Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/21/2024
08000 >>> 08310
08300
8311 Types of Claims - There are three types of claims. The type of claim will determine action to be taken in recovery efforts.
8312 Agency Error - Instances of agency error which may result in a claim include, but are not limited to, the following:
8312.01 - Prompt action was not taken on a change reported by the household;
8312.02 - Household income was incorrectly computed;
8312.03 - Coverage continued after the review period expired without benefit of a required redetermination of eligibility; or
8312.04 - Policy was misapplied.
8313 Client Error - Instances of client error which may result in a claim include, but are not limited to, the following:
8313.01 - Non-willful withholding of information from a one-time failure on the part of a client to report a change timely (see 7100), which affects eligibility when:
(1) - The worker has reason to believe that the client did not understand his responsibility; and
(2) - There was no oral or written misstatement by the client, or
8313.02 - Willful withholding of information such as:
(1) - Misstatement (oral or written) made by the client in response to oral or written questions from the agency;
(2) - Failure by the client to report a change timely (see 7100), which affects eligibility;
(3) - Failure by the client to report the receipt of a medical coverage payment which he/she knows, or should know, is incorrect;
8314 Fraud Error - A fraudulent error occurs when the client intentionally:
(1) Makes false or misleading statement, misrepresentation, concealment, or withholding of facts for the purpose of improperly establishing or maintaining eligibility; or
(2) Misuses medical benefits, including selling, sharing or trading the medical I.D. number for money or other remuneration, signing for services that were not provided to the recipient, or other misuse as determined by the agency.
An individual shall be considered to have committed fraud when the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction. There is no other method of establishing a fraud claim.
A finding of fraud under these provisions may result in criminal penalty, including fines and imprisonment, but may only result in a period of ineligibility if so ordered by the court. Fraud error status is not established if the court’s resolution to the willful client error is to place the individual on diversion.