Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 12/26/2024
01000 >>> 01400
01350
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.