Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/21/2024
01000 >>> 01410
01400
01410 Disposition of Applications - The purpose of this section is to provide instructions regarding the procedures that follow the determination of eligibility or ineligibility for assistance. Eligibility/ineligibility is certified using KEES procedures. A copy of the Notice of Action is to be sent to medical providers to certify eligibility/ineligibility on medical cases when required.
One of the following case actions must occur within the established time period outlined in 1407.
1410.01 Approval - A notice of approval shall be sent for all programs determined eligible.
(1) Approved - The application will be approved for medical, if automatically eligible, or if determined eligible with respect to all factors including financial.
(2) - Approved - Suspended - If the applicant is eligible with respect to all factors other than financial but there is a spenddown (see 6500), the application will be approved in a spenddown status if there appears to be a likelihood that the spenddown will be met within the 6 month eligibility base period using evidence provided by the client and known to the agency. This is an administrative procedure to meet the application disposition time requirements and to preserve the original application date. However, there is no eligibility until the spenddown is met. See 1412 concerning suspension. The individual will however be enrolled with a KanCare managed care organization (MCO). They will be eligible for any value-added services the MCO provides. A medical card will be issued by the MCO, and claims billed will be applied to the spenddown.
For all individuals enrolled in KanCare, the MCO, will issue a medical ID card. For non-KanCare recipients, medical cards are issued by the fiscal agent.
1410.02 Denial - A denial shall be processed to assure that the applicant is provided with his/her denial notice in a timely manner. A notice of denial shall be sent at the time of denial, clearly explaining the reason for the denial.
(1) - Found Ineligible - A denied application may be reinstated without a new application at any time within the original 45-day processing timeline. In no case does the denial of the application abridge that individual's right to reapply at any time.
(2) - Failure to Provide Required Information/Cooperation - An application shall be denied after a period of 12 days from the date of a written request for information, but no later than 45 -days from the date of application when the applicant has failed to provide required information or cooperate with eligibility requirements. The applicant must be informed in writing of the 12-day standard and the date by which the verification /cooperation must be received.
If the information is subsequently received or the household cooperates within the 45-day application processing time period, the application shall be reactivated and, if eligible, benefits prorated from the date of application. If the information/ cooperation is not received within the above time frames, then the client must re-apply.
(3) - Spenddown - When a spenddown is established for a minor who would otherwise be eligible for CHIP coverage, eligibility staff must ascertain the likelihood that the spenddown will be met. In order to make this determination and prevent delaying CHIP approval, contact with the applicant must be made as quickly as possible. The applicant must be informed of the spenddown amount and given a 12- day notice to respond to the likelihood that the spenddown will be met within the 6-month eligibility base period. If the applicant fails to respond or it does not appear that the spenddown will be met, the application will be denied (or case closed for failure to meet the spenddown) and CHIP coverage will be authorized. In spenddown cases where there is no possibility of CHIP eligibility, the spenddown is established, and the case remains open throughout the base period. At the end of the base period, staff determines if there is a need for further spenddown coverage.
(4) - Another Agency Assumes Responsibility - The agency may dispose of the application if another agency assumes complete responsibility for meeting the applicant's need.
(5) - Cannot be Located - The agency may dispose of the application if the applicant has moved and cannot be located. The agency shall not send a notice of decision.
1410.03 Pending - If a decision cannot be made on an application within the applicable timely processing period because of agency delay, the application shall not be denied. Eligibility staff shall notify the applicant(s) that the application is still pending, and what action must be taken to complete the application process and what date the action must be taken by, or the request will be denied.
1411 Provisions Specific to Medical Eligibility - Suspension of medical benefits does not shorten an established medical eligibility base period and a new application is not required to reinstate assistance within the period. Regardless of the procedure used, medical eligibility shall not be suspended without meeting notice requirements related to adverse action. Benefits shall not be suspended for more than 6 months except in rare cases where there is clear documentation that circumstances have changed so that medical eligibility can reasonably be expected within the next 6 month period. If the case is not to be closed, medical eligibility on a medical only case will be suspended.
1412 Termination of Assistance - Case closures will always be effective the last day of a given month. To protect credibility with medical providers, the termination date may not be changed after issuance of a medical card. However, the date of death will be used for a deceased individual since there are no eligible services after that date.
1413 Reinstatement of Assistance - Medical assistance can be reinstated in the month following the month of closure or suspension if the reason for the closure has been cured by the end of the month following the month of the closure/suspension and all other eligibility requirements are met. The exception to this is if medical assistance was discontinued due to whereabouts unknown (see 7230). If the individual was discontinued due to whereabouts unknown and confirms their whereabouts prior to the end of their review period, coverage shall be reinstated back to the date of termination, unless the consumer reports a change in circumstances that will impact eligibility. If this information becomes known, the agency will be required to act on the information. See 1334.
A new application is not required for reinstatement purposes unless the current review period has expired. However, if the review form is returned within the three month reconsideration period (see 7431), the form can be used to redetermine eligibility.