907 KAR 20:010. Medicaid procedures for determining initial and continuing eligibility other than procedures related to a modified adjusted gross income or to former foster care individuals.

 

      RELATES TO: KRS 205.520, 42 C.F.R. 435.530, 435.531, 435.540, 435.541, 435.914, 435.916, 42 U.S.C. 416, 1382, 1396a, b, d

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 U.S.C. 1396a

      NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with a requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes provisions relating to determining initial and continuing eligibility for assistance under the Medicaid Program.

 

      Section 1. Definition. (1) "Department" means the Department for Medicaid Services or its designee.

      (2) "First month of SSI payment" means the first month for which an SSI-related Medicaid recipient is determined to be eligible for SSI payments.

      (3) "Partnership" means an entity that meets the criteria established in 907 KAR 1:705, Demonstration project: services provided through regional managed care partnerships (1115 Waiver), Section 5, and, under contract with the department in accordance with KRS Chapter 45A, agrees to provide, or arrange for the provision of, health services to members on the basis of prepaid capitation payments.

 

      Section 2. Eligibility Determination Process. (1)(a) Except as provided in subsection (3) or (5) of this section, eligibility shall be determined prospectively.

      (b) To receive or continue to receive assistance, a household shall meet technical and financial eligibility criteria:

      1. Pursuant to this section:

      2. Pursuant to Section 3 of this administrative regulation: and

      3. As established in the following administrative regulations for the appropriate month of coverage:

      a. 907 KAR 1:011, Technical eligibility requirements;

      b. 907 KAR 1:640, Income standards for Medicaid; and

      c. 907 KAR 1:645, Resource standards for Medicaid.

      (2) A decision regarding eligibility or ineligibility for Medicaid shall be supported by facts recorded in the case record.

      (a) The applicant or recipient shall be the primary source of information and shall:

      1. Furnish verification of financial and technical eligibility as required by the following administrative regulations:

      a. 907 KAR 1:011, Technical eligibility requirements;

      b. 907 KAR 1:640, Income standards for Medicaid; and

      c. 907 KAR 1:645, Resource standards for Medicaid; and

      2. Give written consent to those contacts necessary to verify or clarify a factor pertinent to the decision of eligibility.

      (b)1. The department may schedule an appointment with an applicant or recipient to receive specified information as proof of eligibility.

      2. Failure to appear for the scheduled appointment or to furnish the requested information shall be considered a failure to present adequate proof of eligibility if the applicant or recipient was informed in writing of the scheduled appointment and the required information.

      (3) Retroactive eligibility for Medicaid not related to the receipt of SSI shall be effective no earlier than the third month prior to the month of application if:

      (a) A Medicaid service was received;

      (b) Technical and financial eligibility requirements were met as established in the following administrative regulations:

      1. 907 KAR 1:011, Technical eligibility requirements;

      2. 907 KAR 1:640, Income standards for Medicaid; and

      3. 907 KAR 1:645, Resource standards for Medicaid; and

      (c)1. The applicant resides in a nonpartnership county; or

      2. The applicant resides in a county served by a partnership and meets one (1) of the excluded categories as established in 907 KAR 1:705, Demonstration project: services provided through regional managed care partnerships (1115 Waiver).

      (4) Eligibility for qualified Medicare beneficiary (QMB) coverage shall be effective the month after the month of case approval if technical and financial eligibility requirements were met as established in the following administrative regulations:

      (a) 907 KAR 1:011, Technical eligibility requirements;

      (b) 907 KAR 1:640, Income standards for Medicaid; and

      (c) 907 KAR 1:645.

      (5)(a) Retroactive eligibility for specified low-income Medicare beneficiary (SLMB) benefits, Medicare qualified individuals (QI) benefits or qualified disabled working individuals shall be effective no earlier than the third month prior to the month of application if an individual meets technical and financial eligibility requirements as established in the following administrative regulations:

      1. 907 KAR 1:011, Technical eligibility requirements;

      2. 907 KAR 1:640, Income standards for Medicaid; and

      3. 907 KAR 1:645, Resource standards for Medicaid.

      (b) Retroactive eligibility for a qualified individual shall not include months of a prior year.

      (6) An SSI-related recipient age twenty-one (21) or older, in accordance with HCFA Program Issuance Transmittal Notice, Region IV, May 7, 1997, MCD-014-97, shall be eligible for Medicaid benefits effective the month prior to the first month of SSI payment if the recipient:

      (a) Resides in a partnership county; and

      (b) Meets Medicaid eligibility requirements for that month.

      (7) An SSI-related recipient age twenty-one (21) or older, in accordance with HCFA Program Issuance Transmittal Notice, Region IV, May 7, 1997, MCD-014-97, shall be retroactively eligible for Medicaid benefits effective no earlier than the third month prior to the first month of SSI payment if the recipient:

      (a)1. Resides in a nonpartnership county; and

      2. Meets Medicaid eligibility requirements for these months; or

      (b)1. Resides in a partnership county; and

      2. Meets the requirements for one (1) of the excluded categories established in 907 KAR 1:705, Demonstration project: services provided through regional managed care partnerships (1115 Waiver).

      (8) For an SSI recipient under age twenty-one (21), Medicaid coverage shall:

      (a) Automatically begin with the month prior to the first month of SSI payment; and

      (b) Be available for the three (3) preceding months if the recipient meets Medicaid eligibility requirements for those three months.

 

      Section 3. Continuing Eligibility. (1) A recipient shall be responsible for reporting within ten (10) days a change in circumstances which may affect eligibility. In addition, eligibility shall be redetermined:

      (a) Every twelve (12) months; or

      (b) If a report is received or information is obtained about a change in circumstances.

      (2) Pursuant to the waiver granted by the Secretary, United States Department of Health and Human Services, and promulgated as 907 KAR 1:705, Demonstration project: services provided through regional managed care partnerships (1115 Waiver), a recipient shall have a one (1) time guarantee of six (6) months of eligibility regardless of a loss of technical eligibility for Medicaid during that six (6) month time period if the recipient:

      (a) Resides in a county included in a partnership;

      (b) Did not meet one (1) of the excluded categories established in 907 KAR 1:705, Demonstration project: services provided through regional managed care partnerships (1115 Waiver);

      (c) Did not receive Medicaid in any of the twelve (12) months preceding participation in a partnership;

      (d) Participated in a partnership for less than six (6) months;

      (e) Continued to reside in a partnership region during the guaranteed six (6) month eligibility period; and

      (f) Is not:

      1. An incarcerated recipient;

      2. An alien who is eligible for emergency Medicaid; or

      3. A recipient requesting discontinuance of Medicaid.

 

      Section 4. Determination of Incapacity or Permanent and Total Disability. (1) Except as provided in subsections (2) and (3) of this section, a determination that a parent with whom the needy child lives is incapacitated, or that the individual requesting Medicaid due to disability is both permanently and totally disabled, shall be made by the medical review team following review of both medical and social reports.

      (2) A parent shall be considered incapacitated without a determination from the medical review team if:

      (a) The parent declares physical inability to work;

      (b) The worker observes some physical or mental limitation; and

      (c) The parent:

      1. Is receiving supplemental security income (SSI);

      2. Is age sixty-five (65) or over;

      3. Has been determined to meet the definition of blindness or permanent and total disability as contained in 42 U.S.C. 1382 or 416 by either the Social Security Administration or the medical review team;

      4. Has previously been determined to be incapacitated or both permanently and totally disabled by the medical review team, hearing officer, appeal board, or court of proper jurisdiction without a reexamination requested and there is no visible improvement in condition;

      5. Is receiving retirement, survivors, and disability insurance (RSDI) benefits, federal black lung benefits, or railroad retirement benefits based on disability as evidenced by an award letter;

      6. Is receiving Veterans Administration (VA) benefits based on 100 percent disability, as verified by an award letter; or

      7. Is currently hospitalized and a statement from the attending physician indicates that incapacity will continue for at least thirty (30) days. If application was made prior to the admission, the physician shall indicate if incapacity existed as of the application date.

      (3) An individual shall be considered permanently and totally disabled without a determination from the medical review team if the individual:

      (a) Receives RSDI or railroad retirement benefits based on disability;

      (b) Received SSI based on disability during a portion of the twelve (12) months preceding the application month and discontinuance was due to income or resources, not to improvement in physical condition;

      (c) Has been determined to meet the definition of blindness or both permanent and total disability as contained in 42 U.S.C. 416 or 1382 by the Social Security Administration; or

      (d) Has previously been determined to be permanently and totally disabled by the medical review team, hearing officer, appeal board, or court of proper jurisdiction without a reexamination requested and there is no visible improvement in condition.

      (4)(a) A child who was receiving supplemental security income benefits on August 22, 1996 and who, but for the change in definition of childhood disability established by 42 U.S.C. 1396a(a)(10) would continue to receive SSI, shall continue to meet the Medicaid definition of disability.

      (b) If a redetermination is necessary, the definition of childhood disability effective on August 22, 1996 shall be used.

 

      Section 5. Disqualification. An adult individual shall be disqualified from receiving Medicaid for a specified period of time if the department or a court determines the individual has committed an intentional program violation in accordance with 907 KAR 1:675, Program Integrity.

 

      Section 6. Incorporation by Reference. (1) "HCFA Program Issuance Transmittal Notice Region IV", May 7, 1997, MCD-014-97, is incorporated by reference.

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (21 Ky.R. 2590; Am. 22 Ky.R. 294; eff. 7-26-95; 23 Ky.R. 3642; 4167; eff. 6-16-97; 25 Ky.R. 442; 864; eff. 9-16-98; 26 Ky.R. 1253; 1572; eff. 2-1-2000; 34 Ky.R. 881; 1468; eff. 1-4-2008; Recodified from 907 KAR 1:605, 9-30-2013.)