Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/22/2024
1407
1408 Presumptive Eligibility - (PE) is a process that allows qualified hospitals and qualified entities to determine if an individual is eligible for temporary short-term medical assistance. The PE determination is a simplified process based on information provided by the applicant. Standard application procedures, such as obtaining hard copy documentation, are not required for a presumptive decision. PE grants immediate temporary medical coverage to persons pending their formal application for KanCare. The PE Program is designed for uninsured low-income persons in the following populations:
• Children
• Pregnant Women
January 1, 2014 the Affordable Care Act (ACA) implemented the options for hospitals to self-elect to determine presumptive eligibility and expanded the group for which hospitals could determine. This group includes adults in one of the following groups:
• Low-income Caretakers
• Former Foster Care
• Breast or Cervical Cancer recipients diagnosed through Early Detection Works (EDW)
Presumptive Eligibility for Pregnant Women only covers outpatient ambulatory services related to pregnancy. All other presumptive eligibility groups receive full Medicaid coverage.
Qualified Entities (QEs) eligible to complete PE determinations for the above adult population include all clinics and hospitals. The Presumptive Eligibility determination is final. The applicant household does not have appeal rights regarding the outcome of their presumptive determination.
1408.01 Qualified Hospitals and Qualified Entities - KDHE-DHCF is responsible for certifying all entities qualified to make Presumptive Eligibility decisions. Certain Medicaid enrolled hospitals and Safety Net Clinics have been designated Qualified Entities allowed to make presumptive eligibility decisions.
All entities must complete training and receive certification by KDHE-DHCF prior to making any determinations.
Presumptive Eligibility is determined through the Presumptive Eligibility (PE) Portal. Once entity staff have received training and are deemed certified, they will gain access to the PE Portal.
Qualified Hospital
A qualified hospital is a hospital that
(1) Participates as a Kansas Medicaid provider, notifies KDHE of its election to make presumptive eligibility determinations, and agrees to make presumptive eligibility determinations consistent with Kansas policies and procedures,
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements, and
(3) Has not been disqualified by KDHE.
Qualified Entity
A qualified entity is
(1) Healthcare providers, community-based organizations, schools, head start programs authorized by the state to screen for Medicaid and CHIP eligibility and immediately enroll adults, children, and pregnant women who appear to be eligible,
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements,
(3) Has not been disqualified by KDHE.
1408.02 Qualified Hospital/Entity Responsibilities - Staff at each Qualified Entity/Hospital are responsible for identifying adults, children, and pregnant women who could benefit from the Presumptive Eligibility Program.
Staff will make presumptive decisions as well as inform families of the program. They will also assist families who wish to apply for coverage with completing the KanCare application. This assistance shall include completion and submission of the application, assistance in obtaining supporting documentation, and follow-up with the family to provide support through the application process.
The following processes must be completed by the Qualified Entity when making a presumptive determination:
1. Complete the training program provided by DHCF upon becoming a QE and ensure that new employees are trained.
2. Attend recertification training if mandated by DHCF.
3. Follow all policies and procedures outlined in the PE Resource Manual and training material.
4. Offer PE to uninsured persons accessing services.
5. Confirm through the KMMS that prospective PE recipients are not currently covered.
6. Determine PE based on the information in the PE Portal in accordance with the instructions in the PE Resource Manual and training material and instructions in the PE Portal itself.
7. Assist families in the completion of a KanCare application, which includes providing assistance in obtaining required verifications for application processing; families denied PE should still receive assistance in completion of the KanCare application.
8. Provide the parent/guardian or adult applicant the signed Approval or Denial determination letter Notice and a copy of their application following their PE determination.
9. Provide each parent/guardian or adult applicant determined eligible verification of the coverage start date. This eligibility verification is in the form of an approval letter which includes the approved individual’s name, date of birth, and the date coverage begins. The approval letter is proof of coverage until the individual has their medical card and uses this as proof of eligibility, or the provider must verify eligibility through the KMMS.
10. Inform families in writing and verbally of the reason the applicant(s) was found ineligible for PE coverage and assists the household in completing the formal application process even though the applicant was not presumptively eligible. A presumptive determination is based on household statements and a simplified process which may not have the same outcome as the formal eligibility determination completed by KDHE-DHCF.
11. Educate the parent/guardian or adult that future communication on their KanCare application will be from the KanCare Clearinghouse and provide the parent/guardian or adult with the KanCare Clearinghouse contact information.
12. Provide the family with comprehensive assistance to ensure a successful completion of their KanCare application. This may include contacts with families prior to appointments to encourage them to bring necessary documentation at the time of service, follow-up contacts with the family, assistance in obtaining documentation, and agreeing to photocopy and fax documents to the KanCare Clearinghouse.
13. Meet the performance standards outlined below:
a. 95% of PE determinations are completed accurately,
b. 90% of individuals are offered help from PE staff to complete the full Medicaid application.
c. 85% of approved PE applicants ultimately achieve eligibility through the KanCare process.
14. Maintain a record of PE determinations for 5 years.
15. Maintain client confidentiality.
1408.03 KanCare Clearinghouse Responsibilities - Staff at the KanCare Clearinghouse record the results of each Presumptive Eligibility determination and enter presumptive coverage in the Kansas Eligibility Enforcement System (KEES).
Presumptive Eligibility is determined in the Presumptive Eligibility Portal (PE Portal) and then entered into KEES. The following individual medical subtypes are recorded in KEES:
• PEN/CH – Medicaid Child
• PET/CH – CHIP Child
• PEN/PW – Pregnant Women
• PEN/CT – Adult Caretaker
• PEN/BC – Breast or Cervical Cancer
• PEN/AO – Foster Care Aged Out
The KanCare Clearinghouse is responsible for completing the determination of ongoing eligibility under MAGI programs.
1408.04 Applicant Responsibilities in the Presumptive Eligibility Process - The adult applicant household member is responsible for providing the Qualified Entity staff with household information to be used in making the Presumptive Eligibility determination, see 1211.02. Information provided to each entity for purposes of making a presumptive eligibility determination must be true and correct, see 8410.
1408.05 Period of Presumptive Eligibility - Presumptive Eligibility coverage begins on the date the determination is completed. The approval letter provided to the family by the Qualified Entity shall reflect this date as when the applicant’s coverage begins. Coverage is not provided for days prior to the date on the presumptive eligibility approval letter. The family must complete the KanCare application (and request assistance with unpaid medical bills, if applicable) in order to be determined for potential eligibility for the time prior to the period of presumptive coverage.
Presumptive Eligibility coverage ends the month following the presumptive eligibility determination if a KanCare application is not received.
If the application is received during the presumptive eligibility period, an applicant may continue to receive presumptive coverage until the formal application is processed and a determination of the applicant’s formal eligibility is made.
Children and Adults may only be provided with one Presumptive Eligibility coverage period within a twelve-month period. The applicant must self-declare any prior Presumptive Eligibility coverage to the entity at the time of application. Entities shall check their records to verify Presumptive Eligibility has not been received at their facility. The twelve-month period begins with the month the child or adult is determined eligible for presumptive coverage. For example, Billy is approved for presumptive eligibility on July 10th, 2007. July is the first month of the twelve-month period. Billy cannot receive additional presumptive coverage until July 1, 2008.
Pregnant Women may only be provided one Presumptive Eligibility coverage period per pregnancy.
Presumptive eligibility coverage periods have no impact on continuous eligibility provisions. Continuous eligibility is not applicable until the formal application is processed, see 2310.
The household does not have a right to continuation of benefits upon pending an appeal of the termination of presumptive benefits because the receipt of these benefits is time-limited.