Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/21/2024
08000 >>> 08100
08000
08100 Understated Eligibility -
8110 Understated Eligibility - Understated eligibility occurs when the client does not receive the level or extent of coverage they were entitled to receive. Eligibility staff shall document how the understated eligibility was determined and the reason correction was required. All understated eligibility must be promptly resolved.
8111 Situations Requiring Correction of Understated Eligibility - Understatement of eligibility shall be corrected promptly using the program policies in effect for the month(s) in which the error occurred.
The following are situations in which a correction of understated eligibility is required.
8111.01 - The understated eligibility was the result of agency error;
8111.02 - The agency failed to give the household sufficient time to verify information that resulted in the understated eligibility;
8111.03 - The agency failed to take timely action on reported changes that resulted in the understated eligibility;
8111.04 - There is a fair hearing decision in favor of the household;
8111.05 - Case correction is ordered as a result of a class action lawsuit or other legal proceeding.
8111.06 - A recipient may also be entitled to correction of understated eligibility where a change has been reported and verified timely but the future month has already been authorized due to system cutoff date.
8112 Timely Billing - There may be instances where the medical provider is outside of the timely billing time frame to receive payment for services and the client has already privately paid the bill. The provider may be unwilling to reimburse the client since they will not be able to receive payment from the state. In those instances, the client shall be reimbursed by the state for the verified amounts paid to the provider, up to the allowed rate for the service. There is no other provision for correcting the understated eligibility.
8113 Situations Not Requiring Correction of Understated Eligibility - Even though a technical understatement of eligibility may have occurred, an eligibility correction is not required in the following situations:
8113.01 - The household failed to report a change which would have resulted in an increase in coverage had the change been timely reported.
8113.02 - The household failed to timely provide information necessary to make a change.