Eligibility Policy - 9/10/2026

01000

03000

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, see 3100 – 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: See 2130 for information on minors not living with a caretaker. 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.

2012 2019 Reserved -

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.

2021 Reserved -

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.

2024 2029 Reserved -

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.

2036.01 Reserved -

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.

2037 2039 Reserved -

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 beginning July 31, 2021 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. NOTE: This provision is contingent on DHS extension.

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. beginning February 24, 2022, until further notice (NOTE: eligible status is contingent upon DHS extension).

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 . NOTE: The exemptions above only apply to US citizens. These exemptions do not apply to individuals reporting to be non-citizens (including qualified non-citizens) as the requirements of 2047 apply and documentation of legal status must be obtained.

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-citizen 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 described in 2044 may participate. The agency may not request verification of qualifying 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 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 are 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). If the individual already has a DCF-verified record that results in a qualifying alien/immigration status, this would be considered a Tier 1 verification. Note: If there is a change in immigration status, staff will need to proceed through the tiered verification process. Tier 2 – The Manual SAVE process. Should the agency be unable to verify non-citizen status through Tier 1additional 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 pending the results of a SAVE verification. Note: Secondary verification should be requested when the person's entrance date is in question or if the VLP interface is failing. For persons adjusting status to lawful 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 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 (VLP) should 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 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.

2049 Reserved -

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 & CHIP) - Federal regulations prohibit states from fully terminating Medicaid or CHIP eligibility 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 or CHIP 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 pre-release Medicaid or CHIP eligibility; if determined eligible while incarcerated, a new application will not be required for redetermination upon release. If the individual is considered a qualifying youth under the CAA 2023 reentry requirements, they will be eligible for a limited pre-release benefit program which covers specific services for the 30 days prior to release. Upon release they will remain eligible and continue on the appropriate full-benefit plan. 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. See 2052.06 for additional considerations for incarcerated minors on CHIP. See 2052.08 regarding qualifying youth under the CAA and limited services provided under Medicaid/CHIP in the 30 days prior to release.

2052.06 Incarcerated Minors (CHIP) - A new CHIP eligible applicant cannot generally 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, unless they are within 30 days of release ( 2052.08 ). The other 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 (referred to as the Medicaid inmate payment exclusion), 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 (or 30 days prior to release if they qualify for the limited benefit plan, see 2052.08 ). 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.

2052.08 Limited Pre-release Benefit Plan for Certain Incarcerated Youth and Adults - While the Medicaid inmate payment exclusion applies to incarcerated individuals in most cases, federal legislation under the Consolidated Appropriations Act (CAA) of 2023 requires that certain services must be covered by Medicaid and CHIP for incarcerated youth and adults up to 21 who are post-adjudication (or sentencing) and within 30 days of their release date if they qualify for Medicaid and CHIP programs. This means that when a Medicaid/CHIP recipient or an individual who qualifies for Medicaid/CHIP under the age of 21, or AGO under age 26, becomes incarcerated, the facility must ensure certain services are provided for the required timeframe and that the Medicaid/CHIP agency is billed for these services. The population qualifying for special services under this policy are defined as eligible juveniles and consist of children or young adults who meet the following criteria: a. Eligible for Medicaid (either currently in a CE period or determined eligible based on an application) b. Eligible for CHIP (either currently in a CE period or determined eligible within 30 days prior to release. Prior to that timeframe, they would be denied due to incarcerated status.) c. Under 21 years of age or between 18 and 26 if aged out of the foster care system, including the Kansas Department of Corrections Juvenile Services (KDOC-JS) d. Are being held in a carceral/correctional facility after being convicted. e. Received specific services (see below) during the 30 days prior to their official release The special services referred to above consist of screening and diagnostic services (also referred to as EPSD) and targeted case management (TCM), or case management only for CHIP.

2054 - 2059 Reserved -

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.

2069 2099 Reserved -

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.

2121 - 2129 Reserved -

02121 Verification of Custody - Although verification of who resides in the household is not a condition of eligibility, there may instances where verification of residential custody is needed. This could include but is not limited to the following: a) An application is received for minor child who is currently active on another medical case with another parent or caretaker, b) An application is received for a parent or caretaker who is not requesting coverage for the minor child, but the child is active on another medical case under another parent or caretaker. When verification of residential custody is needed, prior to sending a verification request, contact should be attempted with both the original primary applicant and the new applicant by telephone. If verbal confirmation is provided by the original primary applicant that the minor child is no longer in the home, no further verification is needed. A call will only need to be placed to the new primary applicant if the original primary applicant indicates the child remains in their household. If the new primary applicant reports the minor child is no longer in the home, no additional information is needed, and the case can be denied. If the original primary applicant and new applicant cannot be reached by telephone, a verification request must be sent to both households to provide the opportunity for residential custody to be confirmed. Common forms of written verification include court documents (most recent custody agreement, guardianship etc.), school enrollment paperwork, a signed statement from the absent parent and medical records. Written verification must include the minor child’s name and address. If the requested information is not returned for either household, the child must remain on their currently active case through the remainder of their CE period.

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.

2131 2139 Reserved -

02140 Temporary Absence of a Child or Caretaker - A person is temporarily absent when they are absent from the home due to special circumstances, such as (but not limited to) illness, education, business, vacation, military service, detention in a correctional facility (i.e., incarceration), or a custodial agreement (including foster care). For the absence to be considered temporary, it must be reasonable to assume that the absent person will return to the home. A child who remains part of the household, but is, or is expected to be, out of the home for a temporary period of time shall, if otherwise eligible, qualify to receive assistance as part of the household to which they will return. In addition, a caretaker who is out of the home for one of the reasons above and is expected to return shall also qualify as a part of the household. This is regardless of the length of time away. (See MKEESM 8113 for information related to children in Medicaid approved facilities.) For an adult to be considered a caretaker for medical purposes (i.e. Caretaker Medical program eligibility), they must have care and control of a child and must either be living with the child or considered temporarily absent under IRS definitions (i.e., work, school, etc.). 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. NOTE: These provisions are related to temporary absence from the household. For temporary absence from the state, see 02050 .

2141 Temporary Absence and Foster Care - Children in foster care are considered temporarily absent from their original/family household as long as they are expected to return. For eligibility purposes, the assumption is always that the child will be reintegrated with their family (which is expected to occur within six months), unless formally expressed otherwise or documented by the Department of Children and Families (DCF). This means that when a child is reported out of the home due to entering foster care, they are still considered part of the household size as temporarily absent. However, when an adult is applying for CTM and the only qualifying child (or children) is absent due to being in foster care, a 180-day timeframe is relied upon to determine if the adult applicant qualifies as a caretaker of the absent child. If at the time of application, the child has been in foster care 180 consecutive days or less, it is assumed the child will return home, and the adult may be considered a caretaker for eligibility purposes. If at the time of application, the child has been in foster care for more than 180 consecutive days, the absence will be considered permanent, and the adult will not be considered a caretaker for processing purposes.

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 United Healthcare 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.

2201 2209 Reserved -

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.

2213 2219 Reserved -

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.

2224 2229 Reserved -

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.

2231 - 2239 - Reserved

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 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 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.

2241 2259 Reserved -

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 number 2030 , 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.

2261 2269 - Reserved

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.

2274 2279 Reserved -

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 .

2281 2299 Reserved -

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).

2302 2309 Reserved -

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:

2311.01 - a child turns age 19 (unless pregnant or in a postpartum period, see 02300 and 2301 ;

2311.02 - an individual no longer meets residency requirements;

2311.03 - an individual dies;

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.

2311.11 - Reserved

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.

2313 2319 Reserved -

02320 Continuous Eligibility Medicaid Deemed 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. Note: The mother must be receiving Medicaid coverage in the month the child is born for the child to be considered a continuously eligible Medicaid deemed newborn. A non-deemed newborn cannot become deemed at a later time based on a newly reported birth or pregnancy. See 2501 for more information on non-Medicaid deemed newborns.

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.

2321 2329 Reserved -

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.

2331 - 2339 - Reserved

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.

2341 - 2349 - Reserved

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).

2351 - 2359 - reserved

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.

2404 - 2409 Reserved -

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.

2413 - 2429 Reserved -

02420 State Employee Health Plan - State employees whose child(ren) are on their current SEHP insurance may apply during their open enrollment period and be approved for CHIP coverage beginning January 1st of the following year. As CHIP may not be received concurrently with other comprehensive health insurance and these child(ren) will remain enrolled in the SEHP through the end of the calendar year, specialized handling of these cases will be necessary. Staff will need to partially deny coverage from October through December due to other health insurance (OHI) and approve CHIP beginning January 1st of the following year based on the October application. NOTE: Non-state groups consist of certain public entities who choose to contract with the SEHP, such as cities, counties, and school districts. If an SEHP member applies during their open enrollment period for their child(ren) but does not include an end-date for their reported other health insurance, it is considered best practice to attempt contact and clarify if they are applying with the intent to drop their other coverage once they are notified of their KanCare approval.

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.

2431 - 2439 Reserved -

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 delinquency or closure 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 Deliquency - Payment of CHIP premiums is a requirement for CHIP eligibility with the exception of pregnant CHIP minors, see 02510 . An account meets the definition of delinquent when there are two invoices that have not been paid and have not previously been used to penalize the household. 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, or a consumer previously terminated at review for premium delinquency reapplies and qualifies for CHIP. 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. Failure to pay delinquent premiums at review results in discontinuance. When delinquent premiums are paid, or when a consumer previously closed for premium delinquency reapplies and qualifies for CHIP, the previously penalized delinquent premiums cannot be used again to terminate or deny CHIP coverage. 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. However, a child may not be denied or discontinued for premium delinquency until their annual review. If there is a request to add a child to a CHIP program where there is a premium delinquency on the case, the child may be determined eligible for CHIP benefits despite the delinquency, provided they are otherwise eligible for CHIP. The new applicant child may not be adversely impacted by the premium delinquency until their next review.

2441.01 - Reserved

2442 Impact on Current Recipients - When an ongoing CHIP recipient fails to pay their premium obligation for two invoices and the account becomes delinquent, if the case remains delinquent at review and the child(ren) are otherwise CHIP eligible, coverage is discontinued. Discontinuance may only occur at the point of the CHIP recipient’s review as premium delinquency does not impact a child’s Continuous Eligibility (CE) period.

2442.01 Impact of Payments on Premium Delinquency - If a payment is made of the delinquent amount before the end of the review period, the delinquency is resolved. If payment of the delinquent amount is made after the review period has ended following closure at review, a new request for coverage is required and a new determination is made. If the request is received during the Reactivation period (see 1410.02 ), a verbal request is allowed. After that time, a new application is required, per 1402 . As this would be considered a new determination and not a reinstatement, coverage will not backdate and should begin the date of approval.

2443 Impact on Eligibility for New Applicants (Including Former Residents) - When processing a new request for CHIP, whether a new application or adding a person to an existing program, and there are delinquent premiums, this will have no impact on new CHIP eligibility. This includes both new applicants and former recipients who lost coverage and are now reapplying.

2444 Collection of Past Due Premiums - Following closure at review for premium delinquency, the same delinquent premiums may not be used to negatively impact eligibility for the individual. However, the past due obligation is not forgiven until payment is made. The obligation remains on the consumer’s account, maintained by the fiscal agent. 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.

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.

2447 2449 Reserved -

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;

2452.03 - the child dies;

2452.04 - Reserved

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.

2454 - 2459 Reserved -

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.

2461 - 2469 Reserved -

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 .

2471 - 2479 Reserved -

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 .

2481 2499 Reserved -

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. Once approved on Medicaid/CHIP, a 12-month CE period would apply, as defined in 2310 .

2502 CHIP Deemed Newborns - 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. Note: Medicaid eligibility must be assessed prior to deemed CHIP eligibility when there is sufficient information provided to make the determination. If the updated information received results in the child being Medicaid eligible, the deemed CHIP provisions do not apply.

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.

2504 - 2509 Reserved -

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.

2521 2529 Reserved -

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.)

2532 2539 reserved -

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.

2541 2549 Reserved -

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.

2551 2559 reserved -

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.

2561 2569 Reserved -

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.

2573 2579 Reserved -

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.

2581 2589 Reserved -

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.

2591 2599 Reserved -

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.

2601 2609 Reserved -

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.

2611 2699 Reserved -

2311.04 - Reserved

Eligibility Policy - 9/10/2026

02000

04000

03000: MAGI Budgeting -

03100 MAGI Budgeting Units - A MAGI Budget Unit is defined as a person or group of people that must be included in a single applicant’s eligibility determination. The budget unit is based on the expected tax household. All Family Medical programs determinations are based on the concept of the Individual Budgeting Unit (IBU.) See 2140 for temporary absences. There is one Budget Unit for each member applying for coverage. Tax household members may be included in the Budget Unit of other household members, but each individual has a unique Budget Unit that is used to determine their individual eligibility. This is known as the Individual Budgeting Unit (IBU). Much of the MAGI determination is based on an applicant’s planned tax household. What we need to know is if the applicant intends to file taxes and who they intend to claim on the tax return. The budget unit is not based on how an individual actually files their taxes, but on how they plan to file them. The questions on the application should be answered based on how the individual would file taxes if they filed today. Obtaining tax household information is a requirement of eligibility. In the application process, each individual is required to respond to a set of questions which are used to determine the budgeting unit. This information includes whether or not the individual plans to file taxes, if they will file jointly with a spouse, and who will be claimed as tax dependents on that tax return. It is also necessary to obtain information about the tax household when an individual is being claimed by someone not in their home. The information may be obtained verbally or through KEES form V777. Note: Tax household members not living in the home must be added to the case in KEES. This allows them to be used for the individual budget unit. Their income must also be included so it can be counted for the individual budget unit. Refer to the MAGI – Building Individual Budget Units and MAGI Individual Budget Units (IBU) Examples found in the KDHE Eligibility Policy Appendix for additional information.

3110 Filers - Individuals who plan to file taxes or are expected to be claimed as a tax dependent by someone else are considered Filers. Their IBU includes themselves, their spouse if living together and all individuals claimed as dependents on their tax return.

3120 Non-Filers - Individuals who do not intend to file a tax return or be claimed as a tax dependent, are considered Non-Filers. Their IBU includes the following: IBU for an adult: Individual, spouse, and individual’s children (biological, adopted, and/or step) who are under age 19 if living in the home. IBU for an individual under age 19: Individual, individual’s parents (biological, adopted, and/or step), individual’s siblings (natural, adopted, and step) who are under age 19 if living in the home, and individual’s children (biological, adopted, or step) who are under age 19 if living in the home.

3130 Individuals Claimed as a Dependent - When an individual is claimed as a dependent by another, there are a series of questions we must ask in order to determine if the individual’s IBU is based on the tax household or on the Non-Filer rules. These questions are referred to as ‘exceptions’ on the MAGI IBU Examples document. These questions are: • Is the individual being claimed as a dependent by someone other than their spouse or parent (biological, adopted, or step?) • Is the individual under age 19 and being claimed as a tax dependent by only one parent, but living with both parents (biological or adopted?) • Is the individual under age 19 and being claimed as a tax dependent by a parent (biological or adopted) not in the home? A ‘yes’ answer to any of these questions indicates that the exception has been met and the individual’s IBU is determined based on the Non-Filer rules. When none of the exceptions is applicable, the IBU includes the following: The Individual, the tax filer claiming the individual, the tax filer’s spouse if filing jointly, and all additional persons the tax filer is including as tax dependents. Note: In this situation, it is not relevant if the tax filer, tax filer’s spouse, and other tax dependents live in the same home as the individual.

3140 Inclusion of the Spouse - If not already included in the IBU using the rules above, the spouse of the taxpayer and the spouse of the individual shall be included in the IBU when they reside in the same home.

3150 IBU for a Pregnant Woman - When determining the IBU of the pregnant woman, add the number of babies that are expected for that pregnant person. This is based on self-attestation by the applicant. If staff determine the reported information on the number of babies expected is questionable, verification may be requested.

3151 3199 Reserved -

03200 Additional IBU Provisions - The following additional principles are applicable to MAGI Individual Budgeting Units.

3200.01 - Individuals aged 18 and younger who plan to file taxes, reside with their parents and their parents are not claiming them as a tax dependent are to be determined using the non-filer rules as outlined in 3120 .

3200.02 - Marriage establishes legal responsibility between the couple. Any marriage (including same sex) validly established in Kansas or another jurisdiction either through a civil licensed contract or by common-law (see 3200.03 ) shall be recognized. Once established, the marriage (both civil and common-law) may only be dissolved through a formal divorce court proceeding.

3200.03 - A common-law marriage establishes legal responsibility between the couple. To be considered common-law married, the couple must meet all of the following conditions: a. have the legal capacity to marry, meaning they are at least 18 years old, legally competent, and not already married to someone else b. consider themselves to be presently married c. hold themselves out to the public as married

3200.04 - When an unmarried couple indicates they will file jointly, staff must first make contact to clarify their tax filing intention. If after contact, the couple still attests that they are not married or common-law married and attest to filing jointly, the non-filer rules shall be used for all household members.

3200.05 - In situations where an individual is a member of the budgeting unit, but their income is not included in the determination, such as when the IBU member is an SSI recipient, the individual will be provided with a role in KEES called ‘Family Size Only’.

3201 3199 Reserved -

Eligibility Policy - 9/10/2026

03000

05000

04000: Reserved -

Eligibility Policy - 9/10/2026

04000

06000

05000: Income Guidelines - There are two types of income, earned and unearned. Income shall include money received from such sources as wages, self-employment, unemployment compensation, property rentals, and pensions. Modified Adjusted Gross Income (MAGI) is the budgeting methodology used to determine eligibility for all family medical programs. MAGI budgeting is directly tied to federal income tax rules. Income that is taxable according to federal income tax rules is countable for family medical programs. In addition, tax-exempt Social Security income, interest and foreign income are countable. Income types not specifically addressed as countable or exempt in the following sections will require research to determine if the type of income is taxable according to federal income tax rules. This will be the deciding factor on whether or not income is counted.

05100 General Guidelines - The following general rules are applicable:

5110 - Income must be real. To be real, income must be such that its value can be defined and measured.

5110.01 - Income value must be established by objective measurement.

5110.02 - Income shall be considered available when a client has a legal interest therein and the legal ability to make it available. Earned income is available to the individual producing it and all persons for whom he is a member of their individual budget unit. Unearned income is available to the individual for whom it is intended and all persons for whom he is a member of their individual budget unit.

5110.03 - The income of all persons who are included in the individual budget unit must be considered but will not always be counted. See 5130 for additional information about when an individual may be in the IBU but not have their income included in the determination. If, in the month of application, a member of the IBU has left the home, his or her income shall not be considered as being available to the family in that month. Also see 5400 .

5110.04 - A conversion of property from one form to another shall not be considered as income except for the proceeds from a contract for the sale of property.

5120 MAGI Income Threshold - The MAGI Income Threshold is the minimum income requirement that establishes if an individual is required to file taxes is set by the Internal Revenue Service (IRS) and is subject to periodic changes. The MAGI Income Threshold is used to determine when income shall be counted for certain children and tax dependents. It does not apply to non-dependent adults or to children living with non-parental caretakers. The MAGI Income Threshold is defined annually by the IRS for the previous tax year. The current threshold amounts/limits can be located in the F-8 Kansas Medical Assistance Standards chart in the appendix of the KanCare Policy website. Individuals whose income is above the MAGI Income Threshold are required to file a Federal tax return. Whether or not they actually file a tax return has no impact on how their income is counted for medical assistance purposes. For children living with their parents/stepparents and tax dependents claimed by someone in the IBU, income is countable if it exceeds the MAGI tax filing threshold for earned and/or unearned income. Note: The MAGI income threshold does not apply to SSA income. SSA income is only counted for non-dependent adults and children living with non-parental caretakers, or minors and tax dependents who have taxable income from earnings or interest/dividends that exceed the tax filing threshold. Otherwise, it is considered exempt.

5130 Countable Income for a Child or Tax Dependent - The countable income of a child or tax dependent may be excluded from their own IBU and other IBUs for which they are a member of according to the rules below.

5130.01 Non-Filer Budgeting Units - When the IBU is based on the non-filer rules as defined in 3120 , the income of a child (under age 19) will be excluded when their income is below the MAGI Income Threshold and their parent or step-parent is in the IBU. When these requirements are not met, all taxable income of the child is included in their own IBU and any IBU that they are a member of.

5130.02 Filer Budgeting Units - When the IBU is based on the filer rules as defined in 3110 , also known as Tax Household Budgeting Units, the income of a tax dependent will be excluded when their income is below the MAGI Income Threshold and they are a tax dependent of the Primary Taxpayer. When these requirements are not met, all taxable income of the tax dependent is included in their own IBU and any IBU that they are a member of.

05200 Unearned Income - Unearned income is any income that is not earned and may be derived from benefits (unemployment compensation, Social Security, VA, etc.), pensions, contributions, and settlements. Unearned income received or reasonably assured to be received in a month or in the eligibility base period shall be considered. Gross unearned income shall be considered unless exempt as noted below.

5210 Unearned Income Payments - Unearned Income Payments

5211 Regular Unearned Income - Regular unearned income shall be considered as income when it is reasonably assured to be available in the same monthly amount in the future. Regular unearned income shall be budgeted in accordance with 6000 and subsections.

5212 Irregular Unearned Income - Irregular unearned income results from income which varies in amount from month to month and is expected to continue. Irregular unearned income shall be budgeted in accordance with 6000 and subsections.

5213 Intermittent Unearned Income - Intermittent unearned income is received on other than a monthly basis such as quarterly, semiannually, or annually. It must be considered and averaged. See 6113 . Intermittent unearned income received prior to the first eligibility period shall not be considered. The case record shall clearly indicate that the income is being treated as "intermittent" unearned income. NOTE: An additional benefit check is provided on an annual basis to retired members of the Kansas Public Employer's Retirement System (KPERS) who began receiving a benefit prior to July 2, 1987. This 13th check is generally identical in amount to the monthly benefit. This check is to be treated as intermittent income and budgeted over the entire year by dividing by 12.

5214 Lump Sums - MAGI income (as defined in 5000 ) received as a lump sum is counted as income only in the month received.

05220 Countable Unearned Income - The following sections outline the types of countable unearned income.

5220.01 Annuities Income - Payments from an Annuity are countable if they are taxable. Verification is required. If it is not clear if the income is taxable, send the documentation to the Policy Manager for review.

5220.02 Contract Sales - The proceeds received from the contract sale of property are considered unearned income and are countable. Verification is required.

5220.03 Dividends - Regular payments of dividends earned from an investment are countable as income.

5220.04 Insurance Payments - Only recurring insurance payments that are unrelated to life insurance, burial proceeds, death benefits, or the repair and replacement of property are countable. Verification is required. See 5406 for more information about exempt insurance payments.

5220.05 Interest - Regular payments of interest earned from an investment are countable as income.

5220.06 Lottery/Gambling Winnings - Gambling winnings from any source are treated as unearned income in the month received. Gambling winnings are generally cash, prizes or in-kind items won in a game of chance, including but not limited to lotteries, sweepstakes, wagering pools, bingo games, card games, roulette wheels, dice games, slot machines, or any other game involving an element of chance. Gross amounts are counted even if taxes are taken out prior to paying the household. Gambling winnings are countable using prospective income budgeting standards per 06100 only if the income is expected to continue. In the case of qualified lottery and gambling winnings of $80,000 or greater received in a single payout, the income is to be counted in the month received through a period of up to 120 months, as determined by a formula provided by the 2018 statute, see T5 Gambling Winnings – Income Budgeting Table. Per federal guidelines, states must apply this formula to qualified lottery or gambling winnings received on or after January 1, 2018. With the exception of winnings resulting from games conducted by a tax-exempt religious or charitable organization, any winnings from a lottery, sweepstakes or wagering pool sponsored by a state, multi-state or multi-jurisdictional lottery organization, or any lump sum winnings from bookmaking, slot machine, roulette wheel, dice table, lottery, numbers game, or similar game of chance conducted by a private or for-profit individual or organization shall be counted in accordance with the T5 Gambling Winnings – Income Budgeting Table. Information received on the application or verbally from the consumer regarding the date of receipt and the gross amount of winnings shall be used by KEES to calculate the monthly amount to be budgeted for this income. Note: With respect to non-cash prizes, like car or boat, these should continue to be considered as lump-sum income in the month received. Continued eligibility shall be granted where the counting of income as indicated in this section results in ineligibility and loss of coverage and causes undue medical or financial hardship. For purposes of this provision, hardship shall be defined as follows: 1. Medical Hardship – The individual must demonstrate that the loss of eligibility put the individual at risk of death or permanent disability without the medical coverage. 2. Financial Hardship – The individual must demonstrate that the gambling winnings being counted as income are no longer accessible or available to meet medical needs. When hardship is granted, the gambling winnings shall no longer be counted as income in determining eligibility beginning with the month the hardship was requested.

5220.07 KPERS - Payments received from the Kansas Public Employee Retirement System (KPERS) are countable as income.

5220.08 Native American Tribal Disbursements - This income type refers to income received from casino profits, also known as Per capita income. Income from gaming is countable. All per capita income received by a Kansas Tribe Members is from gaming. Non-Kansas tribes will require additional research to determine the purpose of the disbursement in order to assess whether it is countable or exempt. When this income is received on other than a monthly basis, it is considered intermittent unearned income and the rules of 5213 apply. Also see 5409 for more information about Native American income types that are exempt.

5220.09 Oil Royalties/Mineral Rights - Payments from Oil Royalties and Mineral rights are countable. Verification is required.

5220.10 Pensions - Income payments from a pension are countable. Benefits are considered the income of the person for whom they are intended.

5220.11 Per Capita - Another term used for Native American Tribal Disbursements. See 5220.08 .

5220.12 Railroad Benefits - Railroad benefit payments are countable. Benefits are considered the income of the person for whom they are intended. Verification is required.

5220.13 Rental Income - Income from rental properties shall be treated as countable self-employment income. See 5330 .

5220.14 Retirement Income - Retirement income is countable. Benefits are considered the income of the person for whom they are intended.

5220.15 Social Security - Income from Social Security Disability and Retirement benefits are countable. Benefits are considered the income of the person for whom they are intended.

5220.16 Spousal Support - Spousal support payments, or alimony, as a result of a divorce decree effected or modified after December 31, 2018 are not taxable and are thereby considered exempt income for MAGI purposes; however, spousal support payments from agreements made prior to December 31, 2018 continue to be countable. When this is the case and the spousal support is paid through the court, the gross amount before the fee is deducted is considered countable income. The amount of the fee is considered a household expense and is not to be excluded as income.

5220.17 Trust Income - Payments from a non-special needs trust are countable if they are taxable. Verification is required. If it is not clear if the income is taxable, send the documentation to the Policy Manager for review.

5220.18 Unemployment Compensation - The gross amount of unemployment compensation is countable income, even if some of the payment has been intercepted for payment of child support or other repayment plans.

05300 Earned income - Earned income is income which is received as wages, salary, or profit resulting from the performance of services, including managerial responsibilities, by the recipient. Earned income may be derived from self-employment in the client's own business.

5310 Earned Income Payments -

5311 Regular Earned Income - Regular earned income results from earnings which are reasonably assured to be available in the same monthly amount in the future. (See 6000 and subsections for budgeting.)

5312 Irregular Earned Income - Irregular earned income results from earnings which vary in amount from month to month and are expected to continue. From a practical standpoint, irregular earnings result from full- or part-time employment when payment is received on any basis other than monthly or twice a month. (See 6000 and subsections for budgeting.)

5313 Intermittent Earned Income - Intermittent earned income is received on other than a monthly basis such as quarterly, semiannually, or annually. Such income is to be considered and averaged. Intermittent earned income received prior to the first eligibility period shall not be considered.

05320 Countable Earned Income - The following sections outline the types of countable earned income.

5320.01 Wages - This is income earned from a job. It includes wages earned for hourly work or a salary. Wages also includes bonus pay received while an employee. Wages received from On-the-Job Training (OJT) are also to be considered as earned income. Sick pay received for time off while working (i.e., short-term illness) shall be considered earned income when the person is still considered an employee by the employer and the person will be returning to work when recovered. However, when these payments are provided as a temporary disability insurance or worker's compensation the income is not counted as earned income. See also 5400 . Wages withheld by the employer to purchase benefits are counted as earnings in the pay period that the employee would have normally received them. Benefit "credits" offered in addition to wages which can be used to purchase benefits are not counted as income. If the employee does not use all of the credit to purchase benefits, and the employer pays the excess to the employee as part of their wages, the excess paid is counted as earned income.

5320.02 Bonus and Commission Income - Income from bonuses that are received monthly or more frequently shall be included in the amount of earnings from wages. When bonuses are received less frequently then on a monthly basis they shall be treated as intermittent earned income and only countable once they have been received during an eligibility period. See 5313 .

5320.03 Garnished or Diverted Wages - Available income shall not be reduced by wage earner plans, garnishments, income withholding orders and similar types of income reductions. Such forms of income withholdings are generally used to meet the individual's previous or ongoing obligations and are considered available for the purpose of determining medical eligibility. Wages earned by a household member that are garnished or diverted by an employer and are paid to a third party for a household's expenses, such as rent or child support, shall be considered income. However, if the employer pays a household's rent directly to the landlord in addition to paying the household its regular wages, the rent payment shall be excluded as a vendor payment. In addition, if the employer provides housing to an employee, the value of the housing shall not be counted as income.

5320.04 Military Pay - Military pay is countable as earned income with the exception of most special allowances. Members of the military receive monthly allowances for housing, subsistence, and other reasons. Income from allowances is non-taxable, therefore exempt, with the exception of CONUS COLA which is a monthly Cost of Living Allowance for members stationed in the United States. The two most common allowances, Basic Allowance for Housing (BAH) and Basic Allowance for Subsistence (BAS) are exempt.

5320.05 Overtime - Overtime income is countable and shall be included with regular wages when determining an average.

5320.06 Tip Income - Income from tips shall be included in the amount of earnings from wages for each pay period. Use the amount of average tips reported by the applicant when not included on the paystubs

5320.07 Wages Withheld/Salary Advances - Wages are sometimes paid in advance to an employee, usually at the request of the employee. Wage advances are not counted as income received. Repayment of those advances are not deducted from gross income, either. However, wages held by the employer as a general practice, even if in violation of the law, shall not be counted as income to the household. For example, it is routine in many places of employment for the first week or two weeks of wages to be withheld and not paid until the following pay period. This is legal and the wages would not be counted until received.

5320.08 Work Program/Training - Income from a Work or Training program, such as College Work Study, WIA - Earned, Job Corps, and AmeriCorps/VISTA are countable.

05330 Self-Employment - Self-Employment income is earned income received directly from one's own business, trade, or profession. Some guidelines to determine if an individual is self-employed include whether the person: (1) holds himself out as a business (e.g., advertises), (2) decides when and where to work, obtains own jobs or sales, and pays own expenses, (3) has a risk of a profit or loss, and (4) pays his own FICA and income taxes (although this guideline, by itself, does not necessarily establish self-employment). The absence of one or more of these criteria indicates that the activity is not self- employment. Each situation must be evaluated on a case-by-case basis and documented in the case file as to whether a certain income is self-employment or not. An adjusted gross income amount must be determined by deducting income producing costs from the gross earnings.

5330.01 - Income from rental property and other income-producing personal property shall be considered self-employment earned income, regardless of the amount of time engaged in the production of the income.

5330.02 - A loss from self-employment cannot be deducted from other income nor can a net loss of a business be considered as an income producing cost.

5330.03 - When at least one person has wages and at least one person is self-employed, separate calculations are required and the countable incomes are then totaled. Self-employment income shall be considered and averaged. (See 6200 )

5330.04 - Payments from a roomer or boarder shall be treated as though it were self- employed earned income.

5330.05 - Income from “gig economy” such as (but not limited to) food delivery services, ridesharing or freelance work shall be evaluated on case-by-case basis to determine if it is self-employment or employment.

05400 Exempt Income - With the exception of non-taxable Social Security, non-taxable foreign earned income, and tax-free interest, only income that is taxable is countable. Income from the following sources is exempt as income in the month received. For income types not referenced, additional research is required to determine if the income is taxable.

5401 Child Support - Payments, whether paid for current support, arrears support, or voluntary payments are exempt as income. This includes cash payments and payments made in-kind.

5402 Disability - Disability payments such as those received for Worker’s compensation, short-term disability, or other non-SSA disability payments are exempt as income.

5403 Earnings - Earned income from Strike Pay and Blood/Plasma Sales are exempt.

5404 Educational Income - Income from Grants, Scholarships, Loans, Veteran’s educational income, and Monthly living benefits (stipends) are exempt as income.

5405 Government Payments - Government payments are exempt as income. These payments are described below.

5405.01 Adoption Assistance Subsidy - Payments received for Adoption Assistance are exempt as income in the month received.

5405.02 Cash Assistance - Cash assistance payments, including those received as TAF special allowances are exempt as income in the month received. Examples of Special Allowances payments are special transportation payments and special service payments.

5405.03 Disaster/Emergency Assistance - Federal major disaster and emergency assistance and comparable disaster assistance provided by state or local government or by disaster assistance organizations in conjunction with a presidentially declared disaster are exempt as income in the month received and as a resource in the following months. This includes disaster unemployment assistance to an individual as a result of a major disaster. Individuals cannot be eligible for any other unemployment compensation and also receive disaster unemployment benefits. Payments are limited to 26 weeks. Central Office will notify staff if such disaster unemployment assistance is paid in Kansas due to a major disaster.

5405.04 Energy Assistance/LIEAP - Payments or allowances made under some federal laws for the purpose of providing energy assistance are exempt from consideration as income in the month received. An example of such federal program is the Department of Health and Human Services' Low Income Energy Assistance Program (LIEAP). Other home energy assistance furnished by a federal or state regulated entity whose revenues are primarily derived on a rate-of-return basis, by a private nonprofit organization, by a supplier of home heating oil or gas, or by a municipal utility company which provides home energy, if the assistance provided is based on need, is exempt as income in the month received.

5405.05 Executive Volunteer Programs - Payments received through Service Corps of Retired Executives (SCORE) or Active Corps of Executives (ACE) are exempt as income in the month received.

5405.06 Food Stamps - Value of the benefits issued under the current Food Stamp Act are exempt as income in the month received.

5405.07 Foster Care and Permanent Custodianship - Payments received for providing foster care or permanent custodianship are exempt as income in the month received.

5405.08 Foster Grandparents - Any payment provided to volunteers serving as foster grandparents is exempt as income in the month received and as a resource in the following months.

5405.09 HUD Payments/Housing Assistance - Payments from federal housing programs including negative rent payments made to tenants of subsidized housing under Housing and Urban Development (HUD) regulations is exempt as income in the month received and as a resource in the follow months.

5405.10 Independent Living Payments - Payments received for Independent Living are living exempt as income in the month received.

5405.11 Older American Act Payments - Payments received via the Older American Act are exempt as income in the month received. These include the Senior Community Services Employment Program funded under Title V of the Older Americans Act of 1965 (as amended by P.L. 100-175, the Older Americans Act Amendments of 1987) are exempt as income in the month received. Programs in Kansas funded under Title V include Green Thumb, Project Ayuda (serving Wyandotte, Johnson, Douglas, and Shawnee counties), and the Senior Community Service Employment Program through the Midway Chapter of the American Red Cross (serving Sedgwick, Reno, Harper, Kingman, Butler, Cowley, Harvey, and Sumner counties).

5405.12 Refugee Resettlement Funds - Payments received from a Refugee Resettlement Agency are exempt as income in the month received.

5405.13 Senior Health Aids/Companions - Payments received through Senior Health Aides or Senior Companions are exempt in the month received.

5405.14 Tax Refunds/Rebates/Credits - Legislated tax rebates and refunds are exempt as income in the month received. This also includes Earned Income Tax credit, whether received as a lump sum refund or on an ongoing basis.

5405.15 Gate Money - Money paid to a prisoner upon their release shall be exempt as income in the month of receipt.

5406 Insurance Payments - Payments from life or burial insurance as well as payments made for repair or replacement of property are exempt.

5406.01 Life and Burial Insurance Payments - Payments occasioned by the death of another person to the extent that the payments have been expended or committed to be expended for purposes of the deceased person’s last illness and/or burial. Such payments include, but are not limited to, proceeds from a life insurance or burial insurance policy, gifts, and inheritances.

5406.02 Repair and Replacement - Insurance payments received for the repair or replacement of property is exempt as income. This includes income from a one-time payment or a portion of a one-time payment from a settlement for repair or replacement of property or other settlement, including legal services and medical insurance payments.

5407 Interest and Dividends - Interest earned on a burial fund or on a pre-paid burial space contract account is exempt as income in the month received. Dividends earned on a life insurance policy are exempt as income in the month received.

5408 Loans, Gifts, and Contributions - Cash gifts, Loans, Charitable Donations, and Deemed Sponsor income are exempt.

5408.01 Loans - All loans, including loans from private individuals as well as commercial institutions, including deferred educational loans, shall be exempted from household income. Monies received from reverse mortgages are treated as loans, even if payments are regular and predictable. When verifying that income is exempt as a loan, a legally binding agreement is not required. A simple statement signed by both parties that indicates that the payment is a loan and must be repaid shall be sufficient verification. However, if the household receives payments on a recurrent or regular basis from the same source but claims the payments are loans, the provider of the loans may be required to sign a statement that indicates that repayments are being made or that payments will be made in accordance with an established repayment schedule.

5408.02 Social Fundraising Accounts - Income received from a social fundraising account, such as a Go Fund Me account may be exempt as income depending on the purpose and intent of the account. Contributions received are exempt when the individual donating does not expect to receive anything in return for their contribution. Contributions are also exempt when the payment is made as an investment and the individual expects to receive a return on their investment.

5409 Native American Income - Payments from Tribal owned land, tribal disbursements, Indian Affairs income, and Claims Resettlement Income are exempt. Note: Income from gaming is countable. See 5220.08 .

5410 Reimbursements - Income that is a reimbursement or refund is exempt. Examples of exempt reimbursements are ones for job or training-related expenses such as travel, per diem, uniforms, and transportation to and from the job or training site. Reimbursements that are provided over and above the basic wages for these expenses are excluded; however, these expenses, if not reimbursed, are not otherwise deductible. Reimbursements for the travel expenses incurred by migrant workers are also excluded. Also exempt are medical and dependent care reimbursements, reimbursements to students for specific education expenses such as travel or books, and jury duty payments. To be exempt, these payments must be provided specifically for an identified expense other than normal living expenses and used for the purpose intended. When a reimbursement, including a flat allowance, covers multiple expenses, each expense does not have to be separately identified as long as none of the reimbursement covers normal living expenses.

5411 Social Security - Social Security income is exempt as outlined below.

5411.01 SSI - Income of an SSI recipient (including 1619(b) recipients) and retroactive SSI benefits (even if the individual receiving the benefit is no longer an SSI recipient) are exempt as income in the month received. This does NOT apply to persons receiving long term care in Medicaid approved institutions as provided in MKEESM 8112).

5411.02 Social Security Death Benefits - Social Security death benefits are exempt as income when used toward the cost of burial.

5412 Veteran's Income - All forms of veteran’s income are exempt. These include: Veterans – Aid and Attendance UME – Unusual Medical Expenses Reduced VA Pension – LTC VA Work Therapy VA Housing Allowance Veteran’s Disability Veteran’s Pension

5413 Work Program/Training - Income from a work program may be exempt as income, depending on the type of program and whether or not the income is taxable. Exempt income types are outlined below. Also see 5320.08 for countable work programs.

5413.01 Workforce Investment Act (WIA) - Incentive and Training allowance income received from the Workforce Investment Act of 1998 (WIA) is exempt as income.

5413.02 Vocational Rehab (VR) - Training Allowances and Incentive Maintenance payments received from Vocational Rehabilitation are exempt as income.

5414 5429 Reserved -

5430 Miscellaneous Exempt Income - The following miscellaneous income types are all considered exempt.

5431 Agent Orange - Settlement payments are exempt as income in the month received and as a resource in the following months.

5432 Allocated Income - Income allocated for the support of dependents is exempt as income.

5433 Crime Victims Fund - Payments made pursuant to the Crime Victims Fund (Public Law 103-322), as amended are exempt as income in the month received.

5434 Family Subsidy - Payments provided through the Mental Health and Developmental Disabilities Commission or Family Support payments provided through the Children and Family Services Commission are exempt as income in the month received and as a resource in the following months.

5435 Holocaust Survivors - Reparation payments made to Holocaust survivors are exempt as income in the month received. These payments shall also be exempt for purposes of determining patient liability in a long-term care arrangement.

5436 Hostile Fire/Combat Pay - Hostile fire pay (also known as combat pay) received while in active military service is exempt as income in the month received. See Policy Memo #2005-03-01 Exclusion of Combat Pay for more detailed information.

5437 Individual Development Accounts (IDA) - The interest on an allowable individual development account (IDA), including authorized matching contributions and accrued interest, is exempt as income as long as the account is maintained. For Working Healthy, income deposited into an IDA is also exempt in the month deposited. IDAs are exempt resources for all programs. An allowable IDA meets the following guidelines:

5437.01 - It is established by or on behalf of a TAF recipient or by or on behalf of an individual participating in the Assets for Independence Demonstration Program (AFIA) and is used for a qualified purpose.

5437.02 - A qualified purpose is one or more of the following: (a) - post-secondary education expenses for college or vocational-technical school. Learning Quest or other 529 accounts are not considered IDAs; (b) - first home purchase (must not have owned a home within three years of acquisition); or (c) - business capitalization (business plan must be approved by financial institution or non-profit loan fund). NOTE: Any funds withdrawn from an IDA and used for any purpose other than one of those listed above shall count as unearned income in the month withdrawn.

5437.03 - The IDA must be a trust funded through periodic contributions by the establishing individual and may be matched by or through a qualified entity for a qualified purpose.

5437.04 - A qualified entity to match IDA funds for a TAF recipient is either a not-for-profit organization described in section 501(c)(3) of the IRS code of 1986 and exempt from taxation under section 501(a) or a state or local government agency acting in cooperation with a 501(c)(3) organization. For AFIA participants, matching contributions are made by the federal government through a grantee.

5437.05 - AFIA recipients may only contribute to IDAs with income derived from earnings. Note: The earnings of an adult placed in an IDA are counted as earned income in the month earned.

5437.06 - Parents may establish IDAs for their children as well as for themselves. Children may also contribute their earnings to accounts established by or for them.

5438 In-Kind Income - Benefits are exempt as income in the month received

5439 Japanese Aliens - Payments granted to certain United States citizens of Japanese ancestry and resident Japanese aliens under Title I of P.L. 100-383 (enacted 8-10-88) are exempt as income in the month received and as a resource in the following months.

5440 Student Loan Debt - Student loan debt that is discharged, forgiven, or cancelled after December 31, 2020 or discharged due to death or disability between January 1, 2018 and December 31, 2020.

5441 Ministerial Housing Allowance - A minister’s housing allowance, sometimes called a parsonage allowance or a rental allowance is exempt as income.

5442 Monies Withheld Voluntarily or Involuntarily - Monies withheld from assistance payments (e.g., TAF, GA, SSI) shall be included as countable income if the monies are withheld for the purpose of recovering from a household an overpayment which resulted from the household's fraudulent failure to comply with a state, federal, or federally assisted program which provides assistance on the basis of financial need. (For a definition of "fraudulent," refer to 8400 ).

5442.01 - Mandatory deductions from military pay for educational purposes shall not be included as income (or as a resource) while the individual is enlisted in the armed services. If individuals enroll in an educational institution after they leave the service, the amount withheld from salary plus any amounts matched from the VA will be treated as countable educational income minus expenses. Individuals who choose not to attend any school will receive the withheld monies in a lump sum payment and the payment shall be exempt per item 5440 above.

5442.02 - In addition, for all medical programs, programs not based on financial need that have a portion withheld to repay a prior overpayment received from that same income source, such as SSA, VA, Unemployment or Worker’s Compensation shall not have the portion withheld counted as income.

5443 Radiation Exposure Compensation - Payments made pursuant to the Radiation Exposure Compensation Act, P.L. 101-426 (10-15-90) are exempt as income in the month received and as a resource in the following months. This law compensates individuals for injuries or deaths resulting from exposure to radiation from nuclear testing and uranium mining in Arizona, Nevada, and Utah.

5444 Rehabilitation Services Payments - Income directly provided by Kansas Rehabilitation Services, except as noted in 5320.08 is exempt as income in the month received and as a resource in the following months. Maintenance payments are also exempt as they are in excess of normal living expenses and are considered a reimbursement.

5445 Relocation Assistance - Payments received under the Uniform Relocation Assistance and Real Property Acquisition Policy Act of 1970 are exempt as income in the month received and as a resource in the following months. The applicant’s or recipient’s equity in a home is to be disregarded to the extent that such equity was purchased with payments under the Uniform Relocation Act of 1970.

5446 Renal Dialysis - Special incentive payments received for renal dialysis patients for care in their own home are exempt as income in the month received.

5447 Ricky Ray Hemophilia Act Fund - Payments made pursuant to the Ricky Ray Hemophilia Relief Fund Act, P.L. 105-369 are exempt as income and as a resource for all programs. The payment is a one-time amount of $100,000. NOTE: Interest earned on these exempt funds is not exempt as income. See 5220.05 .

5448 Shared Living - In shared living arrangements; cash paid from one family to another toward the total cost of shelter is exempt as income in the month received.

5449 Susan Walker v. Bayer - Payments made pursuant to a class settlement in the case of Susan Walker v. Bayer Corporation is exempt as income in the month received and as a resource in the following months. This case involved hemophiliacs who contracted the HIV virus from contaminated blood products. Interest earned on retained funds is not excluded and is countable per 5220.05 . Accumulated interest is also countable as a resource beginning the month following the month of receipt, even if commingled with non-exempt funds.

5450 Trust for a VA Child - Money for a child which is held in trust by VA and determined by VA unavailable for subsistence needs is exempt as income in the month received and as a resource in the following months.

5451 Vendor Payments - Money payments that are not payable directly to a household but are paid to a third party for a household expense are vendor payments and exempted as income. A vendor payment is defined as a payment made in money on behalf of a household shall be considered a vendor payment whenever a person or organization outside of the household uses its own funds to make a direct payment to either the household's creditors or a person or organization providing a service to the household. For example, if a relative or friend, who is not a household member, pays the household's rent directly to the landlord, the payment is considered a vendor payment and is not counted as income to the household. Similarly, rent or mortgage payments, made to landlords or mortgagees by HUD or by state or local housing authorities, are other examples of vendor payments and are also exempted.

5452 Spousal Support (Alimony) - Spousal support payments, or alimony, as a result of a divorce decree effected or modified after December 31, 2018 are not taxable and are thereby considered exempt income for MAGI purposes.

5453 5999 Reserved -

Eligibility Policy - 9/10/2026

05000

07000

06000: Budgeting of Income -

06100 Budgeting of Income - A prospective (income estimate or conversion) or income average method of budgeting shall be used to determine eligibility and the amount of assistance. All income shall be counted in the calendar month received except when received on a twice a month or monthly basis. In such instances, income shall be viewed as being received by the client on the day that the payment is ordinarily scheduled. NOTE: For teachers or other school employees who are contractually paid 12 months out of the year, income shall normally be budgeted on a prospective basis as received unless the teacher or school employee has opted to receive their yearly contract salary over fewer than 12 months (such as only over 9 months during the school year). In such instances, the total year's income is to be averaged over 12 months so that a monthly amount of income is considered in determining eligibility and amount of assistance.

6110 Prospective Budgeting - Prospective Budgeting is based on an estimate reflecting the income received and/or expected to be received going forward from the month of application. The basis for any estimate (including tips) must be documented. For self-employment, income shall be budgeted as outlined in 6200 . For intermittent income, the income shall be budgeted as outlined in 6113 . A prospectively estimated budget may be recalculated if information is received that the estimate is no longer correct (e.g., income that was estimated to be received in a month is reduced or terminated). The client must report their change of income, and the change shall be applied in accordance with provisions in 7000 . Earned income information, including pre-tax income deductions, must be analyzed to accurately prospect income. Past information must be evaluated to determine if it represents the future. Paystubs provided must be evaluated before they are determined appropriate to be used in the calculation of income. If bonuses, tips, or commissions are on the pay stub, even when only included as part of Year to Date totals, these must be evaluated to determine whether this income is recurring. If the person is employed where tips are paid, it must be determined if tips are actual or allocated. (Certain employers must allocate tips if the percentage of tips reported by employees falls below a required minimum percentage of gross sales. To "allocate tips" means to assign an additional amount as tips to each employee whose reported tips are below the required percentage.) Pay information provided must be evaluated to determine if there was a recent pay raise that will impact future earnings. Paystubs should also be evaluated to determine if there are any discrepancies in the year-to-date amounts. If so, the missing information must be clarified. When using paystubs, the most recent should be used. Paychecks are deemed acceptable as proof of income when they are dated within the three months prior to the month of application through the final application processing date. Any paycheck received prior to this timeframe will be excluded from income budgeting. Budgeting methods take into consideration the variance that could occur between paystubs and the consumer’s self-attestation. Therefore, regardless of which budgeting method used, no paystub shall be excluded based on not quite matching other stubs submitted or the self-attestation of income. When income is from a new source, the pay rate has increased (or decreased) or when the numbers or hours to be worked has increased or decreased, the income shall be budgeting using the income which is expected to continue in the future. Weekly and biweekly income must be converted to a monthly amount. Budgeting rules are also dependent upon frequency and regularity of income. The case record is to be documented as the method of computation. The following rules apply:

6111 Regular Earned or Unearned Income - Once the full monthly amount is determined, that same amount of income shall be budgeted providing the individual anticipates continued regular income. A new budget is required prior to redetermination only if regular income becomes irregular, there is no longer any income (not applicable to a job change if earnings remain regular), or there is a change in the monthly amount of regular income.

6112 Irregular Earned or Unearned Income - For income and expenses received or billed more frequently than on a monthly basis (i.e., weekly, biweekly, etc.), the amount to be budgeted shall be based on converting the amount to a standard amount of anticipated monthly income.

6112.01 - Income in the same weekly amount are to be multiplied by 4.3. If the income amount received is in differing weekly amounts, an average amount shall be determined and then multiplied by 4.3.

6112.02 - Income in the same amount every 2 weeks are to be multiplied by 2.15. If the income amount received is in differing amounts every 2 weeks, an average amount shall be determined and then multiplied by 2.15.

6112.03 - Income in the same amount twice per month are to be added together to obtain a monthly amount. If the income is in differing amounts twice per month, an average amount shall be determined and then multiplied by 2. NOTE: To prospectively estimate semi-monthly income from a new job, (when paychecks are not available to average) pay periods with varying hours must be taken into account. The easiest and most accurate way to make this determination is to calculate a weekly estimate, times 2.15 times 2. Multiplying the weekly amount time 2.15 will take into account pay periods that have fluctuating hours. For example, a person working 40 hours a week will have more than 80 hours in a pay period when paid semi-monthly. Taking 40 X the hourly rate X 2.15 X 2 will get a closer anticipation of projected income than taking 40 X the hourly rate X 2 X 2.

6113 Irregular and Intermittent Income - Irregular and Intermittent Income received on a monthly basis in differing amounts shall be averaged. The monthly amount shall be established by dividing the income by the proper number of months for the period that the income is intended (e.g., 3 months for quarterly, etc.). A fair estimate for the time period used for averaging shall be established with the client. The case record shall clearly indicate that the income is being treated as intermittent income.

6113.01 - Once a standard monthly amount is established, it may continue to be budgeted through the redetermination period. However, a new budget is required: (1) - for medical assistance when income terminates and there continues to be a spenddown in place; (2) - for CHIP when income decreases and results in elimination or reduction of a premium requirement. For redetermination of eligibility in medical assistance spenddown cases based on a change or termination in income, use the income amounts established for the case through the month the change is reported. In addition, if income continues, establish a new converted monthly amount to be used beginning the month after the change is reported through the end of the base period.

6114 6119 Reserved -

6120 Current Month Budgeting Methods - When budgeting income for the current eligibility month, there are four methods that may be used. These are: Using the Payer Source, Reasonable Compatibility, Full month budgeting method, and Partial Month budgeting method.

6121 Using a Confirmed/Payer Source - When using income which has been verified through an interface through Tier 1, the amount of income is used despite what the client reports. See 1330.01 for more information about Tier 1 sources.

6122.01 Individual Reasonable Compatibility Test - KEES evaluates reasonable compatibility in the order specified below. Reported information is considered reasonably compatible when one of the following is applicable: a) No earnings were reported and both data sources do not return any earned income, or b) The amount of earnings reported by the consumer is greater than the amount received from at least one data source for the applicable time frame, or c) The difference between the self-attested amount and one data source is no greater than 20% of the self-attested amount.

6122.02 Household Reasonable Compatibility Test – Both Below - After the completion of the individual test, each individual will have a reasonable compatibility test conducted against their entire IBU. The Household RC Test determines if both the amount reported by the household members and the amount received from at least one data source are below Medicaid income limits for the applicant’s IBU. This is known as ‘Both Below’; BOTH self-attestation and income from the data source(s) are BELOW Medicaid. For this RC test, all income and data sources in an individual’s IBU are checked to determine if the applicable amounts are below the income limit for that person. When the applicant is determined to be Reasonably Compatibility due to Both Below, no income verification is required to complete their determination. They are eligible to receive Medicaid without asking the consumer to provide additional verification of income.

6122.03 Reasonable Compatibility at Review - As part of the review process, KEES will run a Reasonable Compatibility (RC) Batch which will be used to determine the medical review type for all individual recipients due for review. Due to this, when a pre-populated review is being processed, an RC test might not be required. If the consumer has not reported any changes in income, and the income passed the Reasonable Compatibility Test that was executed by the Batch, it is not necessary to re-run the RC Test. The passing RC test executed by batch is used for the determination. If the RC test executed by batch did not pass, it should still be re-run by the worker at the time of processing, even if no income change has been reported as there may be new data present in KDOL or TALX for the comparison. The RC test completed as part of the review is valid until the end of the third month following the month the test was executed. A new RC test is required for any review with an older RC test.

6123 Full Month Budgeting Method - Full-Month budgeting method is used when a full month of income verification is available. A prospective amount shall be determined and used in place of reported income. The client attestation is not used. A full month of income verification exists when the agency has verification of 30 days of consecutive earnings received by the wage earner within the period beginning 30 days prior to the application date and ending on the date the application is processed for new applications, reviews and changes in circumstance. This “full month” of income is what is used to determine the prospective amount. 30 days’ worth of income is represented by 4 weekly checks, 2 biweekly checks, 2 semi-monthly checks or 1 monthly check. If an additional weekly or bi-weekly check is received within the 30-day period, it shall be included in the prospective determination if available but is not required to meet the definition of full-month budgeting. Additional checks submitted outside of the 30-day window are not used.

6124 Partial Month Budgeting Method - Partial Month budgeting method is used when the income has been determined to NOT be reasonably compatible, and sufficient information has not been provided to complete Full-Month budgeting. If less than 30 days of income is provided for the period preceding the application or review date, or in situations where you do not know if it represents a full month determine a prospective amount based on what is on file. This amount is then compared to the reported income. Use whichever is greater between the amount reported by the applicant and the prospective monthly amount. Note: When there is no income reported by the applicant to use as comparison, the prospective monthly amount may be used as best available information. For Partial Month budgeting, income verification is acceptable as long as it is dated within three months prior to the month of application or review. When budgeting using TALX income at review, the TALX income may be used from up to three months prior to the month the Reasonable Compatibility test was initially run.

6125 Pre-tax and Federal Income Deductions - Pre-tax and federal deductions are amounts that are excluded from the gross income amount used for a MAGI determination. They include pre-tax amounts reported to the IRS by an employer via wage information or by a consumer through filing taxes. For MAGI-based determinations, they may be reported by the consumer at application or review or identified through paystubs or tax forms received. When a consumer reports overall household deductions of $300.00 or less per month, the attested amount may be used in the determination with no further verification needed. For reported amounts in excess of $300.00 per month, verification will be required in most cases. See 1330.05 .

6126 6129 Reserved -

6130 Prior Medical Budgeting Method - The budgeting method used for prior medical months is based on whether or not there has been a change reported by the applicant that occurs in the prior period. The applicant is asked a series of questions on the application to determine if changes in household members or income has occurred in the prior medical period. Despite the client report, there may be instances where the agency is able to determine that no actual change has occurred. These situations shall be treated as though the applicant has not reported a change. In order to be considered a change for purposes of this policy, the change must fundamentally alter the expected income to be received. The reported change must be in the rate of pay (i.e. received a raise or a pay cut) or the regularly scheduled hours of work (i.e. weekly hours were increased or decreased). Missing a few days of work due to sickness or working some occasional extra hours of overtime does not trigger this policy change. If determined that no actual change has occurred, use the ‘No Change’ income budgeting rules. The amount verified and budgeted for the current month is used in each of the prior months. No further verification is required. If the agency or the individual is unable to verify current income, eligibility for the current and prior months shall be denied for failure to provide information. NOTE: The applicant must answer ‘yes’ or ‘no’ to the prior medical questions. These answers cannot be assumed. If responses are not provided, the prior medical determination cannot be completed.

6131 No Reported Changes - If the applicant reports there has been no change in income for the prior period, the prior months are budgeted using the amount that is verified and budgeted for the current month.

6132 Reported Changes: Income - If the applicant reports a change in income for the prior months, the change shall be evaluated to determine if the income change will fundamentally alter the income that is being received. The reported change must be in the rate of pay or the regularly scheduled hours of work. Missing a few days of work to sickness or working some occasionally extra hours of overtime does not trigger this policy. If it is determined that no actual change has occurred, use policies in 6131 . When a change of income has occurred, one of the following budgeting methods will be used.

6132.01 Use of KDOL Wages - If the Reasonable Compatibility test returns a result of ‘Both Below’ with KDOL wages being used, this monthly amount shall be used to determine prior medical eligibility, and no further verification is required. This is regardless of how many sources of employment have been reported. However, if only a Work Number (TALX) amount has been returned, or if KDOL is not below the Medicaid or M-CHIP income limits, actual income must be used to verify prior medical income.

6132.02 Actual Income - In situations where 6132.01 is not applicable, actual verified income shall be budgeted for each month of the prior period. Although the agency must attempt to verify using Tiers 1-3, it is most likely verification through Tier 4 will be necessary. If the information provided by the applicant is incomplete, but eligibility staff are able to determine the actual income received in each prior month, verification shall be considered complete. For example, using year-to-date information on pay stubs to determine the missing checks. If verification for the prior period is not provided, but income for the current period is verified the prior period shall be denied for failure to provide information and the current period approved.

6133 Reported Changes: Household - If the applicant reports a household change in the prior months, the change is evaluated to determine the type of change that has occurred and the potential impact on eligibility. If there were different individuals residing in the home during prior months, then those individuals must be considered when determining budgeting units and income used in the calculations. If the change involves an individual moving in or out of the household who has income, then staff shall refer to 6132 . Note: Verification of household changes is not required, unless necessary to determine custody of a child.

6134 Discrepant or Inconsistent Information - If no change in income or household has been reported, but the agency has information indicating a change has occurred, guidelines in 6132 and 6133 shall be used. Note: It is not necessary to search for additional information/verification when the applicant reports there has been no change. However, when contradictory information exists at the time of the applicant report, the agency must take action on the known information to reconcile the discrepancy.

6135 6199 Reserved -

06200 Self-employment Income Budgeting - See 5330 for guidelines to determine if an individual is self-employed. Self-employment income will be based on the countable net income as reported on the Federal tax return. The individual will be required to provide a copy of the most recent personal tax return including all schedules and attachments. In instances where the individual states they have not filed their tax return and it is after the IRS filing deadline, the previous year’s return may be used if an extension has been filed with the IRS. Verification of the extension is not required. If the individual does not file taxes or has not yet filed taxes because this is a new self-employment business, or the current return is not representative, completion of the KC5150 self-employment worksheet by the individual is required.

6210 Tax Return Filed - When a tax return has been filed, the countable amount of self-employment tax that the individual paid must be deducted from the gross self-employment income. The Schedule 1, also known as Form 1040) or Schedule SE is used to determine the amount of self-employment tax paid located on the deductible part of self-employment tax line. This amount should be deducted from the amount of income taken directly from each schedule where applicable. The following outlines which line on each schedule is used for each type of business: • Business income – Net profit amount from Schedule C or C-EZ • Rental real estate, partnerships, S-corporations – Total rental real estate amount from Schedule E • Farm income – Net farm profit from Schedule F • Capital Gains – Capital Gains amount from the 1040 divided by 12 • Other Gains – Other Gains amount from the 1040 (Schedule 1) divided by 12 When the tax return reports more than one business, the self-employment tax must only be deducted from one of the self-employment businesses, preferably the business that has a net profit larger than the amount of the self-employment tax. When a loss is reported on one or more of the schedules, it is to be treated as zero income for the eligibility determination and cannot be deducted from another source of income, even if the other source is another form of self-employment. Provided the return reflects a full year of self-employment earnings, a twelve month average shall be established.

6211 Tax Return Not Filed or Does Not Contain Full Years Earnings - If a tax return has not been filed (e.g., employment just started or client has not filed a return), the KC5150- Self-employment worksheet is required. The applicant is required to complete the worksheet documenting all income and expenses for the 12 months prior to the month of application. Ledgers and other business records are not accepted as verification of self-employment income. An average is determined by totaling all gross earnings in the months being counted, subtracting the total expenses, and dividing by the respective number of months. The calendar months being used and the corresponding earnings must be clearly documented in the case record.

6212 Need for New Estimate/Average Based on Changes in Income - In cases where the consumer indicates their tax return is not representative of the existing self-employment income, both the most recent personal tax return and the self-employment worksheet are required so staff may evaluate this. The reason for the discrepancy must also be clearly documented by the applicant and is only allowed when there is a definitive change in the amount of business.

6220 Wages from a business - When a business owner pays themselves a wage from the business, this is to be treated as a separate form of income and budgeted separately from the self-employment. Verification of the wages shall follow the Tiered verification policy. However, when the income cannot be verified using Reasonable Compatibility, alternative methods of verification are allowed. When income cannot be verified using Reasonable Compatibility, the individual’s most recent personal tax returns’ Form 1040 may be used if the individual indicates that the wages are only representative of those that have been paid from the business and not a combination of other jobs held. The total amount of wages to be used in the determination can be located on the 1040 Form under wages, salaries, tips etc. When no other verification is available, self-attestation of the wages is accepted.

6230 Capital Gains - For individuals who report self-employment income and provide a tax return as verification, any amount from Capital Gains or Other Gains is countable. Capital Gains can be located on the schedule 1040 or the Schedule D of the tax return. The amount of gains reported under net short and/or long-term capital gain or (loss) shall be used. These amounts will need to be prorated over the year. This will mean dividing the total by 12 to determine the monthly countable amount.

06300 Eligibility Period -

6310 Eligibility Period - The eligibility period is the time period on which need is computed. See Section 7330 for policy and procedures for eligibility reviews.

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 2340.02 and 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.

06400 Medical Program Standards -

6410 Medical Program Standards - For the Medicaid poverty level and CHIP programs, standards have been established based on a percentage of the federal poverty level. If countable income does not exceed these standards, there is eligibility. For the Medically Needy (spenddown) program, standards have been established which are the amounts of monthly income protected from medical expenses to allow applicants/recipients to meet their maintenance needs. If countable income does not exceed these standards, there is eligibility. If countable income exceeds the standards, a person can "spenddown" the excess and become eligible.

6410.01 Standards in the Medicaid Poverty Level Programs - To be eligible, the total countable income must not exceed the monthly poverty level standards based on the appropriate number of individuals. See KDHE Eligibility Policy Appendix F-8 for the Medicaid and CHIP standards.

6410.02 Standards in the Medically Needy Program - The protected income budgeted is the independent living standard for the number of persons in the budgeting unit. See KDHE Eligibility Policy Appendix F-8 for Medically Needy income standards.

06500 Determination of Financial Eligibility -

6510 Need - Need is a factor of eligibility in all categories of assistance and shall be determined through the application of standards by use of the budgetary method.

6511 Financial Eligibility in the Medicaid Poverty Level and CHIP Program - Financial eligibility exists if countable income does not exceed the allowable poverty level standards. A person cannot spenddown to obtain eligibility under any of these programs.

6512 Financial Eligibility in the Medically Needy Program (spenddown) - Financial eligibility exists if allowable incurred medical expenses, as specified in this section, equal or exceed the spenddown for the base period. See 6410.02 for establishing the spenddown amount.

6512.01 Allowable Expenses - Allowable expenses incurred outside of the current eligibility base are only allowable if the individual is still legally obligated to pay the expense and such expenses have not been previously applied to spenddown in any other base period in which the person became eligible. The amount of these expenses applied to spenddown within a particular base period shall be the amount due and owing as of the first day of that base period. This provision includes instances in which the individual has taken out a loan to pay the expense or charged the expense on a credit card. The unpaid portion of the loan or credit card balance attributable to the original medical expense shall be regarded as a due and owing expense which can be applied to spenddown. The amount still due and owing shall be determined by subtracting all payments made on the loan or credit card balance prior to application of the expense in a base period from the original expense amount. The remainder shall be regarded as due and owing. Verification of the initial medical expense as well as payment made will be necessary. All expenses which are incurred by persons in the budgeting unit are allowable within the limitations described above. Such expenses do not actually have to be paid to be allowed against the spenddown. The client will choose which of his allowable expenses he wishes to apply on the spenddown. Failure by designated providers to collect from the client does not shift responsibility to the medical program. A medical payment can be made only for the excess expenses. Payment for or assumption of medical expenses by a third party, whether legally liable or not, negates the client's responsibility to pay; therefore, such medical expenses cannot be considered against the spenddown. This includes the portion of any medical expense paid by Medicare or another health insurance. The portion not covered by insurance, such as the co-payment or deductible, is allowable. See 6512.02 for exceptions of when expenses are allowable when paid by a third-party. The following expenses are allowable against a spenddown when the client provides eligibility staff with evidence that he has incurred such expenses within the limitations established above. (1) - The pro rata portion of medical insurance premiums for the number of months covered in the eligibility base period regardless of the actual date of payment, past or future, are allowable. Medicare premiums not covered by Buy-in are also allowable. Premiums which are subject to Buy-in are not allowable even if the client pays them (or they are withheld) prior to completion of the Buy-in process as such amounts are subject to repayment. NOTE: Additional costs consumers pay for Medicare Replacement polices will not be reimbursed through the Buy-in process but are an allowable medical insurance premium. Premiums for hospital indemnity policies which pay a flat per day amount are not deductible as they are viewed as income replacement policies rather than medical insurance. However, certain indemnity-type policies pay based on specific services received and charges incurred. In these instances, the premiums would be allowable. Each policy will need to be reviewed to determine whether the premium is allowable or not. (2) - If medically necessary, all expenses for medical services incurred by the individual or a member of the budgeting unit are allowable. See KDHE Eligibility Policy Appendix, Eligibility Processing, P-1, Medical Necessity for Allowable Medical Expenses. Medicaid co-payments are deductible. In addition, charges in a Medicaid approved institution can be allowed up to the private rate for individuals subject to the gross income limit and whose income exceeds that limit. Otherwise, the facility can only charge at the monthly state rate if the individual's income is below the limit. Charges in a non-Medicaid approved institution are not allowable including charges incurred during a transfer penalty. (See MKEESM 8111.)

6512.02 Expenses Paid by a Third Party - Medically necessary expenses paid for by a public program funded by the State (or political subdivision of the State, such as a county), other than Medicaid, can be applied to spenddown. Only the portion of the expenses funded by the public program is allowable unless the client will continue to be obligated for the remaining portion of the bill. Such an expense is allowable in the base period in which it was incurred. Examples include expenses paid by Vocational Rehabilitation, the Family Support Program, Kansas Health Insurance Program for the uninsurable, certain programs administered by the Department of Health and Environment, such as those through Children with Special Health Care Needs, the Infant/Toddler Program and Other Title V programs and non-Title II AIDS Drug Assistance Program/Ryan White (MKEESM 2694) payments. Also included are services paid by Donated Dental Services, Adult Emergency Support Services/APS Emergency Funds, the Community Support Medication Program, and expenses subsidized on services received through a Community Mental Health Center or Community Developmental Disability Organization. For prescription drugs purchased with a Medicare Approved Drug Discount Card (MKEESM 2911) the pre-discount cost of the item is allowed toward spenddown. The entire cost of the item is allowable even if the $600 credit was used to purchase the drug. Services provided for or paid through Hill-Burton funds, Ryan White funds or the Kansas Farmworker Health program is NOT allowable.

6513 Meeting a Spenddown - When allowable incurred medical expenses equal or exceed the spenddown amount, eligibility exists. The spenddown for the entire eligibility base must be met before there is eligibility. Once met, eligibility exists for all months of the base period in which categorical, nonfinancial, general, and other financial eligibility criteria are met. Expenses are applied in the order they are received. However, different methods are actually used to account for the expenses, depending upon the type, source, and date of service. Because of this, the process to meet a spenddown is the responsibility of both the eligibility worker and the fiscal agent.

6513.01 Eligibility staff responsibility - The eligibility worker is responsible for determining the appropriate eligibility base period and the total spenddown amount. In addition, eligibility staff shall reduce the total spenddown amount by the following allowable expenses, which have been reported and verified. These are documented in KEES. a. Health insurance premiums; b. Expenses for non-participating members of the budgeting unit; c. Due and owing expenses; d. Allowable nursing facility/institutional expenses (excluding general hospital). No other medical expenses are to be entered in KEES for persons attempting to meet a spenddown. If these expenses satisfy the spenddown in full, the individual will be eligible for reimbursement of medical expenses immediately.

6513.02 MMIS Responsibility - The above information is then sent to the MMIS, where a medical assistance benefit plan of medically needy will be assigned. The presence of a medically needy benefit plan will identify the individual as a person with a spenddown. A medical card is issued for each participating member of the assistance plan. Medicaid providers who deliver medically necessary services and items shall bill the Kansas Medical Assistance Program (KMAP) using the information on the card. All medical expenses may be direct billed to MMIS, not just those covered by the KMAP. If the spenddown has not yet been satisfied, expenses which have been incurred in the base period are applied to reduce the amount of remaining spenddown, subject to TPL limitations. The amount actually billed will be allowed toward spenddown, as providers are restricted to billing at their usual and customary rate. All claims received by the fiscal agent will have a Potential Provider Payment (PPP) status determined. The status indicates if the service is a Medicaid covered service which, if the client were not on spenddown, could potentially be paid by the Medicaid program. The fiscal agent will send weekly notifications to those cases which experience activity on the spenddown in the past week. The notice will itemize all allowable expenses directly billed to the MMIS or through the Beneficiary Billed claims explained in item 6513.03 below.

6513.03 Beneficiary Billed Claims - In the event an individual receives an allowable service and the provider cannot direct bill for the service (e.g., item from a non-Medicaid provider or an expense from a Medicaid provider prior to case approval) a special process has been established to allow such expenses to be used toward the spenddown. Persons must obtain from the provider of the medical service a completed form ES- 3170, Beneficiary/Patient Spenddown Billing Form. The form will capture the necessary information to input a special claim, called a Beneficiary Billed Claim, into the MMIS. This process will also be used to provide for some non-Medicaid covered items and services which cannot be direct billed to Medicaid. The completed form shall be submitted to the eligibility worker for review. If the expense is allowable, the eligibility worker is responsible for input into the MMIS. Items and services billed through the ES-3170 may only be applied toward spenddown and are not considered for payment even if the expense isn't ultimately used toward the spenddown.

6513.04 Spenddown Met - When the total spenddown has been satisfied, the spenddown is considered met for the base period. Bills used to meet the spenddown remain the responsibility of the individual. A combination of accounting methods may be used to actually meet the spenddown. However, the bills used to meet the spenddown are not altered unless the new expenses are listed in 6513.01 above, items a - d or if the last bill used to meet the spenddown was a non-Medicaid covered expense. In this case, if other Medicaid-covered bills have already been applied, the non-Medicaid covered expenses shall be used in full, thus making the Medicaid -covered expenses potentially eligible for reimbursement. When the spenddown is met, the fiscal agent will produce an itemize list of expenses used to meet the spenddown. The list will not include those expenses listed in 6513.01 , items a - d. A copy of this notice will be sent to the assigned eligibility worker.

6513.05 Changes in Spenddown Amount and Status - When changes occur that ultimately impact the total spenddown amount (e.g., changes in income or changes in the assistance plan), the new spenddown amount will be sent to the fiscal agent. Timely and adequate notice is required when reacting to a change to increase the spenddown amount or change the spenddown status from met to unmet. The following rules apply: a. For unmet spenddowns that remain unmet, the new spenddown amount will be effective upon receipt. b. For unmet spenddowns which have been reduced and when applied expenses exceed the new spenddown, the spenddown will now be considered met and only those expenses which aren't subject to potential Medicaid payment and enough expenses which are subject to Medicaid payment to satisfy the spenddown. c. For spenddowns which have been met that are reduced, the expenses used to meet the spenddown will be reviewed and those which are subject to Medicaid reimbursement will be eliminated in reverse date order. d. For spenddowns which have previously been met are increased, the case will be put back into spenddown status and the new spenddown amount will be applied the month following the month the new amount is received or the second month following, depending upon negative action deadline.

6514 Establishing Financial Eligibility in the TransMed Programs - There are no financial eligibility criteria for establishing TransMed coverage. The family must meet the criteria in 2230 and subsections.

6515 Establishing Financial Eligibility in the Extended Medical Program - There are no financial eligibility criteria for establishing the four-month Extended Medical period. The family must meet the criteria in 2240 and subsections.

6516 6519 Reserved -

6520 Continuing Financial Eligibility (MAGI Programs) - When circumstances change, adjustments will be made as necessary depending on the category of medical coverage. For the Medicaid Poverty Level and CHIP programs for caretakers, children and pregnant women, changes in income will not impact eligibility based on continuous eligibility provisions under 2311. Changes in the amount of earned income do not impact eligibility for TransMed. All other changes must be evaluated to determine if eligibility criteria continue to be met. See MKEESM 2650 for CE policies for children on non-MAGI programs.

Eligibility Policy - 9/10/2026

06000

08000

07000: Reporting Changes -

07100 Household Responsibility to Report - Households receiving medical assistance are required to report changes. The specific reporting requirement is determined by the program and the circumstances of the household. There are no additional reporting requirements other than those listed in this section.

7110 Household Responsibility to Report Changes Prior to Approval - Applicants (includes new applications and applications filed after a break of one or more months of assistance) must report all changes of circumstances prior to case approval. The change must be reported within 10 calendar days from the date the change is known. The eligibility worker is responsible for requesting or otherwise obtaining other information or verifications necessary to determine the individual's eligibility for any month.

7120 Household Responsibility to Report Changes After Approval - Medical assistance households are required to report certain changes in circumstances as discussed in this section. All households are to be notified of the appropriate reporting requirements upon approval for assistance.

7130 Reporting Requirements - Medical assistance households are required to report certain changes in circumstances within 10 days from the date the change becomes known to the household. See subsection 7130.02 below for the definition of "becomes known to the household."

7130.01 Change Reporting Requirements - The change reporting requirements for the Family Medical assistance programs are listed below: (1) - Changes in the source of earned and/or unearned income. (2) - Changes in the amount of earned and/or unearned income. (3) - Changes in household composition, including marital status (marriage, separation, or divorce), as well as people moving into or out of the household. (4) - Changes in residence, including moving into or from an institution (i.e. jail/prison) or hospital. (5) – Changes to any third party insurance plan or entitlement/termination of Medicare coverage. Reporting changes is necessary for all household members including children. Households may report a change in their circumstances by telephone, in person, or in writing. Changes in circumstances other than those listed above are not required to be reported until review.

7130.02 Becomes Known to the Household - As indicated in section 7130 above, the household must report changes within 10 days of the date the change becomes known to the household. For purposes of this provision, "becomes known to the household" is defined as: (1) Change in Source of Earned Income - The change is known to the household upon receipt of the first pay check. (2) Change in Earned Income Amount - The change is known to the household on the last day of the month of the change. (3) Change in Source of Unearned Income - The change is known to the household upon receipt of the first payment. (4) Change in Unearned Income Amount - The change is known to the household when the payment is received. (5) Change in Household Composition - The change is known to the household the day the individual enters or leaves the household, the date of marriage, separation, or divorce. (6) Change in Residence - The change is known to the household the day the individual moves. (7) Entitlement to or Termination of Medicare Coverage or a change in a Third Party Insurance plan - The change is known to the household on the effective date of the change.

7140 Processing Reported Changes - When the agency receives information that a change has occurred, the eligibility worker shall act on the change within 10 days after the date the change is reported or becomes known the agency (1334) by taking the following actions: (1) Document in the case file the reported change, the date the change occurred, and the date the change was reported; (2) Determine if verification or additional information is required; (3) Contact the household to request needed information or verification as soon as possible; (4) Changes are effective the month following the month of the change, given timely and adequate notice requirements, with the exception of income changes that are reported at the time of a request to add a new individual. (a) Households reporting changes which would result in a change in benefits must provide any required verification within 12 days of the date of agency request. No change in benefits shall be granted if the household does not provide the required verification. If no verification is required or if the verification required is received within 12 days from the date of verification request, the change in benefits are to be granted effective the month following the month the change is reported. If the verification is received after 12 days from the date the verification was requested, the change benefits would be effective the first month following the month the verification is received. (b) Changes resulting in ineligibility or a decrease in benefits shall effect eligibility the first month possible considering timely notice requirements. (c) When processing an income change along with a request to add coverage for a new individual, the new income must be verified and used in the month of request. This allows the income to be used in the determination for the new person and is also applicable to the rest of the household members in that month. This could result in a change in coverage or the reduction or removal of a premium obligation in the month of report when applicable. (5) If an automated system action occurred on the case prior to a worker becoming aware of the change, the worker must evaluate the effect of the change to determine if any incorrect payment occurred as result.

7150 Notices to Households - The agency shall provide the household with the following notice based on the change in assistance: (1) Timely and Adequate Notice - The agency shall provide the household with a notice of action that meets the definition of timely and adequate notice (as defined in 1422.01 ) if the household's benefits are being reduced or terminated. (2) Adequate Notice - The agency shall provide the household with a notice of action that meets the definition of adequate notice (as defined in 1422 ) if benefits are being increased.

7160 Failure to Report - If the agency discovers that the household has failed to report a change, as required in 7100 and, as a result, received benefits to which it was not entitled, a claim shall be filed against the household. The household is entitled to a timely and adequate notice of adverse action if the household's benefits are reduced or terminated. A household shall not be held liable for a claim because of a change in household circumstances which it is not required to report in accordance with 7100 . Individuals shall not be disqualified for failing to report a change unless disqualified in accordance with fraud disqualification procedures.

07200 Whereabouts of Recipient Unknown -

7210 Reserved -

7220 Reserved -

7230 Whereabouts of Recipient Unknown - In instances when the agency does not know the whereabouts of a recipient, typically due to receiving returned mail with no forwarding address, the agency should attempt to confirm the consumers’ whereabouts through available methods of research, including (as best practice) contact with the consumer via phone. If updated information is not located, coverage is discontinued for all non-pregnant adults on the case allowing adequate notice only. The Notice of Action is to be sent to the last known address. See 1423.06 . The above does not apply if the application for review returns with no forwarding address. That is because assistance will terminate automatically for failure to return those forms. Coverage shall not be terminated for continuously eligible children or pregnant women according to provisions of 2300. If the agency becomes aware that residency requirements of 02050 are no longer met coverage shall be terminated. If at any time prior to the consumer’s next renewal (12-month review period) their whereabouts become known, eligibility must be reinstated. This means that if a consumer contacts the agency after being discontinued due to whereabouts being unknown and they provide an updated in-state address, eligibility must be reinstated back to the date of discontinuance if the consumer is still within the original review period. An exception to this policy exists when a consumer had a change in circumstance during that timeframe that would have caused loss of eligibility such as moving out of state (assuming it was not a temporary absence). It is not required that staff clarify possible changes in circumstance prior to reinstating coverage.

07300 Reviews -

7330 Reviews - All categories of assistance require periodic review. At the expiration of the review period, entitlement of benefits ends. Further eligibility must be determined through the review process. Depending on the type of assistance received and the circumstances of the case, the review may be either passive or non-passive. A non-passive review is based on a new application or review form and verification is required. The purpose of the review is to give the client an opportunity to bring to the attention of the agency his or her needs and to give the agency an opportunity to re-examine all factors of eligibility in order to ensure coverage and eligibility levels continue to be correct. In the process, the appropriate review form shall be used along with the rest of the agency record. The following review types apply:

7330.01 Passive Review - A Passive Review is a review where information known to the agency is used to make a new eligibility determination for an individual due for review. Eligibility is redetermined and reauthorized without worker involvement. The member receives notification in advance, outlining the information used for the redetermination, as well as a separate approval notice once the determination is complete. The member is required to inform the agency of any changes or incorrect information used in the determination. If the recipient has no changes to report, the review process is complete. If the recipient contacts the agency (either orally or in writing) with updated information based on receipt of the review notification, action is taken to update the case. See 7421 regarding passive review responses. If a person qualifies for a passive review but is in the same household with members with a pre-populated review type, or if the data used at passive review will result in coverage on a lesser program, or a change between CHIP and PLN, a pre-populated form will be sent to give them the opportunity to report changes. If the form is not returned, the members with the passive type will be approved using the information in the system. NOTE: In some situations, a child may meet passive criteria and be passively reviewed, while the parent may receive a pre-populated review because they do not meet passive criteria. This is correct, as reviews must be conducted on an individual basis. If a person over the age of one receives a pre-populated review due only to a missing SSN, and the SSN is provided, the person may be administratively (manually) reviewed using the rest of the information on file in absence of a review form. Likewise, if it is identified that a person received a pre-populated review in error due to a citizenship record changing to an unverified status when it had already been verified, the pre-populated form is not required. They may be reinstated if necessary and administratively reviewed and approved using the information on file. An administrative review may also be appropriate in a situation when a person was eligible for a passive review but was not approved by the passive review batch due to a pending record, including a missing or unverified SSN. 1. The following programs are eligible for a passive review due to the program type without any other qualifications: - Deemed Newborns. - Aged Out Foster Care. 2. All other programs must meet the following qualifications, as indicated, to be eligible for a passive review: In order to qualify for a passive review when there is earned income, the income must be reasonably compatible (RC) or Both Below under the automated RC test completed by KEES. Additionally, individuals may qualify for a passive review when no data is returned via income interfaces (KDOL/TALX) and the countable household income on file is under 100% of the Federal Poverty Level (FPL). This may only occur up to five years in a row, at which time the individual would be required to submit a pre-populated review or give a new attestation of income. When unearned, countable income from Social Security (SSA) exists, it must be within $5.00 of the amount found on the SSA data source. Individuals with stable income sources may qualify for passive reviews. Stable income is income that is known to be highly unlikely to change or decrease in value. For MAGI coverage, stable income sources include: KPERs, Pensions/Other Retirement, Railroad Benefits, Trust & Annuity Income. In addition, each of the following program types may be subject to a passive review when specific criteria are met: - Medically Needy (MDN) – The Primary Applicant is not marked deceased or permanently out of the home, there is no self-employment , earned income is reasonably compatible, countable resources are less than 85% of the limit, and the status of the Spenddown is ‘met.’ - Caretaker Medical (CTM), TransMed (TMD) and Extended Medical (EXT) – Earned income is reasonably compatible/both below or income is under 100% FPL with no data sources returned, there is no self-employment, there is no discrepancy in the tax information for the household member(s) due for review, the Primary Applicant is not marked deceased or permanently out of the home, and individuals do not move to a Protected Medical Group, Working Healthy, Medically Needy, or MSP program. - Poverty Level Pregnant Woman (PLN/PW) – Income passes reasonable compatibility/both below or income is under 100% FPL with no data sources returned, the Primary Applicant is not marked deceased or permanently out of the home, and there is no self-employment income. - Poverty Level Pregnant Woman Under 19 (PLT or CHIP) – Income is reasonably compatible/both below or income is under 100% FPL with no data sources returned, the Primary Applicant is not marked deceased or permanently out of the home, and there is no self-employment income. - Poverty Level Newborns and Children (Medicaid and CHIP) – Income is reasonably compatible/both below or income is under 100% FPL with no data sources returned, the Primary Applicant is not marked deceased or permanently out of the home, and there is no self-employment income.

7330.02 Pre-Populated Review - A pre-populated review is required for all other situations where a passive review isn’t sent. A notice of expiration of the review period is sent along with a generated pre-populated review form for completion and return. The forms are generated based on information that is contained within KEES. Recipients are required to update the form with new or changed information and return to the agency. Failure to return the review form will result in discontinuance of coverage for all members with an individual pre-populated review type. Any members who qualify for an individual passive review may not be discontinued for failure to return the review form but will instead be passively reviewed by the system when a pre-populated review is not returned.

7331 Timeframe to Submit a Review Form - A review form including the expiration of the review period shall be sent to each household subject to a pre-populated review as described in 7330.02 . A notice of expiration of review is not required for passively reviewed households ( 7330.01 ). The agency shall provide a pre-populated review form with the notice of expiration. When a review is required and it is known that the recipient is temporarily visiting away from his or her residence, the notice of expiration and review form should be mailed to the temporary address. The pre-populated review form shall be mailed to the household when the Medical Reviews Batch runs, on or about the 15th two months prior to the end of the review period. (Ex: for a December review, the form will be mailed in mid-October). This gives the household approximately 60 days to complete and return the review form to the (see 7410 ). NOTE: The timeframe to submit the form includes timely notice for discontinuance of benefits; therefore, further timely notice is not required to affect benefits for the start of the new review period.

07400 Client Requirements for Timeliness - Reviews -

7410 Review Form - As indicated in 7331 , households subject to a pre-populated review shall be given a minimum of 60 days to return a required review form. The review form shall be mailed to the individual on or about the 15th two months prior to the end of the review period. To be considered timely received, the signed review form (see 1409.01 ) must be returned to the agency by the last day of the last month of the review period. Reviews received outside this period will be considered late. If the review form is not received by the time the discontinuance batch runs (around the 15th of the last month of the review period), coverage will be automatically discontinued 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 received by the last day of the review month, this is considered timely. Eligibility at current levels will continue automatically until the review process is completed. Otherwise, the review discontinuance batch will close the individual by the last day of the review month. For reviews received during the reconsideration period, coverage will not be rescinded, and the effective date will follow application policies (see 7431 ). Note that if a review is received before the last day of the review month but was closed by the review discontinuance batch in error, the discontinuance shall be rescinded and coverage shall be reinstated pending the completion of the review. Due to this process, if a review received on or before the last day of the last month of the review period 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 and new program eligibility will determine if those months are subject to correction, see 7432 .

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. For requested information received during the review reconsideration period, see 7431 . 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 at least 30 calendar days before the end of the review period shall be processed by the end of the review period. 2. A review form received with less than 30 days remaining before the end of the review period shall be processed no later than the last day of the following month. This includes reviews received after the discontinuance batch has run but before the last day of the review period. NOTE: 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.

7430 Failure to Act -

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 through all existing modalities (mail, fax, phone, in-person, and online). Individuals will have until the end of the third month from the date of discontinuance to return the form for processing. After that, they may still return the review form by mail or fax, but the online portal will no longer allow them to submit an online review. Reviews received during the reconsideration period are processed as an application, meaning the effective date of coverage will follow application effective date policies (i.e., first day of the month of application or prior medical period for Medicaid and the date of approval for CHIP). The reconsideration period also applies to information requested in order to process the review. When an individual is discontinued at review due to failure to provide requested information, they have three months to return the information without having to submit a new application. When requested information is received during the reconsideration period, it is also treated as a new application for effective-dating purposes. This means that while the information may be used to complete the determination for the review, the start date of coverage will be based on when the information was received (i.e., first day of the month received for Medicaid and date of approval for CHIP). If prior medical is needed to fill any gap months, the consumer has 60 days from the date the information was received to make the request. 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 review not submitted in a timely manner shall be treated as an initial application. The timeliness provisions of 1407 and subsections apply. 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. For reviews received before the discontinuance batch runs (around the 15th), eligibility will continue with coverage at the current level while the review is awaiting processing. 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 (more beneficial) 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). Timely notice is required, and the new coverage period will begin with the next unpaid month allowing timely notice. For the definition of a timely received review, see 7410 . For definition of timely processing of reviews, see 7420 .

7440 Frequency of Reviews -

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.

Eligibility Policy - 9/10/2026

07000

08000: Incorrect Coverage - Prevention of incorrect benefits is the responsibility of every staff member, contracted staff member, and client. Incorrect coverage includes both understated and overstated eligibility.

08100 Understated Eligibility -

8110 Understated Eligibility - Understated eligibility occurs when the client does not receive the level or extent of coverage they were entitled to receive. Eligibility staff shall document how the understated eligibility was determined and the reason correction was required. All understated eligibility must be promptly resolved.

8111 Situations Requiring Correction of Understated Eligibility - Understatement of eligibility shall be corrected promptly using the program policies in effect for the month(s) in which the error occurred. The following are situations in which a correction of understated eligibility is required.

8111.01 - The understated eligibility was the result of agency error;

8111.02 - The agency failed to give the household sufficient time to verify information that resulted in the understated eligibility;

8111.03 - The agency failed to take timely action on reported changes that resulted in the understated eligibility;

8111.04 - There is a fair hearing decision in favor of the household;

8111.05 - Case correction is ordered as a result of a class action lawsuit or other legal proceeding.

8111.06 - A recipient may also be entitled to correction of understated eligibility where a change has been reported and verified timely but the future month has already been authorized due to system cutoff date.

8112 Timely Billing - There may be instances where the medical provider is outside of the timely billing time frame to receive payment for services and the client has already privately paid the bill. The provider may be unwilling to reimburse the client since they will not be able to receive payment from the state. In those instances, the client shall be reimbursed by the state for the verified amounts paid to the provider, up to the allowed rate for the service. There is no other provision for correcting the understated eligibility.

8113 Situations Not Requiring Correction of Understated Eligibility - Even though a technical understatement of eligibility may have occurred, an eligibility correction is not required in the following situations:

8113.01 - The household failed to report a change which would have resulted in an increase in coverage had the change been timely reported.

8113.02 - The household failed to timely provide information necessary to make a change.

08200 Time Frame -

8210 Time Frame - Once it has been determined that an understated eligibility has occurred, the amount of the underpayment, if any, shall be calculated and the case corrected as soon as possible but no later than 20 calendar days after the worker identifies that a correction is necessary.

8211 Erroneous Denial - When the individual has no coverage due to an erroneous denial, an understatement of eligibility has occurred. For example, the application was incorrectly denied for failure to provide information when the information had been timely received. The first month, or date for date-specific programs (CHIP), that the individual would otherwise be eligible shall be the first month coverage was not received as a result of the erroneous denial.

8212 Erroneous Termination - The month the discontinuance initially occurred shall be the first month coverage was not received as a result of the erroneous discontinuance.

08300 Overstated Eligibility and Claims -

8300 Compromising Claims - The amount of the claim determined by the agency may be reduced in accordance with a court order. The amount determined to be uncollectable shall be the compromised amount of the claim. The original amount of the claim minus the compromised amount shall be the amount then subject to collection.

08310 Types of Claims -

8311 Types of Claims - There are three types of claims. The type of claim will determine action to be taken in recovery efforts.

8312 Agency Error - Instances of agency error which may result in a claim include, but are not limited to, the following:

8312.01 - Prompt action was not taken on a change reported by the household;

8312.02 - Household income was incorrectly computed;

8312.03 - Coverage continued after the review period expired without benefit of a required redetermination of eligibility; or

8312.04 - Policy was misapplied.

8313 Client Error - Instances of client error which may result in a claim include, but are not limited to, the following:

8313.01 - Non-willful withholding of information from a one-time failure on the part of a client to report a change timely (see 7100 ), which affects eligibility when: (1) - The worker has reason to believe that the client did not understand his responsibility; and (2) - There was no oral or written misstatement by the client, or

8313.02 - Willful withholding of information such as: (1) - Misstatement (oral or written) made by the client in response to oral or written questions from the agency; (2) - Failure by the client to report a change timely (see 7100 ), which affects eligibility; (3) - Failure by the client to report the receipt of a medical coverage payment which he/she knows, or should know, is incorrect;

8314 Fraud Error - A fraudulent error occurs when the client intentionally: (1) Makes false or misleading statement, misrepresentation, concealment, or withholding of facts for the purpose of improperly establishing or maintaining eligibility; or (2) Misuses medical benefits, including selling, sharing or trading the medical I.D. number for money or other remuneration, signing for services that were not provided to the recipient, or other misuse as determined by the agency. An individual shall be considered to have committed fraud when the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction. There is no other method of establishing a fraud claim. A finding of fraud under these provisions may result in criminal penalty, including fines and imprisonment, but may only result in a period of ineligibility if so ordered by the court. Fraud error status is not established if the court’s resolution to the willful client error is to place the individual on diversion.

08320 Claim not required -

8321 Claim Not Required - Even though a technical overstatement of eligibility may have occurred, a claim shall not be established in the following instances.

8321.01 - The agency failed to ensure the application used to approve eligibility was signed.

8321.02 - Coverage granted in accordance with the treatment of income policies or the inability of the agency to act on available information due solely to system cutoff dates. Assistance provided under these circumstances does not constitute incorrect coverage.

8321.03 - Overstatement of eligibility that occurred as the result of the household failing to report a change in circumstances they were not required to report.

8321.04 - The overstated eligibility was the result of agency error and the recipient did not receive any medical services within the month, even if capitation payments have been made on their benefit.

8321.05 - An eligibility error related to citizenship or alien status is not considered overstated eligibility when: a. Eligibility was based on verification of satisfactory immigration status by the Immigration and Naturalization Service (INS). b. Eligibility was approved to meet timely processing guidelines, but no INS response to a request for verification of immigration status has been received. c. Eligibility was approved to meet timely processing guidelines, but the reasonable opportunity period for alien applicants to provide documentation of their alien status had not expired.

8321.06 - A previously met spenddown is increased within the base period due to a change in income and the new spenddown amount is not met.

08330 Overstated Eligibility and Claims - Overstated eligibility occurs when an individual receives more coverage than they are entitled to receive. Eligibility staff shall document how the overstated eligibility was determined and the reason case correction was required. All overstated eligibility must be promptly resolved.

8330 Time Frames - The date of discovery for purposes of tracking timely claims shall be the date the case is first identified as potentially having overstated eligibility by the worker, quality assurance, or by other means. Failure to establish a claim within the time frames identified below does not negate the responsibility of the agency to establish or collect on the claim, or of the client to repay any valid overstated eligibility.

8331 - For agency and client errors, the agency is required to prepare the claim and initiate recovery or attempt to initiate recovery or attempt to initiate recovery by the end of the calendar quarter in which the overstated eligibility is first identified.

8332 - For fraud errors, the agency is required to prepare the claim and initiate a referral to the Office of the Medicaid Inspector General for prosecution by the end of the calendar quarter following the calendar quarter in which the overstated eligibility is first identified.

08340 Computing the Claim - In calculating the amount of the claim, the agency shall determine the point at which the correct information should have been reported and acted upon timely allowing for timely notice as appropriate. From that point, the correct coverage shall then be compared against the actual coverage received to determine the difference. The difference in the coverage received versus the coverage entitled to receive is the amount of the claim. The actual amount of the claim shall be:

8341 No Eligibility - For instances where there was no eligibility, the claim is calculated based on whether or not the coverage was provided as managed care or fee for service. a. Managed Care – The amount of the capitated payment made each month, b. Fee for Service – The amount of the paid claims.

8342 CHIP Premiums - For instances related to CHIP premiums, the claim is the amount of the understated premium.

8343 Spenddowns - For Spenddown, the claim is the difference between the capitated payment for an unmet spenddown versus a met spenddown.

8344 8349 Reserved -

08350 Establishing Claims and Repayment Agreements -

8351 Establishing Claims and Repayment Agreements - Once the amount of the overstated eligibility has been determined, a claim in that amount shall be established. The type of the claim (Agency Error, Client Error, or Fraud Error) shall determine which action to take next. 1. Agency Error or Client Error – For purposes of establishing a claim, there is no difference between an Agency Error and a Client Error. Even though the root cause of the error differs, the collection action is the same. 2. Fraud Error – A fraud error can only be established through a finding by a court of appropriate jurisdiction. Therefore, additional steps are required before collection action may commence. A suspected fraud error shall be referred to the Office of the Medicaid Inspector General. The Office of the Medicaid Inspector General will make a determination as to whether or not to pursue the case in court. If a decision is made not to pursue, the claim will be labeled as Client Error and processed as such. If the claim is accepted by the Office of the Medicaid Inspector General for prosecution, no further action shall be taken until a decision by the court has been rendered. Individuals should not receive notice that the case is under investigation for fraud. Client inquiries concerning the possible fraud investigation should be responded with a statement that the case is “under administrative review.” No additional information should be provided. Collection action for an Agency Error or Client Error claim shall be initiated by sending the household a repayment agreement. No action shall be taken on a Fraud Error claim until the court has rendered a decision. The repayment agreement shall include the amount of the claim and the reason the overstated eligibility has occurred. The household is given 10 days to respond to the repayment agreement.

08360 Collecting the Claim -

8361 Collecting Claims - Once the household has been notified of the overstatement of eligibility and repayment requested, collection action shall be initiated. Recovery may only be initiated if there are countable resources that are currently available. This includes any resources counted toward the allowable resource limit outlined in 5130 .

8362 Methods of Collection - Agency Error and Client Error claims shall be collected in one of the following ways:

8362.01 - If the household responds with a payment on the claim, the payment shall be accepted according to established procedures. If the claim is paid in full, no further collection action is required. If the claim is only partially paid, further action is necessary to collect the remaining amount of the claim.

8362.02 - If the household responds with a promise to make payments, the payments shall be accepted according to established procedures. If the payments continue or the claim is paid in full, no further collection action is required. If the household fails to begin making payments or to continue making payments, further action is necessary to collect the remaining amount of the claim.

8362.03 - If the household is unable or unwilling to make a voluntary, a special spenddown shall be imposed. The special spenddown shall be created in an amount equal to the amount to be recovered and shall be considered in the current eligibility base period. Medical expenses may be allowed against the special spenddown requirements if the expense is verified, medically necessary, and reported to the agency on at least a 6-month basis. Medical expenses shall be counted against the regular spenddown (if any) and then the special spenddown. A special spenddown may be used for both automatic and determined eligibles. There is no requirement that the client have a regular spenddown. However, a special spenddown shall not be used in the Medicaid poverty level or CHIP programs. If a special spenddown is imposed on a regular spenddown, the amount of both spenddowns must be met before the overstated eligibility claim is considered satisfied. If unmet, the special spenddown may extend over more than one base period.

8363 Fraud Claims - A claim that has been determined to be fraudulent through a court of appropriate jurisdiction shall be collected in the same manner as other types of claims. A repayment agreement shall be sent to the household as indicated in 8350 . 1. Method of Collection – If the court has not imposed the method of collection, the provisions of 8350 apply. If the court has established how the claim is to be repaid, the agency shall follow that collection method. 2. Disqualification Penalty – An individual who has been convicted of medical assistance fraud under 42 U.S.C. Sec. 1320a-7b shall be ineligible for medical assistance for one year from the date of conviction. Convictions under state law do not carry a disqualification period.

8364 Claims Discharged through Bankruptcy - If the agency becomes aware of any bankruptcy proceedings concerning a household with an uncollected medical assistance claim, KDHE-DHCF Legal Division shall be notified immediately. Legal Division will provide notification when the bankruptcy action is complete. Collection action should then be initiated, resumed, or terminated in accordance with the outcome of the final bankruptcy action.

8370 Terminating Claims - An uncollected claim shall be terminated when either of the following occur: 1. The only remaining household member responsible for the claim is deceased; or 2. The claim has been discharged through a bankruptcy proceeding (see 8364 ).

08400 Determination of Fraud - A fraud error can only be established through a finding by a court of appropriate jurisdiction. Therefore, additional steps are required before collection action may commence. A suspected fraud error shall be referred to the Office of the Medicaid Inspector General. The Office of the Medicaid Inspector General will make a determination as to whether or not to pursue the case in court. If a decision is made not to pursue, the claim will be labeled as Client Error and processed as such. If the claim is accepted by the Office of the Medicaid Inspector General for prosecution, no further action shall be taken until a decision by the court has been rendered. Individuals should not receive notice that the case is under investigation for fraud. Client inquiries concerning possible fraud investigation should be responded with a statement that the case is “under administrative review”. No additional information should be provided.

8410 Definition of Fraud - A fraudulent error occurs when the client intentionally: 1. Makes false or misleading statement, misrepresentation, concealment, or withholding of facts for the purpose of improperly establishing or maintaining eligibility; or 2. Misuses medical benefits, including selling, sharing, or trading the medical I.D. number for money or other renumeration, signing for services that were not provided to the recipient, or other misuse as determined by the agency. An individual shall be considered to have committed fraud when the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction. There is no other method of establishing a fraud claim. A finding of fraud under these provisions may result in criminal penalty, including fines and imprisonment, but may only result in a period of ineligibility if so ordered by the court (see 8363 ). Fraud error status is not established if the court’s resolution to the willful client error is to place the individual on diversion.

8420 Medical Assistance Penalties - An individual who has been convicted of medical assistance fraud under 42 U.S.C. Sec. 1320a-7b shall be ineligible for medical assistance for one year from the date of conviction. Convictions under state law do not carry a disqualification period. Pregnant women who are sanctioned remain eligible for medical coverage when continuous eligibility provisions apply. See 2300 .

8430 Fraud Referral - Before a referral to the Office of the Medicaid Inspector General for prosecution of suspected fraud can be made, it is necessary for the agency to first determine the amount (if any) of the alleged fraudulent overstated eligibility by following the procedures outlined in 8340 . The same act of alleged fraud repeated over a period of time shall not be separated so that separate penalties can be imposed. If it is decided that a case will not be prosecuted for fraud, then the overpayment shall be handled as a client overpayment as outlined in 8313 . The burden of proving fraud is on the agency. All referrals shall be reviewed by the Eligibility Supervisor and Program Integrity Specialist prior to the referral being sent to the Office of the Medicaid Inspector General. There is no minimum amount of alleged fraudulent overstated eligibility required to initiate a fraud referral. Claims (individual program or combined) of less than $1001 are to be referred to an Administrative Disqualification Hearing. Claims (individual program or combined) of $1001 and over are to be referred to the fraud unit who will determine the appropriate course of action.

8440 Reserved -

8450 Reserved -

8460 Reserved -

8470 Reserved -

8480 Imposition of Disqualification Penalties -

8481 Applying the Disqualification Penalty - Once the court has found the individual to be guilty of fraud the disqualification penalty shall be applied as follows:

8481.01 - Individuals found guilty of civil fraud or criminal fraud by a court of appropriate jurisdiction shall be disqualified for a period of one year. If the court fails to impose a disqualification period, a disqualification period shall be imposed in accordance with 8420 , unless contrary to the court order. If a disqualification is ordered, but a date for initiating the disqualification period is not specified, the disqualification period for currently eligible individuals shall be initiated within 45 days of the date the disqualification was ordered. The disqualification period is initiated by the sending of the notice. The notice must be sent within 45 days, with the disqualification starting the month following the month in which the notice is sent (or should have been sent in cases where the agency does not act timely to disqualify the individual). For fraudulent individuals not currently eligible, disqualification periods shall be initiated by notifying the household of the fraud and the specific time period established for disqualification. The disqualification period for individuals not currently eligible shall also be established within 45 days of the date the disqualification was ordered, or within 45 days of the date the court found the individual guilty of fraud as described above. The eligibility worker is responsible for notifying the fraudulent individual of the disqualification period and the effect on the remaining household members, if any.

8481.02 - Once a disqualification period has been imposed against the fraudulent individual, the period of disqualification shall be initiated and shall continue uninterrupted until completed regardless of the eligibility of the fraudulent individual's household. The fraudulent individual's household shall continue to be responsible for repayment of the fraudulent overstated eligibility regardless of its eligibility for program benefits.

8481.03 - If the agency fails to act timely to disqualify the fraudulent individual, the individual can only be disqualified to the extent that the disqualification period has not elapsed. An agency error claim SHALL NOT be established for any overstated eligibility resulting from the fraudulent individual participating in the program when he/she should have been disqualified.

08500 Fraud Recovery -

8510 Fraud Recovery - The remaining household members, if any, shall begin repayment during the period of disqualification imposed by the court. The repayment agreement shall inform the remaining household members of:

8510.01 - The amount owed;

8510.02 - The period of time the overstated eligibility covers;

8510.03 - The repayment methods that are available.

8511 - The household shall have 10 days from the date the notice is mailed to return the completed repayment agreement. If the household fails to return the completed repayment agreement in the time allotted, recovery action shall be imposed in accordance with 8360 , if repayment is not otherwise established by a court. In addition, if the household agrees to make repayment but fails to do so, recovery action shall be automatically imposed and adequate notice only is required.

8520 Reversed Disqualifications - In cases where the determination of fraud is reversed by a court of appropriate jurisdiction, the individual shall be reinstated if otherwise eligible. Understated eligibility shall promptly be corrected as a result of the disqualification.

The Kansas Department of Health and Environment (KDHE) Medicaid Kansas Economic Employment Services Manual (MKEESM) is the source of medical assistance Policy effective August 1, 2017.

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Reserved

Reserved

Several health benefit programs are provided to low income Kansans to help cover the cost of health care.

The Medicaid program is a join federal/state-funded program that covers a majority of low income persons in the State including children, pregnant women, and the elderly and disabled. Policies for family related Medicaid coverage are found in the Kansas Family Medical Assistance Manual (KFMAM).

The CHIP program is based on a federal block grant program and is intended to serve children under the age of 19 who are uninsured and who are not otherwise eligible for Medicaid. Policies for family related coverage are found in the KFMAM.

The MediKan program is a totally State-funded program and covers disabled individuals who do not qualify for Medicaid.

Other medical assistance coverage is also available to persons in need of updated TB care and persons residing in NFMH facilities between the ages of 21 and 65 through state only medical programs.

The Kansas Department of Health and Environment is designated single state agency for both the Medicaid and CHIP Programs. The Secretary of the Kansas Department of Health and Environment has the responsibility to develop state plans for furnishing assistance and services to eligible individuals and to determine the general policies relating to all forms of assistance which are administered by the Division of Health Care Finance. The Kansas programs are independent from programs administered in other states unless otherwise stated in this manual. An application for assistance in Kansas shall be treated as a new application.

Therefore, a new determination of eligibility rendered by another state shall not, in and of itself, affect eligibility in Kansas.

Policies set forth in this manual are based upon various federal and state statutes and administrative regulations. The following citations provide an overview of the primary statutory and regulatory references on which the programs are based.

42 United States Code Annotated (U.S.C.A.), Subsection 1396a et seq.

42 Code of Federal Regulations (C.F.R.), Parts 430 - 456

Kansas Statutes Annotated (K.S.A.), 39-708c, 39-209(e)

Kansas Administrative Regulations (K.A.R.), Chapter 129, Article 6

Kansas Statutes Annotated (K.S.A.), 39-708c, 39-709(d)

Kansas Administrative Regulations (K.A.R.), Chapter 129, Article 6

42 Code of Federal Regulations (C.F.R.), Part 205

Kansas Statutes Annotated (K.S.A.), 75-3306

Kansas Administrative Regulations (K.A.R.), Chapter 30, Article 7 and Chapter 129, Article 7 - for medical only.

Kansas Statutes Annotated (K.S.A.), 39-709b

Kansas Administrative Regulations (K.A.R.), Chapter 30, Articles 2-11

This manual has been developed to implement the policies set forth in the above-mentioned statutes and administrative regulations. Thus, the provisions of the manual are to be followed by program staff when determining eligibility of applicants or recipients for assistance in accordance with K.A.R. Chapter 30, Article 2.

Providing assistance is a continuing and comprehensive process, embracing all parts of the administration of the welfare program. All of the steps or parts of the process are interrelated and must be planned for, and ultimately judged, in terms of the effectiveness of the complete administration.

An individual shall have the right to make application regardless of any question of eligibility or agency responsibility. The right of an individual to make application may not be abridged.

The household has the right to designate an authorized representative.

A client has the right to be provided with information concerning the types of assistance which are provided by the agency. Upon request, the agency shall furnish the client with written general information and will explain to him the categories of assistance for which he may be eligible and the eligibility factors for same.

A client has the right to a private interview whenever he/she is discussing his/her individual situation with the agency.

A client has the right to have a timely decision rendered on his/her application. See 1413 . A recipient has the right to a decision rendered on any other formal request (such as a request for services or for information) within 30 days of its receipt by the agency.

If the client has been wrongfully delayed, denied, or terminated, he/she is due restored benefits.

The client, if eligible, shall be entitled to the correct assistance based upon budgetary standards or allowances in accordance with agency policies.

All clients have a right to equal treatment in similar circumstances and no person shall be denied benefits or be subject to discrimination on the basis of race, color, or national origin, gender, religion, age, disability, political beliefs, sexual orientation, or marital or family status.

The client has the right to file a discrimination complaint with either the Federal or the State agency.

A client has the right to request a fair hearing on any agency decision or lack of action in regard to his application for or receipt of assistance.

An applicant has the right to withdraw his application at any time between the date the application is signed and the date the notice of the agency decision is mailed. A recipient may withdraw from a program at any time.

A client shall be given an opportunity to present his request and to explain his situation.

A client has the right to a written notification of agency action concerning his eligibility for assistance.

Upon request written from a responsible member of the household or its authorized representative, the clients may review their case file. However, the agency may withhold confidential information. Refer to 1224 .

The applicant shall submit an application containing a legible name and address (unless homeless). An application must also be signed to be complete.

A client has the responsibility to supply, insofar as able, information essential to the establishment of eligibility.

Information received in the office through a drop box, mail slot or other such manner at the opening of the business day will be considered as received that business day. This policy does not apply to verification/information that has a time and date stamp, such as e-mails and faxes. Those items are generally considered received the day of the date and time stamp. Information, which is received as a fax or copy, but is required in original form, shall be considered as received when the fax/copy arrives in the office provided the original document arrives in a timely manner as determined at the local level. In general, a fax or copy of a document shall be acceptable without requiring an original (including an application form or interim report form). However, an original document shall be required for establishing age, identity and citizenship and alienage status, and when determined to be necessary based on prudent person judgement.

The client has primary responsibility for providing verification (certain exceptions to these requirements are specified in the verification section). See 1322 .

A client has the responsibility to give written permission for release of information when needed.

A client subject to simplified reporting must report changes based on the provisions of 9121 . These changes are required to be reported within 10-days of the date of the notice of approval.

Change reporters must report within 10 calendar days from the date of the approval notice. See 9110 for specific changes that change reporting persons are required to report.

The client shall cooperate with all program requirements and in supplying required information.

Reserved

Each client shall provide his/her Social Security number. Refer to 2130 .

A client has the responsibility to meet his own needs insofar as he is capable.

Upon request, the agency must explain the rights and responsibilities of clients and the following requirements placed on the agency.

The agency is required to make periodic reviews of eligibility if the application is approved. The agency shall notify the client of the expiration of the review period and shall send the client a renewal form prior to the last month of the review period.

The agency is required to investigate and refer for legal action any alleged fraud related to the receipt of assistance.

The agency shall accept an application containing a legible name and address (unless homeless) and which has been signed. Refer to 1410 .

The agency has the responsibility to process all subsequent applications timely so there will be no break in the benefits the client is eligible to receive.

The agency is responsible for establishing claims for overstated eligibility (either fraud, client, or agency error).

The agency shall restore benefits to the client if benefits were wrongfully denied, delayed, or terminated.

The agency is responsible for giving adequate and/or timely notice of action when appropriate.

Reserved

Reserved

The agency has the responsibility to insure that case file documentation supports the decision to provide, deny or change eligibility, benefits, or services.

Services shall be provided in the most cost-effective manner in order to provide the client with the appropriate services within the resources allowed.

Information concerning applicants or recipients (present and past) is confidential and may not be disclosed to another agency employee, the client, or any other non-agency personnel except as set forth in this section.

Information concerning clients or providers who have been referred for investigation is confidential and may not be released unless the Fraud Unit or the prosecuting attorney to whom the case has been referred for legal action authorizes such disclosure.

The agency may disclose confidential information when the purpose of such disclosure is directly related to: (1) the administration of the medical program; (2) an investigation, prosecution, or criminal or civil proceeding conducted in connection with the administration of the medical program or the SSI program; or (3) the administration of any federal or federally assisted program which provides assistance (in cash or in kind) or services directly to individuals on the basis of need. For exceptions, see 1225 and 1226 .

Throughout this material related to confidentiality of case records, the term agency employee includes contracted employees (e.g., KanCare Clearinghouse and MMIS fiscal agent staff).

The confidential nature of the following information must be safeguarded:

Information contained in applications, reports of investigations, reports of medical examinations, correspondence, and other records concerning the condition or circumstances of any person for whom or about whom information is obtained, and including all such information whether or not it is recorded; and

Records of agency evaluations of such information. General information, not identified with particular individuals, such as total expenditures made, number of recipients, and other statistical information and social data contained in general studies, reports, or surveys of welfare problems, does not fall within the class of material to be safeguarded.

Information entered in the case record is to be made available to the client upon request, for inspection at a time mutually agreeable to the agency and the client, except as set forth below.

Reserved

Medical and psychiatric reports are not to be made available to the client unless signed, written consent is obtained from the medical practitioner who rendered such report.

The names and addresses of complainants are not to be made available to the client.

Investigative reports concerning welfare fraud or other types of overpayments are not to be made available to the client during the course of the investigation or during the time period in which the case has been referred for legal action unless the Fraud Unit, the Office of the Medicaid Inspector General, or the prosecuting attorney to whom the case has been referred for legal action authorizes such disclosure.

NOTE: With the exception of 1224.3 , all documents and records to be used by the agency at a fair hearing are to be made available, upon request, to the appellant or his representative for inspection and/or copying at a reasonable time mutually agreeable to the agency and the client or his representative prior to the date of the hearing.

Information is not to be disclosed to another agency employee unless the employee has a need for the information in the performance of his official duties. The client's signature on the application form authorizes the disclosure of information to other agency personnel if the purpose of such disclosure is connected with the administration of the medical assistance programs.

Information is not to be disclosed to non-agency personnel such as courts, school boards, legislators, prosecuting attorneys, policemen, FBI agents, doctors, social service agencies, state employment offices, public housing authorities, landlords, creditors, relatives, etc., except as set forth below.

Regulations, Plans of Operation, state manuals, and federal procedures which affect the public shall be maintained in the office of the KDHE-DHCF Eligibility Policy Section for examination by members of the public on regular workdays during the regular office hours. The eligibility manual is available on the internet 365 days a year.

Information may be disclosed to non-agency personnel when the purpose of such disclosure is directly related to the administration of the medical assistance programs. This information concerning a client is not to be disclosed without the signed written consent of the client unless the purpose of such disclosure is directly related to those programs. Any information disclosed is to be limited to that which is reasonably necessary to accomplish the purpose of such disclosure. Such purposes include establishing eligibility, determining assistance, and providing services to applicants or recipients.

In the course of providing services to clients, disclosure of information should be made to representatives of other helping agencies or programs only when they can give assurance that:

the confidential nature of the information will be preserved.

the information will be used only for the purposes for which it is made available (such purposes should be reasonably related to the purposes of the medical assistance program and the functioning of the inquiring agencies); and

the standards of protection established by the agency to which the information is disclosed are equal to those established by the agency itself, both with regard to the use of information by staff and the provision of protective office procedures.

Reserved

Information concerning clients is to be disclosed to federal or federally assisted programs which provide assistance (in cash or in kind) or services directly to individuals on the basis of financial need if the requesting agency certifies in writing that the information so requested is necessary to the administration of its program.

Example : SSI.

Information is to be disclosed to the official conducting an investigation, prosecution or criminal or civil proceeding in connection with the administration of the medical assistance program if such information is reasonably necessary to the investigation, prosecution or criminal or civil proceeding. This includes welfare fraud investigations and prosecutions. The client's signature on the application/redetermination form authorizes the disclosure of information from the case record necessary to conduct an investigation, prosecution, criminal or civil proceeding related to eligibility for medical assistance.

Information concerning clients is to be disclosed to the official conducting an investigation, prosecution or criminal or civil proceeding in conjunction with the administration of the SSI program if such information is reasonably necessary to the investigation, prosecution, or criminal or civil proceeding.

Information disclosed pursuant to the above paragraphs shall be provided the appropriate official in the following manner:

The official requesting such information shall be allowed to review pertinent case record material in the agency office during normal working hours.

Such official, upon request, shall be furnished with copies, or authenticated copies, or originals of pertinent case record materials as necessary at no cost. Prior to the release of an original document, a copy of the document shall be placed in the case record with a notation as to the disposition of the original.

If a question arises as to the pertinency of any requested material, consult the Policy Legal Division.

Information concerning the intention of a client to commit a crime and the information necessary to prevent the crime shall be disclosed to the appropriate authorities.

Reserved

Reserved

Information not otherwise authorized to be disclosed by this provision may only be disclosed if the client has the authority to disclose such information and the agency has a signed, written consent on file authorizing the agency to disclose the information to the specific person requesting such information, excepting that such information may be disclosed without signed, written consent in an emergency situation such as death or other serious crises to an appropriate person if the agency deems such unauthorized disclosure to be in the best interest of the client. If such information is disclosed without signed, written consent, the client shall be notified of such disclosure as soon thereafter as possible.

Since all information relative to a client is by law confidential and since clients are advised that any information they reveal is held confidential, any information received by the worker or other person connected with the agency, is by statute, in the nature of a privileged communication just as is the information received by an attorney or physician from his client, or received by a minister in the performance of his function as a spiritual advisor.

The Legal Division must be notified immediately of a subpoena to produce records or of a court order to testify; such notice should be in writing whenever time permits. A staff member who is subpoenaed or whose records are subpoenaed, unless otherwise instructed by the Legal Division, should make appearance at the time and place stated in the subpoena, and should bring the records subpoenaed with him, if any. After being sworn in he should make the following statement to the court in response to the first material question:

"I am attending the court’s hearing as a result of a subpoena. The law and KDHE-DHCF policy require that I call the court’s attention to the laws and regulations limiting use and disclosure of information concerning public assistance. K.S.A. 39-709b limits the use or disclosure of information concerning applicants and recipients of assistance to purposes directly connected with the administration of the assistance program, unless there is written consent given by the client. Section 1902(a)(7) of the Social Security Act, codified at 42 U.S.C. Sec. 1396a(a)(7), and 42 C.F.R. Sec. 431.300, et seq. also limits use and disclosure of information."

The witness will submit the above statement in its entirety to the court and a copy to the attorney and will testify further according to the ruling and instructions of the court. Testifying and releasing confidential information when ordered to do so directly by a judge in an in-court setting is not considered unauthorized disclosure of information per 1229 .

When there is some question as to the disclosure of information to another agency employee, the client or other non-agency personnel, the question is to be referred to the legal division for clearance.

An agency employee who discloses confidential information concerning an applicant or recipient (present and past) in violation of the provisions set forth in 1220 and subsections shall be subject to appropriate disciplinary action (official reprimand, suspension, demotion, dismissal, etc.).

Further, any individual who discloses confidential information concerning an applicant or recipient (present, past) in violation of the provisions set forth in 1220 and subsections shall be subject to criminal prosecution, and if convicted, may be fined up to $1,000 and/or sentenced to the county jail for a period not to exceed six months.

The local worker shall use the prudent person concept in administering the medical assistance programs. The phrase, "prudent person" applies to the particular situation that indicates further verification of information is needed. It also applies to the reasonableness of judgments made by an individual in a given situation based on that individual's experience and knowledge of the program.

It is the responsibility of staff to be prudent when the circumstances of a particular case indicate the need for further inquiry. Additional substantiation or verification should be obtained whenever the information provided by the applicant or recipient is incomplete, unclear, or contradictory.

Circumstances that require a more thorough analysis of a case include:

Real or personal property holdings that are very near or equal to the resource limitation.

An individual who is living at a higher standard of living than known resources or income would permit.

An individual who appears to qualify for potential resources such as Social Security, unemployment benefits, veterans' benefits, medical insurance, etc. (See 2124 and subsections)

An individual who appears to be confused.

An individual who has a history of providing conflicting or incomplete information.

Documents (birth certificates, Social Security cards, etc.) that appear to have been altered.

Information obtained from non-medical assistance programs (Cash Assistance – TANF, Food Assistance, Child Care) through KEES according to the following guidelines: Earned income that is currently budgeted on an open or pending program; or was included on a non-active program if the income started within the past three months. Unearned income that is currently budgeted on another program in any status, except for expired time-limited unearned income. Non-exempt resources that are currently included on an open or pending program. Other information currently used for another open or pending program that, if were validated, would result in a different eligibility outcome. NOTE : Staff should not research non-medical cases unless there is cause, such as a discrepancy or red flag identified.

Documents provided by the applicant (pay stubs, employer statement, tax returns, etc.) that appear to be incomplete due to missing required information (i.e., pay dates, frequency, or tax form Schedule 1 or 1040).

When conflicting or contradictory information is discovered, the eligibility staff person shall research the medical case file and other sources, such as interfaces, to determine if a reasonable explanation exists.

If the discrepancy is not resolved, contact with the consumer is required. First, phone contact must be attempted. If the issue remains unresolved a written request for information is issued, as per 1321(3) below. Eligibility cannot be denied or terminated solely based on the discrepant information until the consumer has been given the opportunity to explain the discrepancy. Unless the consumer consents to negative action based upon their request, a written request for information must be issued prior to any negative action.

Staff are responsible for updating the case file (e.g. journal) with information regarding the discrepancy as well as the resolution. If the staff person made a judgement call regarding a specific situation, an explanation of the facts of the case as well as the factors that lead to the decision are also included in the journal. As each situation is unique, the extent and content of the necessary journal entry will depend upon the circumstance of the case.

Simplified eligibility as adopted by the State is a system by which the agency accepts the individual's statement as the basis of eligibility. For some factors of eligibility, additional information will have to be obtained.

The agency shall:

Use, to the greatest extent possible, the information on the application/redetermination form, as provided by the individual applicant/recipient, for purposes of determining eligibility and extent of entitlement.

Carefully review the form for completeness, clarity, consistency, and lack of error or questionable statement.

Give the applicant/recipient the opportunity to present additional clarification when information on the form is incomplete, unclear, or inconsistent, or where other circumstances in the case indicate to a prudent person that further inquiry needs to be made. Negative action because of failure to provide the information can be taken only when written notice was given allowing at least 12 calendar days from the date the notice is initiated to return the information.

Consider additional information from agency records.

Advise the applicant/recipient when it is necessary for the agency to go to other sources, and when necessary, obtain his consent on the information release form. If he does not consent to the necessary contacts, it may not be possible to determine that initial or continuing eligibility exists. Each applicant and recipient give consent to a full field investigation when he signs the application/redetermination form, but a signed informational release form may be necessary to obtain the needed information. See 1212.4 . NOTE: See 2145.2 and 2145.4 for requirements regarding citizenship/identity verification.

Consider verification/information received by 5:00 PM (or closing time) on a business day as received that day. Any verification/information received (for example, in a drop box) after 5:00 PM (or closing time) on a weekday, holiday or weekend will be considered received the next business day. This policy does not apply to verification/information that has a time and date stamp, such as e-mails and faxes. Those items are considered received the day of the date and time stamp.

Documentary Evidence - Documentary evidence shall be used as the primary source of verification. Documentary evidence consists of a written confirmation of a household's circumstances. Examples are wage stubs, bank statements, utility bills, medical reimbursement statements, and, for Social Security numbers, such evidence as BENDEX printouts, Social Security cards, or any official document containing the Social Security number. Although documentary evidence shall be the primary source of verification, acceptable verification shall not be limited to any single type of document and may be obtained through the household or other sources. Alternate sources of verification, such as collateral contacts and/or home visits, shall be used whenever documentary evidence cannot be obtained. In addition, information received from a payer source interface (such as Social Security, Unemployment Compensation or KPERS) is considered documentary evidence. Also see 1322.4 .

Collateral Contacts - A collateral contact is a verbal confirmation of a household's circumstances made by a person outside of the household. The collateral contact may be made either in person, by mail or over the telephone. The acceptability of a collateral contact shall not be restricted to a particular individual but may be anyone who can be expected to give an accurate third-party verification of the household's statements. Examples of acceptable collateral contacts are employers, landlords, social service agencies, migrant service agencies, and neighbors of the household. When talking with collateral contacts, staff should disclose only the information that is necessary to get the information being sought. Staff should avoid disclosing that the household has applied for benefits, nor should they disclose any information supplied by the household, especially information that is protected per 1223 , or suggest that the household is suspected of wrongdoing. This applies to collateral contacts other than those where there is a need to share full information such as the Social Security Administration. See 1222 .

Home Visits - Failure of a client to cooperate with or consent to a scheduled or unscheduled home visit shall not directly affect eligibility, and no case shall be closed or denied because an applicant/ recipient refuses to grant admittance to his/her home or cooperate during a home visit. If a client refuses to cooperate with or consent to a home visit, a request for information shall be sent to the client. If the client fails to provide adequate verification as requested, then the case may be closed or the application denied, if that is the appropriate action based on the type of information that was not provided.

Discrepancies - Where information from another source contradicts statements made by the household, the household shall be afforded a reasonable opportunity to resolve the discrepancy prior to an eligibility determination. Information needed to resolve the discrepancy shall be requested from the household, however, if the household fails to provide the necessary information, staff may elect to verify the information directly. Households are to be given 12 days to provide necessary verification. If the client does not or refuses to provide adequate verification to resolve the discrepancy, the case may then be closed, or the application denied if that is the appropriate case action.

The household has the primary responsibility for providing documentary evidence to support its statements and to resolve any questionable information. Households may supply documentary evidence in person, by mail, or by an authorized or personal representative. Any reasonable documentary evidence provided by the household shall be accepted by the local office. The local office shall be primarily concerned with how adequately the verification proves the statements on the application. If it would be difficult or impossible for the household to obtain documentary evidence in a timely manner, the worker shall offer assistance to the household in obtaining documentary evidence at the interview and/or send a notice which includes the offer of assistance to all households.

See 2145.4 for requirements regarding citizenship/identity verification.

The household shall not be held responsible when a person outside of the household fails to cooperate with a request for verification.

Case files must contain documentation to support the determination to approve or deny program benefits. Documentation means that a written statement regarding the type of verification and a summary of the information obtained has been entered in the case record. Such statements must be in sufficient detail so that a reviewer would be able to determine the reasonableness of the determination. For example, when income is verified by the presentation of pay stubs, the gross amount of income on each pay stub, and the frequency of receipt of income is included on a copy of the pay stub in the case record or is recorded by the worker elsewhere in the case file.

Where verification was required to resolve questionable information, the worker shall document why the information was considered questionable and how the questionable information was resolved. The worker shall also document why any alternate sources of verification were needed and, if a collateral contact was rejected, the case file shall contain documentation of why the collateral contact was rejected and an alternate chosen.

The physical address of a participant in the Safe at Home, see 1723 , program shall be obtained for the purposes of determining eligibility and benefit level but will not be recorded or documented in the case log or within the agency. To ensure the address is protected, only the Safe at Home mailing address will be entered on KEES. The county of residence will be placed on KEES to issue correct benefits and for a proper managed care assignment. Staff will note in the case file that the client is a Safe at Home participant.

Verification is the use of documentary evidence, collateral contacts, or home visits to establish the accuracy of statements on the application.

The worker shall verify the following information prior to approval for clients initially applying:

Nonexempt Income - Non-exempt income shall be verified in the following manner: Gross Nonexempt Income - Gross nonexempt income shall be verified prior to approval. However, where all attempts to verify the income have been unsuccessful because the person or organization providing the income has failed to cooperate with the household and the worker, and all other sources of verification are unavailable, the worker shall determine an amount to be used based on the best available information. Also refer to 7110 for rules regarding the prospective budgeting of earned income. Zero Earnings - Verification of zero earnings is required in the following manner: MDN, MediKan, and MSP - For Medically Needy (MDN), MediKan, and Medicare Savings Programs (MSP – QMB, LMB and ELMB), it is necessary to verify the absence of earnings. This is applicable to all applicants and their spouse who do not report earnings, report non-wage income only, such as self-employment or unearned income, or fail to answer questions about their income. System interfaces will be checked to verify that no earnings exist. The Reasonable Compatibility Test will be used in Tier 2 to verify that no earnings exist. See 7123(2) for rules related to Reasonable Compatibility. LTC and WKH - For long term care (LTC) and Working Healthy (WKH), self-attestation is accepted. It is not necessary to access earned income interfaces when an individual reports that they do not have earned income or fails to answer questions about earned income on their application. Proof of End of Income - The following is applicable when processing a review or case change where the consumer has reported a source of income has ended. Unearned Income - For all programs, verification is required when an ongoing recipient reports a source of unearned income has ended. Verification is not requested from the consumer if information related to the end of unearned income can be obtained through an interface. Eligibility shall be denied or discontinued if the consumer fails to provide proof unearned income ended in response to a request from the agency. Earned Income - For all programs except Working Healthy (WKH), proof of the end of earned income is required when an ongoing recipient reports earned income has ended. Verification is not requested of the consumer if information related to the end of earned income can be obtained through Tier 2 or Tier 3 interfaces, as appropriate. See 1322.4 . Eligibility shall be denied or discontinued if the consumer fails to provide proof earned income ended in response to a request from the agency. For Working Healthy (WKH) recipients, communication with the Working Healthy Benefits Specialist is necessary to determine when employment ended and whether a Temporary Unemployment Plan (TUP) is needed. See 2664.7 . Earned Income – For all programs, earned income shall be verified under the tiered process as specified in 1322.4 (and subsections).

Non-citizen Status - The worker shall determine from information on the application if individuals identified as non-citizens are eligible non-citizens, as defined in 2140 and subsections. Reserved Documentation of non-citizen status is required for each individual requesting Medical Assistance as described in 2145 . The agency may not request verification of non-citizen status from the applicant or recipient if that information can be verified through an available resource. The agency shall make every effort to verify non-citizen status through those resources. NOTE : If the individual already has a DCF-verified record that results in a qualifying alien/immigration status and does not reflect a change in immigration status, this would be considered a Tier 1 verification per 2146.6 . If the agency is unable to verify non-citizen status, verification shall be waived and a three (3) month reasonable opportunity period for the individual to provide the information shall be applied. If otherwise eligible, the applicant may be approved for assistance. The individual shall be contacted to provide verification and notified of the reasonable opportunity period. See 2146.6 .

Social Security Numbers - When an applicant who is required to apply for a Social Security number wishes to apply through the Social Security Administration, the individual shall be required to supply verification of application for the required SSN prior to the agency's certification of that individual unless the individual claims good cause or qualifies for exemption. The requirement to supply and verify an SSN does not apply to non-citizens who would only qualify for a non-work SSN, such as refugees, asylees, and special immigrants. Refer to 2133 . When an applicant fails to provide an SSN or proof of application for an SSN, they may qualify for a Good Cause exception, see 2133 . A copy of the Social Security Card is not required, and assistance cannot be denied for failure to provide the Social Security card when a number has been provided.

Reserved

Identity Reserved The identity of each person requesting coverage, who is claiming to be a U.S. citizen must be documented. See 2145.2 . This requirement does not apply to the following individuals: Current or former SSI recipients Current or former Medicare beneficiaries Current or former recipients of Social Security Disability benefits Children in foster care or recipients of foster care maintenance Children who are recipients of adoption assistance Children born on or after July 1, 2006, to a Medicaid recipient as outlined in KFMAM 2320 Identity for persons claiming to be non-citizens is accomplished through documentation provided under the requirements of 2146 . All documents used to verify identity must be retained in the case file indefinitely per 1711(9) . For persons exempt from the requirement due to SSI or Medicare status, verification of such status is required. The Reasonable Opportunity to Provide Documentation requirements of 2145.4 are also applicable to requests for identity verification. Acceptable documents and the hierarchical protocol for obtaining acceptable documents are described in the A-1, Non-Citizen Qualification Chart and as follows: Primary Document - a document that verifies both identity and citizenship (as described in 2145.2 and is further defined in the A-1, Non-Citizen Qualification Chart . The availability of a Primary Document shall be explored prior to using another identity document. A person born outside of the U.S. who is now a U.S. citizen, but was not a citizen at birth, must submit a Primary Document. Secondary Identity Document - a document that verifies identity only. The statement of the applicant/recipient that a Primary Document is not available is sufficient to seek a Secondary Document. However, if a primary document is not used, two different documents must be used to establish citizenship and identity. Additional Documents for Children Under Age 16 - Where Primary or Secondary documents are not available to verify identity, special documents may be used for children under 16. Declaration of Identity - As a final option, a written declaration may be used to establish identity for children under age 16 or disabled adults if no other documentation is available. If a declaration is used to establish citizenship it cannot be used for identity verification. Form item, P-7, Declaration of Identity – Child , and form Item P-9, Declaration of Identity – Disabled Adult , may be used for this purpose. The KanCare Clearinghouse manager must approve the declaration. The person making the declaration must: be a United States citizen sign the declaration under penalty of perjury in the presence of a witness, and for children, must be the parent, legal guardian, or caretaker relative of the child. for disabled adults, must be the director or administrator of a residential care facility where the individual resides. The signature of the parent, legal guardian, or caretaker relative made under penalty of perjury in the presence of a witness. When a declaration is used to establish identity, the original must be retained in the case file indefinitely. Any document which reasonably establishes identity shall be accepted and no requirement for a specific type of document, such as a birth certificate, will be imposed. If no such document is available, a collateral contact shall be made and documented in the case file. Multiple Documents - When none of the above items of identity are available, a client may submit three or more of the following documents as verification of identity: employer identification card high school or college diplomas, including GED marriage certificates property deeds/titles divorce decrees Multiple documents can only be used for identity if a second or third level of citizenship has been provided.

Disability - Disability must be verified for persons requesting medical assistance under a disability program (see 2662 ) or requesting MediKan (see 2646 ).

Reserved

Reserved

Resources All trust funds and accounts, including IDA's and annuities, are to be verified by providing a copy of the actual trust instrument as well as any supporting information necessary to establish the availability of the trust (e.g., bank ledgers documenting the value of the trust and wills funding the trust). In addition, all real property (excluding the home in which the applicant/recipient resides), stocks, bonds, and non-exempt retirement funds must be verified. Reported bank accounts shall be verified according to the tiered process described in 1322.4(2) for applications and 9333 for reviews. All burial agreements and plans, life insurance, checking accounts, savings accounts, debit card accounts, and other financial instruments must be verified prior to approval. Other resources, such as vehicles and resources involved in transfers of property, may be verified as the circumstances demand. NOTE: The balance of a Direct Express electronic debit account used for the deposit of federal benefits (Social Security, SSI, VA, Civil Service Annuities) need not be verified if the only monies in the account are from Social Security or SSI benefits, or the value of all countable resources, including the account, are not within $300 of the applicable resource limit.

Reserved

Citizenship Documentation of U.S. citizenship is required for each individual requesting medical assistance as described in 2145.2 . The agency may not request verification of citizenship from the applicant or recipient if that information can be verified through an available resource. The agency shall make every effort to verify citizenship through those resources. If the agency is unable to verify citizenship, verification shall be waived and a three (3) month reasonable opportunity period for the individual to provide the information shall be applied. If otherwise eligible, the applicant may be approved for assistance. The individual shall be contacted to provide the information and notified of the reasonable opportunity period. See 2145.4 .

The following information shall be verified prior to a determination of the benefit amount for households initially applying or when an ongoing recipient reports a change. Failure to provide verification of these items is not grounds for denial or discontinuance, rather the determination would be completed without considering the reported information.

Reserved

Medical expense allowed in the medical assistance programs. The amount of any medical expenses shall be verified prior to being applied toward the applicant/recipient’s share of cost. Reserved All medical expenses used against spenddown, client obligation or patient liability are to be verified including responsibility and amounts of third party payments. Expenses direct billed to the fiscal agent by the medical provider are considered verified but are subject to review by KDHE-DHCF. In addition, non-medical household expenses used to determine the excess shelter deduction for spousal impoverishment income allocation 8144.2 (1) (b) and 8244.2 (2) shall be verified.

Community Spouse Resource Assessment (CSRA) - Verification of all resources shall be requested to determine the Community Spouse Resource Assessment (CSRA). See 8144.1 (2) and 8244.1 (2) . The CSRA shall be calculated based on the resources actually verified. Unverified resources shall not be included in the determination. When verification of resources is requested, the agency shall also provide notification that information not provided will not be included in the CSRA determination. In addition, the agency is also responsible for notifying the individual of any unverified resources not included in the CSRA once the allowance has been established. Applicants have until the later of 45-days from the date of application or 12-days from the date notification of the outcome of the CSRA was sent to provide unverified resource verification. NOTE: Information provided in this section does not absolve the individual from the responsibility to provide verification of any resources owned at the time the long term care arrangement began when the information is being used to determine eligibility. The information provided in this section only allows the eligibility worker to complete the CSRA. Any other reason for the eligibility determination, such as the determination that a transfer of property occurred, a determination of whether the resource is producing income, or the determination of the countable or exempt status of the resource, would require verification of the resources.

The worker shall verify all other factors of eligibility prior to approval only if they are questionable and affect the household's eligibility or benefit level. To be considered questionable, the information on the application must be inconsistent with other information on the application or previous applications or inconsistent with information received by the agency. When determining if information is questionable, the decision shall be based on each household's individual circumstances. Also see 1310 and 1320 .

Household Composition - If questionable, the worker shall verify any factors affecting the composition of a household.

Reserved

Resources - Other than as indicated in 1322.1 (9) , resources are to be verified prior to approval only if inconsistent with other information on the application, previous applications, or other documented information, and the resource affects the household's eligibility. Inconsistent resource information shall be identified in the case record with sufficient documentation and verification to support the agency's action in the event of appeal or for Quality Assurance review.

At application and review, when verifying resource information through the Asset Verification Solution (AVS) as outlined in 1322.4(2) and 9333 respectively, if unreported bank accounts are found, additional verification shall be requested of the consumer if the account balance (in combination with all other countable, non-exempt resources) exceeds the applicable resource limit. Otherwise, contact with the consumer is not required to verify the unreported account and the AVS value is accepted.

The following special verification provisions apply in determining the countable value of reported income, resources, expenses, and deductions.

Income Verification - A four-tiered approach to verifying income needed to determine eligibility shall be used. This method means the agency will try to verify reported income information as much as possible before contacting the consumer for the information. The verification process will proceed in order from Tier 1 through Tier 4. It is acceptable to return to a prior Tier to verify information when a new self-attestation of income is received or when an administrative error is made. For example, when a Reasonable Compatibility test has already been completed in Tier 2, staff may return to Tier 2 to repeat the RC test when the consumer has clarified information or provides new information. Tier 1 - Reported information is verified through the use of a payer source interface (Federal Hub, Social Security, Unemployment Compensation, KPERS). Since this data comes directly from the source of the reported information, it is considered verified. Note: If there is a difference between the reported SSA or SSI amount and the amount verified through the Federal HUB, the Social Security interface (EATSS) may be accessed to resolve the discrepancy. Reported unearned income not verifiable through a payer source interface shall be verified as indicated in 1321 and subsections. Also included as a payor source for purposes of this section are pay stubs, or other comparable documentation voluntarily provided by the employee or employer at the time of application or request for assistance, which are sufficient to determine the countable amount of earned income without request for further verification. To be considered sufficient, the information provided must meet one of the following: All pay stubs received in the 30 days immediately preceding the date of application or request for assistance. pay stubs which allow calculation via year-to-date totals of gross earnings received in the 30 days immediately preceding the date of application or request for assistance. A written statement from the employer attesting to the employee’s gross earnings received in the 30 days immediately preceding the date of application or request for assistance, including the date(s) and frequency of payment; or Any other document or documents from either the employee or employer which verifies the total amount of gross earnings received by the employee in the 30 days immediately preceding the date of application or request for assistance. If the information voluntarily provided is sufficient to verify earned income, no further verification is required. The information voluntarily provided shall be used to determine the amount of earnings. If insufficient to verify the earned income, the information voluntarily provided is not considered a payor source. NOTE: If sufficient information as described above is not voluntarily provided at the time of application or request for assistance, eligibility staff shall not request pay stubs or additional information as part of the Tier 1 process. Verification shall proceed through the remaining Tiers 2 through 4, in order. See also 7123 (2) (Reasonable Compatibility), 7123 (3) (Budgeting Method), and 7241 (Deductions for MDN, QMB, LMB, QWD, and Working Healthy). Tier 2 - Reported information is verified through the use of a secondary non-payer source interface (i.e., The Work Number (TALX), Kansas Department of Labor (KDOL)). This data does not come directly from the source of the reported information but may be used for verification. Use of Tier 2 interfaces to verify earned income for Working Healthy (WKH) and Long Term Care (LTC) is not appropriate. See (c) and (d) below. Tier 3 - Manual research by the eligibility worker is required. This may include review of the Medical and Non-Medical case files, reconciling information received from Tier 2 interfaces, checking other available program information, and making collateral contacts. Any decision to verify reported information at this level must be thoroughly documented. In addition, the manual research shall progress through the following steps in the order listed: The Work Number - When the Work Number data is not successful in establishing reasonable compatibility for reported or no reported earned income in Tier 2, the interface data is used as outlined in 7123.2 . If Work Number data is not available, proceed to researching the medical case file. Medical Case File - The medical case file shall be searched for hard copy verification of the reported information. If no hard copy information is found in the medical case file, proceed to the DCF images. Department for Children and Families (DCF) Images - A manual search of the DCF case records shall be completed for usable images to satisfy verification requirements if a consumer was part of a DCF case for a relevant time period. If verification cannot be obtained from DCF images, proceed to collateral contact. Collateral Contact - Collateral contact shall be made to verify the reported information, when deemed appropriate. If verification cannot be made via collateral contact, proceed to Tier 4 level verification. Tier 4 - As a last resort when the reported information cannot be verified through any other means, contact with the consumer is required. Normally a formal request for information will be sent to the consumer to provide verification. However, in some instances, a phone contact with the consumer may be sufficient.

Resource Verification - A four-tiered approach to verifying resources to determine eligibility shall be used. This method means the agency will try to verify reported resource information as much as possible before contacting the consumer for the information. Tier 1 – Unlike income, there are no source interfaces to verify resources. Tier 1 verification consists of hard copy documentation of the resource voluntarily provided by the individual or directly from the source at the time of application, review, or reported change. Tier 2 – Reported information is verified through the use of a secondary non-source interface – the Asset Verification Solution (AVS). This interface can only be used to verify bank account information in financial institutions. It is not available for all other real or personal property. The use of the AVS for verification purposes shall be employed as described in 5120 concerning resource compatibility between reported and interface resource values. Tier 3 – Manual research by the eligibility worker is required. This may include review of the Medical and Non-Medical case files, reconciling information received from the Tier 2 interface, checking other available program information, and making collateral contacts. Any decision to verify reported information at this level must be thoroughly documented. Tier 4 – As a last resort when the reported information cannot be verified through any other means, contact with the consumer is required. Normally a formal request for information will be sent to the consumer to provide verification. However, in some instances, a phone contact with the consumer may be sufficient. Self-attestation – The value and status of resources may be accepted without further verification when the countable value of all resources exceeds the applicable resource limit for the medical assistance program. The thoughtful and deliberate use of prudent person (see 1310 ) should be employed in making this determination. See Policy Memo 2018-10-01, re: SSI Termination and Verification of Resources and PM2024-06-01, re: Potential Resources and Resource Compatibility Changes for additional guidance. See also 1322.1 (9) , 1322.3 (3) , 9121.1 , 9310.2 (3) , and 9333 (2)(b) .

Expense Verification - Since there are no interface sources for verification of medical expenses (i.e., health insurance premiums, medical bills) or household expenses used to determine the excess shelter expense for spousal impoverishment income allocation [ 8144.2(1)(b) and 8244.2(2) ], those expenses shall be verified as described in 1322.2(2) .

Prior Medical Period Verification - For all medical assistance programs except long term care (LTC), verification of income and resources in a prior medical assistance period shall proceed as follows: No Change Reported - If an individual requesting prior medical assistance reports that there has been no change in income or resources in the prior months from the application month, income and resources verified in the current period are considered verified in the prior period as well and will be budgeted for each of those months. Change Reported - If the individual reports that there has been a change in income and/or resources in the prior period, verification of actual income and/or resources for each of the prior months must be obtained as indicated above. The verified actual income and/or resource amounts will be budgeted for each month of the prior period. NOTE: The applicant must answer ‘yes’ or ‘no’ to the prior medical questions. These answers cannot be assumed. If responses are not provided, the prior medical determination cannot be completed.

Verification of Pre-tax Income and Federal Deductions - When total reported income or federal deductions is over $300.00 per month, verification of deductions will be required for them to be used in the income determination. If proof is not received, processing may be completed without them, and the applicant advised by notice that the amount was not used. Eligibility may not be denied due to failure to provide proof of deductions. NOTE : When multiple individuals have combined pre-tax or federal deductions that total $300, verification of pre-tax deductions is needed for both individuals. Verification of pre-tax income and/or federal deductions will follow the tiered approach of earned income in 1322.4 (1) above. Information on hand, such as the case file and TALX records must be used if available prior to requesting the information from the consumer. Pay stubs must be no older than three months prior to the month of the application to be used. Collateral contact with the employer may also be used but is not required. If there is no available information on file, the information must be requested from the consumer as noted below: Pre-tax income deductions – Pay stubs from the last 30 days or a statement from the employer. Federal/IRS deductions – Corresponding tax form or most recent tax return NOTE: If based on the consumer’s self-attestation of both wages and deductions, the income will exceed guidelines for all programs, it is not necessary to request proof of the deductions.

The agency is required to act on information when it becomes known. The phrase ’Known To The Agency' establishes the point in time that the agency is made aware of information in order to act upon such information for purposes of eligibility determination/redetermination. These policies do not negate the consumer’s responsibility to report information, see 9100 , but are meant to provide required parameters when reacting to new information.

See 9121.1 for processing changes.

Agency means the single state Medicaid/CHIP agency as well as any contractors or other state agency units authorized to determine eligibility for medical assistance or provide direct support of the medical assistance eligibility determination process. Currently, this means the KanCare Clearinghouse, KDHE Outstationed Workers, KDHE Central Office – Eligibility Unit and DCF PPS workers who make medical determinations. It also includes automated systems that determine medical assistance eligibility to the extent the information is used in the medical assistance determination.

The date information is considered known to the Agency establishes the date by which information must be acted upon. This date is determined by the source/channel of the information:

Information reported directly to the Agency by a consumer or third party, by any channel, is considered known on the date it is reported. Examples: The date of a phone call from the consumer reporting a change in income. The date of receipt of written correspondence. The date a Nursing Home reports a change in living arrangement. The date a new application is received, whether for a new household or an existing household reporting a change or a new member.

Information that originally becomes known to another state agency but is communicated to the Agency as part of an approved business process is considered known on the date the information was reported to the Agency. Examples: The date DCF creates a task notifying KDHE of a new medical condition that a mutual client originally reported to DCF. The date DCF creates a task notifying KDHE of a change in health insurance premium amount.

Information obtained through an interface used by the medical assistance programs which populates information directly into KEES is considered known on the date the information is added to KEES. Examples: The date a TBQ adds new Medicare entitlement to the Medicare Information page. The date an SDX task is created from a Social Security interface telling KDHE that SSI has ended.

Information originally obtained through another program through any channel that was not directly reported to the Agency, is considered known based on the type of information received. Information received through a shared data field in KEES and is immediately used for case processing through an automated process is known on the date the information is added to KEES. Example: The date a DCF updates an address in KEES for a mutual client. Information received through a shared data field in KEES is considered known on the earlier of the date the information is used for processing or the date it is viewed by a person considered part of the Agency. Example: DCF updates health insurance premium at the end of the day. The review batch runs that evening and uses the health insurance premium in the new determination. DCF notifies KDHE of the change the following day. The information is considered known on the date of the review batch, because the information was used to redetermine medical benefits. Information available only through a non-shared data field in KEES is considered known on the date it is viewed by someone considered part of the Agency. Example: The date a KDHE staff person views a DCF income record.

Submittal of a signed paper application, an on-line application, or a telephonic application shall be considered a request for assistance. See 1411.5 for signature requirements.

Based on the provisions of 4310 , an application shall include all persons who are required to be in the assistance plan. A new application is not required to add additional household members to existing programs.

Intake may be limited to providing the application form unless the applicant makes an additional request. If there is an intake interview, it must provide the applicant an opportunity to state his request and explain his situation and enable the agency to provide the applicant with needed information or to refer him to other staff members or other agencies for the help requested.

The application form together with the eligibility worker's records (if any), the necessary forms (budgets, notices of action, narratives, etc.), and any required verification must substantiate eligibility or ineligibility.

At the time of application processing, each month shall be viewed separately in determining eligibility or ineligibility. For example, if an application is filed in July but processed in August, ineligibility in August shall not affect the eligibility determination for the month of July.

Application and Additional Information can be requested from the Clearinghouse or any Outstationed Worker site. An application can be filed in person, by mail, by fax, or electronically online. The following application forms are in use:

KC1500 - E&D Medical Application

KC1100 - Family Medication Application

KC1105 - E&D Supplement to KC1100

NOTE: Online applications are received through the KDHE-DHCF Customer Self-Service Portal (CSSP) .

When an application is requested, the agency shall help the household identify their medical needs and assure that the individual receives the appropriate application. The individual shall be encouraged to file the application the same day – in person, by fax, or electronically online. See 1411.2 below for the application date of an online application. An application shall be mailed to the household the same day the request is received.

If the applicant household is homeless and they have no physical street address to list, the application shall be so noted and accepted by the agency.

For ongoing recipients who have completed an application form and who subsequently request additional assistance and for situations in which an additional program is added to a pending application based on a client's request, the following provisions shall apply:

If the new program is requested within the month following the month of application or in the first month of the new review period, a new application, signature, or interview is not required. The date of application for the new program shall be the date the additional request is first received – either orally or in writing, by the agency.

Reserved

If a request is made for a new medical program on an open medical assistance case within an existing review period, additional information may be requested, but a new application is not required unless the medical program has remained active beyond the review period due to timeliness factors. If the medical program has remained active past the required review period, only submittal of a signed application form will constitute a request for coverage.

Reserved

No new application is required if the agency initiates the new program, such as, adding QMB coverage to an open Medically Needy (MN) case.

The date of receipt by the agency of a validly signed application is considered the application date for establishing initial eligibility and for processing purposes. While the applicant is directed to both sign and date the application, the date provided by the applicant (or authorized representative) on the application does not determine the application date (see also 1411.5 ).

Paper Applications – The date a paper application is received by the agency shall be considered the application date. All signed paper applications shall be date-stamped the date physically received at the KanCare Clearinghouse, an Outstation Worker site, or other location designated by the agency. A paper application that is received through the mail or physically delivered to agency personnel on agency premises shall be considered received that date. An application that is received through a drop box, mail slot, or other such manner at the opening of the business day shall be considered that day, even if the application was deposited prior to that date. An application received by the agency via email or fax is deemed an original application and is considered received on the date on the time stamp if received by 5:00pm on a business day. If the application is received after 5:00pm on a business day or on the weekend or a holiday, the application is the next following business day. When an applicant files an application form that is not intended for the medical coverage requested, additional information may be requested, but the application date is the date the application is received by the agency. Completion of the appropriate form is not required to establish the application date for the coverage requested. NOTE : Date-stamping of a paper application by someone other than agency of agency contracted personnel does not constitute a date of receipt for application purposes.

Online Applications – The date an electronically signed online application is received by the agency shall be considered the application date if received by 5:00pm on a business day. If the application is received after 5:00pm on a business day or on the weekend or holiday, the application date is the next following business day.

Other Electronic applications - The application date for other electronic applications received by the agency is described below. MIPPA and FFM applications both have two (2) applications dates – one for processing purposes, and one for eligibility purposes. MIPPA applications – The date the electronic data file is received by the agency from Social Security is the application date for processing purposes and establishes the 45-day processing timeline. The date the original Low-Income Subsidy (LIS) application was filed with Social Security (SSA App Date) is considered the date of request for MSP and therefore is the start date for eligibility purposes. Note: In situations where the SSA App Date is more than three (3) months prior to the Application Date shown on the e-Application, then the LIS/MIPPA application is registered using the SSA App Date as the date of application with KDHE. This is done to ensure the consumer receives coverage beginning with the month of request with the Social Security Administration. FFM Applications – The date the electronic data file is received by the agency from the federally facilitated health insurance marketplace exchange is the application date for processing purposes and establishes the 45-day processing timeline. The date the original health insurance exchange subsidy application was filed with the Federally Facilitated Marketplace (FFM) is considered the date of request for medical assistance and therefore is the start date for eligibility purposes.

Telephonic applications – The application date for a telephonic application is the date the applicant answers all the questions and telephonically signs the application by certifying, under penalty of perjury, that they understand the questions and statements read to them and his/her answers are correct and complete to the best of their knowledge.

Unsigned applications – An unsigned application received by the agency is not considered an application for processing purposes. All unsigned applications shall be promptly returned to the applicant for signature. The entire application shall be returned to allow the applicant to review his/her answers prior to certifying under penalty of perjury that all answers are correct and complete to the best of their knowledge. A cover letter must be attached to the returned application explaining the need to sign the application and return to the agency for processing. If the originally unsigned application is returned with a valid signature, the application date for processing purposes is the date the returned application is received by the agency if received on a business day. If the application is received on the weekend or a holiday, the application date is the next following business day. NOTE: Neither an online nor telephonic application may be submitted without a signature. Therefore, there should never be an online or telephonic application received without a signature. The signature may be invalid (see subsection (6) below), but there should always be a signature.

Invalid Signature - An application received by the agency with an invalid signature is considered an application for processing purposes. An invalid signature is one in which the person who signed the application has no authority to act on behalf of the applicant (see 2110 and subsections). This includes verifiably forged signatures where the person signing the application is attempting to portray themselves as some else. When an application with an invalid signature has been received by the agency, the application (or a copy of the application for online applications) shall be returned to the applicant with instructions to either verify the authority of the person who signed the application or to sign the application in their own name (if legally competent to do so). If verification of authority to sign the application or if the application with the applicant’s own signature is timely received by the agency per 1321 (3) , the application date for this application is determined by the following: This provision also applies where someone other than the applicant, who is verified to act on behalf of the applicant according to 2111 (2)(a) , signs and timely returns the application to the agency. If verification is provided documenting that the person who signed the application was authorized to apply on behalf of the applicant at the time the application was received by the agency, the application date is the date the application was originally received by the agency. NOTE: If the application indicates that the person signing the application has authority to apply on behalf of the applicant (such as a person holding a Durable Power of Attorney or is a guardian or conservator of the applicant), but no verification has been provided at the time of application, the process described in this section does not apply. In that instance, the signature is initially considered valid, and the agency shall send a request for information to provide verification of the authority. If the applicant responds by formally designating the person who signed the application as his/her medical representative according to 2111 (2)(b) , the application date is the date documentation of the medical representative authorization is received by the agency if received on a business day. If the medical representative authorization is received on the weekend or a holiday, the application date is the next following business day. If the application is returned with the applicant’s own signature, and the applicant is legally competent to apply on their own behalf, the application date is the date the returned application with the valid signature is received by the agency if received on a business day. If the returned application is received on the weekend or a holiday, the application date is the next following business day. This provision also applies where someone other than the applicant, who is verified to act on behalf of the applicant according to 2111 (2)(a) , signs and timely returns the application to the agency. If verification of authority to sign the application or if the application with the applicant’s own signature (or of someone who can act on behalf of the applicant) is not timely received, the application shall be denied due to an invalid signature based on the date the application was originally received.

No program request – The application date for an application received with no program request is the date the application is physically received at the KanCare Clearinghouse, an Outstation Worker site, or other location designated by the agency. Immediate contact with the applicant shall be made to determine which programs are being requested. The program(s) requested shall be registered using the date of receipt of the application as the application date for those programs only. Any subsequent request for other programs by the applicant shall be registered with an application date based on the date of request for the additional program(s). NOTE: An online application may not be submitted without a program request. Therefore, there should never be an online application received without a program request.

An individual in need or by another person able to act in the individual's behalf may submit an application for assistance. See 2110 . If the applicant or his representative signs by mark, the names and addresses of two witnesses are required. Obtaining the signatures of all persons in the family group who are requesting assistance and able to act in their own behalf per 2110 is encouraged but cannot be required.

Filing on Behalf of a Deceased Person - An application shall be made on behalf of a deceased person in the month of death or within the three following months by the following individuals: A parent of the decedent where the decedent is a minor. The surviving spouse of the decedent. An adult child of the decedent An adult in the decedent’s tax household; or An executor or administrator (including temporary) of the decedent’s estate.

Filing for Institutionalized Individuals (Not applicable to the MediKan Reintegration Program) - When possible, all necessary information and signed forms will be obtained by institutional personnel. Parents, spouses, guardians/conservators and others who may apply on behalf of the individual per 2110 must always be given the opportunity to apply on behalf of an institutionalized person not able to act in his own behalf. If institutional personnel are unable to obtain an application from the patient or any of the above individuals, the administrator of a licensed facility may apply on behalf of the patient. For minor children, if the length of stay will not exceed 30 days, hospital staff are not allowed to complete the application process. General hospitals are generally not regarded as a licensed facility for this purpose unless approved. However, KDHE policy may approve exceptions on a case-by-case basis. Complete applications will be forwarded to the Clearinghouse for processing. All information pertinent to eligibility and known by institutional staff will be communicated to the Clearinghouse. When the institution acts as an employer to the patient, institutional personnel will be responsible for reporting all earnings to the Clearinghouse.

Filing for Individuals Requesting Tuberculosis Coverage - For persons KDHE determines to be in need of treatment for TB (per 2692 ) who are not eligible for regular medical coverage, the Certification of Need for TB Treatment (ES-3100.3) is normally used for application. The form must include an authorization for care from KDHE as well as an effective date for care.

Filing for Individuals Qualifying for the MediKan Reintegration Program - Discharged staff have the responsibility for initiating a discharge plan for persons being discharged from Medicaid approved psychiatric hospitals, the Larned State Security Program, and the Larned Correctional Mental Health Facility (Central Unit). For MediKan Reintegration program purposes, an approved discharge or release plan shall include: one copy of the ES-3903 , Presumptive Medical Disability Questionnaire, one copy of the ES-3904 , and a completed and signed application form or a referral to the Clearinghouse. All documents are located on the KDHE Eligibility Policy website. In addition, the plan will also include the anticipated date of discharge, documentation that the individual has been referred to Social Security to make application for SSI or SSDI benefits, the individual's address and living arrangement following discharge, and an ongoing treatment plan. The assigned worker shall have at least five working days advance notice to carry out the eligibility functions. Upon receipt of the approved discharge plan, the worker will need to ascertain the current eligibility status of the individual.

Filing for Individuals Being Released from State Correctional Institutions - Discharge staff at the 9 State Correctional Facilities may begin the application process for potentially eligible inmates a maximum of 90 days prior to their release. The correctional facilities are El Dorado (Central, North, and Toronto Unit), Ellsworth, Hutchinson (Central, East, and South Units), Lansing (Central and East Units), Larned (Central and West Units), Norton, Topeka, Wichita Work Release Facility, and Winfield. In such instances, the inmate can sign the application as of the date of completion and the application can be filed with the Clearinghouse where the facility is located. The application must be part of the approved discharge plan for the inmate. Designated Clearinghouse staff shall be responsible for coordinating submission and processing of these applications. Discharge planning staff at each correctional facility are responsible for initiating a release plan which incorporates a completed and signed application for benefits, if appropriate, as well as all supporting documentation for the application. If application is made for medical assistance benefits, the guidelines provided for MediKan Reintegration cases in item (4) above are applicable. This includes completion of the ES-3903 and completion of necessary forms and referrals as well as all medical records obtained by the facility regarding the person's disability. The application shall be registered in KEES at the time of receipt. However, the application is not valid until the release date. As such, the application registration date shall be changed to reflect the release date at the time of release and application processing time frames (including expedited benefits) will be based on that date. The agency shall make an eligibility determination and issue benefits within 30 days following the date of the applicant's release from the institution. If, for any reason, the agency is not notified on a timely basis of the applicant's release date, the agency shall determine benefits based on the date of release. Assistance shall be determined based on the living arrangement the person is residing in upon release. Assistance for the individual shall be prorated for the first month of assistance based on the date of application/discharge.

Filing for Individuals through the Health Insurance Marketplace – Individuals may apply for medical assistance through the Health Insurance Marketplace. The Marketplace application allows any adult member of the tax household to apply for any and all other members of the tax household. Should the agency receive an application via account transfer from the Marketplace, it shall be accepted and processed even if the individual filing the application does not meet the requirements of 2110 and subsections.

The household may voluntarily withdraw its application at any time. The agency shall document in the case file the reason for withdrawal, if any was stated by the household, and that contact was made with the household to confirm the withdrawal. The household shall be advised of its right to reapply at any time subsequent to withdrawal.

As noted in 1411 , an application or review form must be signed to be considered a valid request for assistance. The signature must be both valid (see 1411.2 (6) ) and acceptable. An acceptable signature is one which meets the following requirements.

Paper Applications and Review Forms - Any mark or sign made by the person signing the application with the intent to represent the identity of that person is acceptable. This includes handwritten (wet), typed (mechanical), stamped, and scanned signatures. A handwritten signature does not have to be legible to be acceptable. If the person is marking the application with an “X” (or other symbol) because they are unable to sign their name due to illiteracy or disability, the signature of two (2) witnesses to validate the identity of the person making the mark is required. A signature provided in the wrong place in most instances shall not disqualify the application as long as the signature is both valid and acceptable. This applies to signatures provided on either the signature page or the medical representative authorization page of the application. NOTE: While it is not required that the signature be on the correct signature line, it does need to indicate an agreement/authorization of the items preceding the signature section on the signature page, i.e., the rights and responsibilities section of the application or review form.

Online Applications – In general the applicant (or applicant’s representative authorized to act on behalf of the applicant) should type his/her full name on the application, which constitutes a valid and acceptable signature. However, when less than the applicant’s (or authorized representative’s) full name appears, the following provisions apply. Acceptable – Using the prudent person concept described in 1310 , if the signature submitted on the application provides enough evidence to reasonably identify the signer as the applicant (or authorized representative), the signature is considered acceptable. Examples of acceptable signatures include (but are not limited to) the use of initials, nicknames, or partial names associated with that person instead of his/her legal name, as long as the identity of the signer can reasonably be discerned from the signature. Not Acceptable – If the signature provided on the application does not provide enough evidence to reasonably identify the signer as the applicant (or authorized representative), the signature is considered unacceptable. Examples of unacceptable signatures include (but are not limited to) partial names or nicknames not normally associated with the person’s formal name, an indecipherable combination of letters and/or numbers, or a name totally disassociated from the applicant. When the signature has been determined to be unacceptable, an attempt to contact the applicant should be made to confirm the identity of the person who signed the application. If it is confirmed that the applicant (or authorized representative) signed the application, the signature shall be considered acceptable.

Telephonic Applications – A person applying telephonically shall be required to verbally certify, under penalty of perjury, that they understand the questions and statements read to them, and that the answers are correct and complete to the best of their knowledge. To complete the telephonic signature, the applicant will be required to state their full legal name. That statement will be recorded and attached to the case as a permanent record. Based on this process, the verbal signature shall always be deemed to be acceptable. However, if it is later verified that the person who provided the verbal signature was not the applicant (or authorized representative), the signature is considered to be a forgery, and thus an invalid signature, see 1411.2 (6) . If the application does not contain an acceptable signature, follow the process described in 1411.2 (6) for invalid signatures.

NOTE: While the applicant (or authorized representative) is directed to both sign and date the application, failure to date the application (or provide an incorrect date) does not invalid the signature or the application. As long as an acceptable signature has been provided, the signature requirement has been met. See 1411.2 .

All applications shall be approved or denied on a timely basis except when a determination of eligibility cannot be made within the required period due to the failure of the applicant or a collateral to provide required information. Written notice must be given the applicant by the end of the required period giving the reason(s) for the delay. The approval of an application from a non-citizen who is otherwise eligible may not be delayed beyond the timely processing time frame due solely to the fact that no INS response to a request for verification of immigration status has been received.

Timely action is defined as follows:

Applications Requiring a Disability Determination - Within 90 calendar days of application date. Refer to 1411.2 . This includes cases that require a PMDT or DDS referral.

All Other Applications - Within 45-days of the application date. Refer to 1411.2 . For management purposes the agency shall strive to process applications within 30 days.

The purpose of this section is to provide instructions regarding the procedures which follow the determination of eligibility or ineligibility for assistance. Eligibility/ineligibility is documented using KEES procedures. A copy of the Notice of Action is to be sent to medical providers to certify eligibility/ineligibility when required.

One of the following case actions must occur within the established time period outlined in 1413 .

A notice of approval(s) shall be sent for all programs determined eligible. Notices must contain the amount of benefits and the beginning and ending dates of the review period.

Approved - The application will be approved if automatically eligible or if determined eligible with respect to all factors including financial. All households are to be notified of the appropriate reporting requirements upon approval for assistance benefits. See 9120 .

Approved - Suspended - If the applicant is eligible with respect to all factors other than financial but there is a spenddown (see 7530 ), the application will be approved in a spenddown status if there appears to be a likelihood that the spenddown will be met within the 6-month eligibility base period using evidence provided by the client and known to the agency. Eligibility staff shall refer to the guidance provided in Policy Memo 2017-03-01, re: Living Arrangement Changes including HCBS Termination - Special Project , to determine whether a spenddown should be approved. This is an administrative procedure to meet the application disposition time requirements and to preserve the original application date. However, there is no eligibility until the spenddown is met. See 1422 concerning suspension.

A denial shall be processed to assure that the applicant is provided with his/her denial notice in a timely manner. A notice of denial shall be sent at the time of denial, explaining clearly the reason for the denial.

Found Ineligible An application shall be denied if the applicant is found to be ineligible (i.e., excess income, excess resources, etc.) as soon as possible, but not later than 45-days following the date the application was filed. A denied application may be reinstated without a new application any time within the original 45 day processing time line. See also 1414.2 (3) . In no case does the denial of the application abridge that individual's right to reapply at any time.

Reserved

Failure to Provide Required Information/Cooperation - An application shall be denied after a period of 12-days from the date of a written request for information when the applicant has failed to provide required information or cooperate with eligibility requirements. The applicant must be informed in writing of the 12 day standard and the date by which the verification/cooperation must be received. If the information is subsequently received or the household cooperates within the 45 day application processing time period, the application shall be reactivated and, if eligible, benefits prorated from the date of application. If the information/cooperation is not received within the above time frames, then the client must re-apply. If the requested information/cooperation is not received within the 45-day application processing time period, but is provided within 12-days of the date of denial, the application shall be reconsidered and processed based on the original application date. This gives the applicant the later of 45-days from the date of application or 12-days from the date of denial to provide the information. NOTE : For reviews discontinued for failure to provide or failure to return the review, see the reconsideration period policy in 9350 .

Spenddown - If there is a spenddown which appears unlikely to be met within the 6-month eligibility base period, the application shall be denied. See also 1414.1 (2) .

Another Agency Assumes Responsibility - The agency may dispose of the application if another agency assumes complete responsibility for meeting the applicant's need.

Cannot be Located - The agency may dispose of the application if the applicant has moved and cannot be located. The agency shall not send a notice of decision.

Assistance may be suspended for individuals who are temporarily not eligible. Action to suspend payment must follow the advance notice requirements of 1431 .

Suspension of medical benefits does not shorten an established medical eligibility base period and a new application is not required to reinstate assistance within the period. Regardless of the procedure used, medical eligibility shall not be suspended without meeting notice requirements related to adverse action. Benefits shall not be suspended for more than 6 months except in rare cases where there is clear documentation that circumstances have changed so that medical eligibility can reasonably be expected within the next 6 month period. If the case is not to be closed, medical eligibility on a medical only case will be suspended. See 1414.1 (2) .

Medical assistance can be reinstated in the month following the month of closure or suspension if the reason for the closure has been cured by the end of the month following the month of closure/suspension and all other eligibility requirements are met. The exception to this is if medical assistance was discontinued due to whereabouts unknown (see 9124 ). If the individual was discontinued due to whereabouts unknown and confirmation of whereabouts is received prior to the end of the review period, coverage shall be reinstated back to the date of termination, unless there is a reported change in circumstances that will impact eligibility. Information that becomes known to the agency must be acted upon in accordance with 1323 . For continuation of benefits pending the outcome of an appeal, see 1612 .

A new application is not required for reinstatement purposes unless the current review has expired. However, if coverage was closed for failure to provide or failure to return the review form and the information is returned within the three-month reconsideration period (see 9350 ), the form can be used to redetermine eligibility.

Case closures will always be effective the last day of a given month. To protect credibility with medical providers, the termination date may not be changed after issuance of a medical coverage. However, the date of death will be used for a deceased individual since there are no eligible services after that date.

An applicant or recipient of assistance shall be notified promptly of the action taken on his case. The recipient of assistance shall also be notified of other changes such as an increase or decrease in the amount of the spenddown, cost share, suspension, or reinstatement after suspension.

A notice of action shall be sent promptly to the applicant or recipient with a copy of any manually prepared notices filed in the case record. When appropriate, a copy must be made available on approvals, suspensions or closure to HCBS care coordinator. Specialized notice forms are required for all cases involving a spenddown, and for all cases in which the medical program will assume at least partial payment for care situations.

Notices shall indicate clearly the action taken, the effective date, and such other information as the situation may require. For all approvals, notice must include the beginning and ending dates of the review period. If an application is denied, the applicant shall be informed of the basis for this action. A similar procedure shall be followed for all other changes.

The agency shall give timely and adequate notice of agency actions to terminate, suspend, or reduce assistance except as provided for in 1432 regarding dispensing with timely notice and in 1434 regarding negative actions resulting from information obtained through federal match data. See 9340 for further information on notice provisions for reviews.

Adequate Notice - Adequate means a written notice that includes a statement of what action the agency is taking, the reasons for the intended agency action, the specific manual references supporting such action, an explanation of the individual's right to request a fair hearing, and the circumstances under which assistance may be continued if a fair hearing request is made. All notices must be adequate.

Timely Notice - Timely means that the notice is mailed at least 10 clear days before the effective date of action. Neither the effective date of action nor the mailing date shall be considered in determining this 10 day period. For closures, the consumer must receive the notice prior to the last day of eligibility. For increases in premium or liability, the consumer must receive the notice prior to the 1st of the month for which the change is effective. The Processing Deadline Code Card Chart on the KEES Repository shall be used to identify the last day in which action can be taken in order for timely notice to be provided for the various scenarios.

An increase in an unmet spenddown does not require timely notice; however a change which results in the spenddown changing from met to unmet does require timely notice. When a spenddown for a base period changes from met to unmet, the consumer is notified both by the Clearinghouse and by MMIS. The MMIS notification must be received before the 1st day they return to having an unmet spenddown.

When only adequate notice is required, such notice may be received by the household at the time reduced benefits are received or if benefits are terminated, at the time benefits would have been received if they had not been terminated. The agency is not required to send timely notice but must send adequate notice not later than the date of action when:

The agency denies an application for assistance. However, denials resulting from information obtained through federal match data shall be subject to the provisions of 1434 .

The agency has factual information confirming the death of a client or of the payee when there is no relative available to serve as new payee.

The agency receives a clear written statement signed by a client indicating that he no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the client has indicated, in writing, that he understands that this must be the consequence of supplying such information.

The client has been admitted to an institution and further medical assistance will not be provided to that individual.

The client has been placed in a Medicaid approved institution for long term care or begins HCBS and will receive Medicaid payment for the cost of care.

The client's whereabouts are unknown and agency mail directed to him has been returned by the post office indicating no known forwarding address. The procedures of 9124 must be followed to terminate assistance when the client's whereabouts are unknown.

A client has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance.

Reserved

Assistance is approved and negative case action such as a closure or grant reduction is incorporated into the initial notice of action to the client. However, negative action resulting from information obtained through federal match data shall be subject to the provisions of 1434 .

Reserved

A client is disqualified for fraud through a court of appropriate jurisdiction.

Reserved

The client has been receiving increased benefits to restore lost benefits, the restoration is complete, and the household was previously notified in writing of when the increased benefits would terminate.

Reserved

A client fails to respond to a written repayment agreement within 10-days of the date the notice is mailed and benefit reduction is invoked. See 11125 (3)(b) .

When changes in either state or federal law require automatic adjustment for classes of clients, timely notice of such adjustments shall be given which shall be adequate if it includes a statement of the intended action, the reasons for such intended action, a statement of the specific change in the law requiring such action, and a statement of the circumstances under which a hearing may be obtained and assistance continued.

Based on the provisions of the Computer Matching and Privacy Protection Act, no immediate action to suspend, terminate, reduce, or deny assistance may be taken as a result of information obtained through federal match data which has not been determined to be accurate and reliable by the federal agency producing the data. When the federal information has not been determined to be accurate and reliable, the individual must be given 30 days from the date the notice of action is received to verify or contest the match data. This means that such notice must be sent at least 35 days prior to the effective date of action for recipients or the date the application is to be processed for applicants.

Federal matches currently affected by these provisions include the PARIS, SIEVS (IRS and BEER data) match, VA match, and matches identified via the eDRS. It does not include BENDEX, SDX, SAVE information from INS, and third-party queries obtained through SSA as all of these data exchanges are either considered to be accurate and reliable or involve a computer match process between state and federal records. It also does not include Employment Security matches as this is not a direct federal-state match.

If the individual does not respond to the notice, final action based upon the match data can be taken upon expiration of the 35-day notice period and allowing for timely and adequate notice of action. All or part of the 10-day timely notice period may run concurrently with the 35-day notice period. However, all BEERS and IRS-related match data is to be considered as a lead only and not to be used as primary verification or evidence without further independent verification.

If the individual confirms the validity of the information prior to the expiration of the 35-day period, action can be taken immediately allowing for 10 day timely and adequate notice. In addition, for applicants, action can be taken to deny the application without a 35-day notice period, if the individual has already confirmed the match data through verification provided or information which was incorporated on the application form.

If the individual contests the data during the 35-day notice period, no action can be taken until the information is further verified. If the individual cannot provide verification in regard to IRS or BEER data, contact with such sources as the financial institution, employer, etc. will need to be made.

Client cooperation in the verification process will be essential for any action prior to the 35-day notice period. If the client refuses to cooperate and/or contests the information and verification cannot be otherwise obtained, action can be taken on the case following the expiration of the 35-day notice period and allowing for timely and adequate notice of the action.

A request for a fair hearing is defined as a clear expression, oral or written, to appeal a decision or final action of any agency or employee of KDHE-DHCF. The Office of Administrative Hearings administers the agency's fair hearing program pursuant to the Kansas Administrative Procedure Act (K.S.A. 77-501 et seq.)

A request for fair hearing may be made orally (either in person or by telephone), in writing (either in person or by mail), by fax, or by e-mail.

The rights, responsibilities, and procedures for fair hearings for other interested persons are similar to those applicants/recipients as explained in this section except that hearings for other interested persons shall be held in Topeka.

Any person who is an applicant, recipient or is authorized to represent the applicant/recipient may request a fair hearing for the individual. This includes the applicant/recipient’s attorney or an individual appointed as a Medical Representative. Form KC-6100, Medical Representative Authorization Form , or medical representative section on the application form is required to authorize a medical representative as stated above. This authorization must be signed prior to the date the request for fair hearing is filed.

In addition, the applicant/recipient can provide a written authorization allowing an attorney, or other individual, to request a fair hearing on his/her behalf. For deceased individuals, only persons specifically authorized by a court of appropriate jurisdiction may request a fair hearing or represent the decedent in a fair hearing action.

The date of request shall be the date the agency received the request. The date of request for oral requests is the day the person requests a fair hearing in person or by telephone. The date of receipt of a fair hearing request submitted after business hours by telephone, fax or e-mail shall be the next business day.

Unless preempted by federal law, a request for a fair hearing shall be in writing and received by the agency within 33 days from the date the notice of action is mailed. When a request for a fair hearing is received prior to the effective date of action as prescribed in 1612 , assistance may be continued.

Such request may relate to an applicant's request for assistance which is denied, or is not acted upon with reasonable promptness, and to any recipient who is aggrieved by any agency action resulting in suspension, reduction, discontinuance, or termination of assistance.

If a written or oral request for a fair hearing is received on a Medicaid only program (excludes CHIP) prior to the effective date of action and the notice of adverse action is mailed assistance shall not be suspended, reduced, discontinued, or terminated until a decision is rendered after a hearing, unless:

A determination is made at the hearing by the hearing officer that the sole issue is one of state or federal law or regulation or change in state or federal law and not one of incorrect application of a policy (when appropriate, KanCare Clearinghouse staff should raise this issue in the hearing in order for the referee to render a decision).

A change (except the matter under appeal) affecting the recipient's assistance occurs while the fair hearing decision is pending and the recipient fails to request a hearing after notice of the change.

The request for a fair hearing concerns a discontinued program or service.

Reserved

A mass change affecting the household's eligibility, or level of coverage, or share of cost occurs while the hearing decision is pending.

Assistance shall also be continued at the prior level if the client or agency requests a review by the State Appeals Committee. See 1617 .

NOTE : In any case where action was taken without timely notice, if the recipient requests a hearing within 10 days of the mailing of the notice of action, and the agency determines that the action resulted from other than the application of state or federal law or policy or a change in state or federal law, assistance shall be reinstated and continued until a decision is rendered in the matter as set forth above.

The agency shall promptly inform the household in writing if assistance is reduced or terminated pending the hearing decision. See 1614.5 .

The client or the client's representative shall have adequate opportunity to:

Submit a request for a fair hearing (including a request to expedite as described in 1614.6 ), which may be on the Request for Administrative Hearing form, regarding any agency action. However, a hearing need not be granted if the request concerns only the validity of federal or state law or regulation. In addition, a hearing need not be granted when either state or federal law requires automatic adjustments for classes of recipients unless the reason for an individual appeal is incorrect computation. See 1612 (1) .

Examine the contents of his case file and all documents and records to be used by the agency at the hearing at a reasonable time before the date of the hearing as well as during the hearing. See 1220 and subsections regarding confidential case file information.

At his option, present his case himself, or with the aid of an authorized representative, and bring witnesses.

Establish all pertinent facts and circumstances and advance any pertinent arguments without undue interference.

Question or refute any testimony or evidence, including opportunity to confront and cross-examine adverse witnesses.

Submit evidence to establish all pertinent facts and circumstances in the case.

Every applicant/recipient shall be informed in writing at the time of application and at the time of any subsequent action affecting medical assistance of the right to a fair hearing, the method of obtaining such hearing, and that representation may be by an authorized representative such as legal counsel, relative, friend, or other spokesperson. The applicant/recipient shall be informed of the circumstances under which eligibility may be continued or reinstated during the appeal as well as an explanation that an appeal decision for one household member may result in a change in eligibility for other household members. Information printed on the application/redetermination form and notices of action will provide this information.

Agency hearing procedures shall be uniform, clearly written, and available to any interested party. At a minimum, the procedures shall include time limits for filing requests for appeals, advance notice requirements, hearing timeliness standards, and the rights and responsibilities of persons requesting a hearing. Information about the KDHE hearing procedures for providers for KanCare and fee for service is available at Appeals & Fair Hearings .

The procedures set forth below shall be followed whenever a client makes an inquiry concerning a fair hearing, asks for fair hearing forms, or files a request for a fair hearing.

The worker or supervisor should find out why the client is questioning the agency action.

If the client is only disagreeing with a federal or state law or policy, the reason for such policy should be discussed with the client.

If a client appears to be questioning the application of a federal or state law or policy to his individual situation (incorrect eligibility determination or use of incorrect facts), an administrative review shall be conducted to determine if the agency action was correct. Upon reconsideration, the agency may amend or change its decision at any time before or during the hearing. The hearing shall not be delayed or canceled because of this preliminary review. If a satisfactory adjustment is reached prior to the hearing, the agency shall submit a written report to the hearing officer but the appeal shall remain pending until the client submits a signed written statement withdrawing the request for a fair hearing.

If the client is questioning the decision regarding disability and the decision was made related to an SSI or SSA application for benefits, the client is to be referred to the SSA office to file an appeal. See 2636 .

If the client is questioning the decision regarding disability and the decision was made by Disability Determination Services (DDS) based on an agency request via the DD-1104 and DD-1105 the appeal will be processed through DDS as specified in 1614.6(1) .

When a household member or representative makes an oral request for a fair hearing to the local office or to the Office of Administrative Hearings by telephone or in person, the agency shall document the request by using the Request for Administrative Hearing form. The date of the request shall be the date the oral communication was made to the agency and that date shall appear on the form. Lack of signature by the household member on the form used to document an oral request shall not invalidate the request.

Once a fair hearing request has been received, the agency shall attempt to contact the client, or the client’s representative, by telephone to explain the agency action and the effective date of the action taken.

Unable to Contact – The agency shall make at least two (2) attempts to contact the client by telephone to explain the agency action taken on the case. All unsuccessful attempts to contact the client shall be thoroughly documented in the case file. If the agency is unable to contact the client by phone to discuss the agency action, the agency shall complete an Agency Summary as described in 1614.4 .

Contact Completed – If the agency is able to contact the client by telephone to explain the agency action taken and the client is satisfied with the agency explanation, the client should be asked if he/she is willing to withdraw the fair hearing request. Whether or not the client is willing to voluntarily withdraw the fair hearing request will determine the next action taken by the agency. Client Agrees to Withdraw – If the client agrees to withdraw the fair hearing request, the agency shall complete a Motion to Dismiss based on the client’s decision to withdraw the fair hearing request. There is no need to complete an Agency Summary at this point. See 1614.3 Client Does Not Withdraw – If the client does not agree to withdraw the fair hearing request and states an intent to continue the appeal, the agency shall complete an Agency Summary as described in 1614.4 . See also 1615 concerning dismissal of fair hearing.

The client may withdraw the request for fair hearing at any stage of the appeal process, up to and including the day of the fair hearing. The request must be in writing and signed by the client or the client’s representative. A special form, Notice of Withdrawal of Appeal, is available for this purpose. The agency may offer this form to the client for completion, but any writing evidencing the intent to withdraw shall be accepted.

The request may be submitted to either the agency or directly to the Office of Administrative Hearings (OAH). The request may be delivered by mail, fax, or in person. The appeal process will continue until the written withdrawal request has been formally received by OAH.

Within 15 days after the appellant has filed a request for a fair hearing, the agency shall furnish the appellant and the Office of Administrative Hearings (OAH) with a summary. One copy of the summary shall be sent electronically to the OAH. Another copy shall be mailed to the appellant or representative. The summary shall include the following information:

Name and address of the appellant;

A summary statement concerning why the appellant is filing a request for a fair hearing;

A brief chronological summary of the agency action which led to the appeal and the agency's action after receiving the request for fair hearing;

A statement of the basis for the agency's decision;

A citation of the applicable policies relied upon by the agency;

A copy of the notice which notified the appellant of the decision in question;

Applicable correspondence; and

The name and title of the person or persons who will represent the agency at the hearing.

When the request for fair hearing involves a Disability Determination Services (DDS) disability determination, the process described in 1614.6(1)(c) shall be followed.

If through an agency contract as discussed in 1614.2 , the appellant has withdrawn the appeal (see 1614.3 ), completion of the summary is not necessary. The Request for Administrative Hearing form should then be submitted, along with the Notice of Withdrawal of Appeal, to OAH within 7 days of the date of the request for a fair hearing.

The agency shall promptly inform the client in writing if assistance is to be terminated pending the fair hearing decision. See 1612 concerning continuation of assistance.

A request for a fair hearing on a decision based on a disability determination made by the agency, or contractors, according to 2662 is initially reviewed by the entity responsible for the disability decision.

DDS Disability Determinations – When the agency receives a fair hearing request based on a DDS disability determination, eligibility staff shall take the following actions: The hearing request shall be sent to the Office of Administrative Hearings with an indication that this is an appeal of a DDS disability determination. A DDS reconsideration of the disability determination shall be initiated by completing the following: The agency shall complete a new DD-1104 and forward to DDS, clearly indicating that this is a request for Reconsideration. In addition, the original DD-1104 and DD-1105 , as well as a new signed and dated DD-1103 should be attached. The appellant shall be instructed to complete and sign the DD-1103 release form and return to the agency within 12 days. If timely returned to the agency, the forms, along with a new DD-1104, Disability Determination Request - Medical Assistance Case form completed by the agency with the reconsideration box clearly marked shall be forwarded to DDS for review. The agency shall also include the original disability determination file compiled by DDS. If the appellant fails to timely return the requested forms, no further action on the reconsideration is required. The agency shall complete an Appeal Summary and forward to the Office of Administrative Hearings as indicated above. The Appeal Summary shall be clearly identified as a DDS disability determination appeal. A copy of the DDS disability determination file shall be included. In most instances, the reconsideration process will not be completed by DDS at this point. Staff should report on the Appeal Summary that a disability reconsideration by DDS is in progress. If the reconsideration is completed by DDS before the scheduled hearing date, the decision will determine the next step. If the decision is favorable, eligibility shall be redetermined and approved for coverage if otherwise eligible. The agency shall submit a motion to dismiss the appeal to the Office of Administrative Hearings since the issue is now moot. If the decision is unfavorable, the agency shall submit the reconsideration packet received from DDS as newly received evidence. If the reconsideration is not completed by DDS before the scheduled hearing date, the agency shall request a continuation of the hearing clearly stating the reason for the request. If the request is denied, the agency shall proceed to hearing without the reconsideration decision or documentation. However, the reconsideration process shall continue: The agency may request that the hearing record remain open after the scheduled hearing has occurred to submit the reconsideration decision and documentation once completed. If the request is granted, the agency shall submit the documentation once received. If the request is denied, the reconsideration process will continue, but the ultimate decision and documentation will not be included in the hearing decision. The agency shall still act upon the reconsideration decision, even when reported after the hearing decision is issued. If the DDS decision is unfavorable, no further action is required. The applicant continues to fail to meet disability criteria. If the decision is favorable, the applicant is now determined to be disabled. Eligibility shall be redetermined and approved for coverage if otherwise eligible.

Presumptive Medical Disability Team (PMDT) Determinations – A fair hearing request may involve MediKan or Medicaid. Any request for a fair hearing regarding the disability determination must be sent to the Office of Administrative Hearings. The PMDT shall immediately be notified of the request. For cases where there is sufficient medical evidence, the PMDT will process a reconsideration of the disability determination. All cases approved for Tier 2 but denied Tier 1 will have sufficient evidence and be reconsidered. Any additional information available to the eligibility worker must be noted on the referral (e.g., medical services, social information hospitalizations, etc.). Copies of the fair hearing request and any related materials should be included with the referral. The PMDT may request additional information from the eligibility worker to develop the reconsideration. If the reconsideration establishes that the appellant meets disability criteria, or that a higher level of disability does exist, the case will be referred back to the eligibility worker for redetermination based on the new disability determination. However, if the reconsideration upholds the original disability decision, the case will be prepared for a fair hearing. The PMDT will take the lead in preparing the appeal summary and representing the agency at the hearing, with the support of the eligibility worker.

A request to expedite the fair hearing process may be granted for an appellant who demonstrates an urgent medical need. The request may be made either at the time the fair hearing is filed or any time thereafter up to the actual date of the scheduled hearing. If granted, the hearing will be scheduled as soon as possible. If the expedited request is denied, the hearing process will proceed on a normal schedule.

The following additional provisions apply:

Request – As indicated above, a request to expedite the fair hearing process may be made at the time of the request for fair hearing or at any time prior to the scheduled hearing. If the expedited request is received after the original fair hearing is filed, it is important to note that this is not a separate hearing request, but rather simply a request to expedite the process for the previously filed hearing request. Therefore, to avoid duplicating appeals, whenever an expedited request is received, staff should ascertain whether or not there is already an existing active appeal.

Documentation – An expedited request cannot be granted without documentation supporting a claim of urgent medical need. The documentation must be provided at the time of the expedited request. The supporting documentation should be based on medical records and/or the written opinion of a medical professional familiar with the appellant’s condition and circumstances. A simple statement of medical need is not sufficient proof of an urgent medical need, nor are self-serving statements provided by the appellant or by family and friends lacking medical credentials. NOTE : Refusal or failure to supply supporting documentation with the expedited processing request will result in an automatic denial of the request.

Evaluation – The documentation provided shall be reviewed by KDHE-DHCF clinical staff to determine if the appellant has an urgent medical need which necessitates the need to expedite the fair hearing. An urgent medical need means that the appellant’s life, health or ability to attain, maintain, or regain maximum function is in jeopardy if the hearing process is not expedited. As indicated above, the determination will be based on the documentation (i.e., medical records and/or medical professional statement) provided at the time of the expedited request. That determination is then forwarded to the Fair Hearings Manager. Please note that this evaluation is not the same as a disability determination for eligibility purposes. The purpose of the review is to determine if an urgent medical need exists which warrants expediting the fair hearing process. The review is not intended to determine if the appellant meets the disability criteria for disability-related medical assistance programs.

Decision – Based on the evaluation completed by the clinical team reported to the Fair Hearings Manager, the expedited request shall be either denied or approved. Denied – If the expedited request is denied, formal notification shall be sent to the appellant explaining the reason for the denial. The notification will also state that the regular fair hearing process shall proceed as normal with the hearing scheduled within the usual time frames. The appellant is not entitled to an appeal of this decision. However, the appellant may file a new expedited request anytime up to the date of the scheduled hearing. Approved – If the expedited request is approved, the Fair Hearings Manager will contact the Office of Administrative Hearings to schedule the hearing as expeditiously as possible, but no later than 7 working days after the date the expedited request is received. The agency shall also complete the Appeal Summary and forward to the Office of Administrative Hearings as expeditiously as possible, but no later than 15 days from the date the fair hearing request is received (see 1614.4 ).

An applicant may appeal a decision made by the Federally Facilitated Exchange (FFE) concerning his/her application for coverage and/or eligibility for the subsidy through the Health Insurance Marketplace. That appeal request will be sent to the Marketplace Appeals Center for adjudication. During the appeal process the Marketplace Appeals Center may determine that the appellant is potentially eligible for Medicaid or CHIP coverage.

In that instance, the Marketplace Appeals Center will submit an electronic appeal package to the agency containing consumer account information. The package of information will include not only information provided directly by the applicant when he/she completed the Health Insurance Marketplace application, but also data obtained from the result of any verifications performed by the Federally Facilitated Exchange (FFE). Also included in the package is the appeal request submitted by the appellant. This information shall be used by the agency to review the individual’s eligibility for medical assistance.

NOTE : The agency should only receive an appeal package for individuals who have already applied for and been denied Medicaid and/or CHIP coverage by the agency.

Upon receipt of the appeal package, the agency shall conduct an administrative review of the case based on the information provided and redetermine eligibility for Medicaid and/or CHIP coverage. If the applicant is determined eligible based on the review, coverage shall be promptly approved with notification provided to the applicant. If the agency determines that the applicant is not eligible, the application shall remain denied. The applicant shall be notified of the decision with the right to appeal. Whatever decision is made, the agency shall also notify the FFE of the outcome of the redetermination.

By Kansas statute, the agency has no jurisdiction to determine the facial validity of a state or federal statute. Nor does an administrative law judge from the Office of Administrative Hearings have jurisdiction to determine the facial validity of an agency rule and regulation. So, clients have no right to a fair hearing if they simply disagree with a regulation that results in a loss of eligibility. However, clients may have a hearing if they believe that the agency incorrectly applied such regulation to the client’s individual situation (use of incorrect facts). The issue is whether the client is only challenging the validity of the regulation or really presenting a factual dispute. If there is no dispute between the client and the agency as to the facts involved, the client’s request for a fair hearing in most instances will be dismissed by the hearing officer before the hearing.

As such, if the client is only disagreeing with a federal or state law or regulation (whether a current regulation or one that is changing) and, after following the procedures set forth in 1614.1 (1) - (3) , wishes to file a request for a fair hearing (or fails to withdraw a request previously filed), the agency should complete a Motion to Dismiss form. The form is to be submitted to the Office of Administrative Hearings within 10-days of the request for a hearing. A copy of the appropriate Notice of Action and the Request for Administrative Hearing form should be attached to the motion. Do not submit an appeal summary unless the motion is denied. The agency must mail a copy of the Motion to Dismiss to the appellant. The worker should complete the Certificate of Service and sign it. Write the actual mailing date on the certificate, as well as the appellant's name and address. On the Motion to Dismiss, the line "Such action is based on" should reflect the appropriate law or regulation. (Contact Eligibility Policy as needed for this information.) For dismissal requests regarding major program changes or cutbacks, specific citations will be provided from the Section.

Fair hearings shall also be dismissed if the request is not received within the time periods specified in 1611, or the household or its representative fails, without good cause, to appear at the scheduled hearing, or is received from an individual who is not authorized to represent the applicant/recipient in a fair hearing as indicated in 1610 and 1613(3) .

Assistance shall continue as noted in 1612 until a decision is rendered concerning the dismissal. If the dismissal request is approved, assistance shall be terminated unless the appellant requests State Appeals Committee review within the 15 days allowed. If the dismissal request is denied, assistance must continue until the presiding officer issues an initial order affirming the agency action, unless there is a State Appeals Committee review request.

Fair hearings for applicants or recipients shall be held in the Office of Administrative Hearings or the KDHE District Office. At least 10-days prior to the hearing, advance written notice shall be mailed to all parties involved to permit adequate preparation of the case.

The hearing officer may conduct the fair hearing or any pre-hearing by telephone or other electronic means if each participant in the hearing or prehearing has an opportunity to participate in the entire proceeding while the proceeding is taking place. A party may be granted a face to face hearing or prehearing if good cause can be shown that a fair and impartial hearing or pre-hearing could not be conducted by telephone or other electronic means.

At a hearing, the hearing officer shall regulate the course of the proceedings. To the extent necessary for full disclosure of all relevant facts and issues, the hearing officer shall provide all parties the opportunity to respond, present evidence and argument, conduct cross-examination and submit rebuttal evidence, except as restricted by a limited grant of intervention or by a pre-hearing order.

The hearing officer may, and when required by statute shall, give non-parties an opportunity to present oral or written statements. If the hearing officer proposes to consider a statement by a nonparty, the hearing officer shall give all parties an opportunity to challenge or rebut it and, on motion of any party, the hearing officer shall require the statement to be given under oath or affirmation.

A hearing officer need not be bound by technical rules of evidence, but shall give the parties reasonable opportunity to be heard and to present evidence. Evidence need not be excluded solely because it is hearsay.

All testimony of parties and witnesses shall be made under oath or affirmation. Statements of non-parties may be received as evidence.

Any part of the evidence may be received in written form if doing so will expedite the hearing without substantial prejudice to the interests of any party. Documentary evidence may be received in the form of a copy or excerpt. Upon request, parties shall be given an opportunity to compare the copy with the original if available.

The hearing officer may not communicate, directly or indirectly, regarding any issue in the proceeding while the proceeding is pending, with any party or participant, with any person who has a direct or indirect interest in the outcome of the proceeding or with any person who presided at a previous stage of the proceeding, without notice and opportunity for all parties to participate in the communication.

A fair hearing decision (the initial order) shall be rendered by the hearing officer no later than 90 days after receipt of the request on a Request for Administrative Hearing form or similar document. The decision is sent to the client and the KanCare Clearinghouse.

As stated in the initial order, both the responsible agency and the client/responsible party have the right to request a review of the initial order. The KDHE-DHCF State Appeals Committee reviews the decision of the hearing officer. The request for review is made to the State Appeals Committee. The request must be made within 18 days of the date of the initial decision (15 days from the date the initial order was served plus 3 days mailing time for a total of 18 days). A rehearing may also be requested within 18 days of the initial decision.

Assistance shall be continued at its prior level if an agency-level review is requested and shall continue at this level until a decision is rendered by the appropriate authority. However, final implementation of the order may be delayed pending the outcome of the agency-level review. See 1618 .

The decision of the agency-level review is final and binding upon the client and the agency on the date of the decision. This is true even if the matter is appealed to the District Court. Assistance shall not continue at its prior level following the agency-level decision of the State Appeals Committee unless there is a court order to the contrary.

For decisions favorable to the client which are not pending an agency-level review, the initial order shall be implemented immediately upon receipt of the order. If the agency has requested further review of the initial order, implementation is delayed until a decision on the agency-level review is rendered.

For orders unfavorable to the client, the decision shall not be implemented until the 18th day following the date the initial decision is mailed. This is to allow the client the opportunity to request an agency-level review. If a request is made within the 18 day period, the decision shall not be implemented until the agency-level review is final.

When the hearing decision is favorable to the client, or when the agency decides in favor of the client prior to the hearing, the agency shall promptly make corrective payments.

When the hearing decision upholds agency action, any overstated eligibility made during the fair hearing process is subject to recovery.

Under the federal spousal impoverishment law as described in 8144 (NF) and 8244 (HCBS), the community or institutionalized spouse is entitled to a fair hearing if dissatisfied with the determination of:

The community spouse income allowance [see 8144.2 (NF) or 8244.2 (HCBS)];

the amount of monthly income otherwise available to the community spouse;

the computation of the share of resources [see 8144.1 (NF) or 8244.1 (HCBS)];

the attribution of resources for the initial eligibility test [see 8141 (NF) or 8241 (HCBS)]; or

the community spouse resource allowance [see 8144.1 (NF) or 8244.1 (HCBS)].

In regards, to the above conditions, the hearings officer would determine whether or not the initial determination was correct.

The right to a fair hearing is limited to applicants and recipients. There is no right to a fair hearing on resource assessments made without an application. [See 8144.1 (NF) or 8244.1 (HCBS).]

A fair hearing officer may also increase the amount of the community spouse income allowance if either spouse establishes that a greater allowance is necessary due to exceptional circumstances resulting in significant financial duress. These circumstances shall be defined as expenses which are unforeseen or which are ongoing and are reasonable and necessary for the health, safety, and/or well-being of the community spouse. An additional allowance would only be provided to the extent that the originally determined community spouse income allowance is inadequate to cover the expenses. Expenses which could result in significant financial duress would include costs associated with prescribed special diet foods or supplements, costs of medical, remedial, or other support services necessary for community spouses to maintain themselves in the community, cost of repairs which are necessary to maintain the home in a livable condition, and other costs associated with unforeseen circumstances such as a fire or flood which result in loss of housing, clothing, household goods, or other necessities. Substantiating documentation will be necessary. Financial duress could not be claimed for usual increases in the cost of rent, food, housing, or clothing.

If a finding of financial duress is made, the hearing officer will establish a new community spouse income allowance sufficient to cover such expenses and specify whether the condition is temporary or will be continuing. If temporary, the hearing officer will establish the duration of the additional allowance and advise the client that if the circumstances continue, he or she may request an extension through the fair hearings process. If continuing, the circumstances shall be reviewed on an annual basis at the time of redetermination. In addition, the community spouse is responsible for notifying the agency at any time should the circumstances change. When the exceptional circumstances no longer exist, the community spouse allowance is to be readjusted should the circumstances change.

In addition to the above provisions, the hearing officer may also grant an increase to the community spouse resource allowance if either spouse establishes that an additional amount is necessary in order to raise the community spouse's income to the allowable community spouse income allowance amount as determined in accordance with 8144.2 (NF) or 8244.2 or as determined through a fair hearing. In either instance, the total amount of resources allowed shall be regarded as part of the community spouse resource allowance for eligibility purposes. The allowance may only be increased under this provision when the institutionalized spouse has allocated the maximum amount allowable under 8144.2 (NF) or 8244.2 (HCBS). In addition, the hearing officer must take into account the income-generated value of the current allocation as well as the additional resources requested to be provided to the community spouse and require that they be invested so that the income is maximized (such as a single premium life annuity) based upon the salable or market value of the property.

NOTE : This provision shall not be used to circumvent the resource verification process described in 1322.2 (3) . If the maximum income allocation is already being made, a request to have the hearing officer judicially grant an increase in the community spouse resource allowance is not appropriate. The individual may still request a regular fair hearing on the amount of the community spouse resource allowance where no or partial verification of resources was provided.

A complaint is a verbal or written grievance concerning an agency action or program policy. Any person who is an applicant, recipient, or is authorized to represent the applicant/recipient per 2111 (1), (2) and 2112(1), (2) may file a complaint with the agency.

Upon receipt of a complaint, the KanCare Clearinghouse shall:

Review the situation and determine if corrective action is indicated. The determination should be made by the Eligibility Supervisor or Program Administrator after consulting with the Eligibility Specialist.

Explain the action or policy to the complainant in writing or verbally. If corrective action is necessary, it should be initiated immediately. If corrective action is not indicated, inform the complainant of his right to request a fair hearing and the request procedure.

Complaints received in KDHE-DHCF Administration will be referred to the Section for response. If the response requires KanCare Clearinghouse input, a telephone call or e-mail message outlining the nature of the complaint will be made to the Eligibility Program Administrator or their designee. This person will review the case and determine the appropriateness of the agency's action. If the agency is in error, the Eligibility Program Administrator or their designee will mandate that corrective action be initiated immediately.

Once the determination is completed, the Eligibility Program Administrator or designee will telephone or e-mail the Eligibility Policy Section and provide details of the agency's actions as well as any corrective measures taken. The Eligibility Policy Section will then answer the verbal or written complaint. If the Eligibility Program Administrator wishes to respond to a telephone complaint directly, the Eligibility Policy Section will notify the complainant to expect a telephone call from the Eligibility Program Administrator or designee within a pre-determined time period.

Complaints filed through the above system shall not include complaints alleging discrimination. Refer to 1630 for discussion of Civil Rights complaints. This system shall also not include complaints that should be pursued through the fair hearing process.

Kansas maintains a system to ensure that no person in Kansas shall, on the grounds of race, color, national origin, gender, age, sex, disability, political belief, religion, sexual orientation, or marital or family status, be excluded from participation in, be denied medical assistance or be otherwise subjected to discrimination.

All applicants and participants shall be informed of the following: Rights and responsibilities; KDHE's policy of nondiscrimination; Procedures for filing a complaint; Procedures for filing for a fair hearing.

Regarding race and identity questions on the application the applicant is encouraged to complete all questions regarding race or identity on the application. The applicant shall be informed that the information will be used for statistical purposes and will have no effect on his/her eligibility. However, if the applicant fails to provide this information, it is acceptable for the staff person to complete the questions by observation.

KDHE, either directly or through contacted services, will provide bilingual services as needed.

Local service centers, including contractors, shall complete and mail the KDHE Civil Rights Complaint , KC-6501, to KDHE Policy according to the procedures of this section.

Local service centers, including contractors, shall cooperate with Personnel Services in the investigation and resolution of the complaint;

Local service centers, including contractors, shall take any corrective action indicated by the investigation; and

Local service centers, including contractors, are to insure that medical assistance staff receive training on the civil rights of applicants/recipients as well as procedures for handling civil rights complaints on a regular basis. This includes staff who answer the phones and staff who deal with the public in reception areas.

Upon receiving an oral or written complaint alleging discrimination or other civil rights issue, the entity receiving the complaint shall:

Log the complaint on the KC-6501 , KDHE Civil Rights Complaint form.

Send a copy of the KC-6501 to KDHE. Retain the original in the case file. The referral must be made within 2 days of the complaint.

KDHE Policy will consult with KDHE Legal, Personnel Services, and, if necessary, Senior Leadership to determine corrective action.

KDHE Policy will communicate the recommended corrective action approach to the entity receiving the complaint.

The local entity is responsible for carrying out the corrective action. This may include oral or written explanation, interview, change in agency action, or assisting the complainant to either file for a fair hearing, or another action.

If the complaint cannot be settled within 10-days to the satisfaction of the complainant, inform the complainants that the issued will referred for additional consideration.

Local staff shall contact KDHE Policy for additional remedies. These may include contacting HHS, consultation with KDHE Legal or other agency division to resolve the complaint.

As part of the corrective action, contact with Personnel Services may be necessary.

Staff must cooperate with Personnel Services in investigation and resolution of the complaint, to include taking the necessary actions indicated by the investigation.

Retain a copy of the completed form KC-6501 .

Case records are required for all assistance cases and are to be separate from social service records. The eligibility record shall include required forms to establish eligibility for assistance and additional information and decisions reached regarding eligibility, the type of assistance, notices to the client, and authorization forms.

The case record includes all information about all individuals on a case. The case record is comprised of three (3) main components: 1) All medical information input into KEES, including specified person-level information which may be accessed across medical cases, 2) The medical eligibility record held on KEES, and 3) medical information and documentation in the case file.

The eligibility record also includes output of KEES which is transferred to the MMIS for claims payment and MCO assignment. All data input into KEES is a part of the eligibility and case record.

The case file is the collection of medical documents that support the information contained in the state eligibility system as well as all other medical documentation that relates to the case. Any information received, in any format, in relation to a case must be in the case file. The case file contains all documentation supporting case processing activities. This includes, but is not limited to, application forms, income verification and worksheets, correspondence, legal documents, requests for case maintenance, a log of case actions and customer contacts, and previous eligibility information for the members of the household.

For the purpose of uniformity and convenience in use, the material contained in an electronic storage system is presented in chronological order. Staff are responsible for ensuring all documents are indexed correctly according to the KEES User Manual.

Correspondence plays an important part in the functioning of the program and for this reason much care is needed in planning correspondence. Notices affecting the eligibility shall become a permanent part of the agency's record and are captured by the eligibility system and/or imagining system.

Content of Notices - All notices should contain sufficient information to make clear their purpose, the information desired, and how the information is to be used. The wording should be clear, direct, and adequate to cover the subject. Care should be taken to avoid misunderstanding or misinterpretation.

Scanning - Letters (including the envelope) from clients are to be scanned and retained in the case file. Newspaper clippings, and other material relevant to the case should also be properly identified, dated, and scanned into the case record.

Destroy any material which is older than 36 months and is not currently in effect on active cases with the following exceptions:

The last application which opened the case;

For AABD cases converted to SSI (whether open for medical or not), the application and budget in effect for December 1973 must be retained indefinitely;

Retain indefinitely all documentation needed to establish current eligibility and payment such as the number of months on assistance, transfer of property penalties, division of assets, etc.

Retain indefinitely the screen print of SSDO and copies of all documents used for enumeration purposes.

Retain indefinitely all material pertaining to unrecovered overstated eligibility, including all documentation for the amount and cause of the overstated eligibility.

Retain indefinitely all material pertaining to verification of the immigration status of aliens.

Retain indefinitely all materials pertaining to documentation of common-law marriage or paternity.

Retain documentation of any disability decision made by DDS through the next scheduled DDS review.

Retain indefinitely all documents used to verify citizenship and identify of the individual.

Retain for 60 days hard copy of documents that have been scanned into the electronic storage system.

Material in closed cases may be removed after they have been closed for 36 months except for (1) all material pertaining to unrecovered overstated eligibility, and (2) cases that have a designated period of ineligibility which exceeds the retention period (e.g., transfer of property penalty).

Reserved

Reserved

The Safe at Home Program, enacted in Kansas in 2006 and administered by the Secretary of State's Office, is a confidential address program that benefits victims of domestic violence, sexual assault, stalking and/or human trafficking who have moved to a new location; unknown to their abuser. The program provides (1) a substitute address to be used by participants as their legal address when interacting with state and local agencies, and (2) a free mail forwarding service for first-class mail. Victims can register to vote, obtain a driver's license, etc., without fear that such public records will put them at risk of being located by their abuser.

Participants in this program will have to identify themselves to you and should present an authorization card with the Safe at Home mailing address, a contact phone number, the participant number, and an expiration date.

See 1321.3 for guidance on how the agency is to handle the address in these situations.

Reserved

See Policy Memo 2002-10-02, re: Prepaid Funeral Agreements .

The estate recovery program has been established as a means to recover medical care costs from the estates and property of certain medical assistance recipients. The administration of the Estate Recovery program is the responsibility of the Estate Recovery Unit (ERU) in KDHE-DHCF. ERU handles all post-death recovery actions, court action, lien imposition, negotiations, and other related activities. KDHE-DHCF has delegated some legal and administrative responsibilities to a private contractor, currently Health Management Systems. ERU is responsible for oversight of the contractor. Neither ERU nor the contractor provide eligibility determinations. Eligibility staff are responsible for the determination as well as basic education regarding the Estate Recovery program.

NOTE : Effective July 1, 2025, Medicaid may only recoup ABLE funds after the beneficiary’s death if the beneficiary was age 55 years old or older and received Medicaid-covered services in an assisted living facility, group home, or nursing home. For beneficiaries under age 55, ABLE funds are not subject to recovery as it is now permissible for any remaining ABLE balance (after the beneficiary’s death) to be transferred to the beneficiary’s estate or rolled over to another eligible individual’s ABLE account.

Beginning July 1, 1992, the agency is allowed to establish a legal claim for medical assistance provided after June 30, 1992, to persons who, prior to their death:

were 55 years of age or older (except for recipients of QMB, LMB, or QWD only); or

were receiving long-term institutional care, including when provided through a PACE program at the time of death.

The claim would normally be filed against the client's decedent's, conservatorship’s, and guardianship's estate. These estates consist of the property owned solely by the deceased medical assistance recipient.

Expanded Estate - For medical assistance provided on or before June 30, 2004, the agency's claim applies to the aforementioned estate. However, for medical assistance provided after June 30, 2004, the agency may establish a claim on any property interest owned by the deceased medical assistance recipient. The agency’s claim will apply to the deceased recipient’s 'medical assistance estate' (K.S.A. 39-709). This estate will include all real and personal property in which the deceased individual had any legal title or interest immediately before or at the time of death to the extent of that interest or title. The medical assistance estate includes, without limitation, assets conveyed to a survivor, heir or assign of the deceased recipient through joint tenancy, tenancy-in-common, survivorship, transfer-on-death deed, pay-on-death contract, life estate, trust, annuity, life insurance policy (whole or term life) or similar arrangement. The medical assistance estate is limited to the recipient’s interest in the property. The expanded definition also applies to the surviving spouse of a recipient. Example : A medical assistance recipient has an interest in a house valued at $100,000. He added his daughter’s name to the deed 7 years earlier when his wife died. The deed is a joint tenancy deed with rights of survivorship. He received medical assistance for the period of July 2003 through June 2005 with a total claim amount of $60,000. He received $30,000 in benefits in the period of July 1, 2004, to June 30, 2005, when he died. The house is the only asset. The state has a claim for $30,000 (July 1, 2004 - June 30, 2005) against his half - interest ($50,000) in his house. Assistance provided prior to July 1, 2004, cannot be used as a claim against his interest in the house.

Exceptions to Claims through Courts - If there is a surviving spouse, no probate would be started, and no claim would be filed at the time of the individual’s death. A claim will not be established if the surviving children are under the age of 21 years or are blind or permanently disabled according to Social Security criteria. No claim will be established for those who solely received coverage under QMB, LMB, or QWD.

Priority of Claims in Courts - In cases involving a decedent’s estate, the claim will be a first class claim against the estate of the deceased person. Payment of reasonable funeral expenses will be the only allowable claim prior to a medical assistance claim. In cases involving a guardianship or conservatorship, the claim is discretionary with the court and is payable in the amount determined by the court.

In cases where a medical assistance recipient has received inpatient care from a nursing home or other medical institution and the recipient is not reasonably expected to return home, the agency may impose a lien on the recipient’s real property.

A lien may only be imposed on persons who have received funded care in a Medicaid approved facility (see 8112 and 8172 ), including those receiving institutional care under a PACE plan for at least 6 months. Liens are NOT applicable to persons in independent living (including QMB, LMB and Working Healthy), receiving HCBS, PACE services in the community or to nursing facility residents where payments are not being made to the facility.

Medical Verification - Once the recipient has been continuously institutionalized and received 6 months of compensated institutional care, the agency may presume that the recipient will not be discharged from the facility to return home. When that occurs, the agency will create a report listing all recipients meeting the 6-month threshold and send it to the estate recovery unit (ERU) for review. The report should be run and sent to ERU no later than the end of the seventh month in which compensated institutional care has been received.

Notice to Recipient of Agency’s Intent to Impose Lien - If the agency determines the recipient is not reasonably expected to return home, the ERU will send a notice to the recipient or the recipient’s representative of the agency’s determination and the agency’s intent to impose a medical assistance lien on real property owned by the recipient.

Administrative Hearing - The agency’s notice will advise the recipient or representative of their right to request an administrative hearing. The notice will specify the method and time limits for requesting such hearing. The issue at the hearing will be whether the recipient can reasonably be expected to be discharged and returned home. If no hearing is requested within the time period for requesting a hearing outlined in 1611.1 , the agency may file a lien on the real property of the recipient. If a hearing has been requested, no lien may be imposed until administrative and judicial matters have been completed.

Imposition of Lien - To impose a lien, the agency will file a written lien with the Register of Deeds of the county where the real property is located.

Restrictions on Imposition of Lien - The medical assistance lien may not be imposed on the home of the recipient when any of the following individuals are residing in the home: spouse of such recipient, (lien may be imposed if spouse is not living in the home). recipient’s child who: under the age of 21. blind; or permanently disabled. recipient’s sibling who has equity interest in recipient’s home and who has continuously resided in the home for at least one year immediately prior to the recipient’s admission into a medical facility for long-term care and continues to reside therein.

Content and Value of Lien - The lien shall state the nature and amount of the lien at the time of imposition, the legal description of the property affected and the recipient’s interest in the property. Lien value will be based on the amount of assistance paid on behalf of the recipient beginning 6 months from the date the recipient became eligible for compensated inpatient care until the filing of the lien plus any amount paid thereafter by the agency on behalf of the recipient.

Priority of Lien - The medical assistance lien is junior and subject to all prior liens of record.

Foreclosure of Lien - The agency may foreclose a medical assistance lien by filing an action in a Kansas district court for the county where the property is located. This action may be filed before or after the death of the recipient and may be filed in a civil action or as part of a probate proceeding. Such foreclosure is limited by the restrictions in (9).

Restrictions on Enforcement of Liens - The medical assistance lien may not be enforced after the death of the recipient and his or her spouse. A lien on the home may not be enforced when any of following are residing in the home: recipient’s child who: under the age of 21. blind or permanently disabled. provided care to the recipient, allowing him or her to remain in the home and defer NF entry for at least 2 years. a sibling who had resided in the home for one or more years immediately before the recipient’s admission to the nursing home or medical facility and has resided there continuously since that time.

Release of Liens - The medical assistance lien generally remains on the property unless: the lien is satisfied. the lien is terminated by foreclosure of a prior lien of record or settlement action taken in lieu of foreclosure. the lien is foreclosed by the agency. a waiver of estate recovery action has been granted (see 1725.3 ); or the recipient leaves the nursing home or medical facility and returns to and resides on the property subject to the medical assistance lien for a continuous period of 90 days.

Lien Dormancy - If the medical assistance lien has not been foreclosed within 10 years from the date of filing the lien, the lien will become dormant and cease to operate as a lien on the real estate. Such dormant lien may be revived under the provisions of K.S.A. 60-2403 et seq.

A recipient, a recipient's spouse, or a member of recipients surviving family may request a waiver of estate recovery action including liens when there will an undue hardship. This waiver could apply to either or both court claims and lien imposition. Each case will be examined on its own merits and circumstances. The factors for evaluating a waiver are:

Type of assets involved in the case;

Availability of alternative means for satisfying the claim;

Actions of the family in helping decedent; particularly when such actions helped avoid or reduce medical costs which would have otherwise been incurred by the Medicaid program;

Impact of recovery action on the financial circumstances of the surviving family;

Impact of recovery action on business in which the decedent owned an interest; and

Any other relevant factors.

The determination of recovery action, if any, is a three step process: Notification of death, resource assessment, and determining the value of the claim based on the amount of medical assistance paid by the agency since 7-1-92.

Notification of Death - The Estate Recovery Unit (ERU) shall be responsible for coordinating and obtaining all information concerning the death of any medical recipient. Such information may be obtained from newspaper obituaries, eligibility staff, legal notice from representatives of a recipient's estate, other governmental agencies, or other reliable sources. Upon receipt of notification of death of an individual, the ERU will attempt to match the deceased with case information in KEES. The eligibility worker will confirm any match and other family and/or resource information prior to any ERU recovery activity. If there is a surviving spouse, recovery action will be pended until the death of the surviving spouse.

Resource Assessment - In cases where the deceased has no surviving spouse or dependent children, the ERU will begin a preliminary assessment of the individual's resources. Assessment will consist of determining the type of property, value, and title or ownership. All assets can be considered for recovery including real property, financial accounts, and other personal property (e.g., other liquid assets, cars, furniture, and jewelry).

Determining Value of Claim - ERU will research and determine the cost of medical assistance paid after June 30, 1992 on behalf of a recipient who is 55 years of age or older or who was receiving institutional PACE or HCBS services. Assistance provided to a recipient before the recipient's 55th birthday will not be considered in valuing the claim unless that person was in long term care. The value of assistance received after June 30, 2004 will also be determined and used is handling claims against the expanded estate as per 1725.1 (1) . The estate recovery claim will be reduced by the amount of payments made by a long term care insurance policy on behalf of the recipient.

The ERU will determine the appropriate action to be taken in regard to filing claims. This may occur through one of several avenues including, but not limited to, agreements with heirs, claims against financial accounts, and filing of probate action.

In some circumstances the heirs of the deceased may choose not to initiate probate proceedings. In these instances ERU will determine whether to proceed with probate based on the nature of the agency's claim, value of estate assets, presence of other creditors and any other relevant information.

ERU may file a claim against accounts of a deceased recipient held at financial institutions. Notice of claim will be in writing. The notice of claim will be forwarded to any financial institution identified by ERU as a holder of a recipient's account. After notification of the claim, the financial institution is barred from distributing the account to a beneficiary until the claim of the agency is satisfied.

ERU will also file a claim for monies held in a personal needs account for a recipient at a nursing home. Nursing homes are required to forward the personal needs accounts to the agency upon the death of a recipient of medical assistance. The funds in the personal needs accounts will be used in satisfying the claim. In addition, ERU will advise the appropriate court, if probate proceedings are initiated, of any amounts received by ERU. ERU will also assume responsibility for distribution of the funds in these accounts to funeral homes to cover the unmet expenses of funeral services.

In accordance with Kansas law, funeral homes, cemeteries, life insurance companies and other entities holding funds establishing a burial or funeral agreement for a medical assistance recipient, or the spouse of a former medical assistance recipient,are required to remit any funds remaining after payment of reasonable funeral expenses to ERU. This is applicable to all funeral or burial plans regardless of the funding source, including but not limited to, bank accounts, trusts, annuities, burial insurance, life insurance and certificates of deposit. This also applies to term life insurance policies specifically assigned to a provider of funeral services. It does not apply to non-assigned life insurance polices or accounts. However, such items may become part of the estate and therefore, subject to recovery. To support this provision, all medical assistance applicants or recipients are required to notify the agency upon the establishment of any prearranged burial agreement. This information is then recorded on KEES. In addition, individuals are also required to notify the funeral home holding any pre-arranged burial agreement if medical assistance is approved. The funeral home is then required to notify the entity holding the funds associated with the prepaid account.

Transfers of property by medical assistance recipients subject to the estate recovery provisions can be voided based on State law. The estate recovery unit (ERU) can take legal action against the recipient and have such transfers set aside, thus returning ownership of the property to the individual. This provision is applicable for any transfer made by a Medicaid recipient. Transfers prior to the date of application are also included if the individual transferring property is ultimately approved for prior medical assistance for the date the transfer occurred. Any transfers made prior to the effective date of medical coverage are not voidable but are subject to the provisions of 5720 and subsections.

Recipients subject to voidable transfers. Transfers by the following recipients would be considered under this provision. Persons 55 years of age or older, including those in independent living or long term care arrangements (except for QMB, LMB, or QWD only recipients; and Persons receiving long term institutional or HCBS care. Any partial or total transfer of property may be considered including transfers of exempted property such as a home or a car. Transfers to children, as defined in 1725 , or transfers resulting from the spousal impoverishment provisions of 8144 and 8244 will not be voided. However, transfers between a two spouses other than for spousal impoverishment purposes will be considered. This would include transfer of the home property and later acquired assets which would not fall under the original resource division. Transfers which equal or exceed the following threshold amounts shall be referred to the ERU. These thresholds are to be viewed as a guideline for staff in order to provide latitude to the client to meet ongoing living expenses while helping to prevent a concerted attempt to divest resources in order to deplete the estate. They were also developed to avoid unnecessary administrative burden on staff to investigate and refer all transfers.

Property Limits For real property, the total value of the property transferred must be $5,000 or more. For personal property, the total value of the property transferred must be $500 or more. This would include but is not limited to checking accounts, savings accounts, C.D.s, stocks, bonds, life insurance cash values, and trust funds. Information regarding such transfers is to be referred to the ERU for determination of action. Any resulting penalty period per 5720 shall be applied prior to referring to ERU for a determination. If ERU determines action to void the transfer will not be taken, the transfer penalty remains in place. If action to void will be initiated, any payment denied because of a transfer penalty will be reversed and payment may be authorized. If the transfer is ultimately voided, eligibility shall be reevaluated considering the property. It should be noted that the guidelines in this section do not directly parallel the transfer provisions of 5720 . Transfers of property may be voided even though they would not be penalized under the guidelines of 5720 (e.g., transfers between spouses or transfers by persons in independent living.) In addition, only transfers by persons ultimately considered recipients can be voided whereas transfers of both applicants and recipients can be penalized under the provisions of 5720 .

The recipient may choose to make a pre-payment against the Estate Recovery claim. This is a voluntary option available to the recipient and may be appropriate where:

The recipient is reducing excess resources to within the allowable program resource limit in order to retain on-going resource eligibility.

The recipient is no longer receiving assistance but wishes to satisfy the claim in whole or in part prior to death.

A recipient choosing this voluntary option should be referred to Estate Recovery. Estate Recovery will assess the amount of the proposed payment against the current size of the claim to determine if this is an acceptable option. Estate Recovery cannot accept a payment that exceeds the current amount of the claim. The claim will be reduced by the amount of any pre-payment accepted by Estate Recovery.

The National Voter Registration Act of 1995 requires voter registration to be available in public assistance offices. The Act also requires that anyone applying for or receiving public assistance, including Medicaid, be offered the opportunity to register to vote at the time of initial application, each eligibility review, and each report of a change of address. Each individual must be informed of this registration service and offered the same level of assistance in completing the voter registration form or declining the registration activity as the agency provides in completing it’s own forms. The KC-1100, Medical Assistance application for Families with Children , and the KC-1500, Medical Assistance Application for the Elderly and Persons with Disabilities , offers everyone the opportunity to register to vote or to decline to register. Completion of the voter registration question on the application is not a condition of eligibility for assistance. An answer of “Yes”, “No” or blank in the Voter Registration section has no bearing on case processing or eligibility. Those applying on-line are offered the opportunity to link to the Secretary of State’s voter registration site. All those who answer "yes" or leave the voter registration section blank are to be mailed a voter registration application. This means that even if an individual does not complete this section of the application, the agency must provide the individual with a voter registration application. Voter Registration forms can be returned to KanCare and will be sent to the corresponding Secretary of State’s Office within five (5) days of receipt.

The QA system was established to improve program management by providing management information related to payment accuracy and to satisfy federal requirements. The Medicaid Eligibility Quality Control (ME QC) unit within KDHE serves as the designated entity for federal ME QC compliance and is responsible for coordinating and conducting all required federal reviews. Local agency staff are required to cooperate with ME QC in conducting reviews. Cooperation includes, but is not limited to:

Making case files available for review

Responding to inquiries and questions regarding the case

Promptly correcting the case if errors are discovered

Developing and overpayment, if required to do so

Developing Corrective Action Plans

Implementing Corrective Action Plans

Providing program evaluation and follow up

Each entity with responsibility for eligibility determination shall also have a local quality assurance process in place. This will include period case reviews, evaluation and corrective action as necessary.

Reserved

Care needs to be taken to make requests of other agencies only when necessary. In making inquiries in other states, consult the latest edition of "The Public Human Services Directory" for information regarding the agency and whether the state agency acts as a forwarding center. Inquiries should be addressed to the agency concerned whether inside or outside of the state, unless the staff considers this a particular problem which needs to be routed through Program Administration.

A signed copy of the Information Release Form should be included in the correspondence whenever the consent of the client to the giving of that information is needed. This would include information such as medical, legal, or financial.

Out-of-town inquiries should be answered promptly and in sufficient detail to enable the inquiring agency to plan effectively. The local manager or supervisor must read and sign all correspondence when agency policy rather than individual case planning is involved.

This section describes non-financial eligibility requirements which are common to all programs as well as those general program criteria specific to each. Assistance can only be provided when all applicable requirements have been met for a particular program.

In order to apply for assistance, the individual must be legally capable of acting in his or her own behalf. For medical only, see also 1411.3 (6) concerning applications received through the Health Insurance Marketplace.

An adult for application purposes is defined as anyone 18 years of age or older. An adult’s capacity to act in their own behalf determines whether or not they are allowed to apply for assistance.

Legally Incapacitated - Legally incapacitated adults are not eligible to receive assistance unless such assistance is applied for by a: 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. Guardian or Conservator. Medical Representative Representative Payee for Social Security A tax filer who claims (or intends to claim) the adult as a dependent on his or her federal tax return.

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 as described in subsection 1. above 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. The following additional individuals may apply on behalf of a competent adult without requiring authorization from the adult: The partner of the adult with whom there is a mutual child (including an unborn child). The spouse of the adult (see 4312(1) ). A tax filer who claims (or intends to claim) the adult as a dependent on his or her federal tax return. A person with a durable power of attorney (for financial decisions) for the adult. The representative payee for Social Security benefits for the adult. For an individual other than the adult or those listed in subsection (a) above to apply, the individual must be appointed by the adult as his or her medical representative. A signed written authorization from the person for whom they are applying must be obtained. The KC-6100, Medical Representative Authorization Form or medical representative authorization 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(s) shall act in the place of the individual for whom they are applying. The medical representative(s) shall receive copies of all notices and is responsible for completing review forms 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 should be someone who is trusted and knowledgeable about the adult’s circumstances and needs, including his or her 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 adult is unable to file his or her own application and obtaining a 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 adult is acting in his or her behalf, all notices must still be sent to the applicant/recipient in addition to the authorized representative.

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 nor sign an application for the adult or request a fair hearing on behalf of the adult. 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 KC-6200, 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. KC-6200 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. 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.

Release of Protected Health Information Form – 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 adult or request a fair hearing on behalf of the adult. A signed written authorization from the person for whom they are requesting to share or receive information must be obtained. KC-6110, 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.

A minor for application purposes is anyone under 18 years of age. A minor’s capacity to act in his or her own behalf determines whether or not he or she is allowed to apply for assistance.

A minor is presumed to be legally incapable of acting in his or her behalf and therefore may not apply for himself or herself. However, a minor can act in his or her own behalf and receive assistance only under one of the following circumstances: A court has emancipated the minor by bestowing the rights of majority upon the minor. Such an individual is legally an adult. The minor is age 16 or 17 and is or has been married. There is no caretaker exercising parental control over the child or willing to assume parental control and one of the following circumstances exist: The parents of the minor are institutionalized per 8113 . The minor has no parent who is living or whose whereabouts is known. 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. A referral is 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 or designee and documented in the case record. 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. The minor enters an approved transitional living program , such as MINK. Reserved

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: Reserved All medical programs - A court-appointed legal guardian/custodian, or conservator. A representative payee for the minor's Social Security benefits. A responsible adult, with whom the child resides, who meets the definition of a caretaker according to KFMAM 2110 and 2121. An adult with whom the minor resides and who claims, or intends to claim, the minor as a dependent on his or her federal income tax return. 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. A completed Required Authorization for Medical Agent for Minor must be on record. This form is generated on KEES as Form #V075. This authorization is time-limited, and a new authorization form is required at each certification. 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. This confirmation is time limited. New verification is required at each certification. New verification is required at each certification. An individual who meets one of the medical assistance only criteria 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 (see 4310 - Assistance Planning). NOTE : Anytime a minor's health, safety, or current medical condition is judged to be at risk, a referral to PPS would be appropriate.

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 nor sign an application for the minor or request a fair hearing on behalf of the minor. 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 an individual who meets the criteria of (1) or (2) above must be obtained. The KC-6200, Facilitator Authorization Form or Facilitator authorization section on the paper application form may be used for this purpose. 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. 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. 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.

KC-6110 , Release of Protected Health Information Form – 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 minor or request a fair hearing on behalf of the minor. A signed written authorization form must be obtained. The Release of Protected Health Information form may be used for this purpose and must be signed by an individual who meets the criteria of (1) or (2) above. The length of appointment shall be the date entered on line 8 of the form, or 12 months, whichever is shorter.

The client must cooperate with all program requirements. In addition, the client shall cooperate with the agency in the establishment of eligibility including providing necessary information, reporting changes, as required, cooperating in the application process, cooperating in quality assurance reviews, and cooperating in obtaining resources.

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 9121 as appropriate.

To determine eligibility, the application form must be completed and signed, and 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 pregnant women and children under the age of 1 who have continuous eligibility under the Medicaid program or are eligible under the SI program. 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.

Reserved

The agency shall provide education to clients regarding potential resources that they may be entitled to and encourage the client to obtain access to those resources. With exception, the client may not be found ineligible solely for failure to pursue potential resources, as noted below.

The client is required to pursue coverage through Medicare when determined eligible; see 2911.2 .

The client is required to pursue recovery of non-exempt transferred assets; see 5723 and subsections.

Client shall 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.

The client is required to take any necessary action to acquire certain potential resources; see 2124 . 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:

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 2912 .

Reserved

MediKan applicants shall be required to pursue SSA/SSI benefits as a condition of eligibility; see 2181 . In addition, individuals may not be rendered ineligible for a disability determination referral for failure to apply for SSI benefits unless qualifying for MediKan per 2181 .

Recipients who are, or have been, married are expected to fully pursue any spousal elective share rights when the current or former spouse dies. Under Kansas law, a spouse is entitled to a portion of the augmented estate (generally any estate less the homestead). If all resources do not properly pass onto the surviving spouse at the time death, the surviving spouse may file a probate claim to obtain the allowed spousal share. Failure to pursue any spousal elective share rights shall result in ineligibility. The surviving spouse must file for his/her elective share within 6 months of the date of death to protect a claim. For purposes of this section, the surviving spouse must provide verification within 60 days of the date of death that he/she has either filed a claim or is taking positive action to file a claim. If timely verification is not provided, eligibility may be denied or discontinued. If timely verification is provided, the agency shall continue to monitor the case until the claim has been fully adjudicated by the court. Legal staff in the Estate Recovery Unit (ERU) are available to assist with technical details regarding potential actions. All cases involving potential spousal elective share issues shall be referred to ERU. When spousal rights have been forfeited a transfer of property penalty may be applied; see 5422. For additional guidance, see Policy Memo 2002-12-03, Spousal Elective Share and Policy Memo 2018-07-01, Spousal Elective Share Filing Requirement .

Failure to meet these requirements without good cause shall:

Reserved

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.

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 2132 ) or an application filed for one before assistance is approved.

For newborns, see 2132 . For non-citizens, see Policy Memo, 2000-12-01, re: Access to Benefits for Qualifying and Non-qualifying Aliens and Their Families .

For those individuals who provide an SSN prior to approval or visit during any contact, the specialist shall record the SSN and verify it according to 2131(1) . For those individuals required to provide an SSN who do not have one, who do not know if they have one, or who are unable to find their SSN, or for whom the SSN provided appears questionable, 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.

An SSN may be applied for on a newborn child through the SSA's Enumeration at Birth process. 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.

If an individual has been issued more than one number by Social Security, all numbers issued to that individual shall be provided. The current assigned number for that individual shall be used for eligibility purposes. Assignment of a new number occurs in limited circumstances including adoption of a child, the number is too similar to another family member’s number, more than one individual has been assigned or is using the number, identity theft, domestic violence, or religious objection to the assigned number.

The Social Security number(s) reported by the client shall be verified by an automated match with the Social Security Administration Through the Federal Hub. Determine if SSNs are verified, by using the F10 (pop-up) function on the EATSS system, 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.

Official document containing the SSN. Often, a SSN may be unverified due to a name or date of birth difference between our records and those owned by SSA.

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 2136 . 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.

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.

A verified SSN shall be re-verified only if the identity of the individual or the SSN becomes questionable.

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 2134 . 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.

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 2133 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.

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 only qualify for a non-work SSN (see those under 2142.1 ) 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.

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 9121.1 .

The agency is authorized to use SSNs in the administration of the medical assistance programs. 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.

The following referral procedure shall be used for persons who must apply for an SSN.

Refer all persons needing to apply for an original or replacement SSN per 2130 to the appropriate local SSA office. The top half of this form is to be completed by staff including the case name and case number and the name and address of the office and worker making the referral. Up to 4 case members needing to apply for a number can be referred on one form.The state welfare ID number is to be indicated on the form so that the SSN will be entered in the KEES system automatically once assigned. That ID number must be listed in the following sequence: First 2 digits are the State Bendex Code, 17. The next 10 digits are the client ID number from KEES. List all of the digits as one continuous number. Example: 1700112345678.

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.

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 2134 .

A copy of the completed referral form is to be kept in the case file as proof of application for an SSN.

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. In these instances, staff would provide an SS-5 for the client to complete along with a referral form. The SS-5, referral form, and necessary documentation would then need to be mailed by the client to the appropriate district SSA office.

The original documents (e.g., birth certificate, other identification, etc.) must be sent to support the application. Photocopies are not acceptable.

Staff should inform the client of the necessary documentation needed and assist him or her in completing the SS-5.

Once the application is received, SSA will return the referral form as with the walk-in procedure. 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.

See PM2000-12-01, re: Access to Benefits for Qualifying and Non-qualifying Aliens and Their Families .

Eligibility for assistance shall be limited to those individuals who are citizens or who meet qualified non-citizen status as specified in 2142 .

Non-citizens who are not described in 2142 , 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 2691 or TB as described in 2692 or victims of trafficking as described in 2144 . 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 INS 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, 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.

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 was 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 2141.1 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 2142 for medical program assistance. See additional details for this group under 2142.1 (11) .

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. In addition, many persons born in the U.S. territories are also citizens. Most other individuals born outside of 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.

For persons born on or before January 13, 1941, at least one parent is a citizen who lived in the U.S. prior to the child's birth.

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.

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.

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 county 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 2145 for citizenship documentation requirements.

Eligibility for medical benefits is limited to the following groups of qualifying non-citizens who also meet state residency requirements. Documentation requirements are specified in the A-1, Non-Citizen Qualification Chart .

5 year ban on receipt of assistance described in 2142.2 does NOT apply to the following non-citizens.

The following non-citizens are eligible for assistance:

Refugees admitted under 207 of the Immigration and Nationality Act (INA); NOTE: Non-citizens who are certified victims of severe forms of trafficking are eligible to the same extent as non-citizens who are admitted to the U.S. as refugees under section 207 of the INA. See 2144 . 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 2146.7 for a list of documents that will confirm Iraqi and Afghan Special Immigrant status.

Asylees granted asylum under 208 of the INA;

Aliens whose deportation has been withheld under Section 243 (h) of the INA or removal withheld under Section 241(b)(3) of the INA;

Cuban or Haitian entrants as defined in section 501 of the Refugee Education Assistance Act of 1980;

Persons admitted as an Amerasian Immigrant pursuant to section 584 of the Foreign Operational Export Financing, and Related Programs Appropriations Act of 1988;

Persons who have obtained lawful permanent resident status or who have been battered per 2142.2 (3) below and are honorably discharged veterans or are on active duty in the United States armed forces. The former or current spouse and/or dependent children of such persons are also potentially eligible under this provision. (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.);

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 2146 ;

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

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 INS. This also includes the person's children who have also been battered or subject to extreme cruelty.

American Indians born in Canada to whom the provisions of Section 289 of the INS 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.

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).

Afghan Humanitarian Parolees with an arrival date in the United States beginning July 31, 2021, or who were paroled after September 30, 2022, 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, 2022. Afghan Humanitarian Parolees who do not meet these criteria are subject to the 5-year waiting period for Medicaid and CHIP. NOTE: This provision is contingent on DHS extension.

Afghans with a Special Immigrant Visa (SIV) and Afghan Special Immigrant Parolees (SI/SQ).

Ukrainian Humanitarian Parolees who paroled into the U.S. beginning February 24, 2022, until further notice ( NOTE : eligible status is contingent upon DHS extension).

If otherwise eligible, the following non-citizens who entered the U.S. after August 22, 1996 qualify for assistance 5 years after their date of entry to the United States:

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.

Persons lawfully admitted for permanent residence;

Persons granted parole or conditional entry status;

Persons who do not meet one of the statuses listed in (1) or (2) 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 INS. This also includes the person's children who have also been battered or subject to extreme cruelty.

Reserved

The Trafficking Victims Protection Act of 2000, Public Law No. 106-386, makes adult victims of severe forms of trafficking who have been certified by the U.S. Department of Health and Human Services (HHS) eligible for benefits and services to the same extent as refugees. Children who have been subjected to trafficking are also eligible like refugees but do not need to be certified. The Trafficking Victims Protection Reauthorization Act of 2003 (TVPRA), Public Law 108-193, expands the categories of non-citizens eligible to participate under the Trafficking Victims Protection Act of 2000 to include minor children, spouses and in some cases the parents and sibling of victims of severe trafficking. Also see item 5 below.

HHS' Office of Refugee Resettlement (ORR) will make certification determinations and issue letters of certification for victims of severe forms of trafficking. ORR also will issue similar letters for children who have been subjected to trafficking.

When a victim of trafficking applies for benefits; the procedures for refugees are in effect with the following exceptions:

Accept the certification letter provided by ORR as proof of a status that confers eligibility for benefits instead of requiring Immigration and Naturalization Service (INS) documentation, such as the I-94 Arrival/Departure Card. Applicants must submit the original certification letter to receive benefits.

Call the trafficking verification toll-free number, 1-866-401-5510 to confirm the validity of the certification letter or similar letter for children and notify ORR of the benefits for which the individual has applied. ( NOTE : at this time, SAVE does not contain information about victims of severe forms of trafficking. Until further notice, do not contact SAVE concerning victims of severe forms of trafficking.) See item 5.

The individual's "entry date" for refugee benefits purposes is the certification date, which appears in the body of the certification letter or letter for children.

Issue benefits to the same extent as a refugee, provided the victim of a severe form of trafficking meets other program eligibility criteria (e.g., income levels). Record the expiration date of the certification letter or letter for children so that benefit-granting agencies will be prepared to conduct re-determinations of eligibility at that time.

Victims of trafficking are issued T Visas. Under the TVPRA, eligible relatives of trafficking victims are entitled to visas designated as T-2, T-3, T-4 or T-5 (collectively referred to as "Derivative T Visas"), and after issuance of the visas are eligible for federally funded benefits to the same extent as direct victims of severe trafficking, provided that they meet the other eligibility criteria for the programs. Under TVPRA, the relatives of victims of trafficking are entitled to Derivative T Visas under the following conditions: In the case of an alien who is awarded a T visa and who is under 21 years of age on the date the T visa application was filed, Derivative T Visas are available to the alien's spouse, children, unmarried siblings under 18 years of age on the date on which the alien's visa application was filed, and parents. In the case of an alien who is awarded a T visa and was 21 of age or older on the date the T visa application was filed, the Derivative T Visas are available to the alien's spouse and children.

It should be noted that a copy of the certification letter is not to be accepted. The client must present the "original" letter in order to qualify for benefits. Even if you know that an individual has been certified as a trafficking victim, that individual is not eligible for benefits until they have presented the original certification letter. It should also be noted that the Act does not give victims of trafficking refugee status under immigration laws. Rather, victims of trafficking are treated like refugees for benefits purposes.

If an individual applies who appears to qualify as a trafficking victim but the individual does not have the supporting documentation, the worker should contact KDHE-DHCF Policy for guidance.

Reserved

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 requesting medical coverage who claim to be a U.S. citizen. This requirement does not apply to the following individuals:

Current or former SSI recipients

Current or former Medicare beneficiaries

Current or former recipients of Social Security Disability benefits

Children in foster care or recipients of foster care maintenance

Children who are recipients of adoption support payments

Children born on or after July 1, 2006, to a Medicaid recipient as outlined in KFMAM 2320

NOTE: The exemptions above only apply to U.S. citizens. These exemptions do not apply to individuals reporting to be non-citizens (including qualified non-citizens) as the requirements of 2146 apply and documentation of legal status must be obtained.

All documents used to verify citizenship must be retained in the case file indefinitely per 1711 (9) . For persons exempt from the requirement due to SSI or Medicare status, verification of such status is required.

Acceptable documents and the hierarchical protocol for obtaining acceptable documents are described in A-1, Non-Citizen Qualification Chart . When obtaining documents the following applies:

Primary Document - A document that verifies both citizenship and identity (as described in 1322.1(5) ) and is further defined in . The availability of a Primary Document shall be explored prior to using a secondary or other citizenship document. Persons born outside of the United States who were not citizens at birth per 2141 must submit a Primary Document.

Secondary Citizenship Documents - A document verifying citizenship only. The statement of the applicant/recipient that a Primary Document is not available is sufficient to seek a secondary or other document. However, if a primary document is not used, two different documents must be used to establish citizenship and identity.

Third and Fourth Level Citizenship Documents - These may only be used if primary or secondary documents are not available. These documents 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 client that no other primary documents were available.

Written Declaration - A written declaration may be used as verification of citizenship if no other documents are available. The KanCare Clearinghouse Manager, or designee, must approve the declaration in order for it to be considered acceptable verification. A declaration must be provided by at least two separate individuals, one of whom is not related to the individual, who have personal knowledge of the event(s) establishing the claim of citizenship. Item P-8, Third-Party Declaration of Citizenship is used for this purpose. The person(s) making the declaration must: provide proof of his/her own citizenship and identity, and provide information why documentary evidence establishing the individual’s claim of citizenship does not exist or cannot be readily obtained as part of the declaration, and 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.

Reserved

For most foreign born individuals attesting to be U.S. citizens, primary documentation as established in 2145.2 is necessary. However, secondary or subsequent documents may be used to verify citizenship and identity for persons considered citizens at birth.

The following provisions apply when an applicant or recipient declares U.S. citizenship but is unable to provide verification.

The agency may not request verification of citizenship and identity 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 through those resources. The following automated and manual verification resources shall be utilized:

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 ( 2145.2 ). EATSS may not be used to verify citizenship or identity of individuals who do not meet that criterion.

The Electronic Verification of Vital Events (EVVE) database. The EVVE interface provides access to birth records for individuals born in Kansas (and 48 other states and territories) to verify citizenship only. 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 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.

Research by the agency. If the agency has been unable to verify citizenship and identity 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.

NOTE : For verification of citizenship and identity, it is acceptable to access the file in Tier 3 to determine if documentation has previously been provided before accessing the Tier 2 sources. Both Tier 2 and Tier 3 must be followed before proceeding to 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 (ROP).

An application shall not be delayed or denied because the agency was unable to verify citizenship or identity. If otherwise eligible, the application shall be processed and approved granting a reasonable opportunity period (ROP) to the individual to provide the verification. The ROP shall be three (3) calendar months commencing from the date of approval. If prior medical assistance has been requested and the individual is otherwise eligible, coverage shall be approved for these prior months as well.

If proof of citizenship or identity is provided, the ROP ends, and additional information is not necessary.

If the individual fails to provide verification (or the agency is unable to independently verify) by the end of the ROP, 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 1 : 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 March 11th with notification that verification must be provided by June 11th. Verification is provided within the ROP on April 23rd. Eligibility continues without interruption.

If the individual failed to provide verification (and the agency was unable to independently verify) by June 11th, coverage would end effective June 30th (assuming action was taken by timely notice deadline).

Example 2 : 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 February 27th with notification that verification must be provided by May 27th. The recipient fails to provide verification within the ROP. Coverage ends effective June 30th.

If the individual provides verification by July 31st (the month after the month coverage ends), eligibility may be reinstated without a new application/request for assistance. If verification is provided after July 31st, 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.

Applicants/recipients who are identified as non-citizens on their application shall be required to document and verify their non-citizens status. The agency shall determine, from documentation obtained, 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 2142 may participate.

For the categories listed in 2142 , the person may also present other documents which indicate the person's immigration status and which the agency may determine are reasonable evidence of immigration status. For persons who can qualify based on a date of entry on or before August 22, 1996, documentation such as employment or school records can be used to demonstrate that the person was in the country if they did not have legal status or documentation during that time period. Also refer to the status and documentation on the chart and the Guidance on Noncitizen Verification in the A-1, Non-Citizen Qualification Chart .

NOTE : Mexican Consulates have started issuing Matricula Consular ID cards (also known as Matricula Consular de Alta Seguridad (MCAS) or Certificate of Consular Registration) to Mexican foreign nationals that reside in the US. For a card to be issued, the person must appear in person at the consular office and present several documents showing proof of nationality and address. These cards are sufficient to identify the individual and as proof of nationality. These cards are NOT sufficient to verify an immigrant legal immigration status in the US or eligibility for any program benefits. Appropriate documents as listed above and in the chart, A-1 , must be provided to establish eligibility for program benefits.

If the appropriate BCIS form does not clearly indicate eligible or ineligible status, the agency is responsible for offering to contact BCIS. The agency does not need to offer to contact BCIS on the non-citizen's behalf when the person does not provide an BCIS document.

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.

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 9121.1 and 9122.7 as appropriate.

The immigration status of all alien clients must be verified through the Non-Citizen VLP (Verify Lawful Presence) through the Federal Hub (including subsequent Systematic Alien Verification for Entitlements (SAVE)) program which is operated by Department of Homeland Security (DHS). (See 2146.6 )

Detailed instructions on primary and secondary verification procedures are contained in the A-10, Systematic Alien Verification for Entitlements (SAVE) Program Guide. 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 persons 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.

The results of the SAVE verification queries must be retained indefinitely in the case record along with copies of the immigration status documentation provided by the alien.

Reserved

The following provisions apply when an applicant or recipient declares legal non-citizen status but is unable to provide verification of the status.

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. 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:

The Non-Citizen VLP (Verify Lawful Presence) through the Federal HUB (including subsequent SAVE processes).

NOTE : If the individual already has a DCF-verified record that results in a qualifying alien/immigration status and does not reflect a change in immigration status, this would also be considered a Tier 1 verification. See also 1322.1 (2) .

The manual SAVE (Systematic Alien Verification for Entitlements) process. Should the agency be unable to verify non-citizen status through Tier 1, 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 pending the results of a SAVE verification.

NOTE : Secondary verification should be requested when the person’s entrance date is in question or if the VLP interface is failing. For persons adjusting status to lawful 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.

Research by the agency. If the agency has been unable to verify 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 (VLP) may be attempted again if additional information is found in the file that will assist in the process.

Contact with the applicant or recipient. If the agency is unable to verify non-citizen status via any of the means above, verification shall initially be waived and a Reasonable Opportunity Period (ROP) applied as described below. The individual shall be contacted to provide verification and notified of the Reasonable Opportunity Period (ROP).

Reasonable Opportunity Period (ROP) for Non-Citizens - An application shall not be delayed or denied because the agency was unable to verify non-citizen status. If otherwise eligible, the application shall be processed and approved granting a reasonable opportunity period (ROP) to the individual to provide the verification. The ROP shall be three (3) calendar months commencing from the date of approval. If prior medical assistance has been requested and the individual is otherwise eligible, coverage shall be approved for the prior months as well.

The following processes shall be utilized:

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 status.

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.

Verify Lawful Presence (VLP) – The Tier 1 and Tier 2 processes are completed as indicated above. 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 : 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.

If proof of legal non-citizen status is provided, the ROP ends and additional information is not necessary.

If the individual fails to provide verification (or the agency is unable to independently verify) by the end of the ROP, 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 1 : The agency is unable to verify legal non-citizen status for an applicant for medical assistance. Since the individual is otherwise a qualifying non-citizen and eligible, assistance is approved on August 7th with notification that verification must be provided by November 7th. Verification is provided within the ROP on September 30th. Eligibility continues without interruption.

If the individual failed to provide verification (and the agency was unable to independently verify) by November 7th, coverage would end effective November 30th (assuming action was taken by timely notice deadline).

Example 2 : The agency is unable to verify legal non-citizen status for an applicant for medical assistance. Since the individual is otherwise a qualifying non-citizen and eligible, assistance is approved on September 29th with notification that verification must be provided by December 29th. The recipient fails to provide verification within the ROP. Coverage ends effective January 31st.

If the individual provides verification by February 28th (the month after the month coverage ends), eligibility may be reinstated without a new application/request for assistance. If verification is provided after February 28th, a new application/request is required.

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. The following documents will confirm both status and date of entry for Iraqi and Afghan special immigrants.

Iraqi Special Immigrants 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. 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. 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. 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. 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. 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.

Afghan Special Immigrants 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. 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. 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. 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. 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. 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.

A client must be a resident of the state.

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. In addition, individuals who continue to receive a Kansas state supplementary payment while living out-of-state are regarded as Kansas residents.

The following provisions apply to a non-institutionalized individual:

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).

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 the parent or caretaker).

For an institutionalized individual, see 2152 .

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. The person must be otherwise eligible for Medicaid or CHIP. This would not apply, however, to the MediKan program.

The state of residence for an institutionalized individual shall be:

The state in which the individual’s parent or guardian resides, if the individual is legally incompetent and became incapable of stating intent before the age of 21.

The state in which the individual is living and intends to reside, if the individual is legally competent and capable of stating intent; or

The state that placed the individual in the out-of-state institution. 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. Individuals who are placed in care facilities outside of Kansas by an appropriate agency retain their Kansas residence.

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.

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. Persons 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.

Failure to cooperate with CSS does not impact medical coverage.

A previous finding of noncooperation by a voluntary household shall not impact future assistance under any program.

Reserved

Recipients of SSI are not eligible for MediKan coverage, but are eligible for medical assistance upon application. See 2630 .

Both Medicaid and MediKan 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, pregnant women, and the aged and disabled. MediKan is a totally state regulated and funded program and covers disabled individuals who do not qualify for Medicaid. Separate state-funded programs are also operated for TB eligibles and residents of an IMD (see section 8112.4 ) between 21 and 64 years old. Eligibility policy for the AIDS Drug Assistance Program is the responsibility of Kansas Department of Health and Environment – Division of Health Care Finance (KDHE-DHCF).

Both the Medicaid and MediKan programs provide payments for comprehensive medical care and services furnished either through managed care entities or by enrolled providers. Payments are limited based on the scope of their practice, as defined by state law, and within the scope of services covered through the specific program. Specific services for which payment can be made and the proper payment rate (including capitation rates for managed care) are established by the Kansas Department of Health and Environment – Division of Health Care Finance (KDHE-DHCF) and are reviewed and adjusted periodically. Information on covered services can normally be obtained from 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 KDHE-DHCF. Establishing eligibility/ineligibility of applicants/recipients based on the policies established within the limitations set forth by the Code of Federal Regulations and the Kansas Administrative Regulations is the responsibility of the KanCare Clearinghouse. Licensed or certified medical practitioners determine the necessity of specified medical services, subject to review and approval by KDHE-DHCF. Payments (either capitated payments or direct service payments) are made directly to the provider (vendor) of medical services rendered to individuals certified as eligible. A contracted fiscal agent is used to process medical claims.

Both 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. ethodologies 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 non-disabled children. The MediKan program is authorized through state legislation as well as the Kansas Administrative Regulations.

The Medicaid program is divided into two segments, the "categorically needy" and the "medically needy."

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, although ineligible for cash assistance, 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 defined 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. This would include 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 within each individual group. The categorically needy consists of both mandatory populations and optional populations. When determining eligibility, mandatory categories take precedent over optional categories of coverage. Mandatory Groups - As a condition of receiving federal funds, certain groups must be covered under the Medicaid plan. These groups include: Persons meeting Caretaker Medical criteria whose countable income does not exceed 38% of the Federal Poverty Level. SSI recipients, including those deemed to be receiving SSI. Pregnant women and children under the age of 1 whose countable income does not exceed 171% of the federal poverty level. Children ages 1 through 5 whose countable income does not exceed 149% of the federal poverty level. Children ages 6 through 18 whose countable income does not exceed 133% of the federal poverty level. Children receiving federally funded foster care or adoption support payments. Persons eligible for restricted coverage under the Qualified Medicare Beneficiary program (QMB), any of the Low Income Medicare Beneficiary (LMB) programs, or Qualified Working Disabled (QWD) program. Special protected groups such as the Pickle Amendment, Disabled Adult Children, etc. Non-citizens meeting all eligibility criteria for any Medicaid program except for the citizenship/alienage provisions, under SOBRA. Young Adults ages 18-26 who have aged out of Foster Care (were in Foster Care the month of their 18th birthday). Presumptive Eligibility for children, Caretaker Medical, Pregnant Women, Breast and Cervical Cancer, Foster Care - aged out. Persons meeting TransMed and Extended Medical criteria. Optional Groups - Kansas has elected to cover the following optional groups under the Medicaid plan: Persons receiving services under the State's home-and-community based services (HCBS) waiver or Program of All - Inclusive Care for the Elderly (PACE) and certain NF residents. Children who do not meet the age criteria of the poverty level programs reflected above and who are financially eligible for Family Medical. (This primarily includes children who receive only state-funded foster care or adoption support payments.) Children under the age of 21 in long term institutional settings or between the ages of 19 and 22 and in the HCBS/SED waiver. Persons with disabilities between the ages of 16 and 64 with earned income under the Working Healthy program. Persons diagnosed with and receiving treatment for breast & cervical cancer.

Medically Needy - The medically needy segment is comprised of those persons, who while meeting the non-financial criteria of one of the categorically needy programs such as age or disability, do not qualify because of excess income or resources or, in the case of pregnant women and children, have income which exceeds the poverty level guidelines of either Poverty Level Programs or CHIP. Most persons in the medically needy group are obligated for a share of their medical costs through the "spenddown" process. Coverage of this group is optional under federal law. If a state chooses this option, it must cover pregnant women (including coverage of the 12-month postpartum period) and children. Kansas provides coverage for the following groups: Pregnant women Children up to age 18 or age 18 and not acting on their own behalf Persons 65 years of age and older Persons who are disabled or blind under SSA standards.

The MediKan program provides coverage of certain health care costs for disabled adults who meet the eligibility requirements of 2640 . MediKan is funded with all state funds. There is no federal fund participation in this program.

The following sets forth a description of some of the Medicaid categories and the MediKan program category and the eligibility criteria specific to each. Persons not meeting the criteria for any of these categories are not eligible for either program. Eligibility criteria for all other Medicaid categories as well as the State's CHIP program can be found in the Kansas Family Medical Assistance Manual.

Title 19 coverage shall continue through the end of the established review period as outlined in 2650 . The person must continue to meet non-financial criteria.

The household is required to report applicable changes within ten days.

Once financial eligibility is established for a child(ren) under 19-years of age in the Elderly & Disabled program, the continuous eligibility provisions of 2650 , 2651 , 2652 , and 2653 are applicable to the child. Eligibility will continue to be provided to the child(ren) until the end of the individual’s continuous eligibility period as established in these sections even if the household no longer meets financial criteria or experiences household changes.

All Elderly & Disabled Medical cases shall be reviewed at least once every twelve months (see 9370 ).

SSI recipients, persons determined by the Social Security Administration to be eligible for an SSI payment, and persons who qualify for continuing SSI recipient status are eligible for medical assistance if the requirements specified below are met. Individuals who receive only state supplemental payments or who meet section 1619 guidelines are included in this provision. (See 2633 and 2634 respectively.) There is no eligibility under this section for other persons in the household unless they qualify in their own right.

Elderly or disabled persons who have not applied for SSI and who appear to be potentially eligible should be referred to SSA for a determination. For cases in which an SSI determination of disability is pending, DDS may be contacted when additional information is needed related to the disability determination or a decision is still pending at the end of 90 days.

SSI provisions do not allow for payment to start to an eligible individual until the month following the month of application for SSI. However, the SSI application month shall still be treated as though an SSI payment had been provided and SI eligibility granted for that month.

NOTE : For persons who have applied or been approved for SSI disability a DD-1106, Medical Onset Date Verfication form may be submitted to DDS in order to determine the medical onset date of disability. This date would be necessary if retroactively claiming FFP on medical expenditures or determining eligibility prior to the effective date of SSI eligibility. DDS will return the completed original with the onset date information.

The cooperation, transfer of property (institutional/HCBS recipients only), and residence requirements contained in 2100 must be met and the trust provisions of 5620 and subsections are applicable in determining eligibility. In addition, persons convicted of medical fraud or who have a special spenddown may not be eligible based on the provisions of 11221.3 and 11126.1(3) respectively.

Eligibility under this section extends to any of the 3 months prior to application for medical if the applicant was determined eligible for SSI by the SSA for that time. If the applicant desires coverage for prior months in which he was not eligible for SSI, a determination of other eligibility under another category (such as Medically Needy, poverty level coverage for pregnant women and children, etc.) is required.

Former recipients of Aid to the Aged, Blind, or Disabled (ABD) who were converted to the SSI program in 1974 with a state supplemental payment are eligible for medical as long as they continue to receive such payment and meet the eligibility requirements of 2631 . This includes the converted essential persons whose needs were included in determining the previous ABD payment.

Individuals eligible for SSI under the provisions of section 1619 of the Social Security Act are eligible for medical assistance as indicated above. Section 1619 permits disabled individuals to work at the "substantial gainful activity" level without jeopardizing their SSI disability status. SGA is any work which continues to pay more than the current monthly income limit set by SSA. The SGA limit is adjusted manually. 1619(a) eligibles continue to receive a cash benefit as their earnings do not exceed the SSI benefit levels. They are identified on the State Data Exchange Interface (SDX) as in current pay status. 1619(b) eligibles do not receive a cash benefit as their earnings exceed SSI benefit levels but continue to be eligible for medical assistance. They are identified on the SDX Interface as terminated individuals with a Medicaid Indicator code of "B." However, this code will only be reflected at the time SSI benefits are terminated and will not otherwise be reflected on an ongoing basis. It may be necessary to verify 1619(b) status with SSA.

Based on the drug addiction and alcoholism provisions of the SSI program, SSI benefits are not available to individuals whose drug addiction or alcoholism is a contributing factor to the determination of disability (i.e., would not be found disabled if the drug abuse and/or alcohol abuse were to stop). These provisions became effective as of March 29, 1996. Medical eligibility under the SI or Medically Needy program shall not be provided in such instances. However, SSI beneficiaries whose benefits are terminated due to these provisions and who are medical recipients shall continue to be eligible for Medicaid if they timely appeal the SSI decision and are otherwise eligible except for the disability determination. Such eligibility continues throughout the appeal process. Verification from SSA that the appeal was filed timely is required.

When an individual loses SSI recipient status due to an action taken by SSA to suspend, stop payment or terminate benefits, the following provisions apply.

If the individual timely appeals the SSI eligibility decision by SSA to suspend, stop payment or terminate benefits, SSI recipient status continues. The appeal is timely if filed within 60 days of notification of the SSA action. If the appeal is filed within 10-days of the notification, the recipient can choose to continue SSI benefits throughout the entire appeal process (disability related action) or through the first level of appeal (non-disability related action. The recipient shall continue to be eligible for SI medical assistance (if otherwise eligible) throughout the appeal process. Verification from SSA that the appeal was timely filed is required.

If the individual does not appeal the SSA decision to suspend, stop payment or terminate SSI benefits, or the decision is no longer under appeal, SI medical assistance shall continue while eligibility under another medical assistance program (if any) is determined. Once that determination is complete, SI medical assistance shall be discontinued giving timely and adequate notice. Continued SI medical assistance provided pending the eligibility determination in most instances is not considered overstated eligibility subject to a claim. See 11121.1 (5) and 11122 (7) .

In addition, there may be instances where the suspension or stop payment of SSI benefits is temporary. If contact with SSA verifies that benefits will be reinstated within the next two months, SI medical assistance may continue. Otherwise, eligibility under another medical assistance program must be determined as indicated above. See Policy Memo 2018-10-01, re: SSI Termination and Verification of Resources for further guidance.

NOTE : If the agency has information that the SSI recipient has resources, including income, which the SSA verifies will make the individual ineligible for SSI, EATSS SDX information will be disregarded, and the individual would no longer be considered an SSI recipient. The process to determine eligibility under another medical assistance program described above would apply.

When an SSI recipient enters an institution the following provisions apply.

An SSI recipient who enters an institution for a temporary (short term) stay (see 8113 ) will continue to receive SSI benefits. SSI recipient status continues. An SSI recipient who enters a medical institution for a long term stay in which Medicaid will pay for all or a portion of their care will be limited to a maximum $30/month SSI benefit for each full month in the institution. As a result, some individuals may lose their SSI benefit while institutionalized if their countable income exceeds $30/month. SSI recipient status would cease for those who lose their SSI benefit. Continued eligibility for those losing SSI recipient status shall be determined as described in 2636 .

NOTE : An individual age 21 to 64 residing in a mental health nursing home will continue to receive unreduced SSI benefits because Medicaid will not pay for their care in the facility. The full amount of the SSI benefit, and any other countable income, shall be budgeted in determining the monthly patient liability. See 8112.4 (2) .

There is no SSI eligibility for individuals who reside in most public institutions such as prisons or other correctional facilities (see 8111 ), unless it is a medical facility for which Medicaid payments can be provided, such as the state psychiatric (except for residents age 21 to 64) and intellectual disability hospitals. SSI payments may be reinstated to these individuals once they return to the community. This provision does not apply to SSI recipients who are in the institution less than a full calendar month.

SSI recipients in a Medicaid approved institution for a long term stay may have a patient liability if income exceeds the $62/month protected income level beginning with the month following the month of entrance (see 8172 ). SSA may continue SSI benefits for up to 3 months following the month of entrance (2 months for 1619 eligibles). Those SSI payments shall be disregarded in determining the patient liability if long term stay budgeting is being applied. Any other countable income shall be included in the determination.

NOTE : The transfer of property provisions apply to an individual who retains SSI recipient status while institutionalized. See 5720.1 .

If an individual makes application for medical and has been or is later denied disability status under the SSI program, there is no eligibility for automatic status and, unless the individual otherwise qualifies for another FFP medical program, the application shall be denied. However, if the individual requests reconsideration of the disability decision or formally appeals the SSI decision within the allowable SSA reconsideration/appeal period, the medical application date shall be protected for purposes of eligibility (including prior eligibility). Verification of the timely request or appeal must be documented. If the client obtains disability status upon reconsideration or wins the SSI appeal and reapplies for medical, automatic eligibility shall be provided back to the protected medical application date, including the 3 prior months, provided that the individual is determined eligible for SSI for this entire time period.

Based on the provisions of the Budget Reconciliation Act of 1997, children who lose eligibility for SSI benefits due to changes in the SSI childhood disability criteria resulting from the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) shall continue to be eligible for medical assistance as long as they would be otherwise eligible for SSI except for the loss of disability status. See also 2636 regarding children whose termination of benefits is timely appealed. This group of children is limited to those receiving SSI benefits as of August 22, 1996, including those who have been receiving SSI in another state and subsequently move to Kansas. Documentation of SSI termination due to the new disability criteria is required as well as verification that the individual was receiving SSI on August 22, 1996. The Social Security Administration provides periodic lists of individuals who no longer meet disability criteria under these provisions.

In order to continue medical coverage under this provision, the general eligibility requirements of cooperation and residency contained in 2100 must be met. In addition, financial eligibility must be redetermined on a yearly basis. This can be accomplished in one of two ways. First, a Medicaid poverty level determination in accordance with the Kansas Family Medical Assistance Manual is to be done and children meeting this criteria set up under the Poverty level program. If the child does not meet the financial criteria for Poverty level program, falls into CHIP or loses poverty level coverage, an SSI financial determination is to be done. Countable resources of the custodial parent(s) and the child must be below the appropriate resource standard per 5130 . Countable income shall be determined through use of the electronic SSI eligibility worksheet. The income of the custodial parents (including any stepparents) and the child, and any of the child's natural or adoptive siblings is to be considered on this worksheet. If the countable income obtained is less than current one-person SSI beneficiary level, the child remains eligible. Procedures set forth in Policy Memo 1999-09-01, re: Self-Employment, Assistance Planning, Adding Child to Plan, Newborns, Retroactive Coverage, IM-3160 Revision regarding ex parte redeterminations shall be utilized to the extent possible when completing the financial determination.

Coverage under this provision is available through the month the child turns age 18. Continued medical eligibility after this time would then have to be determined under other existing categories (e.g., Medically Needy if person meets adult disability criteria).

MediKan is a state only funded medical assistance program for adults who meet the following eligibility criteria.

The general eligibility criteria of act in own behalf ( 2110 ), cooperation ( 2120 ), SSN ( 2130 ), citizenship and alienage ( 2140 ), and residency ( 2150 ) must be met. The assistance planning rules of 4310 are also applicable. Persons convicted of medical assistance fraud per 11221(3) are not eligible.

The MediKan program is limited to adults age 18 to 64.

MediKan coverage is not available to an individual who is entitled to SSA disability or SSI benefits, or who is eligible for or receiving Medicaid assistance.

MediKan eligibility is dependent upon meeting disability criteria. All mandatory filing unit members of the family group must be included in the assistance plan in accordance with 4310 . The mandatory filing unit shall consist of either a single individual or a married couple living together. Assistance shall be limited to those individuals meeting the Tier II disability level as defined in MKEESM 2662(3)

For a married couple living together, both spouses must meet the disability criteria. If one spouse is Tier II, and the other spouse is Tier I (or already meets SSA disability criteria, or is 65 or older), the Tier II spouse may qualify for MediKan while the other spouse may be eligible for Medicaid. If only one spouse is Tier II and the other spouse is not disabled (or 65 or older), there is no MediKan eligibility for either spouse.

Assistance under the MediKan program shall be limited to a fixed 12-month coverage period beginning with the first eligible month. This 12-month coverage period is a lifetime limit. Once established, the coverage period continues to run consecutively for 12 months even if the individual becomes otherwise ineligible (i.e.: excess income or resources, moved out of state, marries a non-disabled person) and eligibility is discontinued. Eligibility may be reestablished within the fixed 12-month coverage period if otherwise eligible but shall not extend past the established fixed 12-month coverage period.

There is no MediKan eligibility after the expiration of this coverage period. If only one spouse has reached the limit, the other spouse is not eligible while living together.

Reintegration is a special MediKan coverage program that has been established to provide time-limited medical assistance to eligible adults being discharged from Medicaid approved psychiatric hospitals or released from the Larned Correctional Mental Health Facility Central Unit or from the Larned State Security Program. See Policy Directive, PD2019-04-01, Medikan Reintegration - Date of Discharge , for further guidance.

An approved discharge plan shall be established for each individual and must include: Submission to the PMDT one copy of the ES-3903, Presumptive Medical Disability Questionnaire ; and One copy of the ES-3904, HIPPA Compliant Authorization to Disclose Information to KDHE . All documents are located on the KDHE Eligibility Policy website.

Eligibility under this process shall be based on the patient's reported income, resources and other information contained on the completed application form, including the client's living arrangement following discharge. If the client is in need and is not obviously ineligible for some other program factor, eligibility shall be approved. To help facilitate the Reintegration discharge process, a resident may have medical assistance coverage administratively reinstated without an application if discharged within a previously established 12-month review period. A medical card shall be available to the client at the end of discharge.

If the person being discharged is returning to live with his or her spouse or is going directly into a nursing facility or other institutional setting (other than specialized living arrangements), there is no eligibility for MediKan coverage. Persons eligible for SSI, including those in a suspended status, but who have not received benefits at the time of release, are eligible for MediKan in the interim period prior to receipt of the initial or reinstated SSI benefits.

Because a complete eligibility determination has not been completed, assistance under the Reintegration program is limited to the month of discharge and the two following months. In most instances the full medical eligibility determination should be completed by the second month following the month of discharge. In rare situations, the time limitation can be extended for good cause (e.g., presumptive eligibility could continue as long as the client is cooperating in providing required information in order for the agency to make a final eligibility determination).

Coverage months under the Reintegration program do not count against the 12 month lifetime MediKan coverage period, see 2645 . Nor does Reintegration approval start the fixed coverage period for regular MediKan. As long as all eligibility requirements are met, there is no limit on the number of times Reintegration may be approved.

Once financial eligibility is established as of the date the case is processed under a MAGI program, all eligible non-pregnant children shall be eligible for a 12-month period. 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 who subsequently enter a household, request assistance, and are determined eligible for Medicaid shall also receive continuous eligible for a 12-month period.

When a family contains individuals eligible under different assistance plans, individual continuous eligibility periods may differ. Continuous eligibility periods will not always align with other household members.

Once continuous eligibility is established for individuals under the age of 19, coverage shall not switch between medical aid codes, except as noted in 2652 .

Continuous Eligibility begins with the first month of eligibility (see 2650 above) in the current review period and continues regardless of any changes in income or income. Such eligibility shall continue unless one of the following circumstances occurs:

The child turns age 19;

An individual no longer meets residency requirements;

The child dies;

There is a voluntary request for case closure (i.e., voluntary withdrawal);

The child is later found to have not been initially eligible due to agency error or fraud.

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.

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, a new application would be required for the child to 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 8111.1 (3) and KFMAM 2052.05 for Medicaid minors.

As stated in 2650 , aid code changes are not permissible during a CE period, with exception to situations listed below where Poverty Level Medical (PLN) coverage shall be determined (unless the child is eligible to be transitioned back to the family’s active MAGI coverage program for the duration of the CE period).

Child loses SSI recipient status;

Child is terminated from HCBS waiver services;

Child is discharged from a Medicaid approved facility.

The following situations will allow a change in coverage within the CE period and a new 12-month CE period will be set.

CHIP to SI Medical Program;

CHIP to Long Term Care (LTC) Coverage (applies to both HCBS and NF coverage);

Poverty Level Medical (PLN) to SI Medical Program;

Poverty Level Medical (PLN) to Long Term Care (LTC)

Caretaker Medical (CTM) to SI Medical Program;

Caretaker Medical (CTM) to Long Term Care (LTC)

Medical assistance is available for persons who are aged or disabled and who are not financially eligible for SSI cash benefits. In addition, assistance is also available to children in a state institution.

The individual must have attained the age of 65 prior to or within any month for which eligibility is being determined.

To receive Medicaid coverage based on disability, the individual must be determined blind or disabled in accordance with Social Security Administration (SSA) disability standards for any month in which eligibility is determined. To receive MediKan coverage, the individual must meet the MediKan definition of disability.

SSA Definition of Disability (Medicaid) - The inability to do any substantial gainful activity due to a medically determinable physical or mental impairment that is expected to last for a continuous period of at least 12 months or result in death.

SSA Definition of Blindness (Medicaid) - Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens, which has lasted (or is expected to last) for a continuous period of at least 12 months or result in death.

MediKan Definition of Disability - A severe impairment that significantly limits the individual’s physical or mental ability to perform basic work activities and is expected to last at least 12 months or result in death. Basic work activities include but are not limited to: Physical functions such as walking, standing, sitting, lifting, pushing, pulling, and carrying; Capacities for seeing, hearing, and speaking; Understanding, carrying out, and remembering simple instructions; Use of judgement; Responding appropriately to supervision, coworkers, and usual work situations; Dealing with changes in a routine work setting.

The presence of a severe impairment alone does not preclude the individual from performing past relevant work or adjusting to other work.

The Social Security Administration determines disability or blindness as part of the eligibility determination for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). Individuals receiving either Social Security Disability benefits or SSI based on disability are considered to have met the disability standard.

Verification of an SSA disability determination is required. Verification may be obtained through electronic data sources or SSA-issued documentation. Receipt of Social Security benefits alone does not automatically indicate the individual meets disability criteria, as some SSA benefits are not based on a disability determination (e.g., early retirement or survivor's benefits). Contact with the local SSA office may be needed to determine whether a disability decision has been made.

The state's Presumptive Medical Disability Team (PMDT), with certification by the Disability Review Team (DRT), determines whether the individual meets disability or blindness criteria for purposes of Presumptive Medicaid (Tier 1) and MediKan (Tier 2) eligibility.

Individuals must meet Tier 1 disability criteria to qualify for Medicaid under Presumptive Disability. To qualify for MediKan, individuals must meet Tier 2 disability criteria. The PMDT will initially consider disability under Tier 1 criteria and, if not met, disability under Tier 2 is evaluated.

An individual meets Tier 1 disability criteria when the impairment satisfies the SSA disability or blindness standards. The Tier 1 determination will evaluate if the impairment(s) meet or equal a listing described in Appendix 1 of CFR 404, Subpart P and the Medical-Vocational guidelines in Appendix 2 of C.F.R. 404, Subpart P.

An individual meets Tier 2 disability criteria when the individual has a severe impairment that significantly limits the ability to perform basic work activities but does not meet SSA disability standards due to the ability to perform past relevant work or adjust to other work.

If a severe impairment does not exist, Tier 2 criteria are not met.

A disability determination for Medicaid or MediKan purposes may only be made by an entity authorized by KDHE-DHCF. Disability determinations made by other agencies are not sufficient. Where a disability determination has been made by another entity, such as the Veterans Administration or Railroad Retirement Board, a disability determination by SSA must be obtained in order to qualify for Medicaid.

Social Security - When a final SSA disability (or blindness) determination has not been made, the individual is initially referred to SSA for a disability determination for SSI or SSDI. If SSA will not complete the disability determination for reasons unrelated to disability, the case may be referred for a disability determination by DDS.

Presumptive Medicaid Disability Team (PMDT) and The Disability Review Team (DRT) with KDHE - The PMDT, with certification by the DRT, determines disability for Presumptive Medicaid and MediKan (see 2640) determinations only. These determinations apply to individuals potentially eligible for Social Security benefits or when otherwise authorized by the agency. The DDS referral process is used where there is no potential eligibility for SSI or SSDI benefits. Verification of the disability duration is not required prior to referral; the referral may be based on the individual’s statement regarding duration.

Disability Determination Services - DDS determines disability or blindness when SSA has not (or will not) make a determination for reasons unrelated to disability, including but not limited to the individual not pursuing benefits through the Social Security Administration (SSA) ( 2124.1 ), or being ineligible to receive a cash payment from SSI or SSDI. Reasons for cash ineligibility that would require a DDS referral may include, but are not limited to, insufficient work history, excess income or resources, or a transfer of property penalty. SSA will also not make a disability determination on a deceased individual with no active application on file. When an individual is referred to DDS due to SSA denying for reasons unrelated to disability, documentation of the SSI/SSDI denial is required prior to referring to DDS, except when authorized by KHDE-DHCF Eligibility Policy. (See 2662.3 )

Initial Disability Determinations - DDS will determine disability beginning with the first month required for the Medicaid determination. A disability onset date will be established for individuals with favorable disability determinations.

Disability Onset Date for Medicaid - DDS will determine an onset date for Medicaid determinations prior to the onset of SSI. Example : An individual applies for Medicaid on May 10 and requests prior medical. SSA approved their SSI benefit with payments beginning May, and SSI eligibility beginning in April. Disability criteria are met for both April and May. However, because there is no potential for cash benefits in February and March, SSA will not make a disability determination for the individual in those months. A referral is sent to DDS to determine whether the individual meets the disability criteria in February and March.

When the Social Security Administration (SSA) has not made, or will not make, a disability determination for reasons unrelated to disability, a referral may be made to Disability Determination Services (DDS) to determine whether the individual meets the applicable disability criteria. Eligibility staff are responsible for gathering the required information and submitting the referral to DDS. DDS may request additional information prior to rendering a decision. Refer to the KanCare KDHE- External Forms for copies of the forms referenced in this section.

Referral Requirements Eligibility staff must complete the required forms and provide available information regarding the individual’s medical providers and disability history when submitting a referral to DDS. DD-1104 – Disability Determination Referral Sections I and II of the DD-1104 must be completed to provide general identifying information about the individual. If the individual does not have a Social Security number (SSN) (e.g., undocumented individuals applying for SOBRA coverage only), this must be indicated on the form. The requested onset date must be noted Section II. This is typically the month of application or up to three months prior to the application month when prior medical coverage is being determined. If available, a copy of the Social Security denial notice indicating denial for a reason other than disability should be included with the referral. DD-1105 – Social and Medical History Sections I, II, and III of the DD-1105 must be completed to provide social, employment, and medical history. The individual, medical representative, or another knowledgeable party (such as a case manager) may assist in completing the form. If someone other than the individual completes the form, the name and relationship of the person must be included on the form. Medical providers who have treated the individual since the alleged onset date must be identified on the form. Additional pages may be attached if necessary. DD-1103 – Authorization for Release of Medical Information The DD-1103 is used to obtain authorization for the release of medical information. The client must sign the form unless unable to do so due to the person's medical condition. If the individual is unable to sign, a person authorized to act on the individual’s behalf may sign the form. The reason the individual is unable to sign must be documented. If the form is signed by a mark, a witness must attest to the signature. The form must also be dated at the time of signature. Eligibility staff must complete the appropriate section of the form. The completed DD-1103 , DD-1104 , and DD-1105 forms must be submitted to DDS for review and completion of Section III of the DD-1104 . Submission must occur through approved agency transmission methods in accordance with established procedures. Copies of submitted forms must be retained in the case file.

DDS Determination Process DDS is responsible for obtaining additional medical evidence necessary to make a disability determination, provided the applicant and agency have supplied available information regarding medical providers who have treated the individual. DDS will document the following on the DD-1104 : Disability determination (approval or disapproval) Decision date Disability onset date Review date (diary date) Pertinent diagnosis DDS will return the completed original DD-1104 and DD-1105 with copies of any pertinent medical information to the agency. The agency will monitor pending DDS referrals and follow up as necessary in accordance with established agency procedures. Upon receipt of the DDS determination, eligibility staff shall complete the eligibility determination using the DDS decision documented on the DD-1104 .

Specific Referrals The following types of referrals require the inclusion of additional information. SOBRA Referrals A non-qualifying alien may be eligible for emergency medical services under the SOBRA program (see 2691 ). When eligibility for a disability-based program must be determined, a DDS referral using the DD-1104 form is required. The referral must clearly indicate that it is a SOBRA referral and include any medical records obtained through the MS-2156 process. Deceased Applicant An application for assistance may be submitted on behalf of a deceased individual (see 1411.3(1) ). When eligibility must be determined under a disability-based program, a referral to DDS may be required. The referral must clearly indicate that the individual is deceased and include the date of death. Available supporting documentation, such a death certificate and medical records, should be included. Child In some instances, a child claiming a disability may not qualify under other medical programs, such as poverty level or Caretaker Medical. In these cases, a referral to DDS may be necessary to determine eligibility under the Medically Needy program. The referral must clearly indicate that this is a child referral. Referrals may also be required when the disability status of a non-applicant/recipient child affects the eligibility determination of another individual. Example : An elderly individual applying for long term care coverage establishes a special needs trust for a minor grandchild. To determine whether the trust is exempt from transfer of property penalty provisions (see 5720 ), the grandchild must meet disability criteria. If the child has not been determined disabled by SSA, a DDS determination may be required.

Reconsideration and Appeal If DDS issues an unfavorable disability determination, the individual has the right to request a reconsideration of the decision. The agency must submit a new DD-1104 to DDS clearly identifying the request as a reconsideration. DDS will review the original record along with any additional medical evidence provided. Favorable Reconsideration If disability is approved through the reconsideration process, eligibility must be determined based on the disability finding. Unfavorable Consideration If the reconsideration decision remains unfavorable, the individual may request a fair hearing. When a fair hearing is requested: The agency will submit the required appeal documentation to the Administrative Hearing Office (AHO). DDS will represent the disability determination during the hearing process. If the hearing decision upholds the DDS determination, no further action by the agency is required. If the hearing decision overturns the DDS determination, the application must be reinstated and processed based on the disability finding. See also 1614.1(4) and (5) and (5) and 1614.3(9) for additional guidance.

Continuation Review When DDS makes a favorable disability determination, the DD-1104 returned to the agency will include a review date, also referred to as a “diary date”. The diary date indicates when the individual’s disability status must be reviewed to determine continued eligibility. When a review is required, a referral is submitted to DDS to reassess the individual’s disability status. The referral must include all the previous information used to make the original decision, including the returned DD-1104 and DD-1105 forms. DDS will then review the individual's disability status to determine if the individual continues to meet disability criteria. DDS will document the review determination on the DD-1104 and return the decision to the agency. If the determination remains favorable, eligibility may continue and a new diary date is established. If the determination is unfavorable, the individual no longer meets disability criteria, and adverse action may be required.

A disability determination by the Presumptive Medical Disability Team (PMDT) is required for individuals seeking Presumptive Medicaid (Tier 1) or MediKan (Tier 2). The agency determines whether an individual meets the criteria for a referral to the PMDT and initiates the referral when appropriate. Disability determinations (and redeterminations) are made by the PMDT and certified by the Disability Review Team (DRT), unless otherwise specified by policy.

A referral to the PMDT may be made for both Medicaid (Tier 1) and MediKan (Tier 2), or for Medicaid only (Tier 1 only). A referral for MediKan only is not appropriate. Individuals who do not meet the financial or non-financial criteria for MediKan may be referred for Medicaid only. When a referral is made for both Medicaid and MediKan, the PMDT considers disability under both programs. Persons who have reached the MediKan lifetime limit may be referred for Medicaid only.

The referral to the PMDT must indicate which program(s) are applicable. Examples: An application is received for an individual who has already received 12 months of MediKan coverage. The applicant may not receive MediKan, so the only program considered is Medicaid. An application is received for an individual whose countable monthly income is $500.00. This is over the income limit for MediKan, so the only program considered is Medicaid.

Declaration of Disability A referral to the PMDT requires a declaration of disability by the individual. The declaration may be made on the application for medical assistance or through direct contact with the agency. The declaration must include sufficient information to indicate that the disability may meet minimum program requirements. Disability is a requirement for both Medicaid disability-based coverage and MediKan. If the individual does not claim a disability or does not respond to the disability-related questions, a referral to the PMDT is not appropriate. For couples, when only one spouse declares a disability, MediKan eligibility does not exist and any referral to the PMDT would be for Medicaid only.

Duration Requirement The agency must determine whether the individual alleges a disability expected to last at least 12 months or result in death. This durational requirement applies to both Medicaid and MediKan. If the durational requirement is not met, a referral to the PMDT is not appropriate. Example: An individual reports a temporary injury expected to last six (6) months on the application for medical assistance. Because the durational requirement is not met, no referral to the PMDT is made.

Status of SSA Disability Application The agency must determine whether the Social Security Administration (SSA) has made a final disability determination. A determination is not considered final if the SSA application is still pending or under appeal. If SSA has not made a final determination, a referral to the PMDT may be made for Medicaid and, when applicable, MediKan. Example: An individual was denied SSA disability benefits and timely appealed the decision and is currently awaiting a hearing. Because the SSA determination is not final, a referral to the PMDT is appropriate.

SSA Determination Older Than 12 Months When an individual reports that a final SSA disability determination occurred more than 12 months prior, the case may be referred to the PMDT. Verification of the date of the SSA determination should be attempted but must not delay the PMDT referral. Example: The applicant reports that Social Security denied their application 18 months prior because of not meeting disability criteria. The EATSS interface confirms the denial. Because more than 12 months have passed since the final SSA determination, a new referral to PMDT is appropriate. The individual must also be referred to reapply for disability benefits with the SSA.

SSA Determination Within Past 12 Month When SSA has made a final disability determination within the past 12 months , a referral to the PMDT is only appropriate if the individual reports a change in condition or a new disability. The individual’s statement regarding the change is sufficient for referral purposes. Example: The applicant was denied by Social Security 6 months ago as their medical condition did not meet SSA disability standards. However, they report on their Medicaid application that the medical condition has worsened. Because a new or worsening condition has been reported, a referral to the PMDT is appropriate. The individual must also be referred to reapply for disability benefits with the SSA.

Application for SSA Benefits Unless verification of a pending SSA disability application verified, the individual must be advised to apply for SSA disability benefits. Verification of a pending SSA application is required prior to MediKan approval. However, medical assistance under Medicaid may not be denied solely because the individual has not applied (or provided verification of applying) for SSA benefits, in accordance with 2124 .

Disability Questionnaires and Medical Information The agency collects medical information necessary for a PMDT disability determination using the following forms: ES-3903 Presumptive Medical Disability Determination Questionnaire ES-3904 HIPAA Compliant Authorization to Disclose Information to KDHE Completion of the required questionnaire and receipt of the original, validly signed release of information are program requirements. These forms allow the PMDT to obtain medical records and complete the disability determination. Failure to provide requested information may delay the disability determination or result in an unfavorable determination. Individuals needing assistance should be directed to friends, family, and other community resources for assistance. In addition, the form includes language directing the applicant to contact the PMDT at their toll-free number (1-888-547-2763) if they have questions about the form. Questionnaires or release forms received, even if only partially complete, should still be forwarded to the PMDT as part of the referral process. Upon receipt of the questionnaire and HIPAA release, the PMDT will review the form and determine if additional information is needed and contact the applicant if necessary.

Disability Determination Process The PMDT develops the disability case and evaluates medical evidence. All disability determinations must be certified by the Disability Review Team (DRT), which consists of qualified medical and disability professionals. The DRT evaluates medical, vocational, and other relevant evidence and makes the final disability determination. Disability determination services may be provided through a contractual arrangement with Disability Determination Services (DDS). The PMDT records and maintains disability determination outcomes and reviews disability statuses when deemed appropriate by the agency. Eligibility staff uses the disability determination to complete the Medicaid eligibility determination and issue required notices in accordance with 1430 .

Individuals seeking medical assistance based on disability must cooperate with the PMDT in completing the disability determination. Failure to cooperate may result in adverse action when cooperation is required to establish eligibility.

Non-cooperation includes, but is not limited to:

Failure to complete the required disability questionnaire (ES-3903) or provide required releases of information;

Failure to attend a scheduled medical evaluation when one is required to develop the disability case;

Failure to assist, when requested, in obtaining medical records necessary for the disability determination.

When non-cooperation occurs, the PMDT notifies Eligibility staff, who then determines the appropriate action in accordance with applicable eligibility and notice requirements.

NOTE : If the individual contacts the agency within 90 days of the original application date and cooperates or requests rescheduling, the application may be reactivated in accordance with 1414.2 (3) .

When either the Clearinghouse or the Presumptive Medical Disability Team (PMDT) becomes aware of a change that may affect a pending disability determination, the change must be shared to ensure the determination is based on current and accurate information. Changes include, but are not limited to, updates in contact information, living arrangements, legal representation, eligibility, or other circumstances that may affect eligibility or the disability determination. Changes that may affect the need for a continuing disability review must be shared in accordance with 2662.7 .

If an eligibility determination is made on the case for reasons unrelated to disability while the disability determination is pending, the PMDT must be notified.

NOTE : A PMDT referral remains valid for up to 12 months. When coverage under PMDT is maintained without a break, staff must not initiate a new PMDT referral at review if the individual remains otherwise eligible and the disability determination is still pending with SSA. If SSA issues a final determination that the individual does not meet disability criteria, the individual is denied or discontinued due to no longer meeting program requirements. (See 2663.4 and 2663.6 )

If the individual later reapplies for SSA disability benefits after a final denial, this does not automatically continue prior PMDT eligibility. A new Medicaid application is required, and a new referral to PMDT must be completed in accordance with 2662.5 .

Disability determinations are subject to periodic review to determine whether the individual continues to meet disability criteria for purposes of Medicaid eligibility.

Continuing disability reviews may be conducted by the Social Security Administration (SSA), Disability Determination Services (DDS), or the Presumptive Medical Disability Team (PMDT), consistent with the source of the most recent disability determination and applicable review requirements.

A continuing disability review may be initiated based on, but not limited to:

A scheduled review or diary date by SSA or DDS;

Information received by the agency indicates a possible change in the individual’s medical condition;

Program requirements for ongoing eligibility under a disability-based coverage group.

When a continuing disability review is required, the agency must ensure that a current disability determination is available to support ongoing eligibility. Individuals are required to cooperate with a continuing disability review in the same manner as an initial disability determination.

If a continuing disability review results in a determination that the individual no longer meets disability criteria, eligibility under all coverage groups must be determined before taking adverse action in accordance with applicable notice and appeal requirements. (See also 2652 , 2662.3 , 2662.8 , PM2018-10-01 , and PM2024-08-01 .)

Note: Continuing disability reviews are not applicable to MediKan Tier 2 disability determinations.

An individual who is dissatisfied with a disability determination made by the Presumptive Medical Disability Team (PMDT) may request a reconsideration of that determination. A request for reconsideration must:

Be received within 60 days of the original PMDT determination date; and

Be supported by a new or worsening condition, or new medical evidence that was not considered as part of the original disability determination.

The PMDT determination is valid for 12 months, and an individual may receive one reconsideration within that time frame.

A reconsideration request received more than 60 days from the date of the PMDT determination shall be denied. If an individual reports a new or worsening condition after the 60-day reconsideration period has expired, a new application is required, and a new referral to PMDT must be submitted.

The PMDT reconsideration decision will be communicated to eligibility staff for appropriate case action. Eligibility staff shall issue a notice of action advising the individual of the reconsideration outcome in accordance with applicable notice and appeal requirements.

The outcome of the disability determination made by PMDT is binding until Social Security reaches a final determination.

If a Tier 1 disability is established, the consumer is considered disabled until SSA reaches a final determination. If Social Security affirms the disability, assistance may continue if all other eligibility factors continue to be met. If Social Security denies disability, categorical assistance is terminated under the disability category.

If a Tier 1 disability is not established, the application for disability-based Medicaid is denied. The application can be reconsidered if new information is presented during the 90-day application time frame (see 1413 ). If the consumer is approved for SSI based on the Social Security application associated with the PMDT, assistance may be provided effective with the Protected Filing Date if all other eligibility factors are met. Cooperation with Social Security disability is required.

The date an application for medical assistance is made is considered the Protected Filing Date if a determination of medical assistance cannot be made because a final determination for Supplemental Security Income (SSI) has not been issued. The initial application date is active as long as the individual cooperates with the medical assistance determination and the SSI application is pending an initial determination or is in appeal status. Verification of a timely appeal is required. Failure to cooperate with MediKan criteria does not impact the medical protected filing date.

Medical assistance under the Medicaid program is available to individuals who meet Social Security disability criteria as determined by the Presumptive Medical Disability Team (PMDT) and Disability Review Team (DRT) (see 2662 ). Eligibility is determined under existing program rules for the applicable medical coverage group for individuals with a qualifying disability determination.

A Presumptive Medical Disability case differs from a regular medical assistance case only by the entity making the disability determination. Except for coverage under SSI-related Presumptive Medical Disability, Social Security does not make disability determinations for PMD; disability determinations are made by the PMDT and DRT. Medical assistance cannot be authorized until the PMDT issues a disability determination.

Age - A PMD determination is available only to individuals under age 65. Because Medicaid for the aged is available at age 65, a PMD determination is not necessary for individuals in this age group.

A PMD determination is not required for individuals who are eligible under another Medicaid category , such as Caretaker Medical. However, a PMD determination may be completed for an individual who is currently eligible under another coverage group when that coverage is ending, or when the individual seeks services that require a disability determination. PMD is also applicable for children seeking coverage under a disability-related group. Because MediKan eligibility is limited to adults, only Tier 1 determinations apply to children. The PMDT and DRT apply SSA childhood disability criteria when making disability determinations for children.

A PMD determination is necessary only when another Medicaid or CHIP coverage group is not available, or when the child seeks services that require a disability determination.

Example : A 16-year-old child receives CHIP (Title 21) coverage. The child’s parent seeks Home and Community-Based Services (HCBS) for Physical Disability (PD) waiver services, which are not available under CHIP and require a disability determination. Because access to services is limited without a disability determination, the child is appropriate for PMD consideration.

To qualify under Presumptive Medical Disability, the individual must meet the disability criteria described in 2662 and its subsections. The disability must be expected to last at least 12 months or result in death. Disability determinations are made by the PMDT and DRT in accordance with these sections.

Presumptive Medical Disability is available under any medical assistance program that requires a disability determination. All applicable general, financial and non-financial eligibility rules for the specific medical assistance program apply, including but not limited to:

Working Healthy (see 2664 )

Nursing Facility/Institutional (see 8100 )

Home and Community Based Services (HCBS) (see 8200 )

Medically Needy/Spenddown (see 7532 )

SSI-Related (see 2663.3 )

Individuals who meet PMD disability criteria and are otherwise eligible for SSI cash assistance are eligible for medical assistance without a spenddown. Except for the disability determination, which is made by the PMDT rather than SSA, all general and non-financial eligibility requirements of the Medically Needy program apply.

Financial Eligibility - The financial methodologies, exemptions, and disregards used for the Medically Needy program apply. One-month base periods are used. Financial eligibility exists when countable resources do not exceed the limit in 5130 and countable income does not exceed the applicable income standard in the F-8, Kansas Medical Assistance Standards .

If income or resources exceed the allowable limits, eligibility under another medical assistance program may be considered, such as Working Healthy or Medically Needy with a spenddown.

A final disability determination made by Social Security takes precedence over a PMD disability determination (see 2663.6 ). For a new PMD determination, one of the following conditions must be met:

Social Security has not made a final determination of disability or blindness within the past 12 months (also see 2662 ); or

Social Security has made a final determination of disability or blindness within the past 12 months, and the individual reports a change in condition or new disability (see 2662 ).

Persons who do not meet these criteria may qualify for MediKan coverage under a Tier 2 disability determination. Individuals who meet Tier 1 criteria but do not meet the conditions above may not receive Medicaid under PMD but may receive MediKan.

Reserved

A final disability determination by Social Security occurs when SSA approves benefits or determines the individual does not meet disability criteria, and no further administrative appeal rights remain. If the individual does not request a timely appeal (per the SSA allowed timeframes), the SSA determination is final. A timely appeal places the SSA determination in pending status and is not considered final.

Coverage under PMD must be monitored for a final SSA disability determination. Coverage ends when SSA makes a final determination.

Favorable SSA Decision - A favorable SSA decision is a finding of disability and may, but does not always, result in benefit payment. A favorable decision is treated as a reported change and processed in accordance with the change processing rules of the applicable medical assistance program. The PMD eligibility segment must be closed and a final eligibility determination made under the appropriate Medicaid coverage group. For example: For Medically Needy, the change is processed the month following the month of change. For Working Healthy, the change is processed the following month, but will not impact the monthly premium amount until the 6-month desk review or regular review. If the individual becomes eligible under another Medicaid program, eligibility must be established under that group. Ongoing eligibility remains subject to continuing disability reviews as described in 2662.7 . PMD-eligible months do not need to be overlaid with non-PMD Medicaid eligibility. However, eligibility must be reviewed for prior months when: The individual’s protected filing date with Medicaid is prior to the effective date of PMD eligibility. If a disability onset date is established prior to the date of PMD eligibility, coverage must be determined for the applicable months. The individual receives Tier 2/MediKan coverage. Coverage under Medicaid must be determined for MediKan eligible months.

Unfavorable SSA Decision - If SSA determines the individual does not meet disability criteria, eligibility under PMD ends. Coverage provided during the presumptive period is not overstated when eligibility was otherwise correctly determined.

If the individual timely appeals the SSA decision and SSA accepts the appeal, the determination is not final and eligibility may continue if all other eligibility requirements are met.

NOTE : When SSA will not make a disability determination and a referral is made to Disability Determination Services (DDS) as described in 2662.2(3) , the DDS decision is considered the final disability determination for purposes of this section. A subsequent SSA application does not establish a protected filing date for the original medical assistance application associated with the DDS decision. See also the note in 2662.10 .

Medical coverage is available to persons with disabilities who have earned income and who meet the requirements of this section. Coverage for this group is provided under authority of the Ticket to Work and the Work Incentives Improvement Act of 1999 (TW-WIIA) and is available beginning July 1, 2002.

Persons eligible for Working Healthy do not have a spenddown, however a premium may be required as noted below. The full Medicaid benefit package is available to those eligible and persons are not subject to managed care. A referral to the HIPPS program per 2912 is required for all program participants.

Persons must also meet Social Security’s disability criteria. Because of this, all persons potentially eligible for Working Healthy also meet categorical criteria for other Medicaid programs (Medically Needy/spenddown, SI, QMB, etc.). It is most often in the client’s best interest to be found eligible under the Working Healthy program as opposed to the regular medically needy (or spenddown) group. When processing a medical application for an employed person, coverage must first be considered under Working Healthy. However, if the Medically Needy determination results in no spenddown, the client is placed in Medically Needy/spenddown, not Working Healthy. If a premium would be required, the individual must agree to pay the premium prior to enrolling in Working Healthy including premiums for prior months.

Coverage under the limited Medicare Savings Programs (QMB and LMB) must be considered as well and would not be impacted by the decision to enroll in Working Healthy. Persons eligible for coverage as an SSI recipient, including deemed recipients such as those eligible under the 1619(b) provisions, are not eligible for Working Healthy as they shall remain covered under the SI program.

Working Healthy recipients are not eligible for HCBS per 8200 , however, personal services may be available through the WORK program (see 8400 ). Persons entering a nursing facility for a period exceeding the temporary stay criteria of 8113 are not eligible for Working Healthy coverage. Ongoing eligibility for a current Working Healthy recipient entering one of these living arrangements must be determined using the provisions applicable. A new application is not required.

To support persons with disabilities currently working or wishing to work, regional Benefits Specialists are located throughout the state. Because increased income or assets can result in the loss or reduction of other benefits (e.g., Section 8 housing), persons must understand the impact increased earnings will have on these other benefits. Benefits Specialists are available to provide this type of service and planning. They have been trained in the various state and federal programs and are a key piece to successful employment. The Benefits Specialists will also be able to discuss any personal care services (attendant care) available to the individual and make appropriate referrals for such services. To ensure that all Working Healthy eligibles are aware of the service, a referral to the regional Benefits Specialist shall be made for every person working or expressing interest in employment. The decision to cooperate with the Benefits Specialist shall not impact eligibility under the Working Healthy group.

The general eligibility criteria of act in own behalf ( 2110 ), cooperation ( 2120 ), SSN ( 2130 ), citizenship and alienage ( 2140 ), and residency ( 2150 ) must be met.

The assistance planning rules of 4310 are also applicable. LTC and HCBS recipient spouses and parents are not included in the plan. Spouses or parents who otherwise meet the requirements of the MS program (i.e., elderly, or disabled) shall have a separate plan, but are not excluded from the plan nor are Working Healthy participants excluded from the plan of the spouse. Separate case numbers are required if two MS plans exist in the same family group.

Persons convicted of medical assistance fraud per 11221 (3) are not eligible.

Persons must be age 16 or over but under age 65. Coverage may be provided through the end of the month of the individual’s 65th birthday. Persons must also meet the disability/blindness criteria of 2662 . There is no requirement that the person must have actually received Social Security disability or SSI benefits in the past. In addition, a referral directly to DDS may also be applicable per 2662.1 .

Persons determined no longer disabled due to medical improvement may be eligible for continued coverage as per 2665 .

Persons must have verified earned income. For Working Healthy, earned income is income received from wages or self-employment resulting from the performance of services (see 6300 ) which meets the following criteria:

Social Security/OASDI or Medicare Tax Withholding : Evidence of payment or withholding of these taxes must be presented to participate in Working Healthy. These taxes are paid under the Federal Insurance and Contributions Act (FICA). The FICA tax is applicable to the majority of wage and salary payments as employers are required to withhold FICA payments from earned income. Employer letters or statements as well as paycheck stubs may be used to verify FICA withholding. In addition, wages reported on the Kansas Employment Security (KES) ‘BASI’ system also meet this requirement. Generally, the absence of FICA withholding indicates the employer does not consider the individual to be an employee and such income would not be considered earned income for purposes of qualifying for Working Healthy. However, instances exist where wages are not subject to FICA withholding by federal law, such as wages received by a student from the college or university in which the student is enrolled (e.g., a graduate teaching assistant) and certain earnings of a non-resident alien. Eligibility may be approved in these instances if earnings are received and there appears to be an employer-employee relationship. Questionable situations may be referred to KDHE-DHCF Policy Staff for review. Income received in-kind, even if received in return for labor, does not meet the definition. For the self-employed, Social Security and Medicare tax is paid through the Self-Employment Contributions Act (SECA) rather than FICA. Persons claiming self-employment income must have made at least one SECA payment in the past year for the business or self-employment enterprise currently in operation to meet the earned income requirement for Working Healthy. Regular SECA payments must continue to be made and verified for continued eligibility. Verification of payments must minimally be presented annually. There is no eligibility under Working Healthy for a self-employed individual until and unless evidence that the individual is subject to paying SECA taxes is presented. Examples of acceptable proof of SECA taxes includes but is not limited to the following: Tax return including Self-Employment forms filed within the last 12 months (12 months payment requirement can be extended if the current year is not yet due as the tax forms will show the SECA taxes due). NOTE : Individuals that are self-employed are subject to SECA tax payments, however, they may not owe SECA taxes after credits and deductions are applied. Therefore, it is important to note that Working Healthy self-employment criteria is met once the consumer has provided evidence that they are self-employed and subject to SECA taxes. Payment voucher dated within the last 12 months (includes individuals newly self-employed that have not filed the previous year’s tax return yet.

Countable Monthly Earned Income Exceeds the Standard Earned Income Disregard : Countable earned income or self-employment income must exceed the standard earned income disregard of 7240 (2) , currently $65.00 per month. For this test, countable income is determined after all applicable income-producing costs, Impairment Related Work Expenses and Blind Work Expenses have been considered. If there is no remaining income after application of these disregards, there is no eligibility for Working Healthy. Example 1 : The applicant earns $10/week at a local restaurant. Converted gross income equals $43.00 ($10/week times 4.3 = $43.00). No IRWE or BWE expenses are reported. The applicant fails the earned income requirement since countable earned income is less than the $65.00/month earned income disregard. Example 2 : The applicant earns $65.01/month as an occasional night relief clerk at a motel. No IRWE or BWE expenses are reported. The applicant meets the earned income requirement since countable earned income exceeds the $65.00/month earned income disregard.

Minimal Earnings Level of the Hourly Federal Minimum Wage (not applicable to self-employment) : Earned income must be at or above the hourly federal minimum wage. Wages below this level are not considered earned income for Working Healthy purposes. For individuals with multiple jobs, the requirement is met if one position is paid at least he federal minimum wage and countable earnings exceed the standard deduction described above. To find the current minimum wage click this https://www.dol.gov/general/topic/wages/minimumwage then scroll down and click on ‘What is the Minimum Wage?'' NOTE : Earned income that is specifically exempt would not be considered in determining the $65.00 per month countable earned income threshold. However, exempt earned income would be considered in determining the minimum wage requirement. Example : The individual has $300.00 per month earned income that is exempt under the Older Americans Act. That $300.00 could be used to determine if the individual is earning at least minimum wage but could not be used to determine if they meet the $65.00 per month threshold.

Financial eligibility exists if countable resources do not exceed the limit in 5130 and countable income does not exceed the limit in 7430 (4) . Countable income is established per 7240 . Also see 7531 . The methodologies, exemptions, and disregards applicable to the spenddown program apply. In addition, see 5430 (20) regarding retirement funds and 6410 (34) regarding deposits into Individual Development Accounts (IDA). These exemptions are applicable only to the Working Healthy program.

Coverage is established under a spenddown for Working Healthy (WH) program. One month base periods apply [see 7330 (1) ].

Twelve (12) month review periods are applicable. A special income reviews every 6 months to establish the premium amount must also be completed.

Requirements for Current Medical Recipients – When a current Medicaid Recipient becomes eligible for Working Healthy (WH), coverage must be adjusted as follows: For persons moving from HCBS, Working Healthy begins the month following the month HCBS services end (see 8272.2 ). Any HCBS obligation due in the final month would still be applicable. For persons moving from LTC to Working Healthy, coverage is adjusted the month the change occurs. If an existing 6-months base period exists when Working Healthy (WH) eligibility begins. The existing base period is shortened to end the month prior to the month WH eligibility begins. One month bases apply thereafter. If a premium is applicable, the person must actually choose Working Healthy prior to taking action. WH eligibility may be backdated up to three months prior to the month of request, provided all WH criteria are met.

Prior Medical Coverage - Prior medical eligibility per 7330 (2) is available for those meeting the criteria.

Ongoing Eligibility - Eligibility continues until the end of the review period as long as all applicable general, financial, and non-financial eligibility criteria continue to be met, including cooperation with the six-month desk review. The change reporting requirements of the spenddown program apply, and eligibility must be adjusted accordingly, given timely and adequate notice as required except for changes resulting in decreased premium amounts (see 2664.5 ) and persons temporarily unemployed (see 2664.7 )

A monthly premium will be charged for coverage under the Working Healthy group for plans with income in excess of 225% of the federal poverty level for an individual and two-person household or 178% for a three-person household. The premium amount is based on a sliding scale keyed from the poverty level percentage of the assistance plan. The rate is based on net countable income (gross income less disregards). See F-8, Kansas Medical Assistance Standards for current premium levels and rates. Premium levels and/or amounts are adjusted annually based on changes in the federal poverty level guidelines.

Agreement to pay Premium – Individuals eligible for Working Healthy (WH) coverage shall not be approved for any month, including prior assistance requests, until the individual has agreed to pay the premium for all months if a premium is required. The individual shall be given an estimated premium based on net countable income and given the option of Working Healthy (WH) coverage or, if otherwise eligible, the potential of Medically Needy (MDN) spenddown or Medicare Savings Program (MSP) coverage. In some cases, HCBS may also be an option for the individual. To ensure the individual has been informed of the premium obligation, the ES-3165 Working Healthy and Premium Information form may be given to the potential premium payer at intake or sent after an estimated premium has been computed. The individual may sign the form indicating his/her knowledge of the premium, however, submitting the form is not a requirement as verbal acknowledgement of the premium and agreement to pay the premium by eligibility staff, Benefit Specialist, or other agency personnel is acceptable. A note or other written communication is also acceptable. No prior agreement is required for cases without a premium obligation.

Premiums For Prior Periods – Premiums in prior periods are determined based on actual, countable income for the month. Varying premiums may result if income or household size fluctuates between base periods in the prior period. Prior to approving coverage for any prior month with a premium obligation, the individual must agree to pay the premium for all months as indicated in section (1) above.

Eligibility Staff Responsibilities – Eligibility staff are responsible for determining the premium obligation. Any required premium will be entered in the KEES eligibility system and will be communicated to the premium billing vendor through an automated report. The premium billing vendor is responsible for premium billing, collection, and monitoring. Eligibility staff are required to communicate with the premium billing vendor regarding status requests on specific cases. The 1-person assistance plan shall be used to determine the premium level for a single individual. The 2-person assistance plan shall be used to determine the premium level for a married couple (including when only one of them is a Working Healthy (WH) recipient). The 2-person assistance plan shall be used for a child under the age of 18 who is living with one parent, and the 3-person assistance plan if living with both parents. American Indian/Alaska Native recipients are exempt from the premium requirement. These individuals may participate in the Working Healthy program without a premium. The classification of an individual as American Indian/Alaska Native is based on self-attestation and requires no further verification. Premium amounts are not reduced or offset by other medical expenses. Individuals or organizations outside of the family group may pay the premium. Premiums are due monthly, but eligibility is not impacted until the individual is a full 2 months behind in paying the premium amount (see (6) below).

Premium Notices – Monthly premium notices will be sent by the premium billing vendor to all households subject to a premium. The initial premium statement will be mailed on either the 1st or 15th of the month, depending on when coverage is authorized. Subsequent monthly premium statements will then be mailed on the 1st day of the month. For new premium cases, the premium amount for the current period and any prior period will be reflected on the premium statement. The initial billing statement will reflect the current month and any prior months. The premium bill will also reflect past premium amount(s) due, if any. All premium payments are due by the last day of the month. Premium payments are to be sent to the following address: KanCare Premium Billing, P.O. Box 842195 Dallas, TX 75284-2195. Information regarding premium status (current overdue) is available to eligibility staff by accessing the premium billing system.

Premium Changes – As indicated in 2664.4 (3) , all applicable changes must be reported. However, changes increasing the amount of countable income (e.g., amount of income, IRWE or family size) and therefore, increasing, or existing or establishing a premium obligation, shall not be acted upon until the next scheduled 6-month desk review or full review. Changes decreasing the amount of countable income which decrease or eliminate the premium obligation are acted upon effective the month following the month the change is reported. In all other situations, the amount of the premium is not adjusted until the next scheduled 12-month review or 6-month desk review if the premium was correctly determined. Incorrect premiums must be corrected per section (8) below.

Impact on Eligibility - Although premiums are due monthly, non-payment of premiums shall not impact eligibility until the individual is a full 2 months behind in making payment. Once the individual is a full 2 months behind in payments, coverage under the Working Healthy (WH) program shall be discontinued effective the last day of the next month, allowing for timely notice. Individuals may be reinstated without additional action if payment is made which lowers the overdue amount to less than 2 full premiums by the last day of the month of discontinuance. The individual must report payment of the premium to eligibility staff in these situations. Individuals in the assistance plan remain ineligible for Working Healthy (WH) coverage until the delinquency is cured. However, eligibility under other categories shall be provided without regard to the delinquent Working Healthy (WH) debt if all other eligibility factors are met. When a former Working Healthy (WH) recipient requests Working Healthy (WH) coverage be reopened, a check of the premium billing system is necessary to determine if there are overdue premiums before coverage is approved. All overdue premium amounts must be paid in full before an otherwise eligible individual may be reapproved for coverage.

6-Month Desk Review – To redetermine any applicable premium obligation, an income desk review shall be conducted between regularly scheduled reviews. Income Review – Because the purpose of the review is to re-budget income, if necessary, earned income must be verified at the 6-month income review. Other questionable eligibility factors may also be verified at this point, but it is not necessary to routinely verify other eligibility factors with this review. The 6-month review is applicable to all Working Healthy (WH) households, including those eligible without a premium. Coverage is discontinued on the last day of the 6-month period for persons who fail to respond to the request for the 6-month desk review or who fail to cooperate with the process. As with a regular 12-month eligibility review, coverage may continue if the individual is behind no more than two full months of premium payments. Setting the Review – The 6-month desk review shall generally occur 6 months following initial Working Healthy (WH) approval and 6 months following each subsequent full 12-month review. The 6-month period begins with the first month of Working Healthy (WH) eligibility and ends on the last day of the 6th month. The prior assistance eligibility period is not considered when establishing the 6-month period. However, if the regular review period ends prior to the 6th month, the 6-month desk review is waived. For example, the full 12-month review period of an ongoing HCBS case expires 12-31-23. The person converts to Working Healthy (WH) 09-01-23. A 6-month review would not be needed because the regular review will occur before the 6th month (02-2024). Coverage may continue if the individual is behind no more than two full months of premium payments.

Premium Adjustments – The following premium adjustments may be required when the premium amount is incorrect. Overstated Premiums - When the agency determines a premium has been overstated for a prior period, immediate action to correct future premiums shall be taken Adequate notice is required. 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 could not be acted upon timely due to system cutoff dates which resulted in the incorrect premium. Failure on the part of the individual to report a change timely (see 8121) shall not result in an adjusted premium for a prior period. 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 given timely and adequate notice requirements. A claim may be established for prior periods. Overstated premiums can be adjusted retroactively if the individual was given notice of the correct premium amount, and the correction regards a billing issue only. Current or future premiums shall never be adjusted to account for understated or overstated past premiums. All requests for adjustments shall be sent to the Benefits Specialist Team Leader, who will determine if refunds or billing modifications are appropriate to account for the adjustment. All other refund requests shall also be sent to the Benefits Specialist Team Leader.

Premium Payment Hardship – Two months of delinquent Working Healthy (WH) premiums may be waived if discontinuing Working Healthy (WH) coverage creates an undue hardship on the individual. The individual’s financial needs due to unforeseen circumstances must be demonstrated in each hardship claim. Undue hardship exists only if the individual can demonstrate actual, not merely probable hardship. Undue hardship does not exist when payment of the premiums causes the individual inconvenience or might restrict his/her lifestyle. It must put the individual at risk of losing their Working Healthy (WH) coverage due to delinquency per section (6) above. Evidence to Support a Claim of Undue Hardship – The individual must supply evidence to support the claim of undue hardship. The evidence should be directly related to the claim of undue hardship. The individual must demonstrate that he or she would be deprived of medical care, food, shelter, or other necessities of life. Hardship may be demonstrated by documentation of one or more unforeseen circumstances as noted in the following list. Comparable reasons may also be considered, but considerable documentation is necessary and must be approved by the KDHE-DHCF Eligibility Policy Team. Housing – The hardship may be housing related: Consumer is homeless. Consumer is more than 30 days behind in rent or mortgage payment. Consumer has received an eviction or foreclosure notice. Utilities – The hardship may be utility related: Consumer received a shut-off notice from their utility company (gas, electric, oil, water, or telephone). Consumer has one or more utilities shut off, one or more of their utility companies is refusing to deliver services because they cannot pay. Medical Expenses – The hardship may be medical expense related: The individual has medical and/or dental bills that KanCare or another insurance provider does not cover which reasonably prevents them from paying their premium. These bills may be for them or someone else in the immediate family that they are financially responsible for (such as a child or spouse). Hardship Timeframes – To be considered a hardship, the request and documentation must support two full months of delinquent premiums asking to be waived. A single month of delinquent premiums is not considered a hardship as it does not cause Working Healthy (WH) coverage to discontinue. Only one hardship waiver may be granted within a 12-month timeframe. Any additional hardship waiver requests must be approved by the KDHE-DHCF Eligibility Policy Team.

When Working Healthy coverage ends, medical eligibility must be considered under other Medicaid coverage groups. Persons with accumulated resources may not be eligible for continuing coverage. The following action shall apply:

Working Healthy to Independent Living - For spenddown cases, the 6-months period begins the month following the month Working Healthy ends.

Working Healthy to HCBS - HCBS budgeting begins the month HCBS begins. Any applicable HCBS obligation is also determined. Working Healthy premiums paid or owed in the month HCBS begins are allowed against the obligation. If the entire premium obligation cannot be accounted for in the initial month, the bill may be allowed over multiple months until the entire obligation is accounted for.

Working Healthy to LTC - LTC budgeting begins the month following the month of entrance unless Spousal Impoverishment provisions apply. Any premium amount must be paid in full the month the arrangements begin.

Working Healthy recipients who become temporarily unemployed and intend to return to work may remain eligible for a period up to 4 months following the month in which employment ended. Unemployment may be for any reason, but the recipient must provide a clear reason for the unemployment. Continued eligibility during the temporary unemployment period is only provided if the individual is otherwise eligible for Working Healthy. A temporary unemployment period may be granted for an individual who is employed but fails to meet the earned income requirements of 2668.3 (FICA/SECA, minimum wage and earnings tests). This extension is not available to persons whose only employment occurred in a prior medical period per 7330 (2) .

Temporary Unemployment Plan – The individual must have an active Temporary Unemployment Plan (TUP) in place in order to receive continued coverage under this provision. Persons who report becoming unemployed shall be referred to the Benefits Specialist for establishment of the TUP and the individual must cooperate with the Benefits Specialist in this process. The purpose of the TUP is to establish a plan to return to work. The Benefits Specialist has much leeway in the establishment of the plan, as the plan shall consider factors such as disability and job skills. Failure to cooperate with establishment of the plan will result in termination of Working Healthy coverage.

Temporary Unemployment Period – The 4-month period shall begin the month following the month unemployment began. If the individual is cooperating with the Benefits Specialist and all other eligibility factors are met, coverage may be provided through the last day of the 4-month period. Any required review, either an annual review or a six month desk review, must be completed at scheduled intervals during the period. Regular reporting requirements also continue to apply. Persons who have not returned to work at the end of the 4-month period are no longer eligible under Working Healthy, but coverage may be considered under other programs (e.g., LMB, QMB, Medically Needy, etc.)

Impact on Premium Obligation – Any changes to the premium obligation as a result of a change in income are made the month following the month of report. Any new or additional income the individual has begun receiving as a result of unemployment (e.g., disability payments from the employer, Social Security payments, etc.) must be considered in the recalculated premium. However, action to change the premium shall not be delayed in anticipation of a change in income source. The premium will be considered and re-budgeted at the next review, annual or 6-months desk review. The individual must remain current on any premiums during this period.

Gainfully employed persons receiving medical coverage under Working Healthy who are determined to no longer meet Social Security disability criteria because of a medical improvement are eligible for extended coverage under the Medically Improved group if the requirements of this section are met. Like standard Working Healthy coverage, authority for this group is provided under TW-WIIA. Coverage begins January 1, 2005.

All general eligibility criteria of the Working Healthy program as per 2664.1 ) must be met. In addition, only those persons actually receiving coverage under the Working Healthy program at the time the disability terminates may receive extended eligibility. However, persons who were enrolled in another eligibility group as 2664 who were other eligible for Working Healthy, may elect to change eligibility to Working Healthy in the last month of coverage. This is only necessary if it will permit the individual to access ongoing coverage. Annual redeterminations are required ( 9373 ).

Loss of disability status must be based on a medically improved disability. Loss of disability status for other reasons will not qualify an individual for extended coverage. Medical improvement must be documented through contact with Social Security or DDS.

The financial eligibility criteria of 2664.4 are applicable, including the resource and income limits. The premium requirements of 2664.5 and subsections are also applicable.

Persons must meet the earned income requirement as per 2664.3 requiring payment for FICA or SECA taxes [see 2664.3(1) for SECA tax requirements]. In addition, the individual must be earning at least the federal minimum wage and working a minimum of 40 hours per month. Persons earning below these levels are not eligible for extended coverage. The extended coverage provisions of 2664.7 are also applicable. To find the current minimum wage click this link, U.S.Department of Labor , then scroll down and click on ‘What is the Minimum Wage?’

Once the individual is determined to have lost disability due to medical improvement, the agency must also document the individual continues to have a medically determinable severe impairment.

This is determined to exist if a medical professional (doctor, nurse practitioner, or psychologist) documents one or more of the following health conditions:

The individual's disability continues to substantially limit the ability to work or conduct daily life activities;

The individual has a mental or physical health problem that has been stabilized by assistive technology, medication, treatment, monitoring by medical professionals, or a combination of all of these, and loss of medical services may result in a deterioration of the condition;

The loss of medical care could result in the individual's not being able to continue in the workforce or the health problems would regress to the point where the individual would meet the SSA definition of disability, and become eligible for Social Security Disability Insurance (SSDI) payments. The Benefit Specialist is responsible for establishing the level of impairment is met. The level of impairment is reviewed annually.

Upon discovery of a suspected case involving a medical improvement, the individual must be referred to the local Working Healthy Benefits Specialist. The Benefit Specialist will verify the reason for loss of disability status and inform the eligibility worker. The Benefit Specialist will also determine if the individual meets the necessary level of impairment initially and at annual review.

Medical assistance is available to a child or young adult under the age of 21 who is residing in a Medicaid approved institution for long term care. See also 8183 . This includes persons currently residing in a Medicaid accredited psychiatric hospital, including Psychiatric Residential Treatment Facilities (PRTF), or intermediate care facility if under the age of 21 or under 22 if receiving inpatient psychiatric care on their 21st birthday (see 8112.4 ). See 2650 regarding the continuous eligibility requirements for children under age 19. See also 8142 (2) and 8143 (3) regarding the obligation of legally responsible relatives.

Institutional personnel are responsible for determining parental obligation to be paid to a state institution. Staff are responsible for providing state institutional staff with any requested income information available in the individual case record for the purpose of establishing this obligation.

The Qualified Medicare Beneficiary (QMB), Low Income Medicare Beneficiary (LMB), and Qualified Working Disabled (QWD) programs provide for coverage of Medicare premiums and/or cost sharing requirements based on the criteria established below.

Persons who are entitled to Medicare benefits under Part A (including those entitled by reason of enrollment in the premium-paying Part A program) or entitled to Medicare Part B-ID (see 2911 ) shall be eligible for restricted medical assistance without a spenddown if:

Their countable income does not exceed 100% of the appropriate federal poverty level and their countable resources do not exceed the allowable nonexempt resource level of 5130 . See F-8, Kansas Medical Standards , or

The individual entitled to Medicare benefits (as specified above) has an active SSI recipient status with Social Security. (See 2671.3 below.)

In addition to the above criteria, the individual must meet the general eligibility requirements of 2100. The individual does not have to be determined disabled to receive QMB coverage.

If approved for QMB, coverage becomes effective with the month following the month in which action is taken on the individual’s case. QMB coverage cannot begin prior to this month. If there is a break in assistance of one or more months, QMB eligibility may only be reestablished effective the month following the month in which action is taken. The following exceptions apply:

Medicare General Enrollment Period (GEP) : For individuals who apply for QMB during the GEP (January through March) and whose Part A coverage begins the first day of the month following the month of enrollment, QMB eligibility will begin the month following the month of enrollment, if otherwise eligible.

Medicare Entitlement Begins : For individuals who become entitled for Medicare while currently receiving medical assistance, QMB coverage will begin with the first month of Medicare Part A entitlement, if otherwise eligible.

QMB in Another State : Individuals moving to Kansas who were receiving QMB in another state may receive continuous QMB coverage in Kansas if they apply in the month following the month QMB coverage ended in the other state and meet all QMB eligibility requirements for that month.

Review reconsideration period : QMB eligibility may be reinstated without a break in assistance if approved during the review reconsideration period (see 9350 ).

Individuals entitled to Medicare Part A may be eligible for QMB. Most individuals entitled to Social Security or Railroad Retirement benefits through their own account or through a spouse's or parent's account and who are age 65 or older or disabled for 24 months, automatically receive Part A coverage. Some individuals must actively apply for Part A coverage, including those with end-stage renal disease, certain disabled widows and widowers, and former federal, state, or local government employees whose employment became subject to the Medicare tax.

Individuals without sufficient work history may enroll in premium Part A at age 65. For example, individuals receiving SSI aged benefits may be eligible for premium Part A, while those receiving SSI disability benefits only would not.

Kansas is a group payer state, meaning individuals must have actual or conditional Part A enrollment before QMB eligibility can be established. Unlike in Part A buy-in states, enrollment in Part B alone is not sufficient to meet the Part A entitlement requirement for QMB.

QMB coverage may begin no earlier than the first month of Part A entitlement. Documentation of current Part A enrollment, the Part A start date, or documentation of conditional Part A enrollment must be obtained when applicable.

Individuals who are not currently enrolled in Part A but appear eligible and request QMB may have QMB eligibility initially determined if they apply for Part A within an allowable Medicare enrollment period (initial enrollment period, GEP, or special enrollment period.) If proof of conditional enrollment is provided, QMB coverage may begin the first day of the month following the month of Medicare enrollment, if otherwise eligible.

Individuals applying for QMB outside an allowable Medicare enrollment period must be denied until they can enroll in Part A and obtain an entitlement or conditional enrollment effective date.

Enrollment is Part A is not required in order to receive other forms of medical assistance; however, individuals seeking QMB coverage must enroll in Part A.

The income and resource methodologies of the Medically Needy program shall be applicable in determining eligibility with the exception of the 6 month base period rule and the allowable resource standards. Only the needs, income, and resources of the individual and his or her spouse or parent(s) shall be considered. Income, and resource methodologies are not applicable to active SSI recipients that are entitled to Medicare Part A, as they are deemed automatically eligible for QMB coverage on the basis of their SSI recipient status. (See 2671 above.)

Countable income shall be determined using the independent living disregards as specified in 7240 . This would also apply to persons in LTC living arrangements. Only that person's income would be considered including the amount of any income the person is allocating to a community spouse or other family members in accordance with 8243 (4) or 8244.2 . This allocation would not be deducted in determining countable income for QMB purposes. However, if an individual applies for QMB status who is receiving such allocation, the amount of that allowance must be considered in determining this person's eligibility.

Beginning January 1 of each year, the amount of any cost-of-living increase in Social Security benefits provided for that year shall be disregarded in determining QMB eligibility both for applicants and recipients until the new federal poverty level standards are put into effect.

The general resource guidelines of 5200 shall be applicable in determining countable resources. A transfer of resources under the spousal impoverishment provisions of 8144 and subsections would not be recognized in the QMB determination until the resource has been formally transferred.

A one-month base period shall be applicable to QMB determinations in accordance with 7330 (1) . Total countable income to be considered in the eligibility base period shall be compared against the appropriate monthly standard see F-8, Kansas Medical Standards . Eligibility exists if the countable income does not exceed this level and resources are within allowable levels.

Eligibility for QMB coverage shall be determined separately for the qualifying individual except in instances in which there is more than one qualifying person in the family group.

In such instances, a single determination for all qualifying persons would be applicable. If the qualifying individual is a legally responsible person and the remaining family members request assistance (e.g., MA), his or her needs, income, and resources would also be included in that eligibility determination.

If the person's countable income exceeds the poverty level standard, there is no eligibility for QMB coverage. Persons who are not eligible for QMB may, however, be able to qualify for regular medical benefits based on a cash or spenddown determination.

Reserved

Medical coverage for QMB only eligibles is limited to payment of Medicare Part A and Part B premium, deductibles and co-insurance. This applies to Medicare covered services and items covered by Medicaid and those which are not covered by Medicaid. Because of this, it is necessary to complete a QMB determination on persons eligible for full Medicaid coverage. QMB eligibles are subject to Medicaid copay requirements, unless otherwise exempt. QMB coverage is designated on the medical identification card.

Persons who are entitled to Medicare benefits under Part A (including those entitled by reason of enrollment in the premium-paying Part A program) shall be eligible for coverage of Part B premiums only if: