Kansas Department of Health & Environment

Kansas Family Medical Assistance

Manual (KFMAM)

Eligibility Policy - 8/10/2020

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01400 Application Process/General Information -

1401 General Information - An application is defined as a request for medical assistance. Individuals can apply for medical assistance in one of the following ways:
a) Online application submitted through the Self Service Portal (SSP)
b) Paper application form submitted by mail or in person at the KanCare Clearinghouse
c) Telephone application
d) Transfer of a request from the Federally Facilitated Marketplace (FFM)
e) Request by phone for individuals in households with already open medical programs (see 1402)
Based on the provisions of 3000, an application shall include all required persons. Required persons are as follows:
- The individual,
- The individual's spouse,
- The individual's children under age 21 living with them,
- The individual's partner who lives with them when they have mutual children,
- Any other individual who is on the individual's tax return (whether or not they live with them), and
- Anyone else under age 21 who lives with the individual and they care for.
The application, together with the agency records (if any), the necessary forms (budgets, notices of action, narratives, etc.), and any required verification must substantiate eligibility or ineligibility.

At the time of application processing, each month shall be viewed separately in determining eligibility or ineligibility. For example, if an application is filed in July but processed in August, ineligibility in August shall not affect the eligibility determination for the month of July.

1402 How to Apply - Each household has the right to file an application on the same day it makes contact with the agency. Application forms can be requested from any local DCF office, KanCare Clearinghouse, or KDHE-DHCF Outstationed Worker. All requests for medical assistance must be made on KDHE-DHCF forms as follows:

KC1100 - Medical Assistance Application for Families with Children

KC1500 - Medical Assistance for the Elderly and Persons with Disabilities

Such applications are to be submitted to the KanCare Clearinghouse, a central operation established to determine eligibility for all medical programs. The current contractor managing the Clearinghouse is MAXIMUS, Inc. Applications provided to the local DCF office are immediately transferred to the Clearinghouse for processing.

Note: Online applications are received through the KDHE-DHCF Customer Self-Service Portal (CSSP).

When an application is requested in person, the household shall be encouraged to file the application that same day. When an application is requested over the telephone or in writing, it shall be mailed the same day, when possible, or the following business day.

NOTE: If the applicant household is homeless and they have no street address to list, the application shall be so noted and accepted by the agency.

Neither an application form nor signature is required to add additional household members to an existing medical program unless the individual requesting coverage is without coverage due to failing to complete a required review. If the individual lost coverage due to not returning a required review form, only submittal of a signed application form will constitute a request for coverage.

1403 Application Date - The date of receipt at the KanCare Clearinghouse, or KDHE Outstationed Worker site of a signed paper application is considered the application date for establishing initial eligibility. Giving a signed paper application to a KDHE Out-stationed Worker during a face-to face- interview at an off-site location, such as a home visit or at the KDHE Out-stationed worker office location, shall also establish the date of application. Date stamping of an application by a DCF office does not constitute a date of receipt for application processing.

All signed applications, shall be date-stamped the date of receipt as indicated above.

Applications received in the office through a drop box, mail slot or other such manner at the opening of the business day shall be considered as received during the previous business day. Applications received via fax shall be considered as received when the fax arrives in the office. This is based on the date and timestamp of the ImageNow system.

NOTE: Applications that are not signed by the applicant are to be returned to the applicant for signature. The entire application must be returned to allow the applicant to review his/her answers prior to certifying under penalty of perjury that all answers are correct and complete to the best of their knowledge. A cover letter must be attached to the application explaining the need to sign the application and to return it to the office for processing.

Note: KDHE-DHCF Online Application - The date the online application (which is electronically signed by the applicant or legal representative) is submitted through KDHE-DHCF shall be considered the application date if submitted on a business day. If the application is submitted on a weekend or holiday, the application date is the next following business day. A weekend is defined as Saturday and Sunday. Staff shall make a notation of the date discrepancy in the case file.
If the application is submitted by an individual with no legal relationship to the applicant, the application date is the date the "Medical Representative Authorization" or "Signature Page" form is received. If neither of these two (2) forms is received within 30 days of the date the online application was received, the application is void.

1404 Who May File - An application for assistance shall be made by the individual in need or by another person able to act in the individual's behalf. See 2010. If the applicant or his representative signs by mark, the names and addresses of two witnesses are required. Obtaining the signatures of all persons in the family group who are requesting assistance and able to act in their own behalf per 2010 is encouraged, but cannot be required.

1404.01 Filing on Behalf of a Deceased Person - For medical, an application may be made on behalf of a deceased person by any responsible person. Application must be made in the month of death or within the three following months.

1404.02 Filing for Institutionalized Individuals - When possible, all necessary information and signed forms will be obtained by institutional personnel. Parents, spouses, guardians/conservators and others who may apply on behalf of the individual per 2010 must always be given the opportunity to apply on behalf of an institutionalized person not able to act in his own behalf. If institutionalized personnel are unable to obtain the required forms from the patient or any of the above individuals, the administrator of a licensed facility may apply on behalf of the patient. General hospitals are not regarded as a licensed facility for this purpose.

Complete applications will be forwarded to the DCF office or Clearinghouse for processing.

All information pertinent to eligibility and known by institutional staff will be communicated to the local office. When the institution acts as an employer to the patient, institutional personnel will be responsible for reporting all earnings to the local DCF office.

Generally the local DCF office where the institution is located will process new applications. However, when appropriate, the local office or Clearinghouse shall determine whether the individual is currently included on an open medical case before processing. If the individual is included on a currently open case, the application shall be denied. The referral and a copy of the application shall be sent to the current county or CH where the appropriate case action will be taken to certify eligibility to the institution. (See 7300) For individuals who currently have an unmet spenddown, the institution should be notified as no FFP can be claimed until the spenddown is met. Medical expenses incurred at the institution shall be considered toward the unmet spenddown and eligibility certified when the spenddown is met.

1404.03 Filing for Individuals through the Federal Health Insurance Marketplace - Individuals may apply for medical assistance through the Federal Health Insurance Marketplace. The Marketplace application allows any adult member of the tax household to apply for any and all other members of the tax household. Should the agency receive an application via file transfer from the Marketplace, it shall be accepted and processed even if the individual filing the application does not meet the requirements of 2110 and subsections. The application shall be registered following standard procedures, establishing the correct individual as the primary applicant.

1405 Withdrawing the Application - The household may voluntarily withdraw its application at any time. The agency shall document in the case file the reason for withdrawal, if any was stated by the household, and that contact was made with the household to confirm the withdrawal. The household shall be advised of its right to reapply at any time subsequent to withdrawal.

1406 Universal Access - An individual or family can apply for medical assistance at either a DCF office or the KanCare Clearinghouse. DCF accepts these applications but does not process them. Applications are gathered and transferred to the KanCare Clearinghouse several times a week. The DCF Service Center where the application is filed shall inform the consumer about the transfer to the KanCare Clearinghouse. The application date is not based on when the application is received by DCF. See 1403.

1407 Time In Which Application is to be Processed and Case Disposition - All applications shall be approved or denied on a timely basis except when a determination of eligibility cannot be made within the required period due to the failure of the applicant or collateral to provide required information. Written notice must be given to the applicant by the end of the required period giving the reason(s) for the delay. The approval of an application from an alien who is otherwise eligible may not be delayed beyond the timely processing time frame due solely to the fact that no USCIS response to a request for verification of immigration status has been received.

Timely action is defined as follows:

1407.01 Reserved -

1407.02 All Other Medical Applications - Within 45 days of the agency's receipt of a signed application. For management purposes the agency shall strive to process applications within 30 days.

1408 Presumptive Eligibility - (PE) is a process that allows qualified hospitals and qualified entities to determine if an individual is eligible for temporary medical assistance. PE grants immediate temporary medical coverage to persons pending their formal application for KanCare. The PE Program is designed for uninsured low-income persons in the following populations:
• Children
• Pregnant Women

January 1, 2014 the Affordable Care Act (ACA) implemented the options for hospitals to self-elect to determine presumptive eligibility and expanded the group for which hospitals could determine. This group includes adults in one of the following groups:
• Low-income Caretakers
• Former Foster Care
• Breast and Cervical Cancer recipients diagnosed through Early Detection Works (EDW)

The PE determination is a simplified process based on information provided by the applicant. Standard application procedures, such as obtaining hard copy documentation, are not required for a presumptive decision.
The Presumptive Eligibility determination is final. The applicant household does not have appeal rights regarding the outcome of their presumptive determination.

Presumptive Eligibility for Children -
Coverage for this group is provided under the Balanced budget Act of 1997. To qualify the child must:
(1) Be under age 19
(2) A U.S Citizen or a documented non-citizen that is either an Asylee, Trafficking Victim, Legal Permanent Resident, or Other Legal Status for five years or more
(3) Resident of Kansas with the intent to remain
(4) Meet income standards

Presumptive Eligibility Pregnant Women
Coverage for pregnant women is for outpatient ambulatory services. To qualify an applicant must:
(1) Be pregnant
(2) A U.S Citizen or a documented non-citizen that is either an Asylee, Trafficking Victim, Legal Permanent Resident, or Other Legal Status for five years or more
(3) Resident of Kansas with the intent to remain
(4) Meet income standards

Low-income Parents and Caretakers -
To qualify for coverage under this category an applicant must:
(1) Be a parent or caretaker relative for an eligible child under 18 in the home
(2) A U.S Citizen or a documented non-citizen that is either an Asylee, Trafficking Victim, Legal Permanent Resident, or Other Legal Status for five years or more
(3) Resident of Kansas with the intent to remain
(4) Meet income standards

Former Foster Care Recipients-
(1) Between the ages of 18 – 26
(2) In Foster Care in Kansas at the time of their 18th birthday
(3) A U.S Citizen or a documented non-citizen that is either an Asylee, Trafficking Victim, Legal Permanent Resident, or Other Legal Status for five years or more
(4) Resident of Kansas with the intent to remain

Breast and Cervical Cancer Recipients-
To qualify for BCC coverage and applicant must be:
(1) Screened and diagnosed for breast or cervical cancer by Early Detection Works
(2) Be in continuous treatment
(3) Not be covered by other insurance, including Medicare.
(4) Resident of Kansas with intent to remain

1408.01 Qualified Hospitals and Qualified Entities - KDHE-DHCF is responsible for certifying all entities qualified to make Presumptive Eligibility decisions. Certain Medicaid enrolled hospitals and Safety Net Clinics have been designated Qualified Entities allowed to make presumptive eligibility decisions.

All entities must complete training and receive certification by KDHE-DHCF prior to making any determinations.

Presumptive Eligibility is determined through the online portal - PE Tool. Once entity staff have received training and are deemed certified, they will gain access to the PE Tool. This security process is managed by staff on the KEES project.

Qualified Hospital
A qualified hospital is a hospital that –
(1) Participates as a Kansas Medicaid provider, notifies KDHE of its election to make presumptive eligibility determinations, and agrees to make presumptive eligibility determinations consistent with Kansas policies and procedures;
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements; and
(3) Has not been disqualified by KDHE.

Qualified Entity
A qualified entity is –
(1) Healthcare providers, community-based organizations, schools, head start programs authorized by the state to screen for Medicaid and CHIP eligibility and immediately enroll children and pregnant women who appear to be eligible.
(2) Assists individuals in completing and submitting the full KanCare application and understanding any documentation requirements;
(3) Has not been disqualified by KDHE.

1408.02 Qualified Hospital/Entity Responsibilities - Staff at each Qualified Entity/Hospital are responsible for identifying adults, pregnant women, and children who could benefit from the Presumptive Eligibility Program.

Staff will make presumptive decisions as well as inform families of the program. They will also assist families who wish to apply for coverage with completing the KanCare application. This assistance shall include completion and submission of the application (either with a KC1100-paper application or an online application through CSSP), assistance in obtaining supporting documentation, and follow-up with the family to provide support through the application process.

The following processes must be completed when making a presumptive determination:

1. Complete the training program provided by DHCF upon becoming a QE and ensure that new employees are trained.
2. Attend recertification training if mandated by DHCF.
3. Follow all policies and procedures outlined in the PE Resource Manual and training material.
4. Offer PE to uninsured persons accessing services.
5. Confirm through the MMIS that prospective PE recipients are not currently covered.
6. Determine PE based on the information on the PE Tool in accordance with the instructions in the PE Resource Manual and training material and instructions in the PE Tool itself.
7. Assist families in the completion of a KanCare application, which includes providing assistance in obtaining required verifications for application processing; families denied PE should still receive assistance in completion of the KanCare application.
8. Fax the signed Approval or Denial Notice and Facilitator Authorization form along with any other required documentation to the KanCare Clearinghouse within two business days of the presumptive eligibility determination.
9. Provide the parent/guardian or adult applicant the signed Approval or Denial Notice and Facilitator Authorization form following their PE determination.
10. The Qualified Entity provides each parent/guardian or adult applicant determined eligible verification of the coverage start date. This eligibility verification is in the form of an approval letter which includes the approved individual’s name, date of birth and the date coverage begins. The approval letter is proof of coverage for up to 7 days. After 7 days, the individual has their medical card and uses this as proof of eligibility or the provider must verify eligibility through the MMIS.
11. The Qualified Entity informs families of the reason the applicant (s) was found ineligible for PE coverage and assist the household in completing the formal application process even though the applicant was not presumptively eligible. A presumptive determination is based on household statements and a simplified process which may not have the same outcome as the formal eligibility determination completed by KDHE-DHCF.
12. Educate the parent/guardian that future communication on their KanCare application will be from the KanCare Clearinghouse and provide the parent/guardian with the KanCare Clearinghouse contact information.
13. Provide the family with comprehensive assistance to ensure a successful completion of their KanCare application. This may include contacts with families prior to appointments to encourage them to bring necessary documentation at the time of service, follow-up contacts with the family, assistance in obtaining documentation, and agreeing to photocopy and fax documents to the KanCare Clearinghouse.
14. Meet the performance standards outlined below:
a. 95% of PE determinations are completed accurately,
b. 98% of PE determinations and KanCare applications are submitted to the KanCare Clearinghouse within 2 days of the PE determination, and
c. 60% of the PE applicants ultimately achieve eligibility through the KanCare process.
15. Maintain a record of PE determinations.
16. Maintain client confidentiality.

1408.03 KanCare Eligibility Clearinghouse Responsibilities - Staff at the KanCare Eligibility Clearinghouse record the results of each Presumptive Eligibility determination and enter presumptive coverage in the KEES system.

Presumptive Eligibility is determined in the Presumptive Eligibility Tool (PE Tool) and then entered into KEES. The following individual medical subtypes are recorded in KEES:

• PEN/CH – Title 19 child
• PET/CH – Title 21 child
• PEN/PW – Pregnant Women
• PEN/CT – Adult Caretaker
• PEN/BC – Breast and Cervical Cancer
• PEN/AO – Foster Care Aged out

The KanCare Eligibility Clearinghouse is responsible for completing the determination of ongoing eligibility for presumptively eligible children under MAGI programs.

The KanCare Eligibility Clearinghouse makes certain that presumptive coverage ends when the formal determination of eligibility is complete. Coverage shall end at the end of the month following the month of the presumptive determination when the application is not received.

1408.04 Applicant Responsibilities in the Presumptive Eligibility Process - The adult applicant household member is responsible for providing the Qualified Entity staff with household information to be used in making the Presumptive Eligibility determination (see 1211.02.) Information provided to each entity for purposes of making a presumptive eligibility determination must be true and correct (see 8410.)

1408.05 Period of Presumptive Eligibility - Presumptive Eligibility coverage begins on the date the determination is completed. The approval letter provided to the family by the Qualified Entity shall reflect this date as when the applicant’s coverage begins. Coverage is not provided for days prior to the date on the presumptive eligibility approval letter. The family must complete the KanCare Family application (and request assistance with unpaid medical bills, if applicable) in order to be determined for potential eligibility for the time prior to the period of presumptive coverage.

Presumptive Eligibility coverage ends the month following the presumptive eligibility determination.

If the application is received during the presumptive eligibility period, an applicant may continue to receive presumptive coverage until the formal application is processed and a determination of the applicant’s formal eligibility is made. This includes allowing the applicant a reasonable opportunity period to provide necessary citizenship and identity documents as defined in KFMAM 2046.

Children and Adults may only be provided with one Presumptive Eligibility coverage period within a twelve-month period. The applicant must self-declare any prior Presumptive Eligibility coverage to the entity at the time of application. The twelve-month period begins with the month the child or adult is determined eligible for presumptive coverage. For example, Billy is approved for presumptive eligibility on July 10th, 2007. July is the first month of the twelve-month period. Billy cannot receive additional presumptive coverage until July 1, 2008.

Pregnant Women may only be provided one Presumptive Eligibility coverage period per pregnancy.

Presumptive eligibility coverage periods have no impact on continuous eligibility provisions. Continuous eligibility is not applicable until the formal application is processed (See 2310.)

Adequate notice is required to end temporary presumptive benefits.

The household does not have a right to continuation of benefits upon pending an appeal of the termination of presumptive benefits because the receipt of these benefits is time-limited.

1409 Reserved -

1410 Disposition of Applications - The purpose of this section is to provide instructions regarding the procedures that follow the determination of eligibility or ineligibility for assistance. Eligibility/ineligibility is certified using KEES procedures. A copy of the Notice of Action is to be sent to medical providers to certify eligibility/ineligibility on medical cases when required.

One of the following case actions must occur within the established time period outlined in 1407.

1410.01 Approval - A notice of approval shall be sent for all programs determined eligible.

(1) Approved - The application will be approved for medical, if automatically eligible, or if determined eligible with respect to all factors including financial.

(2) - Approved - Suspended - If the applicant is eligible with respect to all factors other than financial but there is a spenddown (see 6500), the application will be approved in a spenddown status if there appears to be a likelihood that the spenddown will be met within the 6 month eligibility base period using evidence provided by the client and known to the agency. This is an administrative procedure to meet the application disposition time requirements and to preserve the original application date. However, there is no eligibility until the spenddown is met. See 1412 concerning suspension. The individual will however be enrolled with a KanCare managed care organization (MCO). They will be eligible for any value-added services the MCO provides. A medical card will be issued by the MCO and claims billed will be applied to the spenddown.

For all individuals enrolled in KanCare, the MCO will issue a medical ID card. For non-KanCare recipients, medical cards are issued by the fiscal agent.

1410.02 Denial - A denial shall be processed to assure that the applicant is provided with his/her denial notice in a timely manner. A notice of denial shall be sent at the time of denial, explaining clearly the reason for the denial.

(1) - Found Ineligible - A denied application may be reinstated without a new application at any time within the original 45 day processing timeline. In no case does the denial of the application abridge that individual's right to reapply at any time.

(2) - Failure to Provide Required Information/Cooperation - An application shall be denied after a period of 12 days from the date of a written request for information, but no later than 45 days from the date of application when the applicant has failed to provide required information or cooperate with eligibility requirements. The applicant must be informed in writing of the 12-day standard and the date by which the verification /cooperation must be received.

If the information is subsequently received or the household cooperates within the 45 day application processing time period, the application shall be reactivated and, if eligible, benefits prorated from the date of application. If the information/ cooperation are not received within the above time frames, then the client must re-apply.

(3) - Spenddown - When a spenddown is established for a minor who would otherwise be eligible for CHIP coverage, eligibility staff must ascertain the likelihood that the spenddown will be met. In order to make this determination and prevent delaying CHIP approval, contact with the applicant must be made as quickly as possible. The applicant must be informed of the spenddown amount and given a 12 day notice to respond to the likelihood that the spenddown will be met within the 6 month eligibility base period. If the applicant fails to respond or it does not appear that the spenddown will be met, the application will be denied (or case closed for failure to meet the spenddown) and CHIP coverage will be authorized. In spenddown cases where there is no possibility of CHIP eligibility, the spenddown is established and the case remains open throughout the base period. At the end of the base period, staff determines if there is a need for further spenddown coverage.

(4) - Another Agency Assumes Responsibility - The agency may dispose of the application if another agency assumes complete responsibility for meeting the applicant's need.

(5) - Cannot be Located - The agency may dispose of the application if the applicant has moved and cannot be located. The agency shall not send a notice of decision.

1410.03 Pending - If a decision cannot be made on an application within the applicable timely processing period because of agency delay, the application shall not be denied. The Case Manager shall notify the applicant(s) that its application is still pending, and what action, it must take to complete the application process and what date the action must be taken or the case will be denied.

1411 Provisions Specific to Medical Eligibility - Suspension of medical benefits does not shorten an established medical eligibility base period and a new application is not required to reinstate assistance within the period. Regardless of the procedure used, medical eligibility shall not be suspended without meeting notice requirements related to adverse action. Benefits shall not be suspended for more than 6 months except in rare cases where there is clear documentation that circumstances have changed so that medical eligibility can reasonably be expected within the next 6 month period. If the case is not to be closed, medical eligibility on a medical only case will be suspended.

1412 Termination of Assistance - Case closures will always be effective the last day of a given month. To protect credibility with medical providers, the termination date may not be changed after issuance of a medical card. However, the date of death will be used for a deceased individual since there are no eligible services after that date.

1413 Reinstatement of Assistance - Medical assistance can be reinstated in the month following the month of closure or suspension if the reason for the closure has been cured by the end of the month following the month of the closure/suspension and all other eligibility requirements are met. A new application is not required for reinstatement purposes unless the current review period has expired. However, if the review form is returned within the three month reconsideration period (see 7431), the form can be used to redetermine eligibility.

1420 Written Notice of Case Action - An applicant or recipient of assistance shall be notified promptly of the action taken on his case. The recipient of assistance shall also be notified of other changes such as an increase or decrease in the spenddown, cost share, suspension, or reinstatement after suspension.

1421 Notice of Action - Shall be sent promptly to the applicant or recipient with a copy of any manually prepared notices filed in the case record. Specialized notice forms are required for all cases involving a spenddown, and for all cases in which the medical program will assume at least partial payment for care situations.

Notices shall indicate clearly the action taken, the effective date, and such other information as the situation may require. For all medical approvals, notice must include the beginning and ending dates of the review period. If an application is denied, the applicant shall be informed of the basis for this action. A similar procedure shall be followed for all other changes.

1422 Timely and Adequate Notice - The agency shall give timely and adequate notice of agency actions to terminate, suspend, or reduce assistance except as provided for in 1422.01 regarding dispensing with timely notice and in 1425 regarding negative actions resulting from information obtained through federal match data. See 7420 for further information on notice provisions for reviews.

1422.01 Adequate Notice - Adequate means a written notice that includes a statement of what action the agency is taking, the reasons for the intended agency action, the specific manual references supporting such action, an explanation of the individual's right to request a fair hearing, and the circumstances under which assistance may be continued if a fair hearing request is made. All notices must be adequate.

1422.02 Timely Notice - Timely means that the notice is mailed at least 10 clear days before the effective date of action. Neither the effective date of action nor the mailing date shall be considered in determining this 10 day period. For closures, the consumer must receive the notice prior to the last day of eligibility. For increases in premium, the consumer must receive the notice prior to the 1st of the month for which the change is effective. The Processing Deadlines Code Card Chart on the KEES Repository shall be used to identify the last day in which action can be taken in order for timely notice to be provided for the various scenarios.

An increase in an unmet spenddown does not require timely notice; however a change which results in the spenddown changing from met to unmet does require timely notice. When a spenddown for a base period changes from met to unmet, the consumer is notified both by the Clearinghouse and by MMIS. The MMIS notification must be received before the first day they return to having an unmet spenddown.

1423 Adequate Notice Only - When only adequate notice is required, such notice may be received by the household at the time reduced benefits are received or if benefits are terminated, at the time benefits would have been received if they had not been terminated. The agency is not required to send timely notice but must send adequate notice not later than the date of action when:

1423.01 - The agency denies an application for assistance. However, denials resulting from information obtained through federal match data shall be subject to the provisions of 1425.

1423.02 - The agency has factual information confirming the death of a client or of the payee when there is no relative available to serve as new payee.

1423.03 - The agency receives a clear written statement signed by a client indicating that he no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the client has indicated, in writing, that he understands that this must be the consequence of supplying such information.

1423.04 - The client has been admitted to an institution and further medical assistance will not be provided to that individual.

1423.05 - The client has been placed in a Medicaid approved institution for long term care or begins HCBS and will receive Medicaid payment for the cost of care.

1423.06 - The client's whereabouts are unknown and agency mail directed to him has been returned by the post office indicating no known forwarding address.

1423.07 - A client has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance.

1423.08 - A child is removed from the home as a result of a judicial determination, or voluntarily placed in foster care by his legal guardian.

1423.09 - Assistance is approved and negative case action such as a closure is incorporated into the initial notice of action to the client. However, negative action resulting from information obtained through federal match data shall be subject to the provisions of 1425.

NOTE: Timely and adequate notice must be given for any termination in benefits resulting from information obtained by the consumer or other sources.

1423.10 - A client is disqualified for fraud through a court of appropriate jurisdiction.

1423.11 - A premium requirement is established or increased for a CHIP case per 2440.

1423.12 - The agency receives a request to end coverage on the basis of the cost of the CHIP premium obligation.

1424 Automatic Benefit Adjustments for Classes of Clients - When changes in either state or federal law require automatic adjustment for classes of clients, timely notice of such adjustments shall be given which shall be adequate if it includes a statement of the intended action, the reasons for such intended action, a statement of the specific change in the law requiring such action, and a statement of the circumstances under which a hearing may be obtained and assistance continued.

1425 Notice of Actions Resulting from Federal Match Data - Based on the provisions of the Computer Matching and Privacy Protection Act, no immediate action to suspend, terminate, reduce, or deny assistance in the medical program may be taken as a result of information obtained through federal match data which has not been determined to be accurate and reliable by the federal agency producing the data. When the federal information has not been determined to be accurate and reliable, the individual must be given 30 days from the date the notice of action is received to verify or contest the match data. This means that such notice must be sent at least 35 days prior to the effective date of action for recipients or the date the application is to be processed for applicants.

Federal matches currently affected by these provisions include the SIEVS (IRS and BEER data) match and VA match. It does not include BENDEX, SDX, SAVE information from INS, and third party queries obtained through SSA as all of these data exchanges are either considered to be accurate and reliable or involve a computer match process between state and federal records. It also does not include Employment Security matches as this is not a direct federal-state match.

If the individual does not respond to the notice, final action based upon the match data can be taken upon expiration of the 35 day notice period and allowing for timely and adequate notice of action. All or part of the 10 day timely notice period may run concurrently with the 35 day notice period. However, all BEERS and IRS-related match data is to be considered as a lead only and not to be used as primary verification or evidence without further independent verification.

If the individual confirms the validity of the information prior to the expiration of the 35 day period, action can be taken immediately allowing for 10 day timely and adequate notice. In addition, for applicants, action can be taken to deny the application without a 35 day notice period, if the individual has already confirmed the match data through verification provided or information which was incorporated on the application form.

If the individual contests the data during the 35 day notice period, no action can be taken until the information is further verified. If the individual cannot provide verification in regard to IRS or BEER data, contact with such sources as the financial institution, employer, etc. will need to be made.

Client cooperation in the verification process will be essential for any action prior to the 35 day notice period. If the client refuses to cooperate and/or contests the information and verification cannot be otherwise obtained, action can be taken on the case following the expiration of the 35 day notice period and allowing for timely and adequate notice of the action.

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