Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/21/2024
06000
07100 Household Responsibility to Report - Households receiving medical assistance are required to report changes. The specific reporting requirement is determined by the program and the circumstances of the household. There are no additional reporting requirements other than those listed in this section.
7110 Household Responsibility to Report Changes Prior to Approval - Applicants (includes new applications and applications filed after a break of one or more months of assistance) must report all changes of circumstances prior to case approval. The change must be reported within 10 calendar days from the date the change is known. The eligibility worker is responsible for requesting or otherwise obtaining other information or verifications necessary to determine the individual's eligibility for any month.
7120 Household Responsibility to Report Changes After Approval - Medical assistance households are required to report certain changes in circumstances as discussed in this section.
All households are to be notified of the appropriate reporting requirements upon approval for assistance.
7130 Reporting Requirements - Medical assistance households are required to report certain changes in circumstances within 10 days from the date the change becomes known to the household. See subsection 7130.02 below for the definition of "becomes known to the household."
7130.01 Change Reporting Requirements - The change reporting requirements for the Family Medical assistance programs are listed below:
(1) - Changes in the source of earned and/or unearned income.
(2) - Changes in the amount of earned and/or unearned income.
(3) - Changes in household composition, including marital status (marriage, separation, or divorce), as well as people moving into or out of the household.
(4) - Changes in residence, including moving into or from an institution (i.e. jail/prison) or hospital.
(5) – Changes to any third party insurance plan or entitlement/termination of Medicare coverage.
Reporting changes is necessary for all household members including children. Households may report a change in their circumstances by telephone, in person, or in writing. Changes in circumstances other than those listed above are not required to be reported until review.
7130.02 Becomes Known to the Household - As indicated in section 7130 above, the household must report changes within 10 days of the date the change becomes known to the household. For purposes of this provision, "becomes known to the household" is defined as:
(1) Change in Source of Earned Income - The change is known to the household upon receipt of the first pay check.
(2) Change in Earned Income Amount - The change is known to the household on the last day of the month of the change.
(3) Change in Source of Unearned Income - The change is known to the household upon receipt of the first payment.
(4) Change in Unearned Income Amount - The change is known to the household when the payment is received.
(5) Change in Household Composition - The change is known to the household the day the individual enters or leaves the household, the date of marriage, separation, or divorce.
(6) Change in Residence - The change is known to the household the day the individual moves.
(7) Entitlement to or Termination of Medicare Coverage or a change in a Third Party Insurance plan - The change is known to the household on the effective date of the change.
7140 Processing Reported Changes - When the agency receives information that a change has occurred, the eligibility worker shall act on the change within 10 days after the date the change is reported or becomes known the agency (1334) by taking the following actions:
(1) Document in the case file the reported change, the date the change occurred, and the date the change was reported;
(2) Determine if verification or additional information is required;
(3) Contact the household to request needed information or verification as soon as possible;
(4) Changes are effective the month following the month of the change, given timely and adequate notice requirements, with the exception of income changes that are reported at the time of a request to add a new individual.
(a) Households reporting changes which would result in a change in benefits must provide any required verification within 12 days of the date of agency request. No change in benefits shall be granted if the household does not provide the required verification. If no verification is required or if the verification required is received within 12 days from the date of verification request, the change in benefits are to be granted effective the month following the month the change is reported. If the verification is received after 12 days from the date the verification was requested, the change benefits would be effective the first month following the month the verification is received.
(b) Changes resulting in ineligibility or a decrease in benefits shall effect eligibility the first month possible considering timely notice requirements.
(c) When processing an income change along with a request to add coverage for a new individual, the new income must be verified and used in the month of request. This allows the income to be used in the determination for the new person and is also applicable to the rest of the household members in that month. This could result in a change in coverage or the reduction or removal of a premium obligation in the month of report when applicable.
(5) If an automated system action occurred on the case prior to a worker becoming aware of the change, the worker must evaluate the effect of the change to determine if any incorrect payment occurred as result.
7150 Notices to Households - The agency shall provide the household with the following notice based on the change in assistance:
(1) Timely and Adequate Notice - The agency shall provide the household with a notice of action that meets the definition of timely and adequate notice (as defined in 1422.01) if the household's benefits are being reduced or terminated.
(2) Adequate Notice - The agency shall provide the household with a notice of action that meets the definition of adequate notice (as defined in 1422) if benefits are being increased.
7160 Failure to Report - If the agency discovers that the household has failed to report a change, as required in 7100 and, as a result, received benefits to which it was not entitled, a claim shall be filed against the household. The household is entitled to a timely and adequate notice of adverse action if the household's benefits are reduced or terminated.
A household shall not be held liable for a claim because of a change in household circumstances which it is not required to report in accordance with 7100. Individuals shall not be disqualified for failing to report a change unless disqualified in accordance with fraud disqualification procedures.
07200 Whereabouts of Recipient Unknown -
7230 Whereabouts of Recipient Unknown - In instances when the agency does not know the whereabouts of a recipient, the agency should attempt to confirm the consumers’ whereabouts through available methods of research, including (as best practice) contact with the consumer via phone. If updated information is not located, coverage may be discontinued for all non-pregnant adults on the case regardless of continuous eligibility allowing adequate notice only. The Notice of Action is to be sent to the last known address. See 1423.06.
Coverage shall not be terminated for continuously eligible children or pregnant women according to provisions of 2300. If the agency becomes aware that residency requirements of 02050 are no longer met coverage shall be terminated.
7330 Reviews - All categories of assistance require periodic review. At the expiration of the review period, entitlement of benefits ends. Further eligibility must be determined through the review process. Depending on the type of assistance received and the circumstances of the case, the review may be either passive or non-passive. A non-passive review is based on a new application or review form and verification is required.
The purpose of the review is to give the client an opportunity to bring to the attention of the agency his or her needs and to give the agency an opportunity to re-examine all factors of eligibility in order to ensure coverage and eligibility levels continue to be correct. In the process, the appropriate review form shall be used along with the rest of the agency record.
The following review types apply:
7330.01 Passive Review - Passive Review - A Passive Review is a review where information known to the agency is used to make a new eligibility determination for an individual due for review. Eligibility is redetermined and reauthorized without worker involvement. The member receives notification outlining the information used for the redetermination. The member is required to inform the agency of any changes or incorrect information used in the determination. If the recipient has no changes to report, the review process is complete. If the recipient contacts the agency (either orally or in writing) with updated information based on receipt of the review notification, action is taken to update the case. See 7421 regarding passive review responses.
If a person qualifies for a passive review but is in the same household with members with a pre-populated review type, or if the data used at passive review will result in coverage on a lesser program, or a change between CHIP and PLN, a pre-populated form will be sent to give them the opportunity to report changes. If the form is not returned, the members with the passive type will be approved using the information in the system.
If a person over the age of one receives a pre-populated review due only to a missing SSN, and the SSN is provided, the person may be administratively (manually) reviewed using the rest of the information on file in absence of a review form. Likewise, if it is identified that a person received a pre-populated in error due to a citizenship record changing to an unverified status when it had already been verified, the pre-populated form is not required. They may be reinstated if necessary and administratively reviewed and approved using the information on file.
1. The following programs are eligible for a passive review due to the program type without any other qualifications:
- Deemed Newborns.
- Aged Out Foster Care.
2. All other programs must meet the following qualifications, as indicated, to be eligible for a passive review:
In order to qualify for a passive review, when earned income exists it must meet reasonable compatibility under the automated RC test completed by KEES. When unearned, countable income from Social Security (SSA) exists, it must be within $5.00 of the amount found on the SSA data source. In addition, each of the following program types may be subject to a passive review when specific criteria are met:
- Medically Needy (MDN) – There is no self-employment or earned income, countable resources are less than 85% of the limit, and the status of the Spenddown is ‘met.’
- Caretaker Medical (CTM), TransMed (TMD) and Extended Medical (EXT) – Earned income is reasonably compatible, there is no self-employment, there is no discrepancy in the tax information for the household member(s) due for review, and individuals do not move to a Protected Medical Group, Working Healthy, Medically Needy, or MSP program.
- Poverty Level Pregnant Woman (PLN/PW) – Passes the income test and passes reasonable compatibility.
- Poverty Level Pregnant Woman Under 19 (PLT or CHIP) – Income is reasonably compatible and does not contain self-employment income.
- Poverty Level Newborns and Children (Medicaid and CHIP) – Income is reasonably compatible and does not contain self-employment income.
7330.02 Pre-Populated Review - A pre-populated review is required for all other situations where a passive review isn’t sent. A notice of expiration of the review period is sent along with a generated pre-populated review form for completion and return. The forms are generated based on information that is contained within KEES.
Recipients are required to update the form with new or changed information and return to the agency. Failure to return the review form will result in discontinuance of coverage for all members with an individual pre-populated review type. Any members who qualify for an individual passive review may not be discontinued for failure to return the review form but will instead be passively reviewed by the system when a pre-populated review is not returned.
7331 Notice of Expiration - A notice of expiration of the review period shall be sent to each household subject to a pre-populated review as described in INVALID LINK - Please ensure that there is a "^" after the section number and the section number you are trying to link to is currently active.. A notice of expiration of review is not required for passively (7330.02) or super-passively (7330.01) reviewed households. The agency shall provide a pre-populated review form with the notice of expiration. When a review is required and it is known that the recipient is temporarily visiting away from his or her residence, the notice of expiration and review form should be mailed to the temporary address.
The notice of expiration and pre-populated review form shall be mailed to the household on or about the 15th of the next to last month of the review period. This gives the household approximately 30 days to complete and return the review form to the agency (see 7410).
NOTE: The notice of expiration provides timely notice of the ending of benefits; therefore, further timely notice is not required to affect benefits for the start of the new review period.
07400 Client Requirements for Timeliness - Reviews -
7410 Review Form - As indicated in 7331, households subject to a pre-populated review shall be given a minimum of 30 days to return a required review form. The review form shall be mailed to the individual on or about the 15th of the next to last month of the review period. To be considered timely received, the signed review form (see 1409.01) must be returned to the agency by the 15th of the last month of the review period. If the review form is not timely received, coverage will be automatically discontinued the evening of the 15th with an effective date of the last day of the last month of the review period, see 7431.
7410 Review Form - As indicated in 7331, individuals subject to a pre-populated review shall be given a minimum of 30 days to return a required review form. The review form shall be mailed to the individual on or about the 15th of the next to last month of the review period. To be considered timely received, the signed review form (see 1409.01) must be returned to the agency by the 15th of the last month of the review period. If the review form is not timely received, coverage will be automatically discontinued the evening of the 15th with an effective date of the last day of the last month of the review period, see 7431.
7410.01 Using an Application Form as a Review - An application form shall be used as the review in the following circumstances:
- Received within two months prior to the Review Due month.
- Received any month after the Review Due month through the current month when the Review Discontinuance Batch has not been run.
The application is used to complete the review when all members of the household are listed on the application. The application must be reviewed for consistency with the known case information. If additional information is needed to process the review, it shall be requested from the consumer, but another application form or review form is not required.
It is not necessary for the applicant to have requested coverage for all household members on the application. If individuals who are due for review, are listed on the application form, it is assumed that they wish for coverage to continue, and the form shall be used as a review for them. If the form does not include all household members, it shall be used to determine eligibility for the newly requested individual. If the Review Due date is in the past, manual action shall be taken to discontinue the remaining household members for failing to return their review.
7410.02 Continuation of Coverage Pending Completion of Review - When a review form is timely received (see 7331) and registered before the change processing deadline, eligibility at current levels will continue automatically until the review process is completed. If the review is timely received, but not registered before the change processing deadline, coverage will be automatically discontinued. In that instance, the discontinuance shall be rescinded and coverage reinstated while the review is pending. Note that if an untimely review is received during the review reconsideration period (see 7431), the discontinuance shall be rescinded but coverage shall not be reinstated pending the completion of the review.
Due to this process, if a timely received review is not timely processed by the agency, as defined in 7420, the current level of coverage for the individual(s) due for review may continue past the end of the review period for one or more months [extended month(s)]. The date the timely review is received will determine if those months are subject to correction.
7411 Information/Verification - All information and/or verification shall be provided by the requested date. Clients must submit any required verification or additional information within 12 days from the date of the initial request in order to ensure the rights to uninterrupted benefits. However, if the requested information is provided after adverse action is taken, but during the review reconsideration period, as described in 7431, the adverse action may be rescinded and the review reinstated for processing.
Follow the verification requirements at initial application, except that non-citizen status, providing an SSN, residency, and identity, do not have to be reverified unless a change has been reported or it is questionable.
7420 Agency Action on Timely Review - If the review form is timely filed and all review requirements have been met, the agency shall promptly process the review to ensure correct and timely coverage is provided. Timely processing shall be defined as follows:
1. A review form received before the 1st day of the last month of the review period shall be processed by the change processing deadline in the last month of the review period.
2. A review form received on or after the 1st day of the last month of the review period shall be processed by the change processing deadline in the month after the last month of the review period. Whenever possible, the agency, though not required, shall still attempt to process the review by the change processing deadline in the last month of the review period.
This process may result in an extended month of coverage. Any extended month of coverage provided under this process is subject to adjustment as indicated in 7410.02(2) if understated eligibility has occurred. However, in no instance shall a claim subject to recovery be created for the extended month (see 8321.02)).
3. Due to the nature of the program, all Medically Needy (MDN) reviews, regardless of when received, shall be processed by the change processing deadline in the last month of the review period. This will ensure that a new 6-month eligibility base period is properly established beginning with the month after the month the review period ends. See also 1410.01(2).
All households shall be notified of the appropriate reporting requirements upon review approval. See 7120.
7421 Passive Review Responses - After being passively reviewed, the consumer is required to contact the agency (either orally or in writing) if any of the information on file needs to be updated. Reaction to this change is based on when the change was reported and the type of eligibility resulting due to the change.
- If the change was reported by the last day of the old review period, the change is processed as a Passive Review Response.
- If the change was reported after the last day of the old review period, the change is not considered a passive review response. It is treated like any other change that is reported outside of the review process. Anyone already passively reviewed and continuously eligible will not be negatively impacted.
To process the Passive Review Response, staff update the case with the changes and redetermine eligibility for the next review period. If eligibility will be the same or better than the previous review period, the change is effective with the first month of the next review period. If the result is adverse, such as a premium increase or a change to a lower hierarchy program such as CTM to TMD, the change will be effective in the next unpaid month allowing for timely notice.
For passive review responses reported by the end of the old review period, the reported change can result in a change in coverage and/or premium even if coverage has already been approved. If the passive review response includes a request for medical assistance for a new individual, the change to add the individual is processed for the month of request but coverage for existing members is protected for any paid months by continuous eligibility rules. When a premium is involved, if a positive change, the change is made for the month after the month of report.
7431 Review Reconsideration Period - If the review form is not returned by the end of the current review period, the individual has a three-month reconsideration period to return the review form. Individuals will have until the end of the third month from the date of discontinuance to return the form for processing. The reconsideration period also applies to information requested in order to process the review. An application or review form received after that period is treated like a new application, including any request for prior medical assistance. If the requested information is provided after the reconsideration period expires, a new application may be required.
A review reconsideration period is not applicable to an individual who is approved at review or is denied at review for not meeting eligibility criteria. Any application for review not submitted in a timely manner shall be treated as an initial application. The timeliness provisions of 1407 and subsections apply.
When eligibility has been discontinued for failure to provide requested verification and the verification is later provided within the review reconsideration period described above, eligibility shall not be reinstated pending completion of the review. The discontinuance shall be rescinded, but no coverage past the end of the review period shall be provided, unless and until the review is fully processed.
Note: An individual who timely submits a review form but submits all verification in an untimely manner shall lose the right to a prompt review of eligibility (see 7420).
7432 Agency Failure to Act Timely - If the agency fails to timely process a timely received review form, an administrative processing error may have occurred. Eligibility will continue with coverage at the current level while the review is pending. This may result in one or more months of coverage past the end of the review period before the review is processed [extended month(s)]. Once the review is processed, the extended months of coverage resulting from the delay shall be reevaluated as follows:
1. If the new level of coverage determined by the untimely agency review is the same as the previous coverage, no adjustment to the extended month(s) is required. No administrative error, other than delayed processing, has occurred.
2. If the new level of coverage determined by the untimely agency review is greater than the previous coverage, the extended month(s) must be adjusted accordingly. Coverage for those extended month(s) shall be enhanced to match the newly determined coverage. The agency shall promptly update the coverage and notify the recipient(s) of the change.
3. If the new level of coverage determined by the untimely agency review is less than the previous coverage, including discontinuance of coverage, an agency error overstated eligibility has occurred for the extended month(s). Agency action must be taken to determine the amount of the overstated eligibility and establish a claim according to 8300 and subsections.
7441 Frequency of Reviews - All MAGI-based medical program recipients shall be reviewed once every 12 months and no more frequently than once every 12 months.