cost for a family is the cost of employer health insurance they are already paying for, there would be no good reason to refer to the HIPPS project. These kinds of cases would likely not meet cost-effectiveness criteria and, by picking up the cost of the family's premium, the family may no longer be able to meet spenddown.
In essence, this initial screening shall be regarded as a type of cost-effectiveness determination. It is applicable primarily to new applicants who have had no previous track record in terms of assistance or of having specific or ongoing medical needs. If, upon meeting spenddown for the first time, there appears to be the likelihood for additional medical expenses or recurring medical needs, the case is to be referred to the HIPPS Unit. Otherwise, the case should be reviewed again at the time of redetermination or at the time any medical change becomes known and a possible referral made at that time once spenddown has been met.
For ongoing cases, the same rules would generally apply when a client begins work. Once spenddown is met, the Case Manager specialist should briefly review the situation based on expenses presented and their knowledge of the recipient or family. If spenddown has been met for at least 2 base periods and there appears to be likelihood this will continue because of medical conditions, a referral should be sent to the HIPPS unit for processing. The HIPPS unit will then determine cost-effectiveness in these instances but not take action to begin enrollment and payment until spenddown is met as indicated above for applications.
02590 HIPPS Eligibility - Impact on Eligibility - As mentioned previously, the client must cooperate in providing information to complete the form as well as enrolling for and retaining employer health insurance coverage that has been determined cost-effective. Per 2020.03, failure to do so in either the cash or medical programs would result in ineligibility for the affected individual. That individual would be the person who is employed.
For CTM purposes, if the individual is a parent or other caretaker, only that individual would be rendered ineligible. For all medical-only programs including SI, CTM, and TransMed, only the individual would be ineligible.
There is a potential for good cause to be granted in some instances. As situations become known that may involve good cause, they are to be referred to the Area EES Field Administrator for consultation with EES and AMS central office staff.
02600 Certificates of Creditable Coverage - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that group health plans furnish certificates of creditable coverage whenever an individual's health coverage ceases. HIPAA lists Medicaid and most health insurance plans, as forms of creditable coverage. CHIP is also considered creditable coverage. The purpose of the certificate is to document that the individual had prior health coverage and thus reduce or eliminate any preexisting condition exclusion under subsequent health benefit coverage the individual may obtain. As long as an individual's creditable coverage is not interrupted by a significant break (defined has a break of 63 or more full days where no creditable coverage exists), creditable coverage may be combined from different periods. A group health plan must reduce the length of any preexisting condition exclusion period they apply by the amount of the individual's creditable coverage. A coverage period of 18 months or more would eliminate any exclusion period.
Certificates of creditable coverage are issued to Medicaid recipients under any program, including those covered under the SOBRA provisions, those losing automatic medical coverage as a result of termination of cash assistance, and persons terminated from TransMed. Certificate issuance is the responsibility of the Fiscal Agent. Certificates are sent out once a month to all individuals whose medical eligibility terminated the first day of the prior month. The certificate documents all periods of creditable coverage in the past 24 months. For spenddown consumers, only the base periods in which the spenddown is actually met are considered creditable and, in such instance, all six months are credited. Certificates are not sent to individuals with a date of death on file.
NOTE: Certificates for CHIP eligible individuals will be the responsibility of the contracting HMO to issue.
Replacement certificates can be sent to individuals, employers or insurance companies upon request. These certificates are issued through the MMIS.
2610 Notice of Privacy Practice - The Health Insurance Portability and Accountability Act (HIPAA) also requires group health plans to provide a notice explaining the uses and disclosures of protected health information to participants in the plan. All health care assistance programs administered by KanCare, including Medicaid, MediKan, CHIP as well as other state-funded groups (such as tuberculosis coverage) are considered group health plans for purposes of this requirement. The notice must also explain the legal duties and responsibilities of the agency and provide an explanation of the rights of the insured. The Notice of Privacy Practice (NOPP) is used for this purpose.
03100 MAGI Budgeting Units - A MAGI Budget Unit is defined as a person or group of people that must be included in a single applicant’s eligibility determination. The budget unit is based on the expected tax household. All Family Medical programs determinations are based on the concept of the Individual Budgeting Unit (IBU.) See 2140 for temporary absences.
There is one Budget Unit for each member applying for coverage. Tax household members may be included in the Budget Unit of other household members, but each individual has a unique Budget Unit that is used to determine their individual eligibility. This is known as the Individual Budgeting Unit (IBU).
Much of the MAGI determination is based on an applicant’s planned tax household. What we need to know is if the applicant intends to file taxes and who they intend to claim on the tax return. The budget unit is not based on how an individual actually files their taxes, but on how they plan to file them. The questions on the application should be answered based on how the individual would file taxes if they filed today.
Obtaining tax household information is a requirement of eligibility. In the application process, each individual is required to respond to a set of questions which are used to determine the budgeting unit. This information includes whether or not the individual plans to file taxes, if they will file jointly with a spouse, and who will be claimed as tax dependents on that tax return. It is also necessary to obtain information about the tax household when an individual is being claimed by someone not in their home. The information may be obtained verbally or through KEES form V777.
Note: Tax household members not living in the home must be added to the case in KEES. This allows them to be used for the individual budget unit. Their income must also be included so it can be counted for the individual budget unit.
Refer to the MAGI – Building Individual Budget Units and MAGI Individual Budget Units (IBU) Examples found in the KDHE Eligibility Policy Appendix for additional information.
3110 Filers - Individuals who plan to file taxes or are expected to be claimed as a tax dependent by someone else are considered Filers. Their IBU includes themselves, their spouse if living together and all individuals claimed as dependents on their tax return.
3120 Non-Filers - Individuals who do not intend to file a tax return or be claimed as a tax dependent, are considered Non-Filers. Their IBU includes the following:
IBU for an adult: Individual, spouse, and individual’s children (biological, adopted, and/or step) who are under age 19 if living in the home.
IBU for an individual under age 19: Individual, individual’s parents (biological, adopted, and/or step), individual’s siblings (natural, adopted, and step) who are under age 19 if living in the home, and individual’s children (biological, adopted, or step) who are under age 19 if living in the home.
3130 Individuals Claimed as a Dependent - When an individual is claimed as a dependent by another, there are a series of questions we must ask in order to determine if the individual’s IBU is based on the tax household or on the Non-Filer rules. These questions are referred to as ‘exceptions’ on the MAGI IBU Examples document. These questions are:
• Is the individual being claimed as a dependent by someone other than their spouse or parent (biological, adopted, or step?)
• Is the individual under age 19 and being claimed as a tax dependent by only one parent, but living with both parents (biological or adopted?)
• Is the individual under age 19 and being claimed as a tax dependent by a parent (biological or adopted) not in the home?
A ‘yes’ answer to any of these questions indicates that the exception has been met and the individual’s IBU is determined based on the Non-Filer rules.
When none of the exceptions is applicable, the IBU includes the following:
The Individual, the tax filer claiming the individual, the tax filer’s spouse if filing jointly, and all additional persons the tax filer is including as tax dependents. Note: In this situation, it is not relevant if the tax filer, tax filer’s spouse, and other tax dependents live in the same home as the individual.
3140 Inclusion of the Spouse - If not already included in the IBU using the rules above, the spouse of the taxpayer and the spouse of the individual shall be included in the IBU when they reside in the same home.
3150 IBU for a Pregnant Woman - When determining the IBU of the pregnant woman, add the number of babies that are expected for that pregnant person. This is based on self-attestation by the applicant. If staff determine the reported information on the number of babies expected is questionable, verification may be requested.
03200 Additional IBU Provisions - The following additional principles are applicable to MAGI Individual Budgeting Units.
3200.01 - Individuals aged 18 and younger who plan to file taxes, reside with their parents and their parents are not claiming them as a tax dependent are to be determined using the non-filer rules as outlined in 3120.
3200.02 - Marriage establishes legal responsibility between the couple. Any marriage (including same sex) validly established in Kansas or another jurisdiction either through a civil licensed contract or by common-law (see 3200.03) shall be recognized. Once established, the marriage (both civil and common-law) may only be dissolved through a formal divorce court proceeding.
3200.03 - A common-law marriage establishes legal responsibility between the couple. To be considered common-law married, the couple must meet all of the following conditions:
a. have the legal capacity to marry, meaning they are at least 18 years old, legally competent, and not already married to someone else
b. consider themselves to be presently married
c. hold themselves out to the public as married
3200.04 - When an unmarried couple indicates they will file jointly, staff must first make contact to clarify their tax filing intention. If after contact, the couple still attests that they are not married or common-law married and attest to filing jointly, the non-filer rules shall be used for all household members.
3200.05 - In situations where an individual is a member of the budgeting unit, but their income is not included in the determination, such as when the IBU member is an SSI recipient, the individual will be provided with a role in KEES called ‘Family Size Only’.
05000: Income Guidelines - There are two types of income, earned and unearned. Income shall include money received from such sources as wages, self-employment, unemployment compensation, property rentals, and pensions.
Modified Adjusted Gross Income (MAGI) is the budgeting methodology used to determine eligibility for all family medical programs. MAGI budgeting is directly tied to federal income tax rules. Income that is taxable according to federal income tax rules is countable for family medical programs. In addition, tax-exempt Social Security income, interest and foreign income are countable.
Income types not specifically addressed as countable or exempt in the following sections will require research to determine if the type of income is taxable according to federal income tax rules. This will be the deciding factor on whether or not income is counted.
05100 General Guidelines - The following general rules are applicable:
5110 - Income must be real. To be real, income must be such that its value can be defined and measured.
5110.01 - Income value must be established by objective measurement.
5110.02 - Income shall be considered available when a client has a legal interest therein and the legal ability to make it available. Earned income is available to the individual producing it and all persons for whom he is a member of their individual budget unit. Unearned income is available to the individual for whom it is intended and all persons for whom he is a member of their individual budget unit.
5110.03 - The income of all persons who are included in the individual budget unit must be considered but will not always be counted. See 5130 for additional information about when an individual may be in the IBU but not have their income included in the determination. If, in the month of application, a member of the IBU has left the home, his or her income shall not be considered as being available to the family in that month. Also see 5400.
5110.04 - A conversion of property from one form to another shall not be considered as income except for the proceeds from a contract for the sale of property.
5120 MAGI Income Threshold - The MAGI Income Threshold is the minimum income requirement that establishes if an individual is required to file taxes is set by the Internal Revenue Service (IRS) and is subject to periodic changes. The MAGI Income Threshold is used to determine when income shall be counted for certain children and tax dependents. It does not apply to non-dependent adults or to children living with non-parental caretakers.
The MAGI Income Threshold is defined annually by the IRS for the previous tax year. The current threshold amounts/limits can be located in the F-8 Kansas Medical Assistance Standards chart in the appendix of the KanCare Policy website. Individuals whose income is above the MAGI Income Threshold are required to file a Federal tax return. Whether or not they actually file a tax return has no impact on how their income is counted for medical assistance purposes.
Note: The MAGI income threshold does not apply to SSA income. SSA income is only counted for minors and tax dependents who have taxable income from earnings or interest/dividends. Otherwise, it is considered exempt.
5130 Countable Income for a Child or Tax Dependent - The countable income of a child or tax dependent may be excluded from their own IBU and other IBUs for which they are a member of according to the rules below.
5130.01 Non-Filer Budgeting Units - When the IBU is based on the non-filer rules as defined in 3120, the income of a child (under age 19) will be excluded when their income is below the MAGI Income Threshold and their parent or step-parent is in the IBU.
When these requirements are not met, all taxable income of the child is included in their own IBU and any IBU that they are a member of.
5130.02 Filer Budgeting Units - When the IBU is based on the filer rules as defined in 3110, also known as Tax Household Budgeting Units, the income of a tax dependent will be excluded when their income is below the MAGI Income Threshold and they are a tax dependent of the Primary Taxpayer. When these requirements are not met, all taxable income of the tax dependent is included in their own IBU and any IBU that they are a member of.
05200 Unearned Income - Unearned income is any income that is not earned and may be derived from benefits (unemployment compensation, Social Security, VA, etc.), pensions, contributions, and settlements. Unearned income received or reasonably assured to be received in a month or in the eligibility base period shall be considered.
Gross unearned income shall be considered unless exempt as noted below.
5210 Unearned Income Payments - Unearned Income Payments
5211 Regular Unearned Income - Regular unearned income shall be considered as income when it is reasonably assured to be available in the same monthly amount in the future. Regular unearned income shall be budgeted in accordance with 6000 and subsections.
5212 Irregular Unearned Income - Irregular unearned income results from income which varies in amount from month to month and is expected to continue. Irregular unearned income shall be budgeted in accordance with 6000 and subsections.
5213 Intermittent Unearned Income - Intermittent unearned income is received on other than a monthly basis such as quarterly, semiannually, or annually. It must be considered and averaged. See 6113. Intermittent unearned income received prior to the first eligibility period shall not be considered. The case record shall clearly indicate that the income is being treated as "intermittent" unearned income.
NOTE: An additional benefit check is provided on an annual basis to retired members of the Kansas Public Employer's Retirement System (KPERS) who began receiving a benefit prior to July 2, 1987. This 13th check is generally identical in amount to the monthly benefit. This check is to be treated as intermittent income and budgeted over the entire year by dividing by 12.
5214 Lump Sums - MAGI income (as defined in 5000) received as a lump sum is counted as income only in the month received.
05220 Countable Unearned Income - The following sections outline the types of countable unearned income.
5220.01 Annuities Income - Payments from an Annuity are countable if they are taxable. Verification is required. If it is not clear if the income is taxable, send the documentation to the Policy Manager for review.
5220.02 Contract Sales - The proceeds received from the contract sale of property are considered unearned income and are countable. Verification is required.
5220.03 Dividends - Regular payments of dividends earned from an investment are countable as income.
5220.04 Insurance Payments - Only recurring insurance payments that are unrelated to life insurance, burial proceeds, death benefits, or the repair and replacement of property are countable. Verification is required. See 5406 for more information about exempt insurance payments.
5220.05 Interest - Regular payments of interest earned from an investment are countable as income.
5220.06 Lottery/Gambling Winnings - Gambling winnings from any source are treated as unearned income in the month received. Gambling winnings are generally cash, prizes or in-kind items won in a game of chance, including but not limited to lotteries, sweepstakes, wagering pools, bingo games, card games, roulette wheels, dice games, slot machines, or any other game involving an element of chance.
Gross amounts are counted even if taxes are taken out prior to paying the household. Gambling winnings are countable using prospective income budgeting standards per 06100 only if the income is expected to continue. In the case of qualified lottery and gambling winnings of $80,000 or greater received in a single payout, the income is to be counted in the month received through a period of up to 120 months, as determined by a formula provided by the 2018 statute, see T5 Gambling Winnings – Income Budgeting Table. Per federal guidelines, states must apply this formula to qualified lottery or gambling winnings received on or after January 1, 2018.
With the exception of winnings resulting from games conducted by a tax-exempt religious or charitable organization, any winnings from a lottery, sweepstakes or wagering pool sponsored by a state, multi-state or multi-jurisdictional lottery organization, or any lump sum winnings from bookmaking, slot machine, roulette wheel, dice table, lottery, numbers game, or similar game of chance conducted by a private or for-profit individual or organization shall be counted in accordance with the T5 Gambling Winnings – Income Budgeting Table. Information received on the application or verbally from the consumer regarding the date of receipt and the gross amount of winnings shall be used by KEES to calculate the monthly amount to be budgeted for this income.
Note: With respect to non-cash prizes, like car or boat, these should continue to be considered as lump-sum income in the month received.
Continued eligibility shall be granted where the counting of income as indicated in this section results in ineligibility and loss of coverage and causes undue medical or financial hardship. For purposes of this provision, hardship shall be defined as follows:
1. Medical Hardship – The individual must demonstrate that the loss of eligibility put the individual at risk of death or permanent disability without the medical coverage.
2. Financial Hardship – The individual must demonstrate that the gambling winnings being counted as income are no longer accessible or available to meet medical needs.
When hardship is granted, the gambling winnings shall no longer be counted as income in determining eligibility beginning with the month the hardship was requested.
5220.07 KPERS - Payments received from the Kansas Public Employee Retirement System (KPERS) are countable as income.
5220.08 Native American Tribal Disbursements - This income type refers to income received from casino profits, also known as Per capita income. Income from gaming is countable. All per capita income received by a Kansas Tribe Members is from gaming. Non-Kansas tribes will require additional research to determine the purpose of the disbursement in order to assess whether it is countable or exempt. When this income is received on other than a monthly basis, it is considered intermittent unearned income and the rules of 5213 apply. Also see 5409 for more information about Native American income types that are exempt.
5220.09 Oil Royalties/Mineral Rights - Payments from Oil Royalties and Mineral rights are countable. Verification is required.
5220.10 Pensions - Income payments from a pension are countable. Benefits are considered the income of the person for whom they are intended.
5220.11 Per Capita - Another term used for Native American Tribal Disbursements. See 5220.08.
5220.12 Railroad Benefits - Railroad benefit payments are countable. Benefits are considered the income of the person for whom they are intended. Verification is required.
5220.13 Rental Income - Income from rental properties shall be treated as countable self-employment income. See 5330.
5220.14 Retirement Income - Retirement income is countable. Benefits are considered the income of the person for whom they are intended.
5220.15 Social Security - Income from Social Security Disability and Retirement benefits are countable. Benefits are considered the income of the person for whom they are intended.
5220.16 Spousal Support - Spousal support payments, or alimony, as a result of a divorce decree effected or modified after December 31, 2018 are not taxable and are thereby considered exempt income for MAGI purposes; however, spousal support payments from agreements made prior to December 31, 2018 continue to be countable. When this is the case and the spousal support is paid through the court, the gross amount before the fee is deducted is considered countable income. The amount of the fee is considered a household expense and is not to be excluded as income.
5220.17 Trust Income - Payments from a non-special needs trust are countable if they are taxable. Verification is required. If it is not clear if the income is taxable, send the documentation to the Policy Manager for review.
5220.18 Unemployment Compensation - The gross amount of unemployment compensation is countable income, even if some of the payment has been intercepted for payment of child support or other repayment plans.
05300 Earned income - Earned income is income which is received as wages, salary, or profit resulting from the performance of services, including managerial responsibilities, by the recipient. Earned income may be derived from self-employment in the client's own business.
5311 Regular Earned Income - Regular earned income results from earnings which are reasonably assured to be available in the same monthly amount in the future. (See 6000 and subsections for budgeting.)
5312 Irregular Earned Income - Irregular earned income results from earnings which vary in amount from month to month and are expected to continue. From a practical standpoint, irregular earnings result from full- or part-time employment when payment is received on any basis other than monthly or twice a month. (See 6000 and subsections for budgeting.)
5313 Intermittent Earned Income - Intermittent earned income is received on other than a monthly basis such as quarterly, semiannually, or annually. Such income is to be considered and averaged. Intermittent earned income received prior to the first eligibility period shall not be considered.
05320 Countable Earned Income - The following sections outline the types of countable earned income.
5320.01 Wages - This is income earned from a job. It includes wages earned for hourly work or a salary. Wages also includes bonus pay received while an employee. Wages received from On-the-Job Training (OJT) are also to be considered as earned income.
Sick pay received for time off while working (i.e., short-term illness) shall be considered earned income when the person is still considered an employee by the employer and the person will be returning to work when recovered. However, when these payments are provided as a temporary disability insurance or worker's compensation the income is not counted as earned income. See also 5400.
Wages withheld by the employer to purchase benefits are counted as earnings in the pay period that the employee would have normally received them. Benefit "credits" offered in addition to wages which can be used to purchase benefits are not counted as income. If the employee does not use all of the credit to purchase benefits, and the employer pays the excess to the employee as part of their wages, the excess paid is counted as earned income.
5320.02 Bonus and Commission Income - Income from bonuses that are received monthly or more frequently shall be included in the amount of earnings from wages. When bonuses are received less frequently then on a monthly basis they shall be treated as intermittent earned income and only countable once they have been received during an eligibility period. See 5313.
5320.03 Garnished or Diverted Wages - Available income shall not be reduced by wage earner plans, garnishments, income withholding orders and similar types of income reductions. Such forms of income withholdings are generally used to meet the individual's previous or ongoing obligations and are considered available for the purpose of determining medical eligibility.
Wages earned by a household member that are garnished or diverted by an employer and are paid to a third party for a household's expenses, such as rent or child support, shall be considered income. However, if the employer pays a household's rent directly to the landlord in addition to paying the household its regular wages, the rent payment shall be excluded as a vendor payment. In addition, if the employer provides housing to an employee, the value of the housing shall not be counted as income.
5320.04 Military Pay - Military pay is countable as earned income with the exception of most special allowances. Members of the military receive monthly allowances for housing, subsistence, and other reasons. Income from allowances is non-taxable, therefore exempt, with the exception of CONUS COLA which is a monthly Cost of Living Allowance for members stationed in the United States. The two most common allowances, Basic Allowance for Housing (BAH) and Basic Allowance for Subsistence (BAS) are exempt.
5320.05 Overtime - Overtime income is countable and shall be included with regular wages when determining an average.
5320.06 Tip Income - Income from tips shall be included in the amount of earnings from wages for each pay period. Use the amount of average tips reported by the applicant when not included on the paystubs
5320.07 Wages Withheld/Salary Advances - Wages are sometimes paid in advance to an employee, usually at the request of the employee. Wage advances are not counted as income received. Repayment of those advances are not deducted from gross income, either.
However, wages held by the employer as a general practice, even if in violation of the law, shall not be counted as income to the household. For example, it is routine in many places of employment for the first week or two weeks of wages to be withheld and not paid until the following pay period. This is legal and the wages would not be counted until received.
5320.08 Work Program/Training - Income from a Work or Training program, such as College Work Study, WIA - Earned, Job Corps, and AmeriCorps/VISTA are countable.
05330 Self-Employment - Self-Employment income is earned income received directly from one's own business, trade, or profession. Some guidelines to determine if an individual is self-employed include whether the person: (1) holds himself out as a business (e.g., advertises), (2) decides when and where to work, obtains own jobs or sales, and pays own expenses, (3) has a risk of a profit or loss, and (4) pays his own FICA and income taxes (although this guideline, by itself, does not necessarily establish self-employment). The absence of one or more of these criteria indicates that the activity is not self- employment. Each situation must be evaluated on a case-by-case basis and documented in the case file as to whether a certain income is self-employment or not. An adjusted gross income amount must be determined by deducting income producing costs from the gross earnings.
5330.01 - Income from rental property and other income-producing personal property shall be considered self-employment earned income, regardless of the amount of time engaged in the production of the income.
5330.02 - A loss from self-employment cannot be deducted from other income nor can a net loss of a business be considered as an income producing cost.
5330.03 - When at least one person has wages and at least one person is self-employed, separate calculations are required and the countable incomes are then totaled. Self-employment income shall be considered and averaged. (See 6200)
5330.04 - Payments from a roomer or boarder shall be treated as though it were self- employed earned income.
5330.05 - Income from “gig economy” such as (but not limited to) food delivery services, ridesharing or freelance work shall be evaluated on case-by-case basis to determine if it is self-employment or employment.
05400 Exempt Income - With the exception of non-taxable Social Security, non-taxable foreign earned income, and tax-free interest, only income that is taxable is countable. Income from the following sources is exempt as income in the month received. For income types not referenced, additional research is required to determine if the income is taxable.
5401 Child Support - Payments, whether paid for current support, arrears support, or voluntary payments are exempt as income. This includes cash payments and payments made in-kind.
5402 Disability - Disability payments such as those received for Worker’s compensation, short-term disability, or other non-SSA disability payments are exempt as income.
5403 Earnings - Earned income from Strike Pay and Blood/Plasma Sales are exempt.
5404 Educational Income - Income from Grants, Scholarships, Loans, Veteran’s educational income, and Monthly living benefits (stipends) are exempt as income.
5405 Government Payments - Government payments are exempt as income. These payments are described below.
5405.01 Adoption Assistance Subsidy - Payments received for Adoption Assistance are exempt as income in the month received.
5405.02 Cash Assistance - Cash assistance payments, including those received as TAF special allowances are exempt as income in the month received. Examples of Special Allowances payments are special transportation payments and special service payments.
5405.03 Disaster/Emergency Assistance - Federal major disaster and emergency assistance and comparable disaster assistance provided by state or local government or by disaster assistance organizations in conjunction with a presidentially declared disaster are exempt as income in the month received and as a resource in the following months.
This includes disaster unemployment assistance to an individual as a result of a major disaster. Individuals cannot be eligible for any other unemployment compensation and also receive disaster unemployment benefits. Payments are limited to 26 weeks. Central Office will notify staff if such disaster unemployment assistance is paid in Kansas due to a major disaster.
5405.04 Energy Assistance/LIEAP - Payments or allowances made under some federal laws for the purpose of providing energy assistance are exempt from consideration as income in the month received. An example of such federal program is the Department of Health and Human Services' Low Income Energy Assistance Program (LIEAP).
Other home energy assistance furnished by a federal or state regulated entity whose revenues are primarily derived on a rate-of-return basis, by a private nonprofit organization, by a supplier of home heating oil or gas, or by a municipal utility company which provides home energy, if the assistance provided is based on need, is exempt as income in the month received.
5405.05 Executive Volunteer Programs - Payments received through Service Corps of Retired Executives (SCORE) or Active Corps of Executives (ACE) are exempt as income in the month received.
5405.06 Food Stamps - Value of the benefits issued under the current Food Stamp Act are exempt as income in the month received.
5405.07 Foster Care and Permanent Custodianship - Payments received for providing foster care or permanent custodianship are exempt as income in the month received.
5405.08 Foster Grandparents - Any payment provided to volunteers serving as foster grandparents is exempt as income in the month received and as a resource in the following months.
5405.09 HUD Payments/Housing Assistance - Payments from federal housing programs including negative rent payments made to tenants of subsidized housing under Housing and Urban Development (HUD) regulations is exempt as income in the month received and as a resource in the follow months.
5405.10 Independent Living Payments - Payments received for Independent Living are living exempt as income in the month received.
5405.11 Older American Act Payments - Payments received via the Older American Act are exempt as income in the month received. These include the Senior Community Services Employment Program funded under Title V of the Older Americans Act of 1965 (as amended by P.L. 100-175, the Older Americans Act Amendments of 1987) are exempt as income in the month received. Programs in Kansas funded under Title V include Green Thumb, Project Ayuda (serving Wyandotte, Johnson, Douglas, and Shawnee counties), and the Senior Community Service Employment Program through the Midway Chapter of the American Red Cross (serving Sedgwick, Reno, Harper, Kingman, Butler, Cowley, Harvey, and Sumner counties).
5405.12 Refugee Resettlement Funds - Payments received from a Refugee Resettlement Agency are exempt as income in the month received.
5405.13 Senior Health Aids/Companions - Payments received through Senior Health Aides or Senior Companions are exempt in the month received.
5405.14 Tax Refunds/Rebates/Credits - Legislated tax rebates and refunds are exempt as income in the month received. This also includes Earned Income Tax credit, whether received as a lump sum refund or on an ongoing basis.
5405.15 Gate Money - Money paid to a prisoner upon their release shall be exempt as income in the month of receipt.
5406 Insurance Payments - Payments from life or burial insurance as well as payments made for repair or replacement of property are exempt.
5406.01 Life and Burial Insurance Payments - Payments occasioned by the death of another person to the extent that the payments have been expended or committed to be expended for purposes of the deceased person’s last illness and/or burial. Such payments include, but are not limited to, proceeds from a life insurance or burial insurance policy, gifts, and inheritances.
5406.02 Repair and Replacement - Insurance payments received for the repair or replacement of property is exempt as income. This includes income from a one-time payment or a portion of a one-time payment from a settlement for repair or replacement of property or other settlement, including legal services and medical insurance payments.
5407 Interest and Dividends - Interest earned on a burial fund or on a pre-paid burial space contract account is exempt as income in the month received. Dividends earned on a life insurance policy are exempt as income in the month received.
5408 Loans, Gifts, and Contributions - Cash gifts, Loans, Charitable Donations, and Deemed Sponsor income are exempt.
5408.01 Loans - All loans, including loans from private individuals as well as commercial institutions, including deferred educational loans, shall be exempted from household income. Monies received from reverse mortgages are treated as loans, even if payments are regular and predictable.
When verifying that income is exempt as a loan, a legally binding agreement is not required. A simple statement signed by both parties that indicates that the payment is a loan and must be repaid shall be sufficient verification. However, if the household receives payments on a recurrent or regular basis from the same source but claims the payments are loans, the provider of the loans may be required to sign a statement that indicates that repayments are being made or that payments will be made in accordance with an established repayment schedule.
5408.02 Social Fundraising Accounts - Income received from a social fundraising account, such as a Go Fund Me account may be exempt as income depending on the purpose and intent of the account. Contributions received are exempt when the individual donating does not expect to receive anything in return for their contribution. Contributions are also exempt when the payment is made as an investment and the individual expects to receive a return on their investment.
5409 Native American Income - Payments from Tribal owned land, tribal disbursements, Indian Affairs income, and Claims Resettlement Income are exempt. Note: Income from gaming is countable. See 5220.08.
5410 Reimbursements - Income that is a reimbursement or refund is exempt.
Examples of exempt reimbursements are ones for job or training-related expenses such as travel, per diem, uniforms, and transportation to and from the job or training site. Reimbursements that are provided over and above the basic wages for these expenses are excluded; however, these expenses, if not reimbursed, are not otherwise deductible. Reimbursements for the travel expenses incurred by migrant workers are also excluded.
Also exempt are medical and dependent care reimbursements, reimbursements to students for specific education expenses such as travel or books, and jury duty payments.
To be exempt, these payments must be provided specifically for an identified expense other than normal living expenses and used for the purpose intended. When a reimbursement, including a flat allowance, covers multiple expenses, each expense does not have to be separately identified as long as none of the reimbursement covers normal living expenses.
5411 Social Security - Social Security income is exempt as outlined below.
5411.01 SSI - Income of an SSI recipient (including 1619(b) recipients) and retroactive SSI benefits (even if the individual receiving the benefit is no longer an SSI recipient) are exempt as income in the month received. This does NOT apply to persons receiving long term care in Medicaid approved institutions as provided in MKEESM 8112).
5411.02 Social Security Death Benefits - Social Security death benefits are exempt as income when used toward the cost of burial.
5412 Veteran's Income - All forms of veteran’s income are exempt. These include:
Veterans – Aid and Attendance
UME – Unusual Medical Expenses
Reduced VA Pension – LTC
VA Work Therapy
VA Housing Allowance
Veteran’s Disability
Veteran’s Pension
5413 Work Program/Training - Income from a work program may be exempt as income, depending on the type of program and whether or not the income is taxable. Exempt income types are outlined below. Also see 5320.08 for countable work programs.
5413.01 Workforce Investment Act (WIA) - Incentive and Training allowance income received from the Workforce Investment Act of 1998 (WIA) is exempt as income.
5413.02 Vocational Rehab (VR) - Training Allowances and Incentive Maintenance payments received from Vocational Rehabilitation are exempt as income.
5430 Miscellaneous Exempt Income - The following miscellaneous income types are all considered exempt.
5431 Agent Orange - Settlement payments are exempt as income in the month received and as a resource in the following months.
5432 Allocated Income - Income allocated for the support of dependents is exempt as income.
5433 Crime Victims Fund - Payments made pursuant to the Crime Victims Fund (Public Law 103-322), as amended are exempt as income in the month received.
5434 Family Subsidy - Payments provided through the Mental Health and Developmental Disabilities Commission or Family Support payments provided through the Children and Family Services Commission are exempt as income in the month received and as a resource in the following months.
5435 Holocaust Survivors - Reparation payments made to Holocaust survivors are exempt as income in the month received. These payments shall also be exempt for purposes of determining patient liability in a long-term care arrangement.
5436 Hostile Fire/Combat Pay - Hostile fire pay (also known as combat pay) received while in active military service is exempt as income in the month received.
See Policy Memo #2005-03-01 Exclusion of Combat Pay for more detailed information.
5437 Individual Development Accounts (IDA) - The interest on an allowable individual development account (IDA), including authorized matching contributions and accrued interest, is exempt as income as long as the account is maintained. For Working Healthy, income deposited into an IDA is also exempt in the month deposited. IDAs are exempt resources for all programs. An allowable IDA meets the following guidelines:
5437.01 - It is established by or on behalf of a TAF recipient or by or on behalf of an individual participating in the Assets for Independence Demonstration Program (AFIA) and is used for a qualified purpose.
5437.02 - A qualified purpose is one or more of the following:
(a) - post-secondary education expenses for college or vocational-technical school. Learning Quest or other 529 accounts are not considered IDAs;
(b) - first home purchase (must not have owned a home within three years of acquisition); or
(c) - business capitalization (business plan must be approved by financial institution or non-profit loan fund).
NOTE: Any funds withdrawn from an IDA and used for any purpose other than one of those listed above shall count as unearned income in the month withdrawn.
5437.03 - The IDA must be a trust funded through periodic contributions by the establishing individual and may be matched by or through a qualified entity for a qualified purpose.
5437.04 - A qualified entity to match IDA funds for a TAF recipient is either a not-for-profit organization described in section 501(c)(3) of the IRS code of 1986 and exempt from taxation under section 501(a) or a state or local government agency acting in cooperation with a 501(c)(3) organization. For AFIA participants, matching contributions are made by the federal government through a grantee.
5437.05 - AFIA recipients may only contribute to IDAs with income derived from earnings.
Note: The earnings of an adult placed in an IDA are counted as earned income in the month earned.
5437.06 - Parents may establish IDAs for their children as well as for themselves. Children may also contribute their earnings to accounts established by or for them.
5438 In-Kind Income - Benefits are exempt as income in the month received
5439 Japanese Aliens - Payments granted to certain United States citizens of Japanese ancestry and resident Japanese aliens under Title I of P.L. 100-383 (enacted 8-10-88) are exempt as income in the month received and as a resource in the following months.
5440 Student Loan Debt - Student loan debt that is discharged, forgiven, or cancelled after December 31, 2020 or discharged due to death or disability between January 1, 2018 and December 31, 2020.
5441 Ministerial Housing Allowance - A minister’s housing allowance, sometimes called a parsonage allowance or a rental allowance is exempt as income.
5442 Monies Withheld Voluntarily or Involuntarily - Monies withheld from assistance payments (e.g., TAF, GA, SSI) shall be included as countable income if the monies are withheld for the purpose of recovering from a household an overpayment which resulted from the household's fraudulent failure to comply with a state, federal, or federally assisted program which provides assistance on the basis of financial need. (For a definition of "fraudulent," refer to 8400).
5442.01 - Mandatory deductions from military pay for educational purposes shall not be included as income (or as a resource) while the individual is enlisted in the armed services. If individuals enroll in an educational institution after they leave the service, the amount withheld from salary plus any amounts matched from the VA will be treated as countable educational income minus expenses. Individuals who choose not to attend any school will receive the withheld monies in a lump sum payment and the payment shall be exempt per item 5440 above.
5442.02 - In addition, for all medical programs, programs not based on financial need that have a portion withheld to repay a prior overpayment received from that same income source, such as SSA, VA, Unemployment or Worker’s Compensation shall not have the portion withheld counted as income.
5443 Radiation Exposure Compensation - Payments made pursuant to the Radiation Exposure Compensation Act, P.L. 101-426 (10-15-90) are exempt as income in the month received and as a resource in the following months. This law compensates individuals for injuries or deaths resulting from exposure to radiation from nuclear testing and uranium mining in Arizona, Nevada, and Utah.
5444 Rehabilitation Services Payments - Income directly provided by Kansas Rehabilitation Services, except as noted in 5320.08 is exempt as income in the month received and as a resource in the following months. Maintenance payments are also exempt as they are in excess of normal living expenses and are considered a reimbursement.
5445 Relocation Assistance - Payments received under the Uniform Relocation Assistance and Real Property Acquisition Policy Act of 1970 are exempt as income in the month received and as a resource in the following months. The applicant’s or recipient’s equity in a home is to be disregarded to the extent that such equity was purchased with payments under the Uniform Relocation Act of 1970.
5446 Renal Dialysis - Special incentive payments received for renal dialysis patients for care in their own home are exempt as income in the month received.
5447 Ricky Ray Hemophilia Act Fund - Payments made pursuant to the Ricky Ray Hemophilia Relief Fund Act, P.L. 105-369 are exempt as income and as a resource for all programs. The payment is a one-time amount of $100,000.
NOTE: Interest earned on these exempt funds is not exempt as income. See 5220.05.
5448 Shared Living - In shared living arrangements; cash paid from one family to another toward the total cost of shelter is exempt as income in the month received.
5449 Susan Walker v. Bayer - Payments made pursuant to a class settlement in the case of Susan Walker v. Bayer Corporation is exempt as income in the month received and as a resource in the following months. This case involved hemophiliacs who contracted the HIV virus from contaminated blood products. Interest earned on retained funds is not excluded and is countable per 5220.05. Accumulated interest is also countable as a resource beginning the month following the month of receipt, even if commingled with non-exempt funds.
5450 Trust for a VA Child - Money for a child which is held in trust by VA and determined by VA unavailable for subsistence needs is exempt as income in the month received and as a resource in the following months.
5451 Vendor Payments - Money payments that are not payable directly to a household but are paid to a third party for a household expense are vendor payments and exempted as income. A vendor payment is defined as a payment made in money on behalf of a household shall be considered a vendor payment whenever a person or organization outside of the household uses its own funds to make a direct payment to either the household's creditors or a person or organization providing a service to the household. For example, if a relative or friend, who is not a household member, pays the household's rent directly to the landlord, the payment is considered a vendor payment and is not counted as income to the household. Similarly, rent or mortgage payments, made to landlords or mortgagees by HUD or by state or local housing authorities, are other examples of vendor payments and are also exempted.
5452 Spousal Support (Alimony) - Spousal support payments, or alimony, as a result of a divorce decree effected or modified after December 31, 2018 are not taxable and are thereby considered exempt income for MAGI purposes.
06100 Budgeting of Income - A prospective (income estimate or conversion) or income average method of budgeting shall be used to determine eligibility and the amount of assistance. All income shall be counted in the calendar month received except when received on a twice a month or monthly basis. In such instances, income shall be viewed as being received by the client on the day that the payment is ordinarily scheduled.
NOTE: For teachers or other school employees, income shall normally be budgeted on a prospective basis as received unless the teacher has opted to receive their yearly contract salary over fewer than 12 months (such as only over 9 months during the school year). In such instances, the total year's income is to be averaged over 12 months so that a monthly amount of income is considered in determining eligibility and amount of assistance.
6110 Prospective Budgeting - Prospective Budgeting is based on an estimate reflecting the income received and/or expected to be received going forward from the month of application. The basis for any estimate (including tips) must be documented. For self-employment, income shall be budgeted as outlined in 6200. For intermittent income, the income shall be budgeted as outlined in 6113. A prospectively estimated budget may be recalculated if information is received that the estimate is no longer correct (e.g., income that was estimated to be received in a month is reduced or terminated). The client must report their change of income, and the change shall be applied in accordance with provisions in 7000.
Earned income information, including pre-tax income deductions, must be analyzed to accurately prospect income. Past information must be evaluated to determine if it represents the future. Paystubs provided must be evaluated before they are determined appropriate to be used in the calculation of income.
If bonuses, tips, or commissions are on the pay stub, even when only included as part of Year to Date totals, these must be evaluated to determine whether this income is recurring. If the person is employed where tips are paid, it must be determined if tips are actual or allocated. (Certain employers must allocate tips if the percentage of tips reported by employees falls below a required minimum percentage of gross sales. To "allocate tips" means to assign an additional amount as tips to each employee whose reported tips are below the required percentage.)
Pay information provided must be evaluated to determine if there was a recent pay raise that will impact future earnings. Paystubs should also be evaluated to determine if there are any discrepancies in the year-to-date amounts. If so, the missing information must be clarified.
When using paystubs, the most recent should be used. Paychecks are deemed acceptable as proof of income when they are dated within the three months prior to the month of application through the final application processing date. Any paycheck received prior to this timeframe will be excluded from income budgeting. Budgeting methods take into consideration the variance that could occur between paystubs and the consumer’s self-attestation. Therefore, regardless of which budgeting method used, no paystub shall be excluded based on not quite matching other stubs submitted or the self-attestation of income.
When income is from a new source, the pay rate has increased (or decreased) or when the numbers or hours to be worked has increased or decreased, the income shall be budgeting using the income which is expected to continue in the future.
Weekly and biweekly income must be converted to a monthly amount.
Budgeting rules are also dependent upon frequency and regularity of income. The case record is to be documented as the method of computation. The following rules apply:
6111 Regular Earned or Unearned Income - Once the full monthly amount is determined, that same amount of income shall be budgeted providing the individual anticipates continued regular income. A new budget is required prior to redetermination only if regular income becomes irregular, there is no longer any income (not applicable to a job change if earnings remain regular), or there is a change in the monthly amount of regular income.
6112 Irregular Earned or Unearned Income - For income and expenses received or billed more frequently than on a monthly basis (i.e., weekly, biweekly, etc.), the amount to be budgeted shall be based on converting the amount to a standard amount of anticipated monthly income.
6112.01 - Income in the same weekly amount are to be multiplied by 4.3. If the income amount received is in differing weekly amounts, an average amount shall be determined and then multiplied by 4.3.
6112.02 - Income in the same amount every 2 weeks are to be multiplied by 2.15. If the income amount received is in differing amounts every 2 weeks, an average amount shall be determined and then multiplied by 2.15.
6112.03 - Income in the same amount twice per month are to be added together to obtain a monthly amount. If the income is in differing amounts twice per month, an average amount shall be determined and then multiplied by 2.
NOTE: To prospectively estimate semi-monthly income from a new job, (when paychecks are not available to average) pay periods with varying hours must be taken into account. The easiest and most accurate way to make this determination is to calculate a weekly estimate, times 2.15 times 2. Multiplying the weekly amount time 2.15 will take into account pay periods that have fluctuating hours. For example, a person working 40 hours a week will have more than 80 hours in a pay period when paid semi-monthly. Taking 40 X the hourly rate X 2.15 X 2 will get a closer anticipation of projected income than taking 40 X the hourly rate X 2 X 2.
6113 Irregular and Intermittent Income - Irregular and Intermittent Income received on a monthly basis in differing amounts shall be averaged. The monthly amount shall be established by dividing the income by the proper number of months for the period that the income is intended (e.g., 3 months for quarterly, etc.). A fair estimate for the time period used for averaging shall be established with the client. The case record shall clearly indicate that the income is being treated as intermittent income.
6113.01 - Once a standard monthly amount is established, it may continue to be budgeted through the redetermination period. However, a new budget is required:
(1) - for medical assistance when income terminates and there continues to be a spenddown in place;
(2) - for CHIP when income decreases and results in elimination or reduction of a premium requirement.
For redetermination of eligibility in medical assistance spenddown cases based on a change or termination in income, use the income amounts established for the case through the month the change is reported. In addition, if income continues, establish a new converted monthly amount to be used beginning the month after the change is reported through the end of the base period.
6120 Current Month Budgeting Methods - When budgeting income for the current eligibility month, there are four methods that may be used. These are: Using the Payer Source, Reasonable Compatibility, Full month budgeting method, and Partial Month budgeting method.
6121 Using a Confirmed/Payer Source - When using income which has been verified through an interface through Tier 1, the amount of income is used despite what the client reports. See 1330.01 for more information about Tier 1 sources.
6122 Reasonable Compatibility - This budgeting method is used as verification of earnings and the lack of earnings. It is used to determine if wages reported by the consumer are generally consistent with information received through a recognized data exchange or other source. If information from the source is reasonably compatible with the customer’s statement, additional information cannot be requested. Income amounts from both the customer and the source are converted to a monthly amount for the reasonable compatibility test; and the amounts are compared.
The reasonable compatibility test only applies to Tier 2 verification and is used for earnings and when no earned income has been reported. When verifying earnings, the applicant must have provided enough information to determine the reported monthly income in order to do the reasonable compatibility test. In situations where the consumer has reported an hourly wage but failed to report the number of hours worked per week, the self-attestation can be determined using an assumed 40 hours per week. When an hourly wage is provided along with a range of hours, the average of the range of hours is used.
Applicable data sources are The Work Number and the wage records on KDOL (BASI). The reasonable compatibility test is performed in KEES. When the Work Number (TALX) is used, the income from the most recent 30 days will be compared to the reported income.
Note: In most cases the income will be calculated prospectively as an average; however, in instances where the employer does not provide a complete income record – specifically, the employer indicates the frequency as ‘hourly’ – actual income received during the 30-day period starting with the anchor date will be used and should be similar to the average. For a consumer paid bi-weekly who received three paychecks within the 30-day period and is negatively impacted when actual income is used, a new prospective amount must be determined for accurate processing.
When KDOL (BASI) is used, the income from the most recent quarter of the two prior quarters is used to determine an average monthly amount and then compared to the reported income to determine if it can be accepted as verification.
There are two reasonable compatibility tests that are conducted; an individual test and a household-level test. Initially each individual has their income tested to determine if their income is reasonably compatible.
6122.01 Individual Reasonable Compatibility Test - KEES evaluates reasonable compatibility in the order specified below. Reported information is considered reasonably compatible when one of the following is applicable:
a) No earnings were reported and both data sources do not return any earned income, or
b) The amount of earnings reported by the consumer is greater than the amount received from at least one data source for the applicable time frame, or
c) The difference between the self-attested amount and one data source is no greater than 20% of the self-attested amount.
6122.02 Household Reasonable Compatibility Test – Both Below - After the completion of the individual test, each individual will have a reasonable compatibility test conducted against their entire IBU.
The Household RC Test determines if both the amount reported by the consumer and the amount received from one data source are below Medicaid income limits for the applicant. This is known as ‘Both Below’; BOTH self-attestation and income from the data source are BELOW Medicaid. For this RC test, all income in an individual’s IBU is used to determine if it is below the applicable income limit for that person. When the applicant is determined to be Reasonably Compatibility due to Both Below – no income verification is required to complete their determination. They are eligible to receive Medicaid without asking the consumer to provide additional verification of income.
6123 Full Month Budgeting Method - Full-Month budgeting method is used when the income has been determined to NOT be reasonably compatible and a full month of income verification is available. A prospective amount shall be determined and used in place of reported income. The client attestation is not used. A full month of income verification exists when the agency has verification of 30 days of consecutive earnings received by the wage earner within the period beginning 30 days prior to the application date and ending on the date the application is processed for new applications. When processing a review or case change, the pay verification provided must be from the three months prior to the month the Reasonable Compatibility test is initially run.
This “full month” of income is what is used to determine the prospective amount. 30 days’ worth of income is represented by 4 weekly checks, 2 biweekly checks, 2 semi-monthly checks or 1 monthly check. If an additional weekly or bi-weekly check is received within the 30-day period, it shall be included in the prospective determination if available but is not required to meet the definition of full-month budgeting. Additional checks submitted outside of the 30-day window are not used.
6124 Partial Month Budgeting Method - Partial Month budgeting method is used when sufficient information has not been provided to complete Full-Month budgeting. If less than 30 days of income is provided or in situations where you do not know if it represents a full month, determine a prospective amount based on what is on file. This amount is then compared to the reported income. Use whichever is greater between the amount reported by the applicant and the prospective monthly amount.
For Partial Month budgeting, income verification is acceptable as long as it is dated within three months prior to the month of application. Similarly, when processing a review or case change, the pay verification provided must be from the three months prior to the month the Reasonable Compatibility test is initially run.
6125 Pre-tax and Federal Income Deductions - Pre-tax and federal deductions are amounts that are excluded from the gross income amount used for a MAGI determination. They include pre-tax amounts reported to the IRS by an employer via wage information or by a consumer through filing taxes. For MAGI-based determinations, they may be reported by the consumer at application or review or identified through paystubs or tax forms received. When a consumer reports overall household deductions of $300.00 or less per month, the attested amount may be used in the determination with no further verification needed. For reported amounts in excess of $300.00 per month, verification will be required in most cases. See 1330.05.
6130 Prior Medical Budgeting Method - The budgeting method used for prior medical months is based on whether or not there has been a change reported by the applicant that occurs in the prior period. The applicant is asked a series of questions on the application to determine if changes in household members or income has occurred in the prior medical period.
Despite the client report, there may be instances where the agency is able to determine that no actual change has occurred. These situations shall be treated as though the applicant has not reported a change. In order to be considered a change for purposes of this policy, the change must fundamentally alter the expected income to be received. The reported change must be in the rate of pay (i.e. received a raise or a pay cut) or the regularly scheduled hours of work (i.e. weekly hours were increased or decreased). Missing a few days of work due to sickness or working some occasional extra hours of overtime does not trigger this policy change. If determined that no actual change has occurred, use the ‘No Change’ income budgeting rules. The amount verified and budgeted for the current month is used in each of the prior months. No further verification is required. If the agency or the individual is unable to verify current income, eligibility for the current and prior months shall be denied for failure to provide information.
NOTE: The applicant must answer ‘yes’ or ‘no’ to the prior medical questions. These answers cannot be assumed. If responses are not provided, the prior medical determination cannot be completed.
6131 No Reported Changes - If the applicant reports there has been no change in income for the prior period, the prior months are budgeted using the amount that is verified and budgeted for the current month.
6132 Reported Changes: Income - If the applicant reports a change in income for the prior months, the change shall be evaluated to determine if the income change will fundamentally alter the income that is being received. The reported change must be in the rate of pay or the regularly scheduled hours of work. Missing a few days of work to sickness or working some occasionally extra hours of overtime does not trigger this policy. If it is determined that no actual change has occurred, use policies in 6131. When a change of income has occurred, one of the following budgeting methods will be used.
6132.01 Use of KDOL Wages - If the Reasonable Compatibility test returns a result of ‘Both Below’ with KDOL wages being used, this monthly amount shall be used to determine prior medical eligibility, and no further verification is required. This is regardless of how many sources of employment have been reported. However, if only a Work Number (TALX) amount has been returned, or if KDOL is not below the Medicaid or M-CHIP income limits, actual income must be used to verify prior medical income.
6132.02 Actual Income - In situations where 6132.01 is not applicable, actual verified income shall be budgeted for each month of the prior period. Although the agency must attempt to verify using Tiers 1-3, it is most likely verification through Tier 4 will be necessary.
If the information provided by the applicant is incomplete, but eligibility staff are able to determine the actual income received in each prior month, verification shall be considered complete. For example, using year-to-date information on pay stubs to determine the missing checks.
If verification for the prior period is not provided, but income for the current period is verified the prior period shall be denied for failure to provide information and the current period approved.
6133 Reported Changes: Household - If the applicant reports a household change in the prior months, the change is evaluated to determine the type of change that has occurred and the potential impact on eligibility. If there were different individuals residing in the home during prior months, then those individuals must be considered when determining budgeting units and income used in the calculations. If the change involves an individual moving in or out of the household who has income, then staff shall refer to 6132.
Note: Verification of household changes is not required, unless necessary to determine custody of a child.
6134 Discrepant or Inconsistent Information - If no change in income or household has been reported, but the agency has information indicating a change has occurred, guidelines in 6132 and 6133 shall be used.
Note: It is not necessary to search for additional information/verification when the applicant reports there has been no change. However, when contradictory information exists at the time of the applicant report, the agency must take action on the known information to reconcile the discrepancy.
06200 Self-employment Income Budgeting - See 5330 for guidelines to determine if an individual is self-employed. Self-employment income will be based on the countable net income as reported on the Federal tax return. The individual will be required to provide a copy of the most recent personal tax return including all schedules and attachments. In instances where the individual states they have not filed their tax return and it is after the IRS filing deadline, the previous year’s return may be used if an extension has been filed with the IRS. Verification of the extension is not required. If the individual does not file taxes or has not yet filed taxes because this is a new self-employment business, or the current return is not representative, completion of the KC5150 self-employment worksheet by the individual is required.
6210 Tax Return Filed - When a tax return has been filed, the countable amount of self-employment tax that the individual paid must be deducted from the gross self-employment income. The Schedule 1, also known as Form 1040) or Schedule SE is used to determine the amount of self-employment tax paid located on the deductible part of self-employment tax line. This amount should be deducted from the amount of income taken directly from each schedule where applicable. The following outlines which line on each schedule is used for each type of business:
• Business income – Net profit amount from Schedule C or C-EZ
• Rental real estate, partnerships, S-corporations – Total rental real estate amount from Schedule E
• Farm income – Net farm profit from Schedule F
• Capital Gains – Capital Gains amount from the 1040 divided by 12
• Other Gains – Other Gains amount from the 1040 (Schedule 1) divided by 12
When the tax return reports more than one business, the self-employment tax must only be deducted from one of the self-employment businesses, preferably the business that has a net profit larger than the amount of the self-employment tax.
When a loss is reported on one or more of the schedules, it is to be treated as zero income for the eligibility determination and cannot be deducted from another source of income, even if the other source is another form of self-employment.
Provided the return reflects a full year of self-employment earnings, a twelve month average shall be established.
6211 Tax Return Not Filed or Does Not Contain Full Years Earnings - If a tax return has not been filed (e.g., employment just started or client has not filed a return), the KC5150- Self-employment worksheet is required. The applicant is required to complete the worksheet documenting all income and expenses for the 12 months prior to the month of application. Ledgers and other business records are not accepted as verification of self-employment income.
An average is determined by totaling all gross earnings in the months being counted, subtracting the total expenses, and dividing by the respective number of months. The calendar months being used and the corresponding earnings must be clearly documented in the case record.
6212 Need for New Estimate/Average Based on Changes in Income - In cases where the consumer indicates their tax return is not representative of the existing self-employment income, both the most recent personal tax return and the self-employment worksheet are required so staff may evaluate this. The reason for the discrepancy must also be clearly documented by the applicant and is only allowed when there is a definitive change in the amount of business.
6220 Wages from a business - When a business owner pays themselves a wage from the business, this is to be treated as a separate form of income and budgeted separately from the self-employment. Verification of the wages shall follow the Tiered verification policy. However, when the income cannot be verified using Reasonable Compatibility, alternative methods of verification are allowed. When income cannot be verified using Reasonable Compatibility, the individual’s most recent personal tax returns’ Form 1040 may be used if the individual indicates that the wages are only representative of those that have been paid from the business and not a combination of other jobs held. The total amount of wages to be used in the determination can be located on the 1040 Form under wages, salaries, tips etc. When no other verification is available, self-attestation of the wages is accepted.
6230 Capital Gains - For individuals who report self-employment income and provide a tax return as verification, any amount from Capital Gains or Other Gains is countable. Capital Gains can be located on the schedule 1040 or the Schedule D of the tax return. The amount of gains reported under net short and/or long-term capital gain or (loss) shall be used. These amounts will need to be prorated over the year. This will mean dividing the total by 12 to determine the monthly countable amount.
6310 Eligibility Period - The eligibility period is the time period on which need is computed. See Section 7330 for policy and procedures for eligibility reviews.
6311 Eligibility Periods for Medical Programs - An eligibility or base period is the length of time used in determining financial eligibility for an individual or family. The length of the base period varies from one to six months depending on the medical program and any changes of circumstance as referenced in 6311.01. Eligibility shall be determined from the date of application. See 1403.
For all medical programs other than CHIP, the month of application establishes the first month of the current eligibility base period provided all eligibility factors, with the exception of a spenddown, have been met. On request of the client, a 3-month prior eligibility base period shall be established. (See 6311.02.) For cases determined eligible without a spenddown, the effective date of eligibility will correspond with the beginning of the eligibility base and will begin with the first day of the first month of the medical base period. For spenddown cases, eligibility cannot be certified until the spenddown has been met. However, the effective date of eligibility may precede the date on which the spenddown is actually met.
Since suspension, closure, and denial are alternative administrative procedures that result in the withholding of benefits to the client when there is unmet spenddown, a base period can be established and maintained regardless of which procedure is chosen. Denied applications establish an eligibility base period and an application month when the reason for denial is excess income resulting in spenddown. (See 6311.02(3). Closures within an eligibility base period because of increased spenddown do not change the base period. A reapplication received outside of a previously established base shall be treated as a new application without regard to any previous base except for a determination of prior medical eligibility. (See 6311.02.) Once an eligibility base is established, it can be shortened or changed in accordance with 6311.01. Ineligible months are counted as part of the eligibility base period only when ineligibility occurs within an established base period.
For CHIP, the month of application does not establish the first month of the current eligibility base period. The base period begins with the first month the eligible individual is enrolled in a managed care health plan per 2470. With the exception of CHIP newborns as outlined in 2500, there is no eligibility for CHIP for any months prior to that first enrollment month. Thus, the effective date of eligibility and the eligibility base period will always correspond to the first day of the first enrollment month.
6311.01 Current Eligibility Periods - The eligibility base will be 1 month base for all MAGI programs with the exception of Medically Needy. The eligibility base will be 6 months for Medically Needy cases. The 6 month base will be shortened, however, in the following circumstances:
(1) - When a recipient becomes eligible for CTM or SSI.
(2) - When a recipient begins receiving long term care in a Medicaid-approved institution.
(3) - When a recipient begins HCBS.
(4) - When a recipient is transferred from a Family Medical Medically Needy program to a Disability related Medically Needy program or vice versa. .
(5) - When the only person in an assistance plan dies and eligibility has not been determined due to a spenddown.
If the applicant dies or if an application is made on behalf of a deceased person, eligibility will begin no earlier than the third month prior to the month of application.
(6) - When the only recipient on the Medically Needy case becomes eligible for Medicaid poverty level coverage, or coverage through foster care.
(7) - When two or more Medically Needy recipient family groups combine into one. In such instances, the previous bases shall be shortened and a new base period started with the combined family group.
6311.02 Prior Medical Eligibility (Not Applicable to CHIP) - An applicant for medical assistance may request a determination of medical eligibility for a 3-month period prior to the month of application. The month of application establishes this prior medical period. A request for prior medical must be made in the month of application or the two following months. When a request for coverage is not processed within the applicable case disposition timeline as defined in 1407, the period to request prior medical is extended to 12 days following the date of the determination. Requests made after this time shall be denied. See 2340.02and 2460.02 regarding prior coverage determinations for children being added to an existing PLN program.
Prior eligibility can be established even though there is no eligibility for the current base period. However, there is no eligibility in any prior month for an individual who does not qualify for Medicaid.
NOTE: Prior CHIP coverage is only available for certain CHIP eligible newborns. (See 2500)
A 3-month eligibility base shall be used unless one of the following conditions exist:
(1) - Part or all of the prior base period falls into a previously established medical base period.
(2) - Part or all of the base period falls within any month in which the client was a Medicaid recipient.
(3) - The individual is not categorically eligible for any medical program in one or more months of the base period (i.e., is not a child, a pregnant woman, or a caretaker).
(4) - The individual was not part of the current family group in one or more months of the base period.
If, in the above instances, the assistance request includes other individuals in the family group, only the individual would be excluded for the applicable months. If the assistance request is only for the individual, the prior base period shall be shortened to exclude those months.
A one month base period shall be used in accordance with 6311.01 for each month of the prior period. Eligibility can be determined for any one or all of the 3 prior months.
Financial factors of eligibility apply to the entire base period. Eligibility factors other than the income shall affect eligibility for each of the months separately. Eligibility shall be effective only for the months in which the client meets both the financial and nonfinancial factors of eligibility.
06400 Medical Program Standards -
6410 Medical Program Standards - For the Medicaid poverty level and CHIP programs, standards have been established based on a percentage of the federal poverty level. If countable income does not exceed these standards, there is eligibility. For the Medically Needy (spenddown) program, standards have been established which are the amounts of monthly income protected from medical expenses to allow applicants/recipients to meet their maintenance needs. If countable income does not exceed these standards, there is eligibility. If countable income exceeds the standards, a person can "spenddown" the excess and become eligible.
6410.01 Standards in the Medicaid Poverty Level Programs - To be eligible, the total countable income must not exceed the monthly poverty level standards based on the appropriate number of individuals. See KDHE Eligibility Policy Appendix F-8 for the Medicaid and CHIP standards.
6410.02 Standards in the Medically Needy Program - The protected income budgeted is the independent living standard for the number of persons in the budgeting unit. See KDHE Eligibility Policy Appendix F-8 for Medically Needy income standards.
06500 Determination of Financial Eligibility -
6510 Need - Need is a factor of eligibility in all categories of assistance and shall be determined through the application of standards by use of the budgetary method.
6511 Financial Eligibility in the Medicaid Poverty Level and CHIP Program - Financial eligibility exists if countable income does not exceed the allowable poverty level standards. A person cannot spenddown to obtain eligibility under any of these programs.
6512 Financial Eligibility in the Medically Needy Program (spenddown) - Financial eligibility exists if allowable incurred medical expenses, as specified in this section, equal or exceed the spenddown for the base period. See 6410.02 for establishing the spenddown amount.
6512.01 Allowable Expenses - Allowable expenses incurred outside of the current eligibility base are only allowable if the individual is still legally obligated to pay the expense and such expenses have not been previously applied to spenddown in any other base period in which the person became eligible. The amount of these expenses applied to spenddown within a particular base period shall be the amount due and owing as of the first day of that base period. This provision includes instances in which the individual has taken out a loan to pay the expense or charged the expense on a credit card. The unpaid portion of the loan or credit card balance attributable to the original medical expense shall be regarded as a due and owing expense which can be applied to spenddown.
The amount still due and owing shall be determined by subtracting all payments made on the loan or credit card balance prior to application of the expense in a base period from the original expense amount. The remainder shall be regarded as due and owing. Verification of the initial medical expense as well as payment made will be necessary.
All expenses which are incurred by persons in the budgeting unit are allowable within the limitations described above. Such expenses do not actually have to be paid to be allowed against the spenddown. The client will choose which of his allowable expenses he wishes to apply on the spenddown. Failure by designated providers to collect from the client does not shift responsibility to the medical program. A medical payment can be made only for the excess expenses.
Payment for or assumption of medical expenses by a third party, whether legally liable or not, negates the client's responsibility to pay; therefore, such medical expenses cannot be considered against the spenddown. This includes the portion of any medical expense paid by Medicare or another health insurance. The portion not covered by insurance, such as the co-payment or deductible, is allowable. See 6512.02 for exceptions of when expenses are allowable when paid by a third-party.
The following expenses are allowable against a spenddown when the client provides eligibility staff with evidence that he has incurred such expenses within the limitations established above.
(1) - The pro rata portion of medical insurance premiums for the number of months covered in the eligibility base period regardless of the actual date of payment, past or future, are allowable.
Medicare premiums not covered by Buy-in are also allowable. Premiums which are subject to Buy-in are not allowable even if the client pays them (or they are withheld) prior to completion of the Buy-in process as such amounts are subject to repayment.
NOTE: Additional costs consumers pay for Medicare Replacement polices will not be reimbursed through the Buy-in process but are an allowable medical insurance premium.
Premiums for hospital indemnity policies which pay a flat per day amount are not deductible as they are viewed as income replacement policies rather than medical insurance. However, certain indemnity-type policies pay based on specific services received and charges incurred. In these instances, the premiums would be allowable. Each policy will need to be reviewed to determine whether the premium is allowable or not.
(2) - If medically necessary, all expenses for medical services incurred by the individual or a member of the budgeting unit are allowable. See KDHE Eligibility Policy Appendix, Eligibility Processing, P-1, Medical Necessity for Allowable Medical Expenses.
Medicaid co-payments are deductible. In addition, charges in a Medicaid approved institution can be allowed up to the private rate for individuals subject to the gross income limit and whose income exceeds that limit. Otherwise, the facility can only charge at the monthly state rate if the individual's income is below the limit. Charges in a non-Medicaid approved institution are not allowable including charges incurred during a transfer penalty. (See MKEESM 8111.)
6512.02 Expenses Paid by a Third Party - Medically necessary expenses paid for by a public program funded by the State (or political subdivision of the State, such as a county), other than Medicaid, can be applied to spenddown. Only the portion of the expenses funded by the public program is allowable unless the client will continue to be obligated for the remaining portion of the bill. Such an expense is allowable in the base period in which it was incurred. Examples include expenses paid by Vocational Rehabilitation, the Family Support Program, Kansas Health Insurance Program for the uninsurable, certain programs administered by the Department of Health and Environment, such as those through Children with Special Health Care Needs, the
Infant/Toddler Program and Other Title V programs and non-Title II AIDS Drug Assistance Program/Ryan White (MKEESM 2694) payments. Also included are services paid by Donated Dental Services, Adult Emergency Support Services/APS Emergency Funds, the Community Support Medication Program, and expenses subsidized on services received through a Community Mental Health Center or Community Developmental Disability Organization. For prescription drugs purchased with a Medicare Approved Drug Discount Card (MKEESM 2911) the pre-discount cost of the item is allowed toward spenddown. The entire cost of the item is allowable even if the $600 credit was used to purchase the drug. Services provided for or paid through Hill-Burton funds, Ryan White funds or the Kansas Farmworker Health program is NOT allowable.
6513 Meeting a Spenddown - When allowable incurred medical expenses equal or exceed the spenddown amount, eligibility exists. The spenddown for the entire eligibility base must be met before there is eligibility. Once met, eligibility exists for all months of the base period in which categorical, nonfinancial, general, and other financial eligibility criteria are met.
Expenses are applied in the order they are received. However, different methods are actually used to account for the expenses, depending upon the type, source, and date of service. Because of this, the process to meet a spenddown is the responsibility of both the eligibility worker and the fiscal agent.
6513.01 Eligibility staff responsibility - The eligibility worker is responsible for determining the appropriate eligibility base period and the total spenddown amount. In addition, eligibility staff shall reduce the total spenddown amount by the following allowable expenses, which have been reported and verified. These are documented in KEES.
a. Health insurance premiums;
b. Expenses for non-participating members of the budgeting unit;
c. Due and owing expenses;
d. Allowable nursing facility/institutional expenses (excluding general hospital).
No other medical expenses are to be entered in KEES for persons attempting to meet a spenddown. If these expenses satisfy the spenddown in full, the individual will be eligible for reimbursement of medical expenses immediately.
6513.02 MMIS Responsibility - The above information is then sent to the MMIS, where a medical assistance benefit plan of medically needy will be assigned. The presence of a medically needy benefit plan will identify the individual as a person with a spenddown.
A medical card is issued for each participating member of the assistance plan. Medicaid providers who deliver medically necessary services and items shall bill the Kansas Medical Assistance Program (KMAP) using the information on the card. All medical expenses may be direct billed to MMIS, not just those covered by the KMAP. If the spenddown has not yet been satisfied, expenses which have been incurred in the base period are applied to reduce the amount of remaining spenddown, subject to TPL limitations. The amount actually billed will be allowed toward spenddown, as providers are restricted to billing at their usual and customary rate.
All claims received by the fiscal agent will have a Potential Provider Payment (PPP) status determined. The status indicates if the service is a Medicaid covered service which, if the client were not on spenddown, could potentially be paid by the Medicaid program.
The fiscal agent will send weekly notifications to those cases which experience activity on the spenddown in the past week. The notice will itemize all allowable expenses directly billed to the MMIS or through the Beneficiary Billed claims explained in item 6513.03 below.
6513.03 Beneficiary Billed Claims - In the event an individual receives an allowable service and the provider cannot direct bill for the service (e.g., item from a non-Medicaid provider or an expense from a Medicaid provider prior to case approval) a special process has been established to allow such expenses to be used toward the spenddown. Persons must obtain from the provider of the medical service a completed form ES- 3170, Beneficiary/Patient Spenddown Billing Form. The form will capture the necessary information to input a special claim, called a Beneficiary Billed Claim, into the MMIS. This process will also be used to provide for some non-Medicaid covered items and services which cannot be direct billed to Medicaid. The completed form shall be submitted to the eligibility worker for review. If the expense is allowable, the eligibility worker is responsible for input into the MMIS. Items and services billed through the ES-3170 may only be applied toward spenddown and are not considered for payment even if the expense isn't ultimately used toward the spenddown.
6513.04 Spenddown Met - When the total spenddown has been satisfied, the spenddown is considered met for the base period. Bills used to meet the spenddown remain the responsibility of the individual. A combination of accounting methods may be used to actually meet the spenddown. However, the bills used to meet the spenddown are not altered unless the new expenses are listed in 6513.01 above, items a - d or if the last bill used to meet the spenddown was a non-Medicaid covered expense. In this case, if other Medicaid-covered bills have already been applied, the non-Medicaid covered expenses shall be used in full, thus making the Medicaid -covered expenses potentially eligible for reimbursement.
When the spenddown is met, the fiscal agent will produce an itemize list of expenses used to meet the spenddown. The list will not include those expenses listed in 6513.01, items a - d. A copy of this notice will be sent to the assigned eligibility worker.
6513.05 Changes in Spenddown Amount and Status - When changes occur that ultimately impact the total spenddown amount (e.g., changes in income or changes in the assistance plan), the new spenddown amount will be sent to the fiscal agent. Timely and adequate notice is required when reacting to a change to increase the spenddown amount or change the spenddown status from met to unmet. The following rules apply:
a. For unmet spenddowns that remain unmet, the new spenddown amount will be effective upon receipt.
b. For unmet spenddowns which have been reduced and when applied expenses exceed the new spenddown, the spenddown will now be considered met and only those expenses which aren't subject to potential Medicaid payment and enough expenses which are subject to Medicaid payment to satisfy the spenddown.
c. For spenddowns which have been met that are reduced, the expenses used to meet the spenddown will be reviewed and those which are subject to Medicaid reimbursement will be eliminated in reverse date order.
d. For spenddowns which have previously been met are increased, the case will be put back into spenddown status and the new spenddown amount will be applied the month following the month the new amount is received or the second month following, depending upon negative action deadline.
6514 Establishing Financial Eligibility in the TransMed Programs - There are no financial eligibility criteria for establishing TransMed coverage. The family must meet the criteria in 2230 and subsections.
6515 Establishing Financial Eligibility in the Extended Medical Program - There are no financial eligibility criteria for establishing the four-month Extended Medical period. The family must meet the criteria in 2240 and subsections.
6520 Continuing Financial Eligibility (MAGI Programs) - When circumstances change, adjustments will be made as necessary depending on the category of medical coverage. For the Medicaid Poverty Level and CHIP programs for caretakers, children and pregnant women, changes in income will not impact eligibility based on continuous eligibility provisions under 2311. Changes in the amount of earned income do not impact eligibility for TransMed. All other changes must be evaluated to determine if eligibility criteria continue to be met.
See MKEESM 2650 for CE policies for children on non-MAGI programs.
07100 Household Responsibility to Report - Households receiving medical assistance are required to report changes. The specific reporting requirement is determined by the program and the circumstances of the household. There are no additional reporting requirements other than those listed in this section.
7110 Household Responsibility to Report Changes Prior to Approval - Applicants (includes new applications and applications filed after a break of one or more months of assistance) must report all changes of circumstances prior to case approval. The change must be reported within 10 calendar days from the date the change is known. The eligibility worker is responsible for requesting or otherwise obtaining other information or verifications necessary to determine the individual's eligibility for any month.
7120 Household Responsibility to Report Changes After Approval - Medical assistance households are required to report certain changes in circumstances as discussed in this section.
All households are to be notified of the appropriate reporting requirements upon approval for assistance.
7130 Reporting Requirements - Medical assistance households are required to report certain changes in circumstances within 10 days from the date the change becomes known to the household. See subsection 7130.02 below for the definition of "becomes known to the household."
7130.01 Change Reporting Requirements - The change reporting requirements for the Family Medical assistance programs are listed below:
(1) - Changes in the source of earned and/or unearned income.
(2) - Changes in the amount of earned and/or unearned income.
(3) - Changes in household composition, including marital status (marriage, separation, or divorce), as well as people moving into or out of the household.
(4) - Changes in residence, including moving into or from an institution (i.e. jail/prison) or hospital.
(5) – Changes to any third party insurance plan or entitlement/termination of Medicare coverage.
Reporting changes is necessary for all household members including children. Households may report a change in their circumstances by telephone, in person, or in writing. Changes in circumstances other than those listed above are not required to be reported until review.
7130.02 Becomes Known to the Household - As indicated in section 7130 above, the household must report changes within 10 days of the date the change becomes known to the household. For purposes of this provision, "becomes known to the household" is defined as:
(1) Change in Source of Earned Income - The change is known to the household upon receipt of the first pay check.
(2) Change in Earned Income Amount - The change is known to the household on the last day of the month of the change.
(3) Change in Source of Unearned Income - The change is known to the household upon receipt of the first payment.
(4) Change in Unearned Income Amount - The change is known to the household when the payment is received.
(5) Change in Household Composition - The change is known to the household the day the individual enters or leaves the household, the date of marriage, separation, or divorce.
(6) Change in Residence - The change is known to the household the day the individual moves.
(7) Entitlement to or Termination of Medicare Coverage or a change in a Third Party Insurance plan - The change is known to the household on the effective date of the change.
7140 Processing Reported Changes - When the agency receives information that a change has occurred, the eligibility worker shall act on the change within 10 days after the date the change is reported or becomes known the agency (1334) by taking the following actions:
(1) Document in the case file the reported change, the date the change occurred, and the date the change was reported;
(2) Determine if verification or additional information is required;
(3) Contact the household to request needed information or verification as soon as possible;
(4) Changes are effective the month following the month of the change, given timely and adequate notice requirements, with the exception of income changes that are reported at the time of a request to add a new individual.
(a) Households reporting changes which would result in a change in benefits must provide any required verification within 12 days of the date of agency request. No change in benefits shall be granted if the household does not provide the required verification. If no verification is required or if the verification required is received within 12 days from the date of verification request, the change in benefits are to be granted effective the month following the month the change is reported. If the verification is received after 12 days from the date the verification was requested, the change benefits would be effective the first month following the month the verification is received.
(b) Changes resulting in ineligibility or a decrease in benefits shall effect eligibility the first month possible considering timely notice requirements.
(c) When processing an income change along with a request to add coverage for a new individual, the new income must be verified and used in the month of request. This allows the income to be used in the determination for the new person and is also applicable to the rest of the household members in that month. This could result in a change in coverage or the reduction or removal of a premium obligation in the month of report when applicable.
(5) If an automated system action occurred on the case prior to a worker becoming aware of the change, the worker must evaluate the effect of the change to determine if any incorrect payment occurred as result.
7150 Notices to Households - The agency shall provide the household with the following notice based on the change in assistance:
(1) Timely and Adequate Notice - The agency shall provide the household with a notice of action that meets the definition of timely and adequate notice (as defined in 1422.01) if the household's benefits are being reduced or terminated.
(2) Adequate Notice - The agency shall provide the household with a notice of action that meets the definition of adequate notice (as defined in 1422) if benefits are being increased.
7160 Failure to Report - If the agency discovers that the household has failed to report a change, as required in 7100 and, as a result, received benefits to which it was not entitled, a claim shall be filed against the household. The household is entitled to a timely and adequate notice of adverse action if the household's benefits are reduced or terminated.
A household shall not be held liable for a claim because of a change in household circumstances which it is not required to report in accordance with 7100. Individuals shall not be disqualified for failing to report a change unless disqualified in accordance with fraud disqualification procedures.
07200 Whereabouts of Recipient Unknown -
7230 Whereabouts of Recipient Unknown - In instances when the agency does not know the whereabouts of a recipient, the agency should attempt to confirm the consumers’ whereabouts through available methods of research, including (as best practice) contact with the consumer via phone. If updated information is not located, coverage may be discontinued for all non-pregnant adults on the case regardless of continuous eligibility allowing adequate notice only. The Notice of Action is to be sent to the last known address. See 1423.06.
Coverage shall not be terminated for continuously eligible children or pregnant women according to provisions of 2300. If the agency becomes aware that residency requirements of 02050 are no longer met coverage shall be terminated.
7330 Reviews - All categories of assistance require periodic review. At the expiration of the review period, entitlement of benefits ends. Further eligibility must be determined through the review process. Depending on the type of assistance received and the circumstances of the case, the review may be either passive or non-passive. A non-passive review is based on a new application or review form and verification is required.
The purpose of the review is to give the client an opportunity to bring to the attention of the agency his or her needs and to give the agency an opportunity to re-examine all factors of eligibility in order to ensure coverage and eligibility levels continue to be correct. In the process, the appropriate review form shall be used along with the rest of the agency record.
The following review types apply:
7330.01 Passive Review - Passive Review - A Passive Review is a review where information known to the agency is used to make a new eligibility determination for an individual due for review. Eligibility is redetermined and reauthorized without worker involvement. The member receives notification outlining the information used for the redetermination. The member is required to inform the agency of any changes or incorrect information used in the determination. If the recipient has no changes to report, the review process is complete. If the recipient contacts the agency (either orally or in writing) with updated information based on receipt of the review notification, action is taken to update the case. See 7421 regarding passive review responses.
If a person qualifies for a passive review but is in the same household with members with a pre-populated review type, or if the data used at passive review will result in coverage on a lesser program, or a change between CHIP and PLN, a pre-populated form will be sent to give them the opportunity to report changes. If the form is not returned, the members with the passive type will be approved using the information in the system.
If a person over the age of one receives a pre-populated review due only to a missing SSN, and the SSN is provided, the person may be administratively (manually) reviewed using the rest of the information on file in absence of a review form. Likewise, if it is identified that a person received a pre-populated in error due to a citizenship record changing to an unverified status when it had already been verified, the pre-populated form is not required. They may be reinstated if necessary and administratively reviewed and approved using the information on file.
1. The following programs are eligible for a passive review due to the program type without any other qualifications:
- Deemed Newborns.
- Aged Out Foster Care.
2. All other programs must meet the following qualifications, as indicated, to be eligible for a passive review:
In order to qualify for a passive review, when earned income exists it must meet reasonable compatibility under the automated RC test completed by KEES. When unearned, countable income from Social Security (SSA) exists, it must be within $5.00 of the amount found on the SSA data source. In addition, each of the following program types may be subject to a passive review when specific criteria are met:
- Medically Needy (MDN) – There is no self-employment or earned income, countable resources are less than 85% of the limit, and the status of the Spenddown is ‘met.’
- Caretaker Medical (CTM), TransMed (TMD) and Extended Medical (EXT) – Earned income is reasonably compatible, there is no self-employment, there is no discrepancy in the tax information for the household member(s) due for review, and individuals do not move to a Protected Medical Group, Working Healthy, Medically Needy, or MSP program.
- Poverty Level Pregnant Woman (PLN/PW) – Passes the income test and passes reasonable compatibility.
- Poverty Level Pregnant Woman Under 19 (PLT or CHIP) – Income is reasonably compatible and does not contain self-employment income.
- Poverty Level Newborns and Children (Medicaid and CHIP) – Income is reasonably compatible and does not contain self-employment income.
7330.02 Pre-Populated Review - A pre-populated review is required for all other situations where a passive review isn’t sent. A notice of expiration of the review period is sent along with a generated pre-populated review form for completion and return. The forms are generated based on information that is contained within KEES.
Recipients are required to update the form with new or changed information and return to the agency. Failure to return the review form will result in discontinuance of coverage for all members with an individual pre-populated review type. Any members who qualify for an individual passive review may not be discontinued for failure to return the review form but will instead be passively reviewed by the system when a pre-populated review is not returned.
7331 Notice of Expiration - A notice of expiration of the review period shall be sent to each household subject to a pre-populated review as described in INVALID LINK - Please ensure that there is a "^" after the section number and the section number you are trying to link to is currently active.. A notice of expiration of review is not required for passively (7330.02) or super-passively (7330.01) reviewed households. The agency shall provide a pre-populated review form with the notice of expiration. When a review is required and it is known that the recipient is temporarily visiting away from his or her residence, the notice of expiration and review form should be mailed to the temporary address.
The notice of expiration and pre-populated review form shall be mailed to the household on or about the 15th of the next to last month of the review period. This gives the household approximately 30 days to complete and return the review form to the agency (see 7410).
NOTE: The notice of expiration provides timely notice of the ending of benefits; therefore, further timely notice is not required to affect benefits for the start of the new review period.
07400 Client Requirements for Timeliness - Reviews -
7410 Review Form - As indicated in 7331, individuals subject to a pre-populated review shall be given a minimum of 30 days to return a required review form. The review form shall be mailed to the individual on or about the 15th of the next to last month of the review period. To be considered timely received, the signed review form (see 1409.01) must be returned to the agency by the 15th of the last month of the review period. If the review form is not timely received, coverage will be automatically discontinued the evening of the 15th with an effective date of the last day of the last month of the review period, see 7431.
7410.01 Using an Application Form as a Review - An application form shall be used as the review in the following circumstances:
- Received within two months prior to the Review Due month.
- Received any month after the Review Due month through the current month when the Review Discontinuance Batch has not been run.
The application is used to complete the review when all members of the household are listed on the application. The application must be reviewed for consistency with the known case information. If additional information is needed to process the review, it shall be requested from the consumer, but another application form or review form is not required.
It is not necessary for the applicant to have requested coverage for all household members on the application. If individuals who are due for review, are listed on the application form, it is assumed that they wish for coverage to continue, and the form shall be used as a review for them. If the form does not include all household members, it shall be used to determine eligibility for the newly requested individual. If the Review Due date is in the past, manual action shall be taken to discontinue the remaining household members for failing to return their review.
7410.02 Continuation of Coverage Pending Completion of Review - When a review form is timely received (see 7331) and registered before the change processing deadline, eligibility at current levels will continue automatically until the review process is completed. If the review is timely received, but not registered before the change processing deadline, coverage will be automatically discontinued. In that instance, the discontinuance shall be rescinded and coverage reinstated while the review is pending. Note that if an untimely review is received during the review reconsideration period (see 7431), the discontinuance shall be rescinded but coverage shall not be reinstated pending the completion of the review.
Due to this process, if a timely received review is not timely processed by the agency, as defined in 7420, the current level of coverage for the individual(s) due for review may continue past the end of the review period for one or more months [extended month(s)]. The date the timely review is received will determine if those months are subject to correction.
7411 Information/Verification - All information and/or verification shall be provided by the requested date. Clients must submit any required verification or additional information within 12 days from the date of the initial request in order to ensure the rights to uninterrupted benefits. However, if the requested information is provided after adverse action is taken, but during the review reconsideration period, as described in 7431, the adverse action may be rescinded and the review reinstated for processing.
Follow the verification requirements at initial application, except that non-citizen status, providing an SSN, residency, and identity, do not have to be reverified unless a change has been reported or it is questionable.
7420 Agency Action on Timely Review - If the review form is timely filed and all review requirements have been met, the agency shall promptly process the review to ensure correct and timely coverage is provided. Timely processing shall be defined as follows:
1. A review form received before the 1st day of the last month of the review period shall be processed by the change processing deadline in the last month of the review period.
2. A review form received on or after the 1st day of the last month of the review period shall be processed by the change processing deadline in the month after the last month of the review period. Whenever possible, the agency, though not required, shall still attempt to process the review by the change processing deadline in the last month of the review period.
This process may result in an extended month of coverage. Any extended month of coverage provided under this process is subject to adjustment as indicated in 7410.02(2) if understated eligibility has occurred. However, in no instance shall a claim subject to recovery be created for the extended month (see 8321.02)).
3. Due to the nature of the program, all Medically Needy (MDN) reviews, regardless of when received, shall be processed by the change processing deadline in the last month of the review period. This will ensure that a new 6-month eligibility base period is properly established beginning with the month after the month the review period ends. See also 1410.01(2).
All households shall be notified of the appropriate reporting requirements upon review approval. See 7120.
7421 Passive Review Responses - After being passively reviewed, the consumer is required to contact the agency (either orally or in writing) if any of the information on file needs to be updated. Reaction to this change is based on when the change was reported and the type of eligibility resulting due to the change.
- If the change was reported by the last day of the old review period, the change is processed as a Passive Review Response.
- If the change was reported after the last day of the old review period, the change is not considered a passive review response. It is treated like any other change that is reported outside of the review process. Anyone already passively reviewed and continuously eligible will not be negatively impacted.
To process the Passive Review Response, staff update the case with the changes and redetermine eligibility for the next review period. If eligibility will be the same or better than the previous review period, the change is effective with the first month of the next review period. If the result is adverse, such as a premium increase or a change to a lower hierarchy program such as CTM to TMD, the change will be effective in the next unpaid month allowing for timely notice.
For passive review responses reported by the end of the old review period, the reported change can result in a change in coverage and/or premium even if coverage has already been approved. If the passive review response includes a request for medical assistance for a new individual, the change to add the individual is processed for the month of request but coverage for existing members is protected for any paid months by continuous eligibility rules. When a premium is involved, if a positive change, the change is made for the month after the month of report.
7431 Review Reconsideration Period - If the review form is not returned by the end of the current review period, the individual has a three-month reconsideration period to return the review form. Individuals will have until the end of the third month from the date of discontinuance to return the form for processing. The reconsideration period also applies to information requested in order to process the review. An application or review form received after that period is treated like a new application, including any request for prior medical assistance. If the requested information is provided after the reconsideration period expires, a new application may be required.
A review reconsideration period is not applicable to an individual who is approved at review or is denied at review for not meeting eligibility criteria. Any application for review not submitted in a timely manner shall be treated as an initial application. The timeliness provisions of 1407 and subsections apply.
When eligibility has been discontinued for failure to provide requested verification and the verification is later provided within the review reconsideration period described above, eligibility shall not be reinstated pending completion of the review. The discontinuance shall be rescinded, but no coverage past the end of the review period shall be provided, unless and until the review is fully processed.
Note: An individual who timely submits a review form but submits all verification in an untimely manner shall lose the right to a prompt review of eligibility (see 7420).
7432 Agency Failure to Act Timely - If the agency fails to timely process a timely received review form, an administrative processing error may have occurred. Eligibility will continue with coverage at the current level while the review is pending. This may result in one or more months of coverage past the end of the review period before the review is processed [extended month(s)]. Once the review is processed, the extended months of coverage resulting from the delay shall be reevaluated as follows:
1. If the new level of coverage determined by the untimely agency review is the same as the previous coverage, no adjustment to the extended month(s) is required. No administrative error, other than delayed processing, has occurred.
2. If the new level of coverage determined by the untimely agency review is greater than the previous coverage, the extended month(s) must be adjusted accordingly. Coverage for those extended month(s) shall be enhanced to match the newly determined coverage. The agency shall promptly update the coverage and notify the recipient(s) of the change.
3. If the new level of coverage determined by the untimely agency review is less than the previous coverage, including discontinuance of coverage, an agency error overstated eligibility has occurred for the extended month(s). Agency action must be taken to determine the amount of the overstated eligibility and establish a claim according to 8300 and subsections.
7441 Frequency of Reviews - All MAGI-based medical program recipients shall be reviewed once every 12 months and no more frequently than once every 12 months.
08000: Incorrect Coverage - Prevention of incorrect benefits is the responsibility of every staff member, contracted staff member, and client. Incorrect coverage includes both understated and overstated eligibility.
08100 Understated Eligibility -
8110 Understated Eligibility - Understated eligibility occurs when the client does not receive the level or extent of coverage they were entitled to receive. Eligibility staff shall document how the understated eligibility was determined and the reason correction was required. All understated eligibility must be promptly resolved.
8111 Situations Requiring Correction of Understated Eligibility - Understatement of eligibility shall be corrected promptly using the program policies in effect for the month(s) in which the error occurred.
The following are situations in which a correction of understated eligibility is required.
8111.01 - The understated eligibility was the result of agency error;
8111.02 - The agency failed to give the household sufficient time to verify information that resulted in the understated eligibility;
8111.03 - The agency failed to take timely action on reported changes that resulted in the understated eligibility;
8111.04 - There is a fair hearing decision in favor of the household;
8111.05 - Case correction is ordered as a result of a class action lawsuit or other legal proceeding.
8111.06 - A recipient may also be entitled to correction of understated eligibility where a change has been reported and verified timely but the future month has already been authorized due to system cutoff date.
8112 Timely Billing - There may be instances where the medical provider is outside of the timely billing time frame to receive payment for services and the client has already privately paid the bill. The provider may be unwilling to reimburse the client since they will not be able to receive payment from the state. In those instances, the client shall be reimbursed by the state for the verified amounts paid to the provider, up to the allowed rate for the service. There is no other provision for correcting the understated eligibility.
8113 Situations Not Requiring Correction of Understated Eligibility - Even though a technical understatement of eligibility may have occurred, an eligibility correction is not required in the following situations:
8113.01 - The household failed to report a change which would have resulted in an increase in coverage had the change been timely reported.
8113.02 - The household failed to timely provide information necessary to make a change.
8210 Time Frame - Once it has been determined that an understated eligibility has occurred, the amount of the underpayment, if any, shall be calculated and the case corrected as soon as possible but no later than 20 calendar days after the worker identifies that a correction is necessary.
8211 Erroneous Denial - When the individual has no coverage due to an erroneous denial, an understatement of eligibility has occurred. For example, the application was incorrectly denied for failure to provide information when the information had been timely received. The first month, or date for date-specific programs (CHIP), that the individual would otherwise be eligible shall be the first month coverage was not received as a result of the erroneous denial.
8212 Erroneous Termination - The month the discontinuance initially occurred shall be the first month coverage was not received as a result of the erroneous discontinuance.
08300 Overstated Eligibility and Claims -
8300 Compromising Claims - The amount of the claim determined by the agency may be reduced in accordance with a court order. The amount determined to be uncollectable shall be the compromised amount of the claim. The original amount of the claim minus the compromised amount shall be the amount then subject to collection.
8311 Types of Claims - There are three types of claims. The type of claim will determine action to be taken in recovery efforts.
8312 Agency Error - Instances of agency error which may result in a claim include, but are not limited to, the following:
8312.01 - Prompt action was not taken on a change reported by the household;
8312.02 - Household income was incorrectly computed;
8312.03 - Coverage continued after the review period expired without benefit of a required redetermination of eligibility; or
8312.04 - Policy was misapplied.
8313 Client Error - Instances of client error which may result in a claim include, but are not limited to, the following:
8313.01 - Non-willful withholding of information from a one-time failure on the part of a client to report a change timely (see 7100), which affects eligibility when:
(1) - The worker has reason to believe that the client did not understand his responsibility; and
(2) - There was no oral or written misstatement by the client, or
8313.02 - Willful withholding of information such as:
(1) - Misstatement (oral or written) made by the client in response to oral or written questions from the agency;
(2) - Failure by the client to report a change timely (see 7100), which affects eligibility;
(3) - Failure by the client to report the receipt of a medical coverage payment which he/she knows, or should know, is incorrect;
8314 Fraud Error - A fraudulent error occurs when the client intentionally:
(1) Makes false or misleading statement, misrepresentation, concealment, or withholding of facts for the purpose of improperly establishing or maintaining eligibility; or
(2) Misuses medical benefits, including selling, sharing or trading the medical I.D. number for money or other remuneration, signing for services that were not provided to the recipient, or other misuse as determined by the agency.
An individual shall be considered to have committed fraud when the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction. There is no other method of establishing a fraud claim.
A finding of fraud under these provisions may result in criminal penalty, including fines and imprisonment, but may only result in a period of ineligibility if so ordered by the court. Fraud error status is not established if the court’s resolution to the willful client error is to place the individual on diversion.
8321 Claim Not Required - Even though a technical overstatement of eligibility may have occurred, a claim shall not be established in the following instances.
8321.01 - The agency failed to ensure the application used to approve eligibility was signed.
8321.02 - Coverage granted in accordance with the treatment of income policies or the inability of the agency to act on available information due solely to system cutoff dates. Assistance provided under these circumstances does not constitute incorrect coverage.
8321.03 - Overstatement of eligibility that occurred as the result of the household failing to report a change in circumstances they were not required to report.
8321.04 - The overstated eligibility was the result of agency error and the recipient did not receive any medical services within the month, even if capitation payments have been made on their benefit.
8321.05 - An eligibility error related to citizenship or alien status is not considered overstated eligibility when:
a. Eligibility was based on verification of satisfactory immigration status by the Immigration and Naturalization Service (INS).
b. Eligibility was approved to meet timely processing guidelines, but no INS response to a request for verification of immigration status has been received.
c. Eligibility was approved to meet timely processing guidelines, but the reasonable opportunity period for alien applicants to provide documentation of their alien status had not expired.
8321.06 - A previously met spenddown is increased within the base period due to a change in income and the new spenddown amount is not met.
08330 Overstated Eligibility and Claims - Overstated eligibility occurs when an individual receives more coverage than they are entitled to receive. Eligibility staff shall document how the overstated eligibility was determined and the reason case correction was required. All overstated eligibility must be promptly resolved.
8330 Time Frames - The date of discovery for purposes of tracking timely claims shall be the date the case is first identified as potentially having overstated eligibility by the worker, quality assurance, or by other means.
Failure to establish a claim within the time frames identified below does not negate the responsibility of the agency to establish or collect on the claim, or of the client to repay any valid overstated eligibility.
8331 - For agency and client errors, the agency is required to prepare the claim and initiate recovery or attempt to initiate recovery or attempt to initiate recovery by the end of the calendar quarter in which the overstated eligibility is first identified.
8332 - For fraud errors, the agency is required to prepare the claim and initiate a referral to the Office of the Medicaid Inspector General for prosecution by the end of the calendar quarter following the calendar quarter in which the overstated eligibility is first identified.
08340 Computing the Claim - In calculating the amount of the claim, the agency shall determine the point at which the correct information should have been reported and acted upon timely allowing for timely notice as appropriate. From that point, the correct coverage shall then be compared against the actual coverage received to determine the difference. The difference in the coverage received versus the coverage entitled to receive is the amount of the claim. The actual amount of the claim shall be:
8341 No Eligibility - For instances where there was no eligibility, the claim is calculated based on whether or not the coverage was provided as managed care or fee for service.
a. Managed Care – The amount of the capitated payment made each month,
b. Fee for Service – The amount of the paid claims.
8342 CHIP Premiums - For instances related to CHIP premiums, the claim is the amount of the understated premium.
8343 Spenddowns - For Spenddown, the claim is the difference between the capitated payment for an unmet spenddown versus a met spenddown.
08350 Establishing Claims and Repayment Agreements -
8351 Establishing Claims and Repayment Agreements - Once the amount of the overstated eligibility has been determined, a claim in that amount shall be established. The type of the claim (Agency Error, Client Error, or Fraud Error) shall determine which action to take next.
1. Agency Error or Client Error – For purposes of establishing a claim, there is no difference between an Agency Error and a Client Error. Even though the root cause of the error differs, the collection action is the same.
2. Fraud Error – A fraud error can only be established through a finding by a court of appropriate jurisdiction. Therefore, additional steps are required before collection action may commence.
A suspected fraud error shall be referred to the Office of the Medicaid Inspector General. The Office of the Medicaid Inspector General will make a determination as to whether or not to pursue the case in court. If a decision is made not to pursue, the claim will be labeled as Client Error and processed as such. If the claim is accepted by the Office of the Medicaid Inspector General for prosecution, no further action shall be taken until a decision by the court has been rendered.
Individuals should not receive notice that the case is under investigation for fraud. Client inquiries concerning the possible fraud investigation should be responded with a statement that the case is “under administrative review.” No additional information should be provided.
Collection action for an Agency Error or Client Error claim shall be initiated by sending the household a repayment agreement. No action shall be taken on a Fraud Error claim until the court has rendered a decision.
The repayment agreement shall include the amount of the claim and the reason the overstated eligibility has occurred. The household is given 10 days to respond to the repayment agreement.
8361 Collecting Claims - Once the household has been notified of the overstatement of eligibility and repayment requested, collection action shall be initiated. Recovery may only be initiated if there are countable resources that are currently available. This includes any resources counted toward the allowable resource limit outlined in 5130.
8362 Methods of Collection - Agency Error and Client Error claims shall be collected in one of the following ways:
8362.01 - If the household responds with a payment on the claim, the payment shall be accepted according to established procedures. If the claim is paid in full, no further collection action is required. If the claim is only partially paid, further action is necessary to collect the remaining amount of the claim.
8362.02 - If the household responds with a promise to make payments, the payments shall be accepted according to established procedures. If the payments continue or the claim is paid in full, no further collection action is required. If the household fails to begin making payments or to continue making payments, further action is necessary to collect the remaining amount of the claim.
8362.03 - If the household is unable or unwilling to make a voluntary, a special spenddown shall be imposed. The special spenddown shall be created in an amount equal to the amount to be recovered and shall be considered in the current eligibility base period.
Medical expenses may be allowed against the special spenddown requirements if the expense is verified, medically necessary, and reported to the agency on at least a 6-month basis. Medical expenses shall be counted against the regular spenddown (if any) and then the special spenddown.
A special spenddown may be used for both automatic and determined eligibles. There is no requirement that the client have a regular spenddown. However, a special spenddown shall not be used in the Medicaid poverty level or CHIP programs.
If a special spenddown is imposed on a regular spenddown, the amount of both spenddowns must be met before the overstated eligibility claim is considered satisfied. If unmet, the special spenddown may extend over more than one base period.
8363 Fraud Claims - A claim that has been determined to be fraudulent through a court of appropriate jurisdiction shall be collected in the same manner as other types of claims. A repayment agreement shall be sent to the household as indicated in 8350.
1. Method of Collection – If the court has not imposed the method of collection, the provisions of 8350 apply. If the court has established how the claim is to be repaid, the agency shall follow that collection method.
2. Disqualification Penalty – An individual who has been convicted of medical assistance fraud under 42 U.S.C. Sec. 1320a-7b shall be ineligible for medical assistance for one year from the date of conviction. Convictions under state law do not carry a disqualification period.
8364 Claims Discharged through Bankruptcy - If the agency becomes aware of any bankruptcy proceedings concerning a household with an uncollected medical assistance claim, KDHE-DHCF Legal Division shall be notified immediately. Legal Division will provide notification when the bankruptcy action is complete. Collection action should then be initiated, resumed, or terminated in accordance with the outcome of the final bankruptcy action.
8370 Terminating Claims - An uncollected claim shall be terminated when either of the following occur:
1. The only remaining household member responsible for the claim is deceased; or
2. The claim has been discharged through a bankruptcy proceeding (see 8364).
08400 Determination of Fraud - A fraud error can only be established through a finding by a court of appropriate jurisdiction. Therefore, additional steps are required before collection action may commence.
A suspected fraud error shall be referred to the Office of the Medicaid Inspector General. The Office of the Medicaid Inspector General will make a determination as to whether or not to pursue the case in court. If a decision is made not to pursue, the claim will be labeled as Client Error and processed as such. If the claim is accepted by the Office of the Medicaid Inspector General for prosecution, no further action shall be taken until a decision by the court has been rendered.
Individuals should not receive notice that the case is under investigation for fraud. Client inquiries concerning possible fraud investigation should be responded with a statement that the case is “under administrative review”. No additional information should be provided.
8410 Definition of Fraud - A fraudulent error occurs when the client intentionally:
1. Makes false or misleading statement, misrepresentation, concealment, or withholding of facts for the purpose of improperly establishing or maintaining eligibility; or
2. Misuses medical benefits, including selling, sharing, or trading the medical I.D. number for money or other renumeration, signing for services that were not provided to the recipient, or other misuse as determined by the agency.
An individual shall be considered to have committed fraud when the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction. There is no other method of establishing a fraud claim.
A finding of fraud under these provisions may result in criminal penalty, including fines and imprisonment, but may only result in a period of ineligibility if so ordered by the court (see 8363). Fraud error status is not established if the court’s resolution to the willful client error is to place the individual on diversion.
8420 Medical Assistance Penalties - An individual who has been convicted of medical assistance fraud under 42 U.S.C. Sec. 1320a-7b shall be ineligible for medical assistance for one year from the date of conviction. Convictions under state law do not carry a disqualification period.
Pregnant women who are sanctioned remain eligible for medical coverage when continuous eligibility provisions apply. See 2300.
8430 Fraud Referral - Before a referral to the Office of the Medicaid Inspector General for prosecution of suspected fraud can be made, it is necessary for the agency to first determine the amount (if any) of the alleged fraudulent overstated eligibility by following the procedures outlined in 8340. The same act of alleged fraud repeated over a period of time shall not be separated so that separate penalties can be imposed. If it is decided that a case will not be prosecuted for fraud, then the overpayment shall be handled as a client overpayment as outlined in 8313. The burden of proving fraud is on the agency. All referrals shall be reviewed by the Eligibility Supervisor and Program Integrity Specialist prior to the referral being sent to the Office of the Medicaid Inspector General.
There is no minimum amount of alleged fraudulent overstated eligibility required to initiate a fraud referral.
Claims (individual program or combined) of less than $1001 are to be referred to an Administrative Disqualification Hearing.
Claims (individual program or combined) of $1001 and over are to be referred to the fraud unit who will determine the appropriate course of action.
8480 Imposition of Disqualification Penalties -
8481 Applying the Disqualification Penalty - Once the court has found the individual to be guilty of fraud the disqualification penalty shall be applied as follows:
8481.01 - Individuals found guilty of civil fraud or criminal fraud by a court of appropriate jurisdiction shall be disqualified for a period of one year. If the court fails to impose a disqualification period, a disqualification period shall be imposed in accordance with 8420, unless contrary to the court order. If a disqualification is ordered, but a date for initiating the disqualification period is not specified, the disqualification period for currently eligible individuals shall be initiated within 45 days of the date the disqualification was ordered. The disqualification period is initiated by the sending of the notice. The notice must be sent within 45 days, with the disqualification starting the month following the month in which the notice is sent (or should have been sent in cases where the agency does not act timely to disqualify the individual). For fraudulent individuals not currently eligible, disqualification periods shall be initiated by notifying the household of the fraud and the specific time period established for disqualification. The disqualification period for individuals not currently eligible shall also be established within 45 days of the date the disqualification was ordered, or within 45 days of the date the court found the individual guilty of fraud as described above. The eligibility worker is responsible for notifying the fraudulent individual of the disqualification period and the effect on the remaining household members, if any.
8481.02 - Once a disqualification period has been imposed against the fraudulent individual, the period of disqualification shall be initiated and shall continue uninterrupted until completed regardless of the eligibility of the fraudulent individual's household. The fraudulent individual's household shall continue to be responsible for repayment of the fraudulent overstated eligibility regardless of its eligibility for program benefits.
8481.03 - If the agency fails to act timely to disqualify the fraudulent individual, the individual can only be disqualified to the extent that the disqualification period has not elapsed. An agency error claim SHALL NOT be established for any overstated eligibility resulting from the fraudulent individual participating in the program when he/she should have been disqualified.
8510 Fraud Recovery - The remaining household members, if any, shall begin repayment during the period of disqualification imposed by the court. The repayment agreement shall inform the remaining household members of:
8510.02 - The period of time the overstated eligibility covers;
8510.03 - The repayment methods that are available.
8511 - The household shall have 10 days from the date the notice is mailed to return the completed repayment agreement. If the household fails to return the completed repayment agreement in the time allotted, recovery action shall be imposed in accordance with 8360, if repayment is not otherwise established by a court. In addition, if the household agrees to make repayment but fails to do so, recovery action shall be automatically imposed and adequate notice only is required.
8520 Reversed Disqualifications - In cases where the determination of fraud is reversed by a court of appropriate jurisdiction, the individual shall be reinstated if otherwise eligible. Understated eligibility shall promptly be corrected as a result of the disqualification.