Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 4/18/2024
01000 >>> 01400 >>> 1408 >>> 1408.02
1408.01
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.