Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 12/26/2024
07000 >>> 07400
07300
07400 Client Requirements for Timeliness - Reviews -
7410 Review Form - As indicated in 7331, individuals subject to a pre-populated review shall be given a minimum of 30 days to return a required review form. The review form shall be mailed to the individual on or about the 15th of the next to last month of the review period. To be considered timely received, the signed review form (see 1409.01) must be returned to the agency by the 15th of the last month of the review period. If the review form is not timely received, coverage will be automatically discontinued the evening of the 15th with an effective date of the last day of the last month of the review period, see 7431.
7410.01 Using an Application Form as a Review - An application form shall be used as the review in the following circumstances:
- Received within two months prior to the Review Due month.
- Received any month after the Review Due month through the current month when the Review Discontinuance Batch has not been run.
The application is used to complete the review when all members of the household are listed on the application. The application must be reviewed for consistency with the known case information. If additional information is needed to process the review, it shall be requested from the consumer, but another application form or review form is not required.
It is not necessary for the applicant to have requested coverage for all household members on the application. If individuals who are due for review, are listed on the application form, it is assumed that they wish for coverage to continue, and the form shall be used as a review for them. If the form does not include all household members, it shall be used to determine eligibility for the newly requested individual. If the Review Due date is in the past, manual action shall be taken to discontinue the remaining household members for failing to return their review.
7410.02 Continuation of Coverage Pending Completion of Review - When a review form is timely received (see 7331) and registered before the change processing deadline, eligibility at current levels will continue automatically until the review process is completed. If the review is timely received, but not registered before the change processing deadline, coverage will be automatically discontinued. In that instance, the discontinuance shall be rescinded and coverage reinstated while the review is pending. Note that if an untimely review is received during the review reconsideration period (see 7431), the discontinuance shall be rescinded but coverage shall not be reinstated pending the completion of the review.
Due to this process, if a timely received review is not timely processed by the agency, as defined in 7420, the current level of coverage for the individual(s) due for review may continue past the end of the review period for one or more months [extended month(s)]. The date the timely review is received will determine if those months are subject to correction.
7411 Information/Verification - All information and/or verification shall be provided by the requested date. Clients must submit any required verification or additional information within 12 days from the date of the initial request in order to ensure the rights to uninterrupted benefits. However, if the requested information is provided after adverse action is taken, but during the review reconsideration period, as described in 7431, the adverse action may be rescinded and the review reinstated for processing.
Follow the verification requirements at initial application, except that non-citizen status, providing an SSN, residency, and identity, do not have to be reverified unless a change has been reported or it is questionable.
7420 Agency Action on Timely Review - If the review form is timely filed and all review requirements have been met, the agency shall promptly process the review to ensure correct and timely coverage is provided. Timely processing shall be defined as follows:
1. A review form received before the 1st day of the last month of the review period shall be processed by the change processing deadline in the last month of the review period.
2. A review form received on or after the 1st day of the last month of the review period shall be processed by the change processing deadline in the month after the last month of the review period. Whenever possible, the agency, though not required, shall still attempt to process the review by the change processing deadline in the last month of the review period.
This process may result in an extended month of coverage. Any extended month of coverage provided under this process is subject to adjustment as indicated in 7410.02(2) if understated eligibility has occurred. However, in no instance shall a claim subject to recovery be created for the extended month (see 8321.02)).
3. Due to the nature of the program, all Medically Needy (MDN) reviews, regardless of when received, shall be processed by the change processing deadline in the last month of the review period. This will ensure that a new 6-month eligibility base period is properly established beginning with the month after the month the review period ends. See also 1410.01(2).
All households shall be notified of the appropriate reporting requirements upon review approval. See 7120.
7421 Passive Review Responses - After being passively reviewed, the consumer is required to contact the agency (either orally or in writing) if any of the information on file needs to be updated. Reaction to this change is based on when the change was reported and the type of eligibility resulting due to the change.
- If the change was reported by the last day of the old review period, the change is processed as a Passive Review Response.
- If the change was reported after the last day of the old review period, the change is not considered a passive review response. It is treated like any other change that is reported outside of the review process. Anyone already passively reviewed and continuously eligible will not be negatively impacted.
To process the Passive Review Response, staff update the case with the changes and redetermine eligibility for the next review period. If eligibility will be the same or better than the previous review period, the change is effective with the first month of the next review period. If the result is adverse, such as a premium increase or a change to a lower hierarchy program such as CTM to TMD, the change will be effective in the next unpaid month allowing for timely notice.
For passive review responses reported by the end of the old review period, the reported change can result in a change in coverage and/or premium even if coverage has already been approved. If the passive review response includes a request for medical assistance for a new individual, the change to add the individual is processed for the month of request but coverage for existing members is protected for any paid months by continuous eligibility rules. When a premium is involved, if a positive change, the change is made for the month after the month of report.
7431 Review Reconsideration Period - If the review form is not returned by the end of the current review period, the individual has a three-month reconsideration period to return the review form. Individuals will have until the end of the third month from the date of discontinuance to return the form for processing. The reconsideration period also applies to information requested in order to process the review. An application or review form received after that period is treated like a new application, including any request for prior medical assistance. If the requested information is provided after the reconsideration period expires, a new application may be required.
A review reconsideration period is not applicable to an individual who is approved at review or is denied at review for not meeting eligibility criteria. Any application for review not submitted in a timely manner shall be treated as an initial application. The timeliness provisions of 1407 and subsections apply.
When eligibility has been discontinued for failure to provide requested verification and the verification is later provided within the review reconsideration period described above, eligibility shall not be reinstated pending completion of the review. The discontinuance shall be rescinded, but no coverage past the end of the review period shall be provided, unless and until the review is fully processed.
Note: An individual who timely submits a review form but submits all verification in an untimely manner shall lose the right to a prompt review of eligibility (see 7420).
7432 Agency Failure to Act Timely - If the agency fails to timely process a timely received review form, an administrative processing error may have occurred. Eligibility will continue with coverage at the current level while the review is pending. This may result in one or more months of coverage past the end of the review period before the review is processed [extended month(s)]. Once the review is processed, the extended months of coverage resulting from the delay shall be reevaluated as follows:
1. If the new level of coverage determined by the untimely agency review is the same as the previous coverage, no adjustment to the extended month(s) is required. No administrative error, other than delayed processing, has occurred.
2. If the new level of coverage determined by the untimely agency review is greater than the previous coverage, the extended month(s) must be adjusted accordingly. Coverage for those extended month(s) shall be enhanced to match the newly determined coverage. The agency shall promptly update the coverage and notify the recipient(s) of the change.
3. If the new level of coverage determined by the untimely agency review is less than the previous coverage, including discontinuance of coverage, an agency error overstated eligibility has occurred for the extended month(s). Agency action must be taken to determine the amount of the overstated eligibility and establish a claim according to 8300 and subsections.
7441 Frequency of Reviews - All MAGI-based medical program recipients shall be reviewed once every 12 months and no more frequently than once every 12 months.