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