Kansas Department of Health & Environment

Kansas Family Medical Assistance

Manual (KFMAM)


Eligibility Policy - 5/16/2022

01000 >>> 01300 >>> 1330 >>> 1330.04

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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.

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