Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 12/26/2024
02000 >>> 02200
02140
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.