Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/21/2024
1332
1333 Mandatory Verification - Eligibility staff shall verify the following information prior to approval for initial applicants, when processing a review, or a reported change.
1333.01 SSN - An applicant is required to supply their Social Security Number or verification of application for the required SSN prior to approval of coverage unless the individual claims good cause or qualifies for exemption. See 2033. The reported SSN is then verified using either the Federal HUB or SVES in Tier 1, or through EATSS-SSA in Tier 2. Verification of the SSN does not include a copy of the paper SSN card. Verification of the SSN is a once-in-a-lifetime requirement. For persons without an SSN, they must apply for an SSN and provide proof of application. The requirement to supply and verify an SSN does not apply to non-citizens who would only qualify for a non-work SSN, such as refugees, asylees, and special immigrants.
When an applicant fails to provide an SSN or proof of application for an SSN, he or she may qualify for a Good Cause exception, see 2033.
1333.02 Citizenship and Identity - Persons applying for medical assistance attesting to be a citizen must have citizenship and identity verified as described in 2045. Unless otherwise exempt, this applies to all applicants. This is a once-in-a-lifetime requirement. Information is not requested from the client once citizenship and identity are verified.
This requirement does not apply to the following individuals:
- Current or former SSI recipients
- Current or former Medicare beneficiaries
- Current or former recipients of Social Security Disability benefits
- Children currently in foster care or recipients of foster care maintenance. (See 2045 to address verification once released from DCF custody)
- Children who are recipients of adoption support payments
- Children born on or after July 1, 2006 to a Medicaid recipient as outlined in 2320.
Tier 1 verification includes the Federal HUB.
Tier 2 verification includes Web-IZ. When the Web-IZ is from Vital Statistics, it can be used as proof of both citizenship and identity. Otherwise, it is only proof of identity.
Note: For verification of citizenship and identity, it is acceptable to access the file in Tier 3 to determine if documentation has previously been provided before accessing the Tier 2 sources. Both Tier 2 and Tier 3 must be followed before proceeding to Tier 4.
Tier 3 and 4 verification can include birth certificates and other paper documents. See KDHE Eligibility Policy-Appendix Item A-12 and 2045.
1333.03 Non-Citizenship Status - Qualified non-citizenship status must be verified for persons applying for coverage. Verification is not required for SOBRA but may be necessary to establish the individual is not a qualified non-citizen. Verification is accomplished through the Department of Homeland Security and additional verification steps may be necessary. The SAVE process is used to obtain the information. Verification is not requested for non-applicants.
Tier 1 verification includes the Non-Citizen VLP through the Federal HUB, including subsequent SAVE processes.
Tier 2 includes the manual SAVE process.
Tier 3 includes information available in the case file.
A Reasonable Opportunity period may be granted for persons who fall to Tier 4. The Reasonable Opportunity period is granted only if the individual reports a non-citizenship status that would qualify him/her for medical assistance. See 2047.01.
1333.04 Income - Unless otherwise indicated, income must be verified. See also 6122 (Reasonable Compatibility) and 6120 (Budgeting Method).
(1) Self-employment Income - Self-employment income must be verified. It is verified through either the tax return or the KC5150 Self-Employment worksheet as indicated below.
When the applicant indicates they have filed taxes, a copy of their tax return is required. If it is after April 15th and the applicant has not filed their tax return, the prior year's return may be used if they have filed an extension with the IRS. Verification of the extension is not required.
The KC5150 Self-Employment Worksheet is used to request income and expenses for the 12 months prior to the month of application. This form is generated off-system by staff and mailed locally. It is used in the following circumstances:
a) It is a new business and a tax return has not yet been filed
b) It is an existing business, but the applicant has not (or will not) file a tax return.
c) A change in the amount of self-employment income is reported.
d) The tax return is no longer representative of the self-employment income. The reason for the discrepancy must be clearly documented and is only allowed when there is a definitive change in the amount or type of business. When the applicant indicates their tax return is not representative of the existing self-employment income, both the tax return and the KC5150 Self-Employment Worksheet are required.
(2) Unearned Income - Tier One payer interfaces are used to verify SSA income and Unemployment Compensation. Because this information is directly from the source, the amount verified through the interface shall be used regardless of what has been reported by the applicant.
For unearned income types not verifiable through Tier One, self-attestation is accepted as verification of all unearned income with the exception of the following types:
a) Annuity Income
b) Trust Income
c) Contract Sales
d) Insurance Payments
e) Oil Royalties and Mineral Rights
f) Railroad Retirement
(3) Earned Income – Verification of earned income is required for all individuals. When earnings have not been reported, they are verified against available earned income data sources, as outlined below in section (4).
The Reasonable Compatibility test is used in Tier Two. See 6122 for Reasonable Compatibility. When income is not determined to be Reasonably Compatible and the Both Below is not applicable, the following Tier Three sources are used in the order presented and should always be used prior to requesting verification from the applicant.
a.) Work Number (TALX) - When the Work Number/TALX data is not successful in establishing reasonable compatibility, the income details may be used to verify income reported. Staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. Note: Usually TALX will provide a prospective amount for this purpose, but in some instances, it will use an actual amount (i.e. a sum vs. an average) depending on information provided by the employer, see note on 6122.
b) Hard-copy Wage Verifications - Staff shall review the medical case file to determine if hard copy verification has been submitted by the applicant. This could be in the form of paystubs or a statement from an employer. The date of wage verification must be within the three months prior to the month of application when processing a new application. When processing a review or case change, the income must be from the three months prior to when the initial RC test was run.
c) DCF Images - A manual search of the DCF case records shall be completed for usable images to satisfy verification requirements if a consumer was part of a DCF case for a relevant time period. If verification cannot be obtained from DCF images, proceed to collateral contact.
d) Collateral Contact – Collateral contact shall be made to verify the reported information, when deemed appropriate. If verification cannot be made via collateral contact, proceed to Tier 4 level verification.
e) Request Information - If the earnings cannot be verified using the above methods, Tier 4 verification is used. A request for information is sent to the applicant and "the last 30 days of income" is requested as proof.
(4) Zero Earnings – It is necessary to verify the absence of earnings for all individuals. This is applicable to all individuals who do not report earnings, report non-wage income only, such as self-employment or unearned income, or fail to answer questions about their income. Earned income sources are also checked for children. Even though most children will not have earnings found, this income test is a necessary element of the Both Below Reasonable Compatibility test as outlined in 6122. System interfaces will be checked to verify that no earnings exist. The Reasonable Compatibility Test will be used in Tier 2 to verify that no earnings exist. If no earnings are found in both TALX and KDOL (BASI) the zero earnings are considered verified.
When data sources are not able to confirm the absence of earnings, it is necessary to evaluate if proof of the income is going to be required prior to proceeding. When an applicant’s IBU meets the Household RC test for Both Below and there is no other information, other than income, that is still pending, the applicant is eligible and should be approved for Medicaid without further verifying the IBU income. When Both Below is not applicable, continue to Tier 3 sources and use in the order presented:
a) The Work Number/TALX – When Work Number/TALX returns wage information, staff will evaluate the check dates returned on the Reasonable Compatibility Detail page. If the latest check date is older than 30 days, this is indicative that there has been a change in income. The lack of reported earnings is accepted and considered verified. If the latest TALX check date is within the last 30 days, staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. It is considered current and countable income. If the consumer later contests the use of this income, proof of the end of the income would be required and the eligibility will be redetermined if appropriate.
b) Case File – When KDOL (BASI) wages are returned for the quarter prior to the current quarter, staff shall research the case file for information that may indicate the recent loss of employment. If an explanation is found that substantiates the report of no income, then further research into the KDOL (BASI) wages are not required. The zero earnings are considered verified.
(5) Proof of End of Income
Self-attestation of the end or absence of income is acceptable, with the exception of the following:
a) Individual is a CHIP premium-payer and reports a reduction/elimination of income.
b) TransMed (TMD) or Extended Medical (EXT) recipient reports a reduction/elimination of income.
c) The consumer contests to the use of income found in a data source.
1333.05 Medical Expenses - The amount of any medical expenses used to meet a spenddown must be verified in order to allow it against the spenddown. Failure to verify expenses doesn't disqualify the individual, as eligibility is determined without allowing the expense. Medical expenses for Spenddown submitted through Provider Billing protocols in the MMIS are considered verified if proper procedures are followed.