2664.5 Premium Requirement

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.