Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 12/26/2024
6310
6311 Eligibility Periods for Medical Programs - An eligibility or base period is the length of time used in determining financial eligibility for an individual or family. The length of the base period varies from one to six months depending on the medical program and any changes of circumstance as referenced in 6311.01. Eligibility shall be determined from the date of application. See 1403.
For all medical programs other than CHIP, the month of application establishes the first month of the current eligibility base period provided all eligibility factors, with the exception of a spenddown, have been met. On request of the client, a 3-month prior eligibility base period shall be established. (See 6311.02.) For cases determined eligible without a spenddown, the effective date of eligibility will correspond with the beginning of the eligibility base and will begin with the first day of the first month of the medical base period. For spenddown cases, eligibility cannot be certified until the spenddown has been met. However, the effective date of eligibility may precede the date on which the spenddown is actually met.
Since suspension, closure, and denial are alternative administrative procedures that result in the withholding of benefits to the client when there is unmet spenddown, a base period can be established and maintained regardless of which procedure is chosen. Denied applications establish an eligibility base period and an application month when the reason for denial is excess income resulting in spenddown. (See 6311.02(3). Closures within an eligibility base period because of increased spenddown do not change the base period. A reapplication received outside of a previously established base shall be treated as a new application without regard to any previous base except for a determination of prior medical eligibility. (See 6311.02.) Once an eligibility base is established, it can be shortened or changed in accordance with 6311.01. Ineligible months are counted as part of the eligibility base period only when ineligibility occurs within an established base period.
For CHIP, the month of application does not establish the first month of the current eligibility base period. The base period begins with the first month the eligible individual is enrolled in a managed care health plan per 2470. With the exception of CHIP newborns as outlined in 2500, there is no eligibility for CHIP for any months prior to that first enrollment month. Thus, the effective date of eligibility and the eligibility base period will always correspond to the first day of the first enrollment month.
6311.01 Current Eligibility Periods - The eligibility base will be 1 month base for all MAGI programs with the exception of Medically Needy. The eligibility base will be 6 months for Medically Needy cases. The 6 month base will be shortened, however, in the following circumstances:
(1) - When a recipient becomes eligible for CTM or SSI.
(2) - When a recipient begins receiving long term care in a Medicaid-approved institution.
(3) - When a recipient begins HCBS.
(4) - When a recipient is transferred from a Family Medical Medically Needy program to a Disability related Medically Needy program or vice versa. .
(5) - When the only person in an assistance plan dies and eligibility has not been determined due to a spenddown.
If the applicant dies or if an application is made on behalf of a deceased person, eligibility will begin no earlier than the third month prior to the month of application.
(6) - When the only recipient on the Medically Needy case becomes eligible for Medicaid poverty level coverage, or coverage through foster care.
(7) - When two or more Medically Needy recipient family groups combine into one. In such instances, the previous bases shall be shortened and a new base period started with the combined family group.
6311.02 Prior Medical Eligibility (Not Applicable to CHIP) - An applicant for medical assistance may request a determination of medical eligibility for a 3-month period prior to the month of application. The month of application establishes this prior medical period. A request for prior medical must be made in the month of application or the two following months. When a request for coverage is not processed within the applicable case disposition timeline as defined in 1407, the period to request prior medical is extended to 12 days following the date of the determination. Requests made after this time shall be denied. See 2340.02and 2460.02 regarding prior coverage determinations for children being added to an existing PLN program.
Prior eligibility can be established even though there is no eligibility for the current base period. However, there is no eligibility in any prior month for an individual who does not qualify for Medicaid.
NOTE: Prior CHIP coverage is only available for certain CHIP eligible newborns. (See 2500)
A 3-month eligibility base shall be used unless one of the following conditions exist:
(1) - Part or all of the prior base period falls into a previously established medical base period.
(2) - Part or all of the base period falls within any month in which the client was a Medicaid recipient.
(3) - The individual is not categorically eligible for any medical program in one or more months of the base period (i.e., is not a child, a pregnant woman, or a caretaker).
(4) - The individual was not part of the current family group in one or more months of the base period.
If, in the above instances, the assistance request includes other individuals in the family group, only the individual would be excluded for the applicable months. If the assistance request is only for the individual, the prior base period shall be shortened to exclude those months.
A one month base period shall be used in accordance with 6311.01 for each month of the prior period. Eligibility can be determined for any one or all of the 3 prior months.
Financial factors of eligibility apply to the entire base period. Eligibility factors other than the income shall affect eligibility for each of the months separately. Eligibility shall be effective only for the months in which the client meets both the financial and nonfinancial factors of eligibility.