Kansas Department of Health & Environment

Kansas Family Medical Assistance

Manual (KFMAM)

Eligibility Policy - 5/16/2022

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01300 Prudent Person - Eligibility staff shall use the prudent person concept in administering the Medical Programs. The phrase, "prudent person" applies to the particular situation that indicates further verification of information is needed. It also applies to the reasonableness of judgments made by an individual in a given situation based on that individual's experience and knowledge of the program.

1310 Staff Responsibility - Staff must be prudent when the circumstances of a particular case indicate the need for further clarification. Additional confirmation or verification should be obtained whenever the information provided by the applicant or recipient is incomplete, unclear, or contradictory.

Circumstances that may require a more thorough analysis of a case include:

1310.01 - An individual who appears to be confused.

1310.02 - An individual who has a history of providing conflicting or incomplete information.

1310.03 - Documents (birth certificates, Social Security cards, etc.) that appear to have been altered.

1310.04 - Information obtained from non-medical through KEES according to the following guidelines:

a. Earned income that is currently budgeted on an open or pending case; or was included on a non-active case if the income started within the past three months.

b. Unearned income that is currently budgeted on another case in any status, except for expired time-limited unearned income.

c. Other information currently used for another open or pending case that, if were validated, would result in a different eligibility outcome.

1310.05 - Documents provided by the applicant (pay stubs, employer statement, tax returns, etc.) that appear to be incomplete due to missing required information (i.e. pay dates, frequency, or tax form Schedule 1 or 1040).

1320 Simplified Eligibility - The applicant is the primary source of information used by the agency for purposes of determining eligibility. For some factors of eligibility, additional information will have to be obtained. The agency shall use, to the greatest extent possible, the information on the application/redetermination as provided by the individual applicant/recipient, for purposes of determining eligibility and extent of entitlement.

1320.01 - Carefully review the application for completeness, clarity, consistency, and lack of error or questionable statement.

1320.02 - Consider additional information from agency records.

1320.03 - Advise the applicant/recipient when it is necessary for the agency to go to other sources, and when necessary obtain his consent on the information release form. If he does not consent to the necessary contacts, it may not be possible to determine that initial or continuing eligibility exists. Each applicant and recipient gives consent to a full field investigation when he signs the application/redetermination form, but a signed informational release form may be necessary to obtain the needed information. See 1211.04.

1320.04 - Give the applicant/recipient the opportunity to present additional clarification when information on the form is incomplete, unclear, or inconsistent, or where other circumstances in the particular case indicate to a prudent person that further inquiry needs to be made. Negative action as a result of failure to provide the information can be taken only when written notice was given allowing at least 12 calendar days from the date the notice is initiated to return the information.

1321 Resolving Conflicting Information - When conflicting or contradictory information is discovered, the eligibility staff person shall research the medical case file and other sources, such as interfaces, to determine if a reasonable explanation exists.

If the discrepancy is not resolved, contact with the consumer is required. First, phone contact must be attempted. If the issue remains unresolved a written request for information is issued, as per 1332.01 below. Eligibility cannot be denied or terminated solely based on the discrepant information until the consumer has been given the opportunity to explain the discrepancy. Unless the consumer consents to negative action based upon their request, a written request for information must be issued prior to any negative action.

Staff are responsible for updating the case file (e.g. journal) with information regarding the discrepancy as well as the resolution. If the staff person made a judgement call regarding a specific situation, an explanation of the facts of the case as well as the factors that lead to the decision are also included in the journal. As each situation is unique, the extent and content of the necessary journal entry will depend upon the circumstance of the case.

1330 Verification - A four-tiered approach is used to verify information needed to determine eligibility. Federal law requires that information available through interfaces and other sources are used prior to contacting the consumer. The verification process will proceed in order from Tier 1 through Tier 4 and is not limited only to verification of income. When a Reasonable Compatibility test has been previously run and it has been determined that an administrative error was made or a new self-attestation is received, it is acceptable to return to a prior tier to verify the information (including running a new RC test with the updated information).

The four tiers apply to all family medical assistance programs. See also 1333.04(3) (Earned Income), 6125 (Pre-tax and Federal Deductions), 6122 (Reasonable Compatibility) and 6120 (Budgeting Method). See 2040 for requirements regarding citizenship/identity verification.

1330.01 Tier 1: Payer Interfaces - Reported information is verified through the use of a payer source interface (Federal Hub, Social Security, Unemployment Compensation, KPERS). Since this data comes directly from the source of the reported information, it is considered verified.

Note: If there is a difference between the reported SSA or SSI amount and the amount verified through the Federal HUB, the Social Security interface (EATSS) may be accessed to resolve the discrepancy.

Reported unearned income not verifiable through a payer source interface shall be verified as indicated in 1330.04(2).

Also included as a payer source for purposes of this section are paystubs, or other comparable documentation voluntarily provided by the employee or employer at the time of application or request for assistance, which are sufficient to determine the countable amount of earned income without request for further verification. To be considered sufficient, the information provided must meet one of the following:

a. All paystubs received in the 30 days immediately preceding the date of application or request for assistance;

b. Paystubs which allow calculation via year-to-date totals of gross earnings received in the 30 days immediately preceding the date of application or request for assistance;

c. A written statement from the employer attesting to the employee’s gross earnings received in the 30 days immediately preceding the date of application or request for assistance, including the date(s) and frequency of payment; or

d. Any other document or documents from either the employee or employer which verifies the total amount of gross earnings received by the employee in the 30 days immediately preceding the date of application or request for assistance.

If the information voluntarily provided is sufficient to verify earned income, no further verification is required. The information voluntarily provided shall be used to determine the amount of earnings. If insufficient to verify the earned income, the information voluntarily provided is not considered a payer source.

Note: If sufficient information as described above is not voluntarily provided at the time of application or request for assistance, eligibility staff shall not request paystubs or additional information as part of the Tier 1 process. Verification shall proceed through the remaining Tiers 2 through 4, in order.

1330.02 Tier 2: Automatic Interfaces - Reported information is verified through the use of a secondary non-payer source interface. Tier 2 interfaces include wage verification from either The Work Number (TALX) or Kansas Department of Labor (KDOL) wages. All resources used to verify citizenship and identity are also included in Tier 2, such as Kansas VRV and KSWebIZ.

No Tier 1 interfaces exist to verify earnings. The Reasonable Compatibility test is used in Tier 2. See 6122 for Reasonable Compatibility. When income is not determined to be Reasonably Compatible and the Both Below is not applicable, the following Tier 3 sources are used in the order presented and should always be used prior to requesting verification from the applicant.

1330.03 Tier 3: Research - Manual research by the eligibility worker is required. This may include review of the case file, reconciling information received from Tier 2 interfaces, checking other available program information, and making collateral contacts. Any decision to verify reported information at this level must be thoroughly documented.

When an IBU for an applicant/recipient meets the Household RC test for ‘Both Below’ (see 6122.02) and all other factors of eligibility have been satisfied, additional verification is not required. The individual is eligible for Medicaid. It is not appropriate to continue to Tier 3 verification for this applicant or to delay approval of coverage while pending for information for other household members.

Manual research shall progress through the following steps in the order listed:

a. The Work Number (TALX) - When the Work Number (TALX) data is not successful in establishing reasonable compatibility in Tier 2, the income details may be used to verify income reported. Staff will obtain the TALX Monthly Income Amount from the Reasonable Compatibility Test Detail in KEES and use this for the determination. If Work Number (TALX) data is not available, proceed to researching the case file.

b. Case File - The medical case file record shall be searched for hard copy verification of the reported information. This includes the images located in the medical case. The date of wage verification must be within the three months prior to the month of application when processing a new application. When processing a review or case change, the income must be from the three months prior to when the initial RC test was run. If no hard copy information is found in the case file, proceed to the DCF images.

c. Department for Children and Families (DCF) Images - A manual search of the DCF case records shall be completed for usable images to satisfy verification requirements if a consumer was part of a DCF case for a relevant time period. If verification cannot be obtained from DCF images, proceed to collateral contact.

d. Collateral Contact – Collateral contact may be made to verify the reported information, when deemed appropriate. If verification cannot be made via collateral contact, proceed to Tier 4 level verification.

1330.04 Tier 4: Request for Information - If the earnings cannot be verified using the above methods, Tier 4 verification is used, and the information is requested from the consumer. See also 6122 (Reasonable Compatibility) and 6120 (Budgeting Method).

(1) Self-employment Income - Self-employment income must be verified through Tier 3 or Tier 4 as there is not a data-source for this information. It is verified through either the tax return or the KC-5150 Self-Employment worksheet as indicated below.

When the applicant indicates they have filed taxes, a copy of their tax return is required. If it is after the IRS mandated filing deadline (typically April 15th) and the applicant has not filed their tax return, the prior year’s return may be used if they have filed an extension with the IRS. Verification of the extension is not required.

The KC-5150 Self-Employment Worksheet is used to request income and expenses for the 12 months prior to the month of application. This form is generated through KEES by staff and mailed locally. It is used in the following circumstances:

a) It is a new business and a tax return has not yet been filed.

b) It is an existing business, but the applicant has not (or will not) file a tax return.

c) A change in the amount of self-employment income is reported.

d) The tax return is no longer representative of the self-employment income. The reason for the discrepancy must be clearly documented and is only allowed when there is a definitive change in the amount or type of business. When the applicant indicates their tax return is not representative of the existing self-employment income, both the tax return and the KC-5150 Self-Employment Worksheet are required.

(2) Unearned Income - Tier 1 payer interfaces are used to verify SSA income and Unemployment Compensation. Because this information is directly from the source, the amount verified through the interface shall be used regardless of what has been reported by the applicant.

For unearned income types not verifiable through Tier 1, self-attestation is accepted as verification of all unearned income with the exception of the following types which will need to be requested from the consumer as Tier 4 verification:

a) Annuity Income

b) Trust Income

c) Contract Sales

d) Insurance Payments

e) Oil Royalties and Mineral Rights

f) Railroad Retirement

(3) Earned Income – Verification of earned income is required for all individuals. A request for information is sent to the applicant and "the last 30 days of income" is requested as proof. Proof of income is acceptable as long as the date of paystubs or employer statement falls within the three months prior to the month of application. If partial income is received from within this timeframe, it may be budgeted using the Partial Month Budgeting Method, see 6124.

1330.05 Verification of Pre-tax Income and Federal Deductions - When total reported pre-tax or federal deductions is over $300.00 per month, verification of deductions will be required for them to be used in the income determination. If proof is not received, processing may be completed without them, and the applicant advised by notice that the amount was not used. Eligibility may not be denied due to failure to provide proof of deductions.

Verification of pre-tax income and/or federal deductions will follow the tiered approach of earned income in 1330. Information on hand, such as the case file and the Work Number (TALX) records must be used if available prior to requesting the information from the consumer. Paystubs must be no older than three months prior to the month of application to be used. Collateral contact with the employer may also be used but is not required. If there is no available information on file, the information must be requested from the consumer as noted below:

a) Pre-tax income deductions – Paystubs from the last 30 days or a statement from the employer

b) Federal/IRS deductions – Corresponding tax form or most recent tax return

Note: If based on the consumer’s self-attestation of both wages and deductions, the income will exceed guidelines for all programs, it is not necessary to request proof of the deductions.

1331 Sources of Verification - Once it has been determined that Tier 4: Request for Information is the only method of verification, the following information applies:

1331.01 Documentary Evidence - Documentary evidence consists of a written confirmation of a household's circumstances. Examples are wage stubs, tax returns, and school enrollment records. Acceptable verification shall not be limited to any single type of document and may be obtained through the household or other sources.

1331.02 Collateral Contacts - A collateral contact is a verbal confirmation of a household's circumstances made by a person outside of the household. The collateral contact may be made either by mail or over the telephone. The acceptability of a collateral contact shall not be restricted to a particular individual but may be anyone who can be expected to give an accurate third-party verification of the household's statements. Examples of acceptable collateral contacts are employers, landlords, social service agencies, migrant service agencies, and neighbors of the household.

1331.03 Self Attestation - Self-attestation or Client Statement is sufficient as verification for several elements. Although it is acceptable to verify those items with a Tier 1 or Tier 2 interface, the individual is never asked to provide verification. An exception exists if the information reported is discrepant or inconsistent. The test for this varies dependent upon the context of the information in question as well as the other information in the case.

A declaration of income is used when determining Reasonable Compatibility of Income as defined in 6122. Declaration of income may be taken from the application form, written correspondence, or through verbal contact with the applicant.

A request for coverage is denied when the self-declared income exceeds the income guidelines for the program and does not require verification. When this occurs, the notice of action shall contain detailed information of what income was used.

1332 Responsibility for Obtaining Verification - The household has the primary responsibility for providing verification to support its statements and to resolve any questionable information. Information may be provided in writing or verbally. Any reasonable evidence provided by the household shall be accepted. Staff shall be primarily concerned with how adequately the verification proves the statements on the application. If it would be difficult or impossible for the household to obtain documentary evidence in a timely manner, staff shall offer assistance to the household in obtaining documentary evidence in a phone call and/or send a notice that includes the offer of assistance to all households. The household shall not be held responsible when a person outside of the household fails to cooperate with a request for verification.

As it relates to income, where all attempts to verify the income have been unsuccessful because the person or organization providing the income has failed to cooperate with the household and the Agency, and all other sources of verification are unavailable, the Eligibility staff shall determine an amount to be used based on the best available information.

1332.01 Discrepancies - Where information from another source contradicts statements made by the household; the household shall be afforded a reasonable opportunity to resolve the discrepancy prior to an eligibility determination. Information needed to resolve the discrepancy shall be requested from the household, however, if the household fails to provide the necessary information, staff may elect to verify the information directly. Households are to be given 12 days to provide necessary verification. If the client does not or refuses to provide adequate verification to resolve the discrepancy, the case may then be closed, or the application denied if that is the appropriate case action.

1333 Mandatory Verification - Eligibility staff shall verify the following information prior to approval for initial applicants, when processing a review, or a reported change.

1333.01 SSN - An applicant is required to supply their Social Security Number or verification of application for the required SSN prior to approval of coverage unless the individual claims good cause. See 2033. The reported SSN is then verified using either the Federal HUB or SVES in Tier 1, or through EATSS-SSA in Tier 2. Verification of the SSN does not include a copy of the paper SSN card. Verification of the SSN is a once-in-a-lifetime requirement. For persons without an SSN, they must apply for an SSN and provide proof of application. The requirement to supply and verify an SSN does not apply to non-citizens.

When an applicant fails to provide an SSN, he or she may qualify for a Reasonable Opportunity Period. See 2045.07

1333.02 Citizenship and Identity - Persons applying for medical assistance attesting to be a citizen must have citizenship and identity verified as described in 2045. Unless otherwise exempt, this applies to all applicants. This is a once-in-a-lifetime requirement. Information is not requested from the client once citizenship and identity are verified.

This requirement does not apply to the following individuals:

- Current or former SSI recipients

- Current or former Medicare beneficiaries

- Current or former recipients of Social Security Disability benefits

- Children currently in foster care or recipients of foster care maintenance. (See2045 to address verification once released from DCF custody)

- Children who are recipients of adoption support payments

- Children born on or after July 1, 2006 to a Medicaid recipient as outlined in 2320.

Tier 1 verification includes the Federal HUB.

Tier 2 verification includes Web-IZ. When the Web-IZ is from Vital Statistics, it can be used as proof of both citizenship and identity. Otherwise, it is only proof of identity.

Note: For verification of citizenship and identity, it is acceptable to access the file in Tier 3 to determine if documentation has previously been provided before accessing the Tier 2 sources. Both Tier 2 and Tier 3 must be followed before proceeding to Tier 4.

Tier 3 and 4 verification can include birth certificates and other paper documents. See KDHE Eligibility Policy-Appendix Item A-12 and 2045.

1333.03 Non-Citizenship Status - Qualified non-citizenship status must be verified for persons applying for coverage. Verification is not required for SOBRA but may be necessary to establish the individual is not a qualified non-citizen. Verification is accomplished through the Department of Homeland Security and additional verification steps may be necessary. The SAVE process is used to obtain the information. Verification is not requested for non-applicants.

Tier 1 verification includes the Non-Citizen VLP through the Federal HUB, including subsequent SAVE processes.

Tier 2 includes the manual SAVE process.

Tier 3 includes information available in the case file.

A Reasonable Opportunity period may be granted for persons who fall to Tier 4. The Reasonable Opportunity period is granted only if the individual reports a non-citizenship status that would qualify him/her for medical assistance. See 2047.01.

1333.05 Medical Expenses - The amount of any medical expenses used to meet a spenddown must be verified in order to allow it against the spenddown. Failure to verify expenses doesn't disqualify the individual, as eligibility is determined without allowing the expense. Medical expenses for Spenddown submitted through Provider Billing protocols in the MMIS are considered verified if proper procedures are followed.

1334 Information Known to the Agency - The agency is required to act on information when it becomes known. The phrase’ Known to the Agency’ establishes the point in time that the agency is made aware of information in order to act upon such information for purposes of eligibility determination/redetermination. These policies do not negate the consumer’s responsibility to report information (see KFMAM 7100), but are meant to provide required parameters when reacting to new information.

See 7140 for processing changes.

1334.01 Definition of Agency - Agency means the single state Medicaid/CHIP agency as well as any contractors or other state agency units authorized to determine eligibility for medical assistance or provide direct support of the medical assistance eligibility determination process. Currently, this means the KanCare Clearinghouse, KDHE Outstationed Workers, KDHE Central Office – Eligibility Unit and DCF PPS workers who make medical determinations. It also includes automated systems that determine medical assistance eligibility to the extent the information is used in the medical assistance determination.

1334.02 Date Information is Known - The date information is considered known to the Agency establishes the date by which information must be acted upon. This date is determined by the source/channel of the information:

1. Information reported directly to the Agency by a consumer or third party, by any channel, is considered known on the date it is reported. Examples:
• The date of a phone call from the consumer reporting a change in income
• The date of receipt of written correspondence
• The date a Nursing Home reports a change in living arrangement
• The date a new application is received, whether for a new household or an existing household reporting a change or a new member

2. Information that originally becomes known to another state agency but is communicated to the Agency as part of an approved business process is considered known on the date the information was reported to the Agency. Examples:
• The date DCF creates a task notifying KDHE of a new medical condition that a mutual client originally reported to DCF
• The date DCF creates a task notifying KDHE of a change in health insurance premium amount

3. Information obtained through an interface used by the medical assistance programs which populates information directly into KEES is considered known on the date the information is added to KEES. Examples:
• The date a TBQ adds new Medicare entitlement to the Medicare Information page
• The date an SDX task is created from a Social Security interface telling KDHE that SSI has ended.

4. Information originally obtained through another program through any channel that was not directly reported to the Agency, is considered known based on the type of information received.

a. Information received through a shared data field in KEES and is immediately used for case processing through an automated process is known on the date the information is added to KEES. Example:
• The date DCF updates an address in KEES for a mutual client.

b. Information received through a shared data field in KEES is considered known on the earlier of the date the information is used for processing or the date it is viewed by a person considered part of the Agency. Example:
• DCF updates health insurance premium at the end of the day. The review batch runs that evening and uses the health insurance premium in the new determination. DCF notifies KDHE of the change the following day. The information is considered known on the date of the review batch, because the information was used to redetermine medical benefits.

c. Information available only through a non-shared data field in KEES is considered known on the date it is viewed by someone considered part of the Agency. Example:
• The date a KDHE staff person views a DCF income record

1340 Discrepancies and Questionable Information - A discrepancy and/or Questionable Information is identified when information from one source contradicts statements from another source. To be considered questionable, the information on the application must be inconsistent with other information on the application or previous applications or inconsistent with information received by the agency. When determining if information is questionable, the decision shall be based on each household's individual circumstances. Also see 1310 and 1320.

Eligibility staff shall verify factors of eligibility prior to approval only if they are questionable and affect the household's eligibility.

1350 Documentation - Case files must contain documentation to support the determination to approve or deny program benefits. Documentation means that a written statement regarding the type of verification and a summary of the information obtained has been entered in the case record. Such statements must be in sufficient detail so that a reviewer would be able to determine the reasonableness of the determination. The results of the Reasonable Compatibility Test along with the Verification Tier used shall be included in the documentation. For example, when income is verified by the presentation of pay stubs, the gross amount of income on each pay stub, and the frequency of receipt of income are included on a copy of the pay stub in the case record or are recorded by the Eligibility Staff elsewhere.

Where verification was required to resolve questionable information, the Eligibility Staff shall document why the information was considered questionable and how the questionable information was resolved. The Eligibility Staff shall also document why any alternate sources of verification were needed and, if a collateral contact was rejected, the case file shall contain documentation of why the collateral contact was rejected and an alternate chosen.

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