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KFMAM Manual - 11/22/2009  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 a guardian or conservator. 2010.02 Not Legally Incapacitated - For medical applications, the spouse, personal representative, (as defined in KEESM 1522), person with a 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, a signed written authorization from the person for whom they are applying must be obtained. The ‘Appointment of Authorized Agent’ X-3 form, found in the KEESM Appendix may be used for this purpose and must be signed by the applicant and at least one witness. 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 review forms and reporting changes.
The medical representative 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 Social Services 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, but could 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. 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) 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 Kansas Health Policy Authority and SRS. A completed ES-3108 - Appointment of Authorized Agent for Minor must be on record. 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.
e) 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 - Assistance Planning). Refer to 2110 to determine who is eligible to receive medical assistance on the basis of being a caretaker of a child.
Note: Anytime a minor's health, safety, or current medical condition is judged to be at risk, a referral to the Children and Family Services' Protection 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 KEESM 4140 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 Health Care Policy/Medical Policy and Children and Family Services (CFS), a referral may be made to CFS 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 HealthWave Clearinghouse Manger, the EES Field Administrator 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 medical program (e.g., Medicaid poverty level or HealthWave).
(3) The minor is placed into independent living by SRS. In situations where the minor’s needs are being met by CFS or a foster care contractor, the minor can not 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 SRS custody.
(4) The minor enters an approved transitional living program, such as MINK.
(5) The minor has been determined able to act in their own behalf for the TAF program, by the EES Program Administrator in the Regional Office. The minor is then eligible for Caretaker Medical assistance on their own case number.
Eligibility workers in the Regional Offices are responsible for approving the cash application and corresponding Caretaker Medical coverage. The worker taking the action will document in the case log and indicate on the INDA screen, for the medical case, that the minor was allowed to apply on their own behalf for TAF based on KEESM 2112. Once all of the casework is completed, the case is to be transferred to the HealthWave Clearinghouse for case maintenance.
If the minor is already receiving medical assistance, the eligibility worker in the Regional Office coordinates with the Clearinghouse to end participation on the open case before establishing medical assistance on the minor's own case number.
The minor, acting on their own behalf as a result of the new TAF rule, will receive twelve-months of continuous eligibility. Continuous Eligibility applies even if the minor leaves the adult-supervised group living arrangement and the EES Program Administrator determines they are no longer able to act in their own behalf for the TAF program.
At the next scheduled medical review, the minor�s ability to apply on their own behalf is to be reviewed. If the minor has left the adult-supervised group living arrangement and is no longer receiving TAF assistance on their own behalf, they are not automatically eligible for Caretaker Medical under this provision. The minor must be able to act in their own behalf in accordance with the provisions outlined above in order to continue receiving medical assistance on their own case.
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, 7120, and 7200 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 pregnant women and children under the age of 1 who have continuous eligibility under the Medicaid program. 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. 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 - 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) - The Social Security number(s) reported by the client shall be verified by an automated match with the Social Security Administration. To determine whether SSNs are verified, use 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.
(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, a 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 via the SSN-1 form (see KAECSES Miscellaneous Forms Section). See 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 SSN's 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.
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 an 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. 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 7212. 2035 Use of SSN - The agency is authorized to use SSN's 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 - Refer all persons needing to apply for an original or replacement SSN per 2031 to the appropriate local SSA office via the SSN-1 form. (See Miscellaneous Forms Section.) 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 Case Manager 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 KAECSES system automatically once assigned. That ID number must be listed in the following sequence:
(1) - First 2 digits are the State Bendex Code, 17.
(2) - The next 10 digits are the client ID number from KAECSES.
(3) - List all of the digits as one continuous number. Example: 1700112345678. 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. 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. (See KEESM Appendix for SS-5 instructions and SSA addresses.)
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. 2037 Entering SSN's on KAECSES - An SSN initially supplied by a client shall be entered on SSDO even if it has not been verified. If the number is not initially known, the date on the SSN-1 shall be entered.
If the number supplied by the client is later determined to be incorrect through either the BENDEX verification process or the SRS validation process, the SSDO screen shall be updated to reflect the proper number or, if the proper number is unknown, the date on the SSN-1 shall be entered. 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 KEESM 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 HealthWave, only the citizenship or non-citizen status of the child who is the primary beneficiary is relevant for eligibility purposes. 2041 - 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
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 lease 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 HealthWave) benefits is limited to the following groups of qualifying non-citizens who also meet state residency requirements. Documentation requirements are specified in KEESM 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); 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 KEESM 2144 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 is required prior to receiving Title 19 Medicaid coverage for individuals claiming to be U.S. citizens. 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 in foster care or recipients of foster care maintenance
(5) - Children who are recipients of adoption support payments
Note: Newborns born to a Title XIX or XXI recipient are not required to provide the verification of citizenship and identity to initially receive coverage. Verification of citizenship and identity is required at the end of their continuous eligibility period.
Documentation of citizenship and identity may be maintained in paper or electronic format. Electronic records may include databases or other records that meet the requirements of acceptable documentation as further outlined below. When the case file is maintained in a paper format, all documents used to verify citizenship and identity must be recorded on the ES-3850, Record of Identity and Citizenship. For those cases maintained in an electronic format, an electronic version of the ES-3850 is sufficient.
When an electronic case file is converted to a paper case file, the ES-3850 must be completed. For those electronic records which cannot be printed, the ES-3850 must indicate what source was used to verify the information, along with indication of when it was verified.
All documents used to verify citizenship and identity must be recorded in the case file indefinitely per 1602 (8).
Because it is often not clear which poverty level category a child will qualify for at the time an application is received and to prevent pending an application multiple times, staff must ask for citizenship and identity verification for all individuals for whom coverage is being requested. If citizenship and/or identity verifications are not submitted, negative action cannot be taken on a child who would fall into the Title XXI program category of assistance.
Acceptable documents and the hierarchical protocol for obtaining acceptable documents are described in the KEESM Appendix Item A-12. When obtaining documents the following applies.
2045.01 Primary Document - A document that verifies both citizenship and identity as defined in KEESM 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/HealthWave 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. KEESM 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. KEESM Appendix 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/HealthWave 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. 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. 2046.01 Reasonable Opportunity to Provide Documentation - The applicant or recipient must be given a full opportunity to provide verification of both citizenship status and identity 2045. Because of the sequential order in which available documentation is evaluated, several attempts from multiple sources to obtain information may be necessary before the individual is successful in providing satisfactory documentation. The eligibility worker or other staff person as designated locally, shall provide assistance in obtaining documentation. Minimally, this includes checking available interfaces, such as KDHE Birth Records and Kansas Department of Revenue Drivers License, but may include making contact with third parties where the individual is not able to do so. This also includes facilitating a declaration as a final step.
For applicants, if the individual is making a good faith effort to obtain documentation, a final determination shall be delayed until satisfactory evidence is provided, the individual is no longer cooperating, or the individual fails to provide further information. This is the case even though a delay in timely processing may result (see 1405). Assistance is not to be delayed for other members of the assistance plan for whom satisfactory documentation has been provided. When satisfactory evidence is provided, the application date is protected and assistance is based on the original application date.
For current recipients, coverage shall continue at the level determined by other eligibility factors. The recipient is granted a reasonable opportunity period to allow them additional time to obtain and provide the required verification of citizenship and identity. The reasonable opportunity period will continue until the next case review or program change at which time the verification must be provided or benefits are discontinued.
Documentation in the case file regarding any delay in processing or any continuation of benefits is required. 2047 Documentation of Legal Status - 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 2044 may participate.
For the categories listed in 2044, 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 KEESM Alien Information Appendix. 2047.01 Documentation Not Clear - If the appropriate USCIS form does not clearly indicate eligible or ineligible status, the agency is responsible for offering to contact USCIS. The agency does not need to offer to contact USCIS on the non-citizen's behalf when the person does not provide an USCIS document. 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. (Also see instructions in SAVE User Manual.) In these situations, the agency has no responsibility to offer to contact USCIS on the non-citizen's behalf.
While awaiting acceptable documentation, the person whose status is questionable shall be ineligible but the eligibility of the remaining members (if any) shall be determined in accordance with the procedures listed in KEESM 4113. If the non-citizen does not wish to contact USCIS, the family or household shall be given the option of withdrawing its application or receiving assistance without that member. 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 7212 as appropriate. 2047.04 Verification of Alien Status through SAVE - The immigration status of all alien clients must be verified through the Systematic Alien Verification for Entitlements (SAVE) program, which is operated by the Department of Homeland Security (DHS). Detailed instructions on primary and secondary verification procedures are contained in the SAVE User Manual. (See KEESM Appendix A-10) 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 person's 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 SAVE verification queries shall be recorded on the SAVE Verification and Cost Avoidance Report (IM-3120.6) which must be retained indefinitely in the case record along with copies of the immigration status documentation provided by the alien. In addition, in response to a secondary verification request, DHS will attach a copy of a Cost Avoidance Report to the DHS (Form G-845). This report is to be completed and returned to DHS as soon after receipt as possible.
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.
Residence is retained until abandoned or established in another state. When a client notifies the agency of a move to another state with the intent to reside there, the client must be informed in writing that assistance is being discontinued giving timely and adequate notice.
For individuals residing in an institution, see KEESM 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 (including being otherwise eligible for MA/CM except for the prohibition around duplicate payments) or HealthWave. 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 SRS 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 KEESM 8112 for definition of a Medicaid approved institution. 02060 Cooperation with CSE - 2061 Cooperation With and Referral to Child Support Enforcement - As a condition of eligibility in the MA/CM Program, the caretaker who is applying for or receiving assistance shall cooperate with the agency in establishing the paternity of a child born out-of-wedlock with respect to whom assistance is requested or received and in obtaining medical support payments for such caretaker and for a child with respect to whom said assistance is claimed.
See 2066 for effect on eligibility for failure to cooperate. For purposes of establishing paternity, the legal parent is presumed to be the biological parent. For MA CM purposes, for situations in which the alleged father is in the home, but paternity must be established, see 2069. For Medicaid there is no requirement that paternity be formally established as specified in 2069. If the parents were not married, verification methods such as obtaining a birth certificate listing both parents or a statement from the father voluntary acknowledging paternity are acceptable. The prudent person concept shall be used. 2062 Cooperation - CSE is responsible for determining whether the caretaker has cooperated in establishing paternity and/or in obtaining support. EES and/or the Case Manager are responsible for determining whether the caretaker has good cause for refusing to cooperate. Cooperation is defined as: 2062.01 - Appearing at the local CSE 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 CSE objectives; 2062.03 - Forwarding to the CSE unit any support payments received from the absent parent which are covered by the support assignment; 2062.04 - Providing information, or attesting to the lack of information, under the penalty of perjury; and 2062.05 - Establishing an agreement with CSE for repayment of assigned support which was received directly and retained by the caretaker relative and maintaining payments under the terms of such a repayment agreement.
NOTE: Case Managers are to notify CSE of those cases in which there is suspected noncooperation such as when the client retains assigned support. 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. Medical Workers have the ultimate responsibility for determining the validity of good cause claims; CSE and Children and Family Services staff may also be involved in making a recommendation for such determinations to Medical Case Managers.
The caretaker is primarily responsible 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) 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 her whereabouts and where the Case Manager does 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 case manager is responsible for notifying CSE of pending good cause claims and subsequent determinations. On new cases this can often be accomplished at the time initial eligibility is determined. The good cause provisions do not negate the timely referral of absent parent cases to CSE. Once a claim of good cause has been substantiated, it shall be reviewed as often as necessary and at each periodic review.
The case manager shall not deny, delay, or discontinue assistance pending a good cause determination as long as the caretaker has complied 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.
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 Referral to Child Support Enforcement - Referral to Child Support Enforcement - The Case Manager is responsible for referring all absent parent cases (including a deceased parent) to CSE. MA CM Family Medical cases with a non-pregnant participating adult who is requesting or receiving coverage shall also be referred. Families requesting medical coverage only for children may elect to participate with CSE but are not required to be referred. See 2072 for voluntary referrals.
It is the function of the case manager to determine continued absence and the function of the CSE staff to obtain support in behalf of the spouse and/or child(ren).
The following information provides guidelines for ongoing cases related to absence from the home:
One or two indications that the absent parent has given the address of the assistance household as his or her address should be treated only as clues for further agency action. The responsibility rests with the agency and cannot be transferred to the parent in the home. Minimally, there must be an interview with (or documented attempts to interview) the absent parent.
If another address (not just for receipt of mail), is established for the absent parent, then he or she cannot be considered as being in the home without substantial data to establish that he or she is actually living there. Lacking such information, if both deny the absent parent's presence in the home, there must be several evidences substantiating presence in the home on an ongoing and current basis before agency action is taken. Such indicators might include address of the assistance household used at the post office, rent receipts in the name of the absent parent for the address of the household, utility bills for two or more months in the name of the absent parent and paid by him or her, other address of the household used at the time of the absent parent's employment over a period of time. Such documentation must be made before taking further action. Since many low income mothers are unable to obtain credit on their own, the documentation of the mother using a charge account in the name of the absent father is not sound data.
For Family Medical, the referral is an automatic process in KAECSES following completion of appropriate screens including SPRD (Specified Relative/Deprivation/Child Support) and CHSE (Child Support Enforcement Referral) and authorization of the program. Subsequent changes (such as the addition or removal of persons from the assistance plan, suspensions, closures, and inter-county transfers) are also communicated automatically in KAECSES. Referrals and subsequent changes are not made when there is no absent parent or when parental rights have been severed. See the KAECSES User Manual for further information on system processing. 2065 Assignment of Support and Effective Date of Assignment - For Medicaid purposes, an application for or the receipt of benefits shall constitute an assignment of support rights and limited power of attorney to the Secretary of SRS. The assignment includes any accrued, present or future rights to support from any other person that the client may have in their own behalf or in behalf of any family member for whom the client receives assistance. If the client is excluded from the MA/CM assistance plan, the assignment does not pertain to alimony. The assignment of support rights and limited power of attorney will automatically become effective without the requirement that any document be signed by the client. Clients are to be advised of the statutory assignment provisions and to submit to the CSE unit all support received by the client on or after the date of approval. Support is subject to assignment when it is actually received by the client.
The effective date of the automatic assignment shall be the date of approval except when the first eligible month is a future month in which case the assignment shall be effective the first day of the first eligible month.
The assignment applies to court ordered and voluntary cash support as well as medical support for MA CM purposes but only to medical support for Medicaid purposes. Also see 5300. In most instances, an assignment ceases to be in effect the last day of the calendar month for which assistance is received. For instances in which cash assistance stops, but medical continues (e.g., TransMed or poverty level Medicaid), the assignment of medical support continues to be in effect as long as medical assistance is provided.
The client must be advised as to the effective date of the assignment.
For MA/CM purposes, spouse support can include voluntary support, military allotments, support orders and alimony (not including property settlements). Designated spouse support in MA CM is treated as a refund to SRS. Spouse support undifferentiated from and in combination with child support shall be treated as child support. Support paid in kind is exempt under the provisions of 5500 and is not considered in assistance budgeting. Following the effective date of assignment, assigned support is not counted as income except the support which is retained during a period when a sanction for failure to cooperate is in effect shall be counted as income. Back support subject to SRS claim is exempt from consideration. See 5300 & 5500 for other provisions regarding treatment of child support. 2066 Failure to Cooperate - There is no penalty in Medicaid if the caretaker refuses to cooperate unless such person is otherwise eligible for MA CM. In these instances, only the caretaker shall be ineligible for assistance unless he or she is found to have good cause for refusing to cooperate. However, medical coverage under all other categories shall be considered for such a caretaker at the time the penalty is applied (see Policy Memo 99-10-10). No penalty is applied to pregnant women and children continuously eligible under 2301 and 2311.
Because penalties only affect coverage under the Family 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 to the family without other alternatives of support, 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: 2066.01 - There is documented evidence that the person was made aware of the cooperation requirement. Information provided in the approval notice fulfills this requirement. 2066.02 - 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. 2067 Medical Noncooperation - For Family Medical, only the non-pregnant adult caretaker is ineligible until the failure or refusal ceases.
For medical, the above periods of ineligibility also apply to recipients. However, only the non-pregnant adult caretaker is ineligible if he/she is covered under Medicaid. There is no penalty for other members of the assistance plan.
A denial or penalty for failure to meet CSE requirements can be imposed only when the caretaker is referred to CSE and CSE determines the person has not cooperated. This may occur after the case is approved, or if local arrangements are made between Health Care Policy/Medical Policy and CSE, may occur as part of the application process resulting in a denial at initial determination. If a previous finding of non-cooperation exists that was incurred as a result of a required referral which required cooperation, the caretaker must be given the opportunity to cooperate prior to denying assistance. Previous non-cooperation by a voluntary household does not impact future assistance. In the following application situations, the person must be referred to CSE and cooperation established in order for there to be eligibility: a) when a prior determination of noncooperation with CSE is yet unresolved; or b) during the process of paternity establishment of the alleged father in the home per 2069.
If cooperation is established, eligibility shall be reinstated effective the day the individual initially agrees to cooperate and if necessary reapplies for assistance, or reinstated effective the first day of the month in which cooperation is established if there is no break in assistance. 2068 Reporting of Support to case manager - The amount of current support received on each MA CM case is reported to the case manager automatically in KAECSES. The case manager shall determine whether or not there is continuing eligibility if the amount of reported support is treated as nonexempt income. (See 5300, 5500 and 6100.) 2069 Paternity of Alleged Father in the Home (Not Applicable to Medicaid) - For situations in which the father is in the home with the child, paternity must be established when MA EM is requested. This provision shall apply to any instance in which both parents (or the father if the mother is not present) in the home claim(s) he is the father, unless either the father or child is excluded from the assistance plan for reasons other than a sanction or other special provision as referenced in KEESM 4120(4). This provision is not applicable while the child is unborn. See KEESM 4100 and subsections for assistance planning provisions involving paternity. Paternity for this purpose must be established in one of the following ways: 2069.01 - The parents were married at the time of the child's birth. For purposes of this provision, a common law marriage shall not establish paternity; 2069.02 - Paternity has been established through appropriate court action; or 2069.03 - The father voluntarily acknowledges paternity and the mother and father have signed the required papers for a voluntary order. 2069.04 - The father is listed on the child's official birth certificate, issued by Vital Statistics, as the child's father. This provision only applies to children born on or after July 1, 1994. This provision does not apply if either of the following conditions exist:
(1) The mother was legally married to someone else at the time of the child's birth; or
(2) The mother was divorced within 300 days of the child's birth.
In the two above situations, HCP is to make a regular referral to CSE for paternity establishment. These paternities must be resolved by a court.
2070 Expedited Paternity Establishment - If paternity is not established through items (1) or (2) above, an immediate referral is to be made to CSE for paternity establishment. This may occur at the time of initial application or when the father begins living in the home at a later time. Since CSE staff are not stationed in all SRS area offices, each area must establish local procedures and timeliness for assuring that cases needing paternity establishment are treated as a high priority. If the mother and father state that he is the biological father of the child, the Case Manager shall provide notice to the mother and father that they must contact CSE within a prescribed period of time and cooperate in establishing paternity. A copy of the notice and any supporting documentation as established by the area are to be sent to the appropriate CSE Unit. Following this, one of the following actions will occur: 2070.01 - If either the mother or father fails to contact or otherwise cooperate with CSE or chooses not to sign the required paternity related forms, CSE shall promptly notify the Case Manager.
Failure of the mother or father to cooperate in establishing paternity by not contacting CSE or refusing to sign required documents for reasons other than claiming his paternity to the child is questionable shall result in ineligibility for the mandatory filing unit of the child per provisions in 2066.
If the father cooperates, but chooses not to sign required documents because paternity is questioned, he shall be treated as a nonrelative to the child(ren) in question. If she refuses to sign required documents because she states the paternity is questionable, she will be eligible as long as she otherwise cooperates in the establishment of paternity. In these situations, the Case Manager will process the application or ongoing case based on the absence of the father. On the system generated referral to CSE, the Case Manager is to make the notation on the message line of CHSE for the child(ren) whose paternity is in question: "Paternity Referral - Alleged father in the home." This will alert CSE that urgent action is needed for an involuntary paternity action. 2070.02 - If the mother and alleged father contact CSE and, following disclosure of basic information including rights and responsibilities, sign the required paper(s), MA EM will notify the Case Manager that paternity has been acknowledged.
Generally, the process can be accomplished within ten working days. Upon receipt of this notification, the Case Manager is to proceed with the eligibility determination. If the family is eligible for MA CM, the Case Manager is to notify CSE which will enable CSE to take appropriate follow-up action on the CSE case. 2071 Special Case Situations - 2071.01 Legal vs. Biological (Alleged) Father - In these situations 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 CSE pending the eligibility determination. In the contact CSE 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 CSE responds that a voluntary order is obtained, the Case Manager will process the case considering paternity established with the father in the home. However, in most instances CSE's response may be that a legal father exists and a voluntary order is not possible. If the persons do not volunteer or do not follow through with this referral to CSE pending eligibility, or if CSE responds that a voluntary order is not possible, 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 CHSE screen should list the legal father as the absent parent and a narrative message "Paternity Referral-Legal vs. Alleged Father" included. Since this initial process is voluntary, the mother and children are not subject to loss of assistance or penalty prior to approval. However, a penalty is applicable if she fails to cooperate with any CSE requirements following case approval. 2071.02 Minor Parent - If one parent is an adult and the other emancipated or if both parents are emancipated, the case is to be treated as though both are adults and handled as described at the beginning of this section (i.e., screened for paternity establishment, referred to CSE pending eligibility if necessary and penalties applied to the mandatory filing unit for noncooperation). See 2010 for emancipation requirements. Note that this provision does not apply if either parent is able to act in own behalf only through provisions in 2010.
If either parent is a minor and not emancipated, CSE cannot expeditiously process a voluntary order. This is because appointment of a guardian ad litem is required and generally takes considerable time. For these situations (or if paternity is otherwise established by marriage or court order), the case may be approved treating him as the father without a referral to CSE pending eligibility. A referral must be made to CSE at the time of case approval, however, if paternity is not otherwise established. In order to make an electronic referral in these situations, the child should procedurally be coded with a "CA" deprivation cause code on SPRD even though there is no absent parent. The CHSE screen should be completed with information on the minor father and a narrative message "Minor Parent Paternity Referral" included. 2071.03 Single Parent Father - This situation addresses circumstances in which the father is in the home while the mother is absent, and he is unable to document paternity to a child(ren) through marriage or a court order.
If the mother is available (e.g., lives in the community) and agrees to cooperate in the process, or if she is deceased and substantiation of death is readily available, a referral to CSE for paternity establishment pending eligibility is required and handled per general instructions earlier in this section.
If he fails to cooperate, the mandatory filing unit is ineligible. If he cooperates, but does not sign a voluntary order because he questions paternity, he is treated as a nonrelative to the child and can receive assistance only if he otherwise qualifies as a caretaker.
If the mother is not available or if documentation of her death is not readily available, the case is to be processed treating him as the father provided other documentation and/or prudent person judgment would merit such. Upon case approval, the CHSE screen must be completed listing the mother as the absent parent and a narrative message "Single Parent Father" included. The father continues to be required to cooperate or the mandatory filing unit is subject to loss of eligibility per 2066 above.
After the case has been processed either including or excluding persons as appropriate, the qualifying parent(s) continues to be responsible to cooperate in establishing or finalizing paternity as necessary. Failure to do so shall result in ineligibility for assistance per provisions in 2066 above. 2072 Voluntary Referral (Medical, except Family Medical) - All households which include a child whose parent(s) is absent may voluntarily request to be referred to CSE. CSE will help with establishing paternity if not already established, and obtaining support. For medical cases not subject to the mandatory referral per 2064, clients requesting CSE services shall be given the name and phone number of the appropriate contact person in the local CSE office. No automated process is in place for referring voluntary CSE participants.
For MA/CM households, refer to KEESM 2550. Failure to cooperate with CSE does not impact medical coverage except as noted in 2066 for caretakers requesting or receiving medical.
A previous finding of noncooperation by a voluntary household shall not impact future assistance under any program, including delayed processing per 2066.01. 02100 Child in Family for Family Medical programs - There must be at least one child in the home or qualifying under temporary absence provisions of 2110. In order for any family member to qualify, a child must be included in the assistance plan for MA/CM benefits unless the child is: (a) unborn; or (b) excluded as an SSI recipient. When the only child is an unborn, the woman must be verified to be pregnant. See KFMAM 1325.01 for pregnancy verification requirements. See KEESM 4100 for assistance planning provisions for MA CM.
NOTE: Children in state custody placed with a caretaker are not entitled to receive both MA CM medical coverage and foster care medical coverage in the same month. Also, families working with Child Welfare Community Based Service (CWCBS) Providers for the receipt of foster care payments for children who have been placed with them are not entitled to receive MA CM for those children. (See 5500) However, a dependent child of a foster care recipient shall have his or her needs met through MA CM if the dependent child and recipient are living together in a foster family home, the dependent child is not in SRS custody, and other MA CM requirements are met. Please refer to EES Policy Memo No. 01-02-02.
A child must be an unborn child, under 18 years of age, or age 18 and working toward attainment of a high school diploma or its equivalent, including students attending a home school that is registered with the Kansas Department of Education. The person may be considered a child the entire month he or she turns 18, or if pursuing a high school diploma or its equivalent the entire month he or she turns age 19. A person acting in their own behalf per 2010 is not considered a child for MA CM 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 can not be approved when a child's date of birth can not be accurately determined. 02110 Living With a Caretaker - A child must be living in a home with a caretaker. A person must have one of the following relationships to 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. See the KEESM Appendix Section T-6 for illustrations of allowable relationships. 2110.02 - A step-father, step-mother, step-brother, step-sister, 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 - The spouses or former spouses (after marriage is terminated by death or divorce) of any persons named in the above groups.
When a person in the home with a child is considered the father based on statements from the client(s) or other documentation as appropriate, he shall be treated as the father for purposes of the provision. However, if in accordance with the provisions in 2069, he is referred to CSE for a voluntary paternity acknowledgment and he cooperates but chooses not to sign necessary documents because he questions that paternity, he shall no longer be treated as the father and would not be an allowable caretaker based on that relationship. He may qualify as a caretaker based on another relationship to the child, however (e.g., stepparent based on marriage to the mother after the birth of the child).
As long as the caretaker has day to day responsibilities for the care and control of the child, eligibility continues even though the child is under the jurisdiction of a court for probation or protective supervision, or legal custody is held by an agency that does not have physical possession of the child.
Note: There are situations in which the rule that a child must be living with a caretaker will conflict with the mandatory filing unit rule. For example, John applies for TAF for himself and his two sons. Also living in his home is Scott, his children's half-brother, who has the same mother but a different father. The boys' mother and John were never married, even by common law; therefore, there is no caretaker relationship between John and Scott. The three boys are a mandatory filing unit, however, due to their blood relationship. The father is also part of this mandatory filing unit because he is legally responsible for his two sons. In this and similar situations, the mandatory filing unit rules will take precedence over the caretaker relative rules. The assistance plan must include John, and all three boys. 02120 Joint Custody - Joint Custody Situations - In situations of joint custody where a child resides with each parent within a calendar month, the parent who has the primary responsibility for exercising parental control, and has the child over 50% of the time, shall be the qualifying caretaker and may apply for and receive MA CM for that child if otherwise eligible. 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 over 50% of the time 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. 02130 Minor Parent Not Living with Caretaker - A minor parent (including a minor expectant mother or father) who is not able to act in own behalf per 2010 and not living with a caretaker as defined in this section may qualify for assistance provided an adult in the family group is applying for or receiving assistance on the minor parent's behalf. Examples: A minor father living with his child and the child's grandmother (not the minor father's parent) can be eligible even though the grandmother does not qualify as a caretaker to the minor father. A pregnant minor not able to act in own behalf living with her unborn's adult father can be eligible even though the father does not qualify as a caretaker to the minor mother.
NOTE: Anytime a minor's health or safety is judged to be at risk, a referral to Children and Family Services would be appropriate. 02140 Temporary Absence of A Child or Caretaker - A child or caretaker who remains a part of the household, but is, or is expected to be, out of the home for 180 consecutive days or less, shall, if otherwise eligible, qualify to receive assistance. In addition, a caretaker who is out of the home for employment or to fulfill a work requirement shall also qualify as a part of the household regardless of the length of time away. A child who is out of the home for a temporary visit with the non custodial parent and who is expected to return within 180 days shall remain on the custodial parent's medical case and CSE (if MA CM) shall be notified of the absence. A child out of the home attending school or in Job Corps remains a part of the household as long as he/she intends to return to the household, regardless of the expected length of absence. The determining factor in the case of a temporarily absent child shall be the caretaker's continued responsibility for the care and control of the absent child. The determining factor in the case of a temporarily absent caretaker shall be the caretaker's continued responsibility for the care and control of the children remaining in the home.
Note: A child may be out of the home for purposes such as visiting the absent parent or vacation. Even though the caretaker's responsibility for care and control is lost, as long as the absence is less than 180 days, they are still considered a caretaker. 02200 General Program Information for Title 19 - 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 either through managed care entities or by enrolled providers within the scope of their practice as defined by state law and within the scope of services covered by SRS. Specific services for which payment can be made and the proper payment rate (including capitation rates for managed care) are established by the Kansas Health Policy Authority (KHPA) and are reviewed and adjusted periodically. 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 KHPA. The HealthWave Clearinghouse and the local SRS office 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 and the Kansas Administrative Regulations. Licensed or certified medical practitioners determine the necessity of specified medical services, subject to review by KHPA or other SRS personnel. Payments (either capitated payments or direct service payments) are made directly to the provider (vendor) of medical services rendered to individuals certified as eligible. KHPA and SRS contracts with a fiscal agent to process medical claims. The current fiscal agent is Electronic Data Systems (EDS).
Medical programs are funded by the Kansas State Legislature through KHPA. 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 TAF program affect Medicaid eligibility in the children and pregnant women categories while those 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. The MediKan program is directly tied to the GA cash program and authorized through state legislation as well as the Kansas Administrative Regulations. 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, 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 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 or because of loss of the earned income disregards (6 months of TransMed benefits), persons ineligible for cash assistance because of requirements that do not apply to medical, and persons who do not receive cash benefits because of the recovery of an entire grant for overpayment purposes. 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 Family Medical criteria.
(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 150% of the federal poverty level.
(4) - Children ages 1 through 5 whose countable income does not exceed 133% of the federal poverty level.
(5) - Children ages 6 through 18 whose countable income does not exceed 100% of the federal poverty level. 2212 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 Medicaid or HealthWave. 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 60 day postpartum period) and children. Kansas provides coverage for the following groups:
(1) - Pregnant women
(2) - Children up to age 18 or age 18 and working toward the attainment of a high school diploma or its equivalent
(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. 02220 Medical Coverage for Families - 2221 Medical Coverage for Families and Medical Assistance Related to the Cash Program - Medical coverage is available to families with children under the Family Medical program and to certain recipients of cash assistance 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). 2222 Family Medical Coverage (associated with TAF and MA-CM) - Persons meeting the following criteria, whether receiving TAF benefits or not, 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 (2021), not receiving SSI (KEESM 2630), SSN (2031), citizenship and alienage (2040), citizenship and identity verification (2045), and residency (2051) must be met. In addition, the age and caretaker requirements of 2100 and 2110 must be met. The assistance planning provisions of KEESM 4100 are also applicable including the mandatory filing unit rules.
The Fugitive felon (KEESM 2182) and drug related conviction (KEESM 2183) requirements are not applicable to the determination of MA CM Family Medical coverage. 2222.02 Financial Eligibility - Financial eligibility shall be determined using the provisions of 5100 and subsections.
Income to be counted shall either be converted or averaged in accordance with 6112 and subsections. The determination shall be based on income rules, such as the 40% disregard and associated one in four preceding months as outlined in 6222. If the countable income is less than the appropriate financial need standard for the family size (shared or non-shared) the family is eligible provided all other eligibility criteria are met. There is no resource test for Family Medical, unless a nonexempt trust exists (see 4010).
All persons meeting these requirements may receive coverage under this program.
TAF recipients with no income or unearned income only shall be eligible for medical benefits. under the MA CM Family Medical program. This includes TAF recipients who are eligible for a payment of less than $10.00 (see KEESM 1512.5 (1)).
For TAF recipients with earned income, a separate determination is required. In addition, a separate determination of medical eligibility IS also requried for all persons denied TAF benefits, including those denied for failure to complete an interview.
The MA CM Electronic Worksheet (KEESM Appendix Item W-6) or the TAF Change Form (KEESM Appendix Item W-11) are used to calculate MA CM eligibility for those not qualified as outlined above. 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 enforcement 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 for those persons whose TAF cash benefits terminate if the only reason for termination is due to a failure to comply with the reporting requirements of KEESM 9100, the work-related requirements of KEESM 3500, or the Quality Assurance requirements of KEESM 2123 or excess resources per KEESM 5130. The person must also continue to meet financial and nonfinancial criteria. An ex parte redetermination of ongoing eligibility for medical coverage is required for all individuals upon the termination of cash eligibility (see Policy Memo 99-10-10). Medical coverage will continue to be provided during this determination.
Family Medical coverage shall be determined independent of any cash fraud disqualification penalty. Persons otherwise eligible shall continue to receive Family Medical coverage when a cash disqualification penalty is applied.
The Family Medical household is required to report applicable changes within ten days. However, if a Family Medical recipient is also receiving TAF cash assistance and is required to monthly report, changes reported on the monthly report form shall be considered timely even if reported after ten days.
Once financial eligibility is established in the Family Medical program, the continuous eligibility provisions of 2301, 2311 and 2320 are applicable to pregnant women, children and newborns. 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 7442). 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 shall be applied to the initial determination of eligibility and only reconsidered at the next review or request for coverage. If the request for coverage is for children only, the hierarchy shall be applied beginning with level 3.
1) MA CM - Eligibility for caretakers with children should be determined first for MACM, as eligibility for this program can lead to MAWT or MAEM coverage. This includes pregnant women.
2) MAWT/MAEM - If caretakers are not eligible for MACM, determine eligibility for MAWT or MAEM.
3) MP Title XIX - If children or pregnant women are not eligible for MACM, MAWT, or MAEM, determine eligibility for MP Title XIX.
4A) MP Title XXI - If children are not eligible for Title XIX determine eligibility for Title XXI. For families with unpaid medical bills who are likely to meet a spenddown, eligibility should be determined for Medically Needy prior to authorization of Title XXI coverage due to the delayed enrollment of Title XXI eligibility.
4B) Medically Needy - A spenddown should be determined for pregnant women or children who exceed eligibility for other medical programs. In addition, children eligible for Title XXI might be better served by the Medically Needy program if their medical bills occur prior to enrollment in a managed care plan.
In addition, a determination of expedited medical eligibility is initially required for all pregnant women applicants.
02230 Transitional Medical Coverage (TransMed) - Persons receiving Family Medical coverage are eligible for medical coverage for a period not to exceed 12 months when the provisions in this section are met.
FFP is available for the medical coverage of all persons who qualify for TransMed. 2230.01 General Eligibility Requirements - General eligibility requirements of act in own behalf (2010), cooperation (2021), not receiving SSI (KEESM 2630), SSN requirements (2031), citizenship and alienage (2040), citizenship and identity verification (2045), residency (2051), and 02100 child in family must be met. If these requirements are not met, the individual is ineligible for TransMed.
CSE cooperation is not required for TransMed. 2230.02 Other Eligibility Requirements for the Initial 6 Months - Eligibility for TransMed shall be established for the first six-month period for each participating member of the Family Medical assistance plan who has:
(1) - Lost eligibility for Family Medical due solely to a recipient caretaker's increase earnings resulting from increased hours of employment or monetary increase in the amount paid for hours of work. The increased earnings must cause the ineligibility. If there is also an increase in other income since the previous month's budgetary determination, then ineligibility must be shown to result solely from the increased earnings without factoring in the increase in that other income.
NOTE: A person who enters the home with earnings causing the loss of Family Medical coverage will not qualify the family for TransMed since the person with the earnings was not a recipient.
If loss of coverage can be directly attributable to one of the above factors, TransMed eligibility must be established without regard to other reasons the case may have become ineligible for Family Medical coverage.
(2) - Been included in a Family Medical plan in which one or more persons correctly received Family Medical in at least 3 of the 6 months immediately preceding the first month of TransMed. 2230.03 Establishing the initial 6- month Coverage Period - The initial 6-month period in which a family is eligible for TransMed is determined as follows:
The TransMed period begins the first month after the increase in earnings is timely reported, providing for timely notice requirements. For example, a family reports on 9/25 that she has a new job with increased earnings that put her family over the income limit for MA-CM. Because of timely notice requirements, coverage under the MA-CM program terminates effective October 31st. The first month of TransMed coverage is November.
For instances in which it is determined that incorrect MA CM coverage was in place due to failure to report or act on an increase in income, TransMed shall be established based on when the program change would have occurred. For example, a review is recieved on February 10th for a family open on MACM. After verification, it is determined the job began on December 5th. The timely report of this income increase would have been required by December 15th. Therefore, the first month of TransMed coverage is January. 2230.04 Eligibility Requirements for the second 6 months - Individuals who continue to meet the General Eligibility Requirements of 2230.01 shall be granted a second 6 months of TransMed if they meet the following requirements:
(1) The family must submit a signed TransMed review form by the last date of the 5th month of coverage. A HealthWave or other medical assistance review will be accepted in place of the TransMed review form, if the application is received within 45 days prior to the 1st day of the 4th month or later.
(2) The family must report and provide complete verification of their gross income for the first three months of the first 6-month period by no later than the last day of the 5th month of coverage in accordance with section 7442.03. Partial income verification will not be accepted.
(3) Once the family has reported their income, the total countable income for the family must not exceed 185% FPL. (See KEESM appendix F-1 indicates 185% of FPL.) See 6222 for additional information regarding deductions. 2230.05 Establishing the Second 6-month Coverage Period - The second 6-month period will start with the first month after the initial 6 - month coverage period ended (the 7th month of TransMed coverage). The end of the second 6-month period will be the 12th month of TransMed eligibility. Eligibility for TransMed will not extend beyond the 12th month of coverage, although the family may qualify again in the future if all of the criteria are met. The 12 month TransMed period is to be determined by counting only those months in which there is no eligibility for Family Medical (MA-CM) as well as the months for which it is subsequently determined that the family received Family Medical (MA-CM) benefits for which they were not eligible. (See 8000.)
If the TransMed review occurs during or after the fifth month of TransMed coverage, the consumer will be provided with ten days to supply the necessary review form and all income verification for the first three months of the TransMed period. 2230.06 Re-establishing TransMed eligibility - Once TransMed eligibility is established, it can be reinstated at any time during the initial six-month period. However, coverage shall not be granted for more than three months prior to the month of request. If the family is reinstated during the initial six-month period, they may be granted coverage but are still subject to the reporting of the initial 3 months income by the end of the 5th month. Failure to report the first three months income and child care expenses by the end of the 5th month will result in ineligibility for the second six months of coverage. If coverage is ended at the end of the initial six months because the family failed to report their earnings by the end of the 5th month, eligibility for TransMed cannot be re-established, unless the agency can verify that the family's failure to report was due to agency action (e.g. the agency can verify that the income review form was sent to the old address after the family had reported their new address).
If the family returns to receipt of MA-CM during any portion of the TransMed period, TransMed eligibility ceases. If financial eligibility is lost again per 2230.02(1) during the initially established TransMed period, the family shall either be reinstated to that existing period, or if the family can qualify, a new TransMed period is to be set. If the family does not qualify for a new TransMed period and is reinstated to the initially established TransMed period during the initial six-months, they must meet the reporting guidelines mentioned in the previous paragraph. If the family moved from TransMed to MA-CM after having already qualified for the second six-month coverage period and they do not qualify for a new TransMed period, they may be reinstated to the remainder of the second six-month eligibility period. If the family moved from TransMed to MA-CM and then lost eligibility for MA-CM again between the initial six-month period and the second six-month period and they do not qualify for a new TransMed coverage period, the family may be reinstated to the initially established TransMed period if they provide income and child care expense information within 10 days of request and meet the income guidelines of 6410.01.
For example, the family first qualifies for TransMed coverage in January. Their six-month income review is set for June. The caretaker reports that she lost her job on May 10th. TransMed coverage ends on May 31st and the family becomes eligible for MA-CM effective June 1st. On June 20th, the caretaker reports that she is again employed and her earnings are too high for MA-CM to continue. Due to timely and adequate notice provisions, their MA-CM eligibility ends on July 31st. Because they were not on MA-CM for three out of the last six months, they do not qualify for a new TransMed period. The family did not report their earnings from the first three months of coverage because they were going to transition to the MA-CM program. Before the family can be reinstated to TransMed coverage for August, the worker shall request the income and child care expenses for the first three months of TransMed coverage (January, February, and March). If the caretaker provides the information and the income is less than the standard in accordance with section 6410.01, the family will be granted TransMed coverage beginning August and ending December 31st. If the caretaker does not provide the income and expense information within 10 days, the family cannot be reinstated to the initially established TransMed period and coverage for the caretaker would end July 31st. Continuous eligibility for the children, however, was re-established with the first month of MA-CM, so they will continue to be covered through May 31st of the following year. 2230.07 Individuals Leaving or Entering the Home - Individuals who leave the family lose eligibility for TransMed. For a child, eligibility ceases when age requirements in 2100 are no longer met. The following individuals may be added to an existing TransMed case if other requirements are met; however, such persons shall not be granted coverage for more than three months prior to the month of request:
(1) - A person who initially qualified for TransMed with the family in the current period;
(2) - A child (including a newborn) of a current TransMed family member who enters the home or loses SSI; or;
(3) - A legally responsible person of a current TransMed family member who enters the home or loses SSI. 02240 Four-Month Extend 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. (See KEESM 2653 extended medical provisions applicable to RE and MA RM recipients.) 2240.01 - They must be included in an assistance plan in which one or more persons received Family Medical in at least 3 of the 6 months immediately preceding the month in which the person(s) became ineligible for such coverage. 2240.02 - There is ineligibility due solely or partially to the budgeting of support in accordance with 5310.01. 2240.03 - There must still be eligibility without the budgeting of support.
Only members of the coverage family group who were eligible for Family Medical coverage are entitled to the 4 month extended coverage. A newborn child of a recipient mother who qualifies for 4 month extended medical in her own right shall also qualify and would qualify for continuing medical coverage under the newborn provisions of 2320. All other nonfinancial factors of eligibility must continue to be met. Changes of circumstances occurring within the 4 month period will be assessed in terms of continued Family Medical eligibility except for the increased support, and must be reported as stated in 7211.
The 4 month extended period is to be determined by counting only those months in which there is no Family Medical benefit as well as the months for which it is subsequently determined that an incorrect medical benefit was provided. (See 8000.) 02250 SSI - Refer to KEESM 2630 02260 Additional SSI - Refer to KEESM 2637 02270 Medicaid Poverty Level - 2271 Medicaid Poverty Level Eligibles - 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, 150% of the appropriate federal Poverty Income Guidelines; 2271.02 - For children ages 1 through 5, 133% of the appropriate federal Poverty Income Guidelines; or 2271.03 - For children ages 6 through 18, 100% of the appropriate federal Poverty Income Guidelines.
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 Family Medical (MA CM, TransMed, Extended Medical), as eligibility is considered for these groups first. They are applicable to all TAF related children and pregnant women and eligibility for medical assistance shall be determined first for these individuals under the poverty level provisions. Persons ineligible under the financial criteria of these programs may meet the eligibility provisions of HealthWave 21 as well as the MA or MS programs. See 2401 and 2351 and respectively.
NOTE: Persons under the age 19 who are pregnant shall first be determined under the pregnant woman provisions. If ineligible under these provisions, eligibility shall then be determined as a child under either the Medicaid or HealthWave program. 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. 02280 MCD Financial Eligibility - Financial Methodologies - Financial eligibility shall be determined based solely on income. Resources shall not be considered.
For children, the needs and income of the child and his or her natural or adoptive parents, if living together, are to be considered. See the assistance planning rules contained in 3112. Persons age 18 and persons under age 18 who are capable of acting in their own behalf per the guidelines of 2010 shall be determined eligible in a separate plan. A separate case shall be established in these instances. However, for an ongoing recipient 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.
For pregnant women, the needs and income of the woman, the unborn child, and the father of the unborn child, if in the home, are to be considered. In addition, for pregnant minors, the needs and income of her parents if in the home are also to be considered. No other income is to be considered.
A poverty level eligible child shall also be included in the determination of eligibility for other family members who may qualify for another medical program (i.e., HealthWave). In a mixed family group consisting of a pregnant woman and children, separate eligibility determinations will be required. See 3112. However, for families in which there are both Medicaid poverty level and HealthWave eligible children, a single family determination is required.
To be eligible, the total countable income must not exceed the monthly poverty level standards referenced in the KEESM 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 pregnant woman or child is not eligible under this provision but the child may then be eligible for HealthWave coverage. See 2400. 02300 Continuous Eligibility for Pregnant Women - Once financial eligibility is established as of the date the case is processed under any program (including FC, SI, and AS) other than HealthWave, MA (except MA CM, MA WT, & MA EM), or MS (including FC, SI, and AS), the pregnant woman 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. This provision does not apply to women for whom expedited eligibility is established per 1407 but who are later determined to be ineligible because the income used to establish such eligibility was incorrect.
This provision also applies to pregnant women who had been AFDC or RE recipients and lose eligibility under those programs because income exceeds the applicable cash standard and poverty standard.
A pregnant woman who initially qualifies for Medicaid 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 MP 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.
Continuous eligibility shall be provided if eligibility 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, continuous eligibility shall end and the woman 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 woman would once again have to qualify for the poverty level program or another medical program, except as noted above for TransMed.
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.
For persons under 19 eligible under these guidelines, a 12 month continuous eligibility period applies (see 2311 for establishing the 12 month period). If the 12 month period ends prior to the last day of the postpartum period, continuous eligibility also continues. 2301 Postpartum Period for Pregnant Women - Eligibility for pregnant women shall continue through the 2nd calendar month following the month of birth of the child or termination of pregnancy provided the woman is or will be a Medicaid recipient for the month of birth or pregnancy termination (including prior eligibility). This provision applies not only to pregnant women who were MP recipients in that month but also to pregnant women who were eligible under another FFP medical program and lost that eligibility in the month of birth or pregnancy termination due to a change in circumstances (e.g., loss of cash eligibility). All general eligibility factors must continue to be met during the extended coverage period. 02310 Continuous Eligibility for MCD Children - Once financial eligibility is established as of the date the case is processed either under the poverty level, Family Medical (including TransMed and extended medical coverage), or MA CM program, all eligible children in a family group shall be eligible for a 12-month period (see 3100 for assistance planning). If a household contains both Medicaid and HealthWave eligible children, the continuous eligibility period for the Medicaid eligible children shall be extended beyond the 12 months to provide for a family continuous eligibility period. However, if there is not current eligibility 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 either HealthWave or Medicaid shall remain eligible through the family's established continuous eligibility period. Newborns eligible under the provisions of 2320 and pregnant women eligible under the provisions of 2301 shall have continuous eligibility periods established independent of the family continuous eligibility period, as the periods established for these groups take precedence for these individual family members.
When a family contains individuals eligible under any combination of poverty level children, HealthWave, newborn or pregnant women categories, individual continuous eligibility periods may differ. When this occurs, the family continuous eligibility period is established by the continuous eligibility period of the non-pregnant/non-newborn children. If the plan contains only pregnant women and/or newborns the continuous eligibility date of these individuals will determine the family continuous eligibility period, in that order. 2311 Continuous Eligibility Period - Continuous eligibility begins with the first month of eligibility (see 2311 above) in the current review period and continues regardless of any changes in income. Neither a loss of contact per 7230 nor the TransMed income and reporting requirements of 2230.04 shall affect eligibility. Such eligibility shall continue unless one of the following circumstances occurs: 2311.01 - the child turns age 19; 2311.02 - the child no longer meets residency requirements; 2311.03 - the child dies; 2311.04 - the child enters an institution or jail; 2311.05 - the child no longer lives with a caretaker who meets the criteria of 2110; 2311.06 - the child is found to not have been initially eligible; 2311.07 - the family fails to cooperate with any review required prior to the end of the 12-month period in accordance with 7440 (not including the 6 month TransMed reporting requirement of 2230.04). Coverage is to continue during the period in which the review is completed as long as the family is cooperating; 2311.08 - the child becomes eligible for HCBS or for SSI (including eligibility under the protected class see KEESM 2639), foster care, or adoption support assistance; 2311.09 - there is a voluntary request for case closure.
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 child would have to qualify again for poverty level coverage or coverage under another medical program. 2312 New Continuous Eligibility Period - A new 12 month continuous eligibility period is established when one of the following occurs, even if there is a current period in effect: 2312.01 - at review per 7440 provided the family cooperates and remains financially eligible; 2312.02 - when a family becomes eligible for Family Medical coverage (MA CM, TransMed or extended medical benefits);
No other changes in circumstances affect the continuous eligibility period. As such, all other changes are effective at the time of the next review including other changes in income and age changes (excluding children turning age 19). 02320 Continuous Eligibility MCD Newborns - A child born to a woman who is eligible for and will receive medical benefits under the MACM, RE, SSI, HCBS, Medicaid poverty level, FC, AS, TransMed, or 4 month extended medical for the month the child is born (including prior medical) will be automatically eligible for coverage through the month the child turns age 1 provided the requirements below are met. This includes children born to women who are only eligible for emergency services due to citizenship but who are otherwise eligible for one of the above named programs. (KEESM 2691)
Coverage must be requested by the caretaker of the newborn prior to the last day of the sixth month following the month of birth. Coverage requested following this time frame will require a complete determination of eligibility.
The child must live with the mother to receive continuous coverage under this provision. This would include periods of temporary absence as defined in 2140. However, in joint custody situations, the child will only be eligible during the period of time he or she resides with the mother. 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 to provide initial eligibility. Proof of citizenship and identity will be required at the time of the next review. 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, 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 one again have to qualify for poverty level coverage or another medical program, except as noted in 2230 regarding TransMed benefits. See Policy Memo 00-04-02 for treatment of newborns born to mothers in foster care.
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. 02340 Changes in MCD Family Unit - The following provisions apply in determining the continuous eligibility period for children when household composition changes. 2340.01 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 2340.02). 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 2312 when removing a child if the continuous eligibility period for a child is broken. 2340.02 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 3110 - Assistance Planning 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 MP 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 3112) and children previously ineligible due to nonfinancial criteria (e.g., the expiration of a crowd out penalty). A verbal request is sufficient to prompt such action.
(a) If a child is a recipient under the MP or Family Medical programs (including eligibility in another plan) and a request is made to add the child to a current MP plan, the child shall be added to the new plan effective the month following termination on the previous plan. 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 for the family unit on the medical program shall be used. However, the income and needs of any new legally responsible persons added to the plan because of the addition of this child shall not be considered in the determination, as the child is continuously eligible through the end of the new family's continuous eligibility period. Changes in the type of coverage (Medicaid or HealthWave) may result. However, coverage shall continue, under the type of coverage initially established, through the end of the family continuous period if the child fails to meet financial criteria in the new household. A full redetermination which includes consideration of the income of any legally responsible persons, shall be completed at the next scheduled review.
(b) If the child is not a current MP or Family Medical recipient, the child is added effective the month of request. The income and needs of any new legally responsible person(s) added to the plan due to the addition of this child must also be considered in the determination for this child. Income currently budgeted on the case shall be used to determine eligibility for the child in the plan. If the child falls into the HealthWave income range, the additional HealthWave requirements of Health Insurance Coverage (2411) and State Employee Status (2420) 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. Income currently budgeted for individuals already included in the plan shall be used to determine eligibility, including eligibility for months prior to the month of request. Changes in the type of coverage (Medicaid or HealthWave) may result. However, coverage shall continue, under the type of coverage initially established, through the end of the child’s initial continuous eligibility period if the child fails to meet financial criteria in the new household.
In either situation, if the family report a change in income that will potentially decrease the amount of premium obligation or status, the new income amount will be budgeted effective the month after the month the request is made for the new child.
(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 the MP or Family Medical programs, and the family unit does not have an active MP program, a review application shall be obtained. See 2460.01 for requirements to remove a child from the previous case. It the family cooperates with the review 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. The case must be processed by first medical card cutoff in the month coverage terminates to provide for ongoing coverage. If coverage is authorized on or before the last day of the month coverage ends, a HealthWave Change Request Form shall be sent to provide coverage for the following month. However, if coverage is authorized after this day, a gap in coverage will result as a HealthWave Change Request Form is not appropriate.
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 (e.g., the birth of a baby combines two plans previously carried on separate case numbers). 02350 Medical Coverage Related to MCD Children and Pregnant Women (MA) - Medical assistance is available for children and pregnant women who are not financially eligible for Family Medical coverage (MA CM, TransMed or Extended Medical) or SSI 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 an MA determination. 2350.01 Age - The person must be under the age of 19. 2350.02 Income and Resource Methodologies - The income methodologies of 4000 are to be used in determining eligibility for this group. There is no resource requirement unless a nonexempt trust exits (see KEESM 5130). The protected income level is based on the number of eligible persons in the plan and any legally responsible persons (except for SSI recipients) in the family group. Expenses for medical services paid or incurred by the eligible persons or legally responsible family group member are allowable in determining eligibility. (See 6500) 2351 MA - This program covers children who meet the Family Medical eligibility factors. There is, however, no coverage for parents or other caretakers of the child under the MA program. To receive medical assistance they would have to qualify under another Medicaid program (e.g., MP or MA PW for pregnant women, MS for disabled or aged individuals, etc.).
NOTE: The continuous eligibility provisions of 2301, 2311, and 2320 are applicable to pregnant women and children who lose eligibility for Family Medical coverage due to excess income unless eligible for continued medical coverage under the TransMed provisions of 2230 or 4 month extended medical provisions of 2271. Should TransMed or 4 month extended eligibility cease prior to the end of the continuous eligibility period, the provisions of 2301, 2311, and 2320 shall be reinstated.
The following requirements must be met. 2352 Pregnant Women (MA PW) - The pregnant woman portion of the MA program is intended to cover pregnant women who are not financially eligible for Family Medical or under the poverty level program. There is no medical eligibility for the father of the unborn child unless he qualifies for Medicaid in his own right.
The following requirements must be met: 2352.01 Pregnant - The woman must be medically determined to be pregnant. 2352.02 Income and Resource Methodologies - The income methodologies of 4000 are to be used in determining eligibility for this group. There is no resource requirement unless a nonexempt trust exits (see KEESM 5130). The needs and income of the woman, unborn child, and the father of the unborn child, if in the home, must be considered. The protected income level is based on the above individuals. In addition, expenses for medical services paid for or incurred by the pregnant woman and any of the above persons are allowable in determining eligibility. (See 2430) 2352.03 Postpartum Medical Coverage - Eligibility as a pregnant woman ends 2 months following the month of birth of the child or termination of pregnancy provided that the woman was accurately receiving FFP medical the month of birth or pregnancy termination (including prior eligibility).
All general eligibility factors must be met during the extended coverage period. Financial eligibility would continue to be determined as though the woman was still pregnant. Thus, the needs of those persons who would be reflected in the determination while the woman was pregnant would be reflected in the extended period (i.e., the pregnant woman, unborn child, and father, if in the home).
02360 Breast and Cervical Cancer - Refer to KEESM 2693 02400 General Program Information for Title XXI - The HealthWave program is designed to cover children up to age 19 who are not financially eligible for Medicaid and whose countable income does not exceed 200% of the federal poverty level. The child must not be covered under current health insurance nor have access to such coverage if the custodial parent is a state employee. If family income is equal to or greater than 151% of the federal poverty level, a monthly family premium is charged for coverage.
HealthWave 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 through SRS.
The HealthWave program provides health coverage through a network of managed care entities. A capitated payment rate is established by the Kansas Health Policy Authority (KHPA) on a per enrollee basis. The overall scope of services covered in the program is similar to those services provided in the Medicaid program. Both the local SRS offices and the Central HealthWave Clearinghouse share 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 eligibles, etc.) do not qualify for HealthWave and thus a determination of Medicaid eligibility must be done prior to establishing coverage under HealthWave. This includes a spenddown determination (MA or MS) if beneficial to the child.
Coverage under the HealthWave program is not effective until the child is enrolled in one of the applicable managed care plans. See 2470. HealthWave 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 HealthWave 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. 2403 State Psychiatric Hospitals - HealthWave XXI coverage continues through out the month of entrance and the following month, regardless of the anticipated length of stay. HealthWave XXI 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. 02410 Health Insurance Coverage for Title XXI - Current 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 a Health Maintenance Organization 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 HealthWave 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 HealthWave is still pending, the insurance would be considered for eligibility purposes. If this is obtained after HealthWave benefits have been approved, even if enrollment with a HealthWave managed care provider has not yet occurred, eligibility shall continue for the entire continuous eligibility period (see 2450 below) and then terminated if health insurance is still in effect. The same is true if the insurance was present at the time the HealthWave benefits are approved but due to a waiting period, the 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 the Title XXI 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. 02420 State Employee Status for Title XXI - State Employee Status - A child whose custodial parent is a state employee and who has access to the State group health insurance plan for the children shall not be eligible for HealthWave coverage regardless of whether the coverage has actually been taken or when coverage becomes effective (for new employees). This is not applicable to 18 year olds unless the 18 year old or his or her spouse is a state employee. As noted in 2411, it does not matter whether the family can afford the coverage, access to the insurance is what results in ineligibility. This eliminates HealthWave coverage for children of most Kansas State employees and would also eliminate coverage for children of employees of any other states, including Missouri, Nebraska, Oklahoma, and Colorado. Children of most employees of Unified School Districts, other educational organizations, (such as community colleges) and some city and county offices in the state that have elected to participate in the State group health plan are also included in this exclusion and would not be eligible for HealthWave.
NOTE: Some part time and temporary state employees may not be eligible for state health insurance coverage. This will need to be verified before final action is taken. It is the custodial parent who must be the state employee and thus this prohibition is not applicable where only a stepparent, absent parent, or caretaker relative is the employee. 02430 Ineligibility for Medicaid - The family does not have the choice between Medicaid and HealthWave benefits. If the child is eligible for Medicaid, including coverage through the poverty level, Family Medical, (MA CM, TransMed or Extended Medical), MA, or MS 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 HealthWave, 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 MA and MS). 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 Medical Expense Supplement (IM-3105.5) shall be used to obtain medical expenses if a request is made through the HealthWave application as well as information concerning resources which is needed for a spenddown determination. 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 HealthWave determination would not be made until the spenddown decision is made.
If spenddown coverage is not established, HealthWave 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 HealthWave 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 HealthWave eligible in the month of application or are not currently eligible for either Medicaid or HealthWave. Eligibility can be established either through a poverty level or spenddown determination for the prior 3 months. 02440 Premium Requirement for Title XXI - A monthly family premium will be charged for HealthWave coverage beginning at 151% 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 151% of poverty but less than 176% of poverty, a $20 monthly premium is charged. If income is greater than or equal to 176% of poverty, a $30 monthly premium is charged.
Only one premium per family is charged regardless of the number of HealthWave 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.
The HealthWave Clearinghouse administers the premium payment system and is responsible for all necessary billing and tracking of payments as well as providing reports. The family will be billed monthly but premium collection shall not be enforced until a review is completed. At that time any premiums due and owing must be paid in full or the HealthWave eligible children cannot receive further assistance. Such children can also not re-qualify for the program at a later date until any delinquent premiums are paid provided the children continue to live in the family unit upon which the premium was assigned (i.e., the case number in which the premium was assigned). This includes HealthWave children who, based on the yearly review, would be eligible for premium free coverage in the next review period. However, as Medicaid eligibility is not affected by non-payment of premiums, any Medicaid eligible child in the family would still qualify even if there are premiums due and owing from a period in which they were HealthWave eligible.
If a case with overdue premiums that are reflected on the Premium Billing History Report is authorized in error at the time of review, coverage shall remain in effect through the month following the month of discovery to give the client the opportunity to provide payment of the past due amount from the prior period. Upon discovery, notification shall be provided to the family informing them of case closure unless the past due amount is paid in full. The family is responsible for notifying the agency that payment has been made. The premiums must be paid, notification to the Case Manager must be made and the case must be reauthorized by the first medical card cutoff for the second month following the month of discovery, because the HealthWave Change Request Form process is NOT applicable in this situation, even if premiums are paid by the end of the month.
Monthly accountings of premium payments for each family will be provided. At the time of review, payments for a family must be up to date as of the last monthly statement available from the HealthWave Clearinghouse for eligibility to continue. Delinquent payments must be made even if the family is no longer subject to any further premium requirement except for Medicaid as indicated above.
Optional MP reviews occurring prior to the end of the continuous eligibility period when adding other programs to an existing case shall not be completed if due and owing premiums exist on the case. (See 7442.01.) However, if a required review occurs on a case prior to the end of the 12-month continuous eligibility period, any premiums not paid at that point must be made current before eligibility is allowed to continue. Payments should be made by mail and consumers are to be strongly encouraged to not make cash payments at the local SRS office.
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. Any changes shall be made effective with the month following the month of change. However, HealthWave coverage will continue through the end of the continuous eligibility period, even if income falls into the Medicaid range. For example, if a child is being added to a case for June and this action results in a decrease of the premium currently required for the family, the decrease would take effect in July the month following the month the child begins to receive coverage. HealthWave coverage will continue. 02450 Continuous Eligibility for Title XXI - 2451 Continuous Eligibility - Once financial eligibility is established as of the date the case is processed, all eligible children in a family group shall be eligible for 12 month period (see 3110 for Assistance Planning). If a household contains both Medicaid and HealthWave eligible children, the continuous eligibility period for the Medicaid eligible children shall be extended beyond the 12 months to provide for a family continuous eligibility period. Children who subsequently enter a household, request assistance and are determined eligible for HealthWave or Medicaid shall remain eligible through the family’s established continuous eligibility period. Newborns eligible under the provisions of 2311 and pregnant women eligible under the provisions of 2300 shall have continuous eligibility periods established independent of the family continuous eligibility period, as the periods established for these groups take precedence for these individual family members.
When a family contains individuals eligible under any combination of poverty level children, HealthWave, newborn or pregnant women categories, individual continuous eligibility periods may differ. When this occurs, the family continuous eligibility period is established by the continuous eligibility period of the non-pregnant/non-newborn children. If the plan contains only pregnant women and/or newborns the continuous eligibility date of these individuals will determine the family continuous eligibility period, in that order. 2452 Continuous Eligibility Period - Continuous eligibility begins with the month following month in which action is taken to approve coverage. This will be the month after enrollment as described in 2470. Coverage continues regardless of any changes in income. A loss of contact per 7230 shall not effect eligibility. Such eligibility shall continue unless one of the following circumstances occurs: 2452.01 - the child turns age 19; 2452.02 - the child no longer meets residency requirements; 2452.03 - the child dies; 2452.04 - the child enters an institution or jail; 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; 2452.07 - the family fails to cooperate with any review required prior to the end of the 12 month period in accordance with 7330. Coverage is to continue during the period in which the review is completed as long as the family is cooperating; 2452.08 - the child becomes eligible for HCBS or for SSI (including eligibility under the protected class in KEESM 2639), foster care, or adoption support assistance; 2452.09 - there is a voluntary request for case closure.
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 or a review completed and there has been less than a calendar month break in assistance. Otherwise, the child would have to qualify again for HealthWave or coverage under another medical program. 2453 New Continuous Eligibility Period - A new 12 month continuous eligibility period is established when one of the following occurs, even if there is a current period in effect: 2453.01 - at review per 7330 provided the family cooperates and remains financially eligible; 2453.02 - when a family becomes eligible for Family Medical coverage (MA CM, TransMed, or Extended medical benefits);
In addition to the above items, when an application is made for or a review occurs under another program (e.g., food stamp application or review) the application may be used to reestablish eligibility by completing a formal review of the MP program. In such an optional review is completed and the family cooperates and remains financially eligible, a new 12 month continuous eligibility period is established.
Although completing a review is not mandatory in these instances, each case situation shall be evaluated to determine if the family would benefit to complete the formal review. Factors to consider when making a decision include the potential of coverage changes in the future, tracking such changes and the administrative action required to ensure proper continuous eligibility is established. However, the ultimate decision will be based on whether it is in the family’s best interest to complete the redetermination, which it will be in most situations.
For example, a family consisting of two Medicaid children with income at 80% of the poverty level applies for food stamps in 11-00. The family continuous eligibility period runs through 04-01. The family’s income remains consistent with the amount previously budgeted for the MP determination. In this case, it is in the family’s best interest to complete a redetermination of the medical program and extend the family’s continuous eligibility period.
If the family remains eligible based on an application for other programs benefits or a review occurring prior to the end of a current 12 month continuous eligibility period, but the income determination results in a change in category from HealthWave to Medicaid or vice versa, the family shall continue HealthWave or Medicaid coverage until the end of the original continuous eligibility period. The new category would then be established for the remainder of the new continuous eligibility period.
All other changes are effective at the time of the next review including changes in income, age changes (excluding children turning age 19), a child becoming insured, or a child's parent becoming a State employee. In addition, closure of a TAF or FS case would not alter the continuous eligibility period. See 2510 for children who become pregnant. 02460 Changes in the Family Unit for Title XXI - 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 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 - Assistance Planning 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 MP 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 3112) and children previously ineligible due to nonfinancial criteria. A verbal request is sufficient to prompt such action.
(a) If a child is a recipient under the MP, or Family Medical programs (including eligibility in another plan) and a request is made to add the child to a current MP plan, the child shall be added to the new plan effective the month following termination on the previous plan. 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 for the family unit on the medical program shall be used. However, the income and needs of any new legally responsible persons added to the plan because of the addition of this child shall not be considered in the determination, as the child is continuously eligible through the end of the new family's continuous eligibility period. Changes in the type of coverage (Medicaid or HealthWave) may result. However, coverage shall continue, under the type of coverage initially established, through the end of the family continuous period if the child fails to meet financial criteria in the new household. A full redetermination which includes consideration of the income of any legally responsible persons, shall be completed at the next scheduled review.
(b) If the child is not a current MP or Family Medical recipient, the child is added effective the month of request. The income and needs of any new legally responsible person(s) added to the plan due to the addition of this child must also be considered in the determination for this child. Income currently budgeted on the case shall be used to determine eligibility for the child in the plan. If the child falls into the HealthWave income range, the additional HealthWave requirements of Health Insurance Coverage (2411) and State Employee Status (2420) 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. Income currently budgeted on the case shall be used to determine eligibility for months prior to the month of request. Changes in the type of coverage (Medicaid or HealthWave) may result. However, coverage shall continue, under the type of coverage initially established, through the end of the child’s initial continuous eligibility period if the child fails to meet financial criteria in the new household. In either situation, if the family report a change in income that will potentially decrease the amount of premium obligation or status, the new income amount will be budgeted effective the month after the month the request is made for the new child.
(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 the MP, or Family Medical programs, and the family unit does not have an active MP program, a review application shall be obtained. See 2460.01 for requirements to remove a child from the previous case. It the family cooperates with the review 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. The case must be processed by first medical card cutoff for the month following the month coverage terminates on the original case number to ensure ongoing coverage. If coverage is authorized on or before the last day of the month coverage ends, coverage is continuous and no additional action is necessary. However, if coverage is authorized after this day, a gap in coverage will result as a HealthWave Change Request Form is not appropriate.
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 (e.g., the birth of a baby combines two plans previously carried on separate case numbers). 02470 Other Issues - Other issues affecting HealthWave 21 include the following:
Effective Date of Coverage - In contrast to the Medicaid program where coverage generally begins as of the month of application, HealthWave coverage begins when the child is enrolled with one of the appropriate HealthWave managed care provider networks. This occurs the day following the day in which action is taken to approve coverage. There is no prior medical eligibility in the HealthWave program so any coverage for months prior to the effective date of enrollment would have to be determined through the Medicaid program. Retroactive enrollment is allowed for certain newborns. See 2500.
The enrollment process is automated and will be administered by the HealthWave Clearinghouse.
A timely processed review will allow for continuation of coverage, including retroactive coverage in some instances. Timely processing occurs when a coverage indicator is received by the fiscal agent on or before the last working day of the month following the review month. Coverage will lapse for reviews processed after this date unless the review application was received on or before the last day of the month a review is due, in which case a HealthWave Change Request Form is needed. 02480 Financial Methodologies for Title XXI - Financial eligibility shall be determined based solely on income. Resources shall not be considered. The needs and income of the child and his or her natural or adoptive parents, if living together, are to be considered. See the assistance planning guidelines contained in 3111 and subsections.
Persons age 18 and persons under 18 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.
For families in which there are both Medicaid poverty level and HealthWave eligible children, a single family determination is required. To be eligible, the total countable income must not exceed 200% of the federal poverty level guidelines. See the Standards section in the Appendix. A one month base period shall be used in accordance with 6311. 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 - If a HealthWave (HW) XXI mother has a child, the child is eligible for HW XXI 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 HW XXI mother is not eligible for 12 months continuous coverage and eligibility will be reviewed at the time the annual review for the case is completed. If the newborn is ineligible at the review, coverage will end; otherwise, the child will be covered under Title XIX or Title XXI, whichever is appropriate. 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 HealthWave or Medicaid as before the addition of the newborn. If adding the newborn reduces or eliminates the premium, the change is effective the month following the month of birth. 2502 - A HealthWave Change Request Form is to be submitted at the time of the birth of a child meeting these provisions so that the child may be added to the managed care roster as quickly as possible, including any retroactive months. The referral is to contain the name of the child, client ID for child, case name, case number, and date of birth. If the MCO notifies the HealthWave Clearinghouse of the birth of a child, the Case Manager will subsequently be notified. If the child is born to a HealthWave XXI recipient mother, action shall be taken immediately to add the child to the case. This notification will contain all necessary information to add the baby. 2503 - An eligibility determination is required for all other newborns including newborns that have HealthWave XXI siblings. If the newborn is being added to a case with an open MP or MA CM program, the child shall be added according to 2460.02. If the request for coverage is received timely as outlined in 6311 and the newborn is determined to be HealthWave XXI eligible, the child shall be added according to 2470. No retroactive coverage is provided to a newborn eligible for HealthWave XXI unless the mother is already enrolled in HealthWave XXI. If adding the newborn to the HealthWave XXI case reduces or eliminates the premium, the change is effective the month following the month of birth. If there is no current open medical program for the family, a new application is needed. 02510 Pregnant Women - If a potentially HealthWave 21 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 HealthWave guidelines. If eligible only as a HealthWave child, a referral must be sent to the HealthWave Clearinghouse for cases maintained in the SRS offices to inform them of the pregnancy. This needs to be done as quickly as the information is known as the managed care capitation rates are higher for pregnant women. The referral needs to include the name of the pregnant child, client ID for child, case name, case number, and expected date of birth. See Policy Memo 99-10-12.
For children who meet the Medicaid pregnant women guidelines, eligibility will be reestablished at the end of the postpartum period in accordance with 2301.
If not eligible, no further assistance would be provided to her and the remaining children would continue eligible for the remainder of their current continuous eligible period.
For an ongoing HealthWave eligible child who becomes pregnant, the child would continue to be covered under the HealthWave program until the end of her continuous eligibility period. A Medicaid pregnant woman determination would be required at the time of the next review for the child and if eligible, coverage shifted to Medicaid. 02520 Child Support Enforcement - There is no requirement to refer a child eligible for HealthWave XXI to CSE 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 HealthWave XXI child where there are no Medicaid eligible siblings and should be directed to the local CSE staff if such a request is made. In these instances, a system generated referral shall not be used. 02530 Third Party Resources - A third party is an individual, institution, corporation, public or private agency (other than the applicant/ recipient or the Department of SRS) 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 HealthWave 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 law suits which might establish such a liability.
NOTE: Once verified, 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. 2531.01 - Inform the Medical Subrogation Unit in writing of failure of Medicaid consumers to utilize such third party liability or of pending law suits, insurance settlements, etc. which might establish such liability. This is not applicable to HealthWave. The Medical Subrogation referral form (Injury) shall be used to notify the unit. (See the KEESM Appendix.) 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 HealthWave. The Medical Subrogation referral form (Adoption) shall be used for this purpose. (See KEESM Appendix.) 02540 Health Insurance Premium Payment System (HIPPS) - Based on federal law, States are permitted to purchase employer-based health insurance 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 HealthWave. Thus all employed medical recipients are impacted including those in the medical only programs such as MA, TransMed, and the Medicaid poverty level programs. Families receiving coverage with HealthWave 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 noneligible 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 CSE. 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 nonlegally 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 SRS. 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/MediKan 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.
The Health Insurance Premium Payment System has been developed jointly by SRS 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 not 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. 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. 02550 HIPPS Referral - Referral Process - Staff should send HIPPS referrals in instances where SRS 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 CSE 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 CSE 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. 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. 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 5500.
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. 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 kind 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. 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 MA CM purposes, if the individual is a parent or other caretaker, only that individual would be rendered ineligible. For all medical-only programs including SI, MA CM, 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. 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. HealthWave 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 HealthWave 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. 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 SRS, including Medicaid, MediKan, HealthWave 21 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.
The NOPP must be sent to each household approved for health care coverage. An additional NOPP must be provided when a new participant is added to the plan, including newborns. Participants with a break in coverage of 12 months or more shall also be sent a new notice.
For additional information regarding the requirements of HIPAA, including an explanation of the referenced disclosure requirements or a definition of protected health information refer to Administrative Procedures Manual #1500. For a copy of the NOPP, see the KEESM Miscellaneous Forms Section.
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