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 to qualify for federal Medicaid
funds. This administrative regulation establishes the definitions for 907 KAR
Chapter 20.
Section 1. Definitions.
(1) "1915(c) home and community based
service" means a service available or provided via a 1915(c) home and community
based services waiver program.
(2)
"1915(c) home and community based services waiver program" means a Kentucky
Medicaid program established pursuant to, and in accordance with,
42 U.S.C.
1396n(c).
(3) "ABD" means a person who is aged, blind,
or disabled.
(4) "Adult scale"
means the scale located in
907
KAR 20:020, Section 1(1), establishing Medicaid income
limits by family size.
(5)
"Advanced practice registered nurse" is defined by
KRS
314.011(7).
(6) "Adverse action" means:
(a) The denial or limited authorization of a
requested service, including the type or level of service;
(b) The reduction, suspension, or termination
of a previously authorized service;
(c) The denial, in whole or in part, of
payment for a service;
(d) The
failure to provide services in a timely manner; or
(e) The failure of a managed care
organization to act within the timeframes provided in
42 C.F.R.
438.408(b).
(7) "After the month of
separation" means the first day of the month that follows the month in which an
individual ceases living in the same household of a Medicaid eligible
family.
(8) "Aid to Families with
Dependent Children" or "AFDC" means an assistance program:
(a) In effect from 1935 through
1996;
(b) For children whose
families had low or no income; and
(c) Administered by the United States
Department of Health and Human Services.
(9) "Ambulatory prenatal care" means
health-related care furnished to a presumed eligible pregnant woman provided in
an outpatient setting.
(10)
"Appeal" means a request for review of an adverse action or a decision by an
MCO related to a covered service.
(11) "Applicant" means an individual applying
for Medicaid.
(12) "Authorized
representative" means:
(a) For a recipient or
applicant who is authorized by Kentucky law to provide written consent, an
individual or entity acting on behalf of, and with written consent from, the
applicant or recipient; or
(b) A
legal guardian.
(13)
"Baseline date" means the date the institutionalized individual was
institutionalized and applied for Medicaid.
(14) "Basic maintenance" means the amount of
income that may be retained by the applicant for living and personal
expenses.
(15) "Blind work expense"
or "BWE" means an SSI program option in which expenses a blind individual
incurs in order to earn income are deducted for an SSI eligibility
purpose.
(16) "Cabinet" is defined
by
KRS
194A.005(1).
(17) "Caretaker relative" means:
(a) An individual:
1. Who is the caregiver of a child;
or
2. On whose tax return the child
is listed as a dependent; and
(b) Who has one (1) of the following
relationships to the child:
1. A
grandfather;
2. A
grandmother;
3. A
brother;
4. A sister;
5. An uncle;
6. An aunt;
7. A nephew;
8. A niece;
9. A first cousin;
10. A relative of the half-blood;
11. A preceding generation denoted by a
prefix of:
a. Grand;
b. Great; or
c. Great-great; or
12. A stepfather, stepmother, stepbrother, or
stepsister.
(18) "Categorically needy" means an
individual with income below 300 percent of the supplemental security income
(SSI) standard who has been receiving hospice or 1915(c) home and community
based services for at least thirty (30) consecutive days.
(19) "Child" means a person who:
(a)
1. Is
under the age of nineteen (19) years;
2.
a. Is a
full-time student in a secondary school or the equivalent level of vocational
or technical training; and
b. Is
expected to complete the program before the age of nineteen (19)
years;
3. Is not self
supporting;
4. Is not a participant
in any of the United States Armed Forces; and
5. If previously emancipated by marriage, has
returned to the home of his or her parents or to the home of another
relative;
(b) Has not
attained the age of nineteen (19) years in accordance with
42 U.S.C.
1396a(l)(1)(D); or
(c) Is under the age of nineteen (19) years
if the person is a KCHIP recipient.
(20) "Community spouse" means the individual
who is married to an institutionalized spouse who:
(a) Remains at home in the community;
and
(b) Is not:
1. Living in a medical institution;
2. Living in a nursing facility; or
3. Participating in a 1915(c) home and
community based services waiver program.
(21) "Community spouse maintenance standard"
means the income standard to which a community spouse's otherwise available
income is compared for purposes of determining the amount of the allowance used
in the post-eligibility calculation.
(22) "Continuous period of
institutionalization" means thirty (30) or more consecutive days of
institutional care in a medical institution or nursing home or both and may
include thirty (30) consecutive days of receipt of a 1915(c) home and community
based service or a combination of both.
(23) "Countable resources" means resources
not subject to exclusion in the Medicaid Program.
(24) "DCBS" means the Department for
Community Based Services.
(25)
"Deemed eligible newborn" means an infant born to a mother who, at the time of
the infant's birth, was a Medicaid recipient.
(26) "Department" means the Department for
Medicaid Services or its designee.
(27) "Dependent child" means a biological
child, a step child, or a child gained through adoption, who:
(a) Lives with a parent in the community;
and
(b) Is claimed as a dependent
by either parent under the Internal Revenue Service Code.
(28) "Dependent parent" means a parent:
(a) Of either member of a couple;
(b) Who lives with the community spouse;
and
(c) Is claimed as a dependent
by either spouse under the Internal Revenue Service Code.
(29) "Dependent sibling" means a brother or
sister of either member of a couple, including a half-brother, half-sister, or
sibling gained through adoption, who:
(a)
Resides with the community spouse; and
(b) Is claimed as a dependent by either
spouse under the Internal Revenue Service Code.
(30) "Enrollee" means a recipient who is
enrolled with a managed care organization for the purpose of receiving Medicaid
or KCHIP covered services.
(31)
"Excess shelter allowance" means an amount equal to the difference between the
community spouse's verified shelter expenses and the minimum shelter
allowance.
(32) "Fair market value"
means an estimate of the value of an asset if sold at the prevailing price at
the time it was actually transferred based on:
(a) The most recent gross tax assessed value
of the property as stated by the local property valuation
administrator;
(b) An independent,
licensed appraiser; or
(c) The
price brought on the property at a public auction conducted by a licensed
auctioneer.
(33) "Family
alternatives diversion payment" means a lump sum payment made to a Kentucky
Transitional Assistance Program applicant:
(a)
To meet short-term emergency needs; and
(34) "First month of SSI payment" means the
first month for which an SSI-related Medicaid recipient is determined to be
eligible for SSI payments.
(35)
"Foster care" is defined by
KRS
620.020(5).
(36) "Gross income" means non-excluded income
that would be used to determine eligibility prior to income
disregards.
(37) "Homestead" means
property:
(a) In which an individual has an
ownership interest; and
(b) That an
individual uses as the individual's principal place of residence.
(38) "ICF IID" means intermediate
care facility for individuals with an intellectual disability.
(39) "Impairment related work expense" or
"IRWE" means an SSI program option in which the United States Social Security
Administration deducts the cost of items or services an individual needs, due
to an impairment, in order to work.
(40) "Incapacity" means a condition of mind
or body making a parent physically or mentally unable to provide the
necessities of life for a child.
(41) "Income" means money received from:
(a) Statutory benefits (for example, Social
Security, Veterans Administration pension, black lung benefits, or railroad
retirement benefits);
(b) A pension
plan;
(c) Rental
property;
(d) An investment;
or
(e) Wages for labor or
services.
(42)
"Individual development account" means an account containing funds for the
purpose of continuing education, purchasing a first home, business
capitalization, or other purposes allowed by federal regulations or
clarifications that meet the criteria established in
921
KAR 2:016.
(43) "Institutionalized" means:
(a) Residing in:
1. A nursing facility;
2. An intermediate care facility for an
individual with an intellectual disability; or
3. A medical institution;
(b) Receiving hospice services;
or
(c) Receiving 1915(c) home and
community based services.
(44) "Institutionalized individual" means an
individual with respect to whom payment is based on a level of care provided in
a nursing facility and who is:
(a) An
inpatient in:
1. A nursing facility;
2. An intermediate care facility for
individuals with an intellectual disability; or
3. A medical institution;
(b) Receiving 1915(c) home and
community based services; or
(c)
Receiving hospice services.
(45) "Institutionalized spouse" means an
institutionalized individual who:
(a)
1. Is in a medical institution, intermediate
care facility for an individual with an intellectual disability, or nursing
facility;
2. Participates in a
1915(c) home and community based services waiver program; or
3. Is receiving hospice services;
(b) Has a spouse who is not an
institutionalized individual; and
(c) Is likely to remain institutionalized for
at least thirty (30) consecutive days while the community spouse:
1. Is not receiving hospice services;
and
2. Remains out of a medical
institution, nursing facility, intermediate care facility for an individual
with an intellectual disability, or 1915(c) home and community based services
waiver program.
(46) "KCHIP" means the Kentucky Children's
Health Insurance Program administered in accordance with
42 U.S.C.
1397aa through jj.
(47) "Kentucky Transitional Assistance
Program" or "KTAP" means:
(a) Kentucky's
version of TANF; and
(b) A money
payment program for children who are deprived of parental support or care in
accordance with
921
KAR 2:006.
(48) "Keogh plan" means a full-fledged
pension plan for self-employed individuals in the United States of
America.
(49) "Long-term care
partnership insurance" is defined by
KRS
304.14-640(4).
(50) "Long-term care partnership insurance
policy" means a policy meeting the requirements established in
KRS
304.14-642(2).
(51) "Managed care organization" or "MCO"
means an entity for which the Department for Medicaid Services has contracted
to serve as a managed care organization as defined by
42
C.F.R.
438.2.
(52) "Mandatory state supplement" is defined
by
42 C.F.R.
435.4.
(53) "Medical institution or nursing
facility" means a hospital, nursing facility, or intermediate care facility for
individuals with an intellectual disability.
(54) "Medically necessary" means that a
covered benefit is determined to be needed in accordance with
907
KAR 3:130.
(55) "Medically needy" is defined by
42 C.F.R.
435.4.
(56) "Medically-needy income level" or "MNIL"
means the basic maintenance standard used in the determination of Medicaid
eligibility for the medically needy.
(57) "Medicare Part A" means federal health
insurance that covers:
(a) Inpatient hospital
or skilled nursing facility services, including blood transfusions;
(b) Hospice services; and
(c) Home health services.
(58) "Medicare qualified
individual group 1 (QI-1)" means an eligibility category in which an individual
would be a qualified Medicaid beneficiary but for the individual's income
disqualifying the individual from being a qualified Medicare beneficiary due to
the circumstances established in
42 U.S.C.
1396a(a)(10)(E)(iv).
(59) "Minimum shelter allowance" means an
amount that is thirty (30) percent of the standard maintenance
amount.
(60) "Minor" means the
couple's minor child or the couple's minor individual older than a child who:
(a) Is under the age of twenty-one (21)
years;
(b) Lives with a community
spouse; and
(c) Is claimed as a
dependent by either spouse under the Internal Revenue Service Code.
(61) "Modified adjusted gross
income" or "MAGI" is defined by
42 U.S.C.
1396a(e)(14)(G).
(62) "Month of separation" means the month in
which an individual ceases living in the same household of a Medicaid eligible
family.
(63) "Monthly income
allowance" means an amount:
(a) Deducted in
the posteligibility calculation for maintenance needs of a community spouse or
other family member; and
(b) Equal
to the difference between a spouse's and other family member's income and the
appropriate maintenance needs standards.
(64) "NF" means nursing facility.
(65) "Nonqualified alien" means a resident of
the United States of America who does not meet the qualified alien requirements
established in
907
KAR 20:005, Section 2.
(66) "Non-recurring lump sum income" means
money received at one (1) time that is normally considered as income,
including:
(a) Accumulated back payments from
Social Security, unemployment insurance, or workers' compensation;
(b) Back pay from employment;
(c) Money received from an insurance
settlement, gift, inheritance, or lottery winning;
(d) Proceeds from a bankruptcy proceeding;
or
(e) Money withdrawn from an IRA
by an individual prior to the individual reaching the age at which a penalty is
not imposed for withdrawing the IRA, KEOGH plan, deferred compensation, tax
deferred retirement plan, or other tax deferred asset.
(67) "Nursing facility" means:
(a) A facility:
1. To which the state survey agency has
granted a nursing facility license;
2. For which the state survey agency has
recommended to the department certification as a Medicaid provider;
and
3. To which the department has
granted certification for Medicaid participation; or
(b) A hospital swing bed that provides
services in accordance with
42 U.S.C.
1395tt and
1396l,
if the swing bed is certified to the department as meeting requirements for the
provision of swing bed services in accordance with
42 U.S.C.
1396r(b), (c), and (d) and
42 C.F.R.
447.280.
(68)
"Old Age, Survivors, and Disability Insurance" or "OASDI" means the social
insurance program:
(a) More commonly known as
"Social Security"; and
(b) Into
which participants make payroll contributions based on earnings.
(69) "Optional state supplement"
is defined by
42 C.F.R.
435.4.
(70) "Other family member" means a relative
of either member of a couple who is a:
(a)
Minor or dependent child;
(b)
Dependent parent; or
(c) Dependent
sibling.
(71) "Other
family member's maintenance standard" means an amount equal to one-third (1/3)
of the difference between the income of the other family member and the
standard maintenance amount.
(72)
"Otherwise available income" means income to which the community spouse has
access and control, including gross income that would be used to determine
eligibility under Medicaid without benefit of disregards for federal, state,
and local taxes; child support payments; or other court ordered
obligation.
(73) "Patient status
criteria" means the patient status criteria established in
907
KAR 1:022.
(74) "Physician" is defined by
KRS
311.550(12).
(75) "Plan to Achieve Self Support" or "PASS"
means an SSI program option that enables a disabled individual receiving SSI
benefits to:
(a) Identify a work
goal;
(b) Identify training, items,
or services needed to reach the work goal; and
(c) Set aside money for installment payments
or a down payment for items needed to reach the work goal.
(76) "Presumptive eligibility" means Medicaid
eligibility determined:
(a) By a provider
authorized by
907 KAR
20:050 to make a presumptive eligibility
determination; and
(77) "Provider" is defined by
KRS
205.8451(7).
(78) "Qualified alien" means an alien who, at
the time the alien applies for or receives Medicaid, meets the requirements
established in
907
KAR 20:005, Section 2(2)(a)2. or 3.
(79) "Qualified disabled and working
individual" is defined by
42
U.S.C.
1396d(s).
(80) "Qualified Medicare beneficiary" or
"QMB" is defined by
42
U.S.C.
1396d(p)(1).
(82) "Qualified provider" means a provider
who:
(a) Is currently enrolled with the
department;
(b) Has been trained
and certified by the department to grant presumptive eligibility to pregnant
women; and
(83) "Qualifying income trust" or "QIT" means
an irrevocable trust established for the benefit of an identified individual in
accordance with
42
U.S.C.
1396p(d)(4)(B).
(84) "Real property" means land or an
interest in land with an improvement, permanent fixture, mineral, or
appurtenance considered to be a permanent part of the land, and a building with
an improvement or permanent fixture attached.
(85) "Recipient" is defined by
KRS
205.8451(9).
(86) "Resource assessment" means the
assessment, at the beginning of the first continuous period of
institutionalization of the institutionalized spouse upon request by either
spouse, of the joint resources of a couple if a member of the couple enters a
medical institution or nursing facility, receives hospice services, or becomes
a participant in a 1915(c) home and community based services waiver
program.
(87) "Resources" mean cash
money and other personal property or real property that:
(a) An individual:
1. Owns; and
2. Has the right, authority, or power to
convert to cash; and
(b)
Is not legally restricted for support and maintenance.
(88) "Retirement, Survivors, and Disability
Insurance" or "RSDI" means an insurance benefit program:
(a) Managed by the United States Social
Security Administration;
(b) Also
known as Social Security Disability or Social Security Disability Insurance;
and
(c) That aims to provide
monthly financial support to individuals who have lost income due to
retirement, disability, or death of a family provider.
(89) "Rural health clinic" is defined by
42 C.F.R.
405.2401(b).
(90) "Satisfactory documentary evidence of
citizenship or nationality" is defined by
42 U.S.C.
1396b(x)(3)(A).
(91) "Significant financial duress" means a
member of a couple has established to the satisfaction of a hearing officer
that the community spouse needs income above the level permitted by the
community spouse maintenance standard to provide for medical, remedial, or
other support needs of the community spouse to allow the community spouse to
remain in the community.
(92)
"Social Security" means a social insurance program administered by the United
States Social Security Administration.
(93) "Social Security number" means a number
issued by the United States Social Security Administration to United States
citizens, permanent residents, or temporary working residents pursuant to
42 U.S.C.
405(c)(2).
(94) "Special income level" means the amount
that is 300 percent of the SSI standard.
(95) "Specified low-income Medicare
beneficiary" means an individual who meets the requirements established in
42 U.S.C.
1396a(a)(10)(E)(iii).
(96) "Spend-down liability" means the amount
of money in excess of the Medicaid income eligibility threshold to which
incurred medical expenses are applied to result in an individual's income being
below the income eligibility threshold.
(97) "Spousal protected resource amount"
means resources deducted from a couple's combined resources for the community
spouse in an eligibility determination for the institutionalized
spouse.
(98) "Spousal share" means
one-half (1/2) of the amount of a couple's combined countable resources, up to
a maximum of $60,000 to be increased for each calendar year in accordance with
42
U.S.C.
1396r-5(g).
(99) "Spouse" means a person legally married
to another under state law.
(100)
"SSI benefit" is defined by
20
C.F.R.
416.2101.
(101) "SSI essential person, spouse, or
nonspouse" means an individual necessary to an SSI recipient to enable the SSI
recipient to be self-supporting.
(102) "SSI general exclusion" means the
twenty (20) dollars disregard from income allowed by the Social Security
Administration in an SSI determination.
(103) "SSI program" means the United States
supplemental security income program.
(104) "SSI standard" means the amount
designated by the Social Security Administration as the federal benefit
rate.
(105) "Standard maintenance
amount" means one-twelfth (1/12) of the federal poverty income guideline for a
family unit of two (2) members, with revisions of the official income poverty
guidelines applied for Medicaid provided during and after the second calendar
quarter that begins after the date of publication of the revisions, multiplied
by 150 percent.
(106) "State plan"
is defined by
42 C.F.R.
400.203.
(107) "State spousal resource standard" means
the amount of a couple's combined countable resources determined necessary by
the department for a community spouse to maintain himself or herself in the
community.
(108) "Support right"
means the right of an institutionalized spouse to receive support from a
community spouse under state law.
(109) "Targeted low-income child" is defined
by
42 C.F.R.
457.310(a).
(110) "Temporary Assistance for Needy
Families" or "TANF" means a block grant program that:
(a) Succeeded AFDC; and
(b) Is designed to:
1. Assist needy families so that children can
be cared for in their own homes;
2.
Reduce the dependency of needy parents by promoting job preparation, work, and
marriage;
3. Prevent out-of-wedlock
pregnancies; and
4. Encourage the
formation and maintenance of two-parent families.
(111) "Title IV-E benefits" means
benefits received via Social Security Act Title IV, Part 3, which is codified
as
42
U.S.C.
670 through
679c.
(112) "Tobacco Master Settlement Agreement"
means an agreement:
(a) Entered into in
November 1998 between certain tobacco companies and states' attorneys general
of forty-six (46) states; and
(b)
1. That settled states' lawsuits against the
tobacco industry for recovery of tobacco-related health care costs;
2. That exempted the tobacco companies from
private tort liability regarding harm caused by tobacco; and
3. In which the tobacco companies agreed to
make various annual payments to the states to compensate for some of the
medical costs incurred in caring for individuals with smoking-related
illnesses.
(113) "Transferred resource factor" means an
amount that is:
(a) Equal to the average:
1. Monthly cost of nursing facility services
in the state at the time of application; and
2. Of private pay rates for semi private
rooms of all Medicaid participating facilities; and
(b) Adjusted annually.
(114) "Trust" means a legal instrument or
agreement valid under Kentucky state law in which:
(a) A grantor transfers property to a trustee
or trustees with the intention that it be held, managed, or administered by the
trustee or trustees for the benefit of the grantor or certain designated
individuals or beneficiaries; and
(b) A trustee holds a fiduciary
responsibility to manage the trust's corpus and income for the benefit of the
beneficiaries.
(115)
"Trusted source" means a source recognized by the federal government or
department as a reliable source for verifying an individual's
information.
(116) "Uncompensated
value" means the difference between the:
(a)
Fair market value at the time of transfer, less any outstanding loans,
mortgages, or other encumbrances on the asset; and
(b) Amount received for the asset.
(117) "Undue hardship" means that:
(a) Medicaid eligibility of an
institutionalized spouse cannot be established on the basis of assigned support
rights; and
(b) The spouse is
subject to discharge from the medical institution, nursing facility, or 1915(c)
home and community based services waiver program due to inability to
pay.
(118) "Valid
immigrant status" is defined by:
(119) "Veteran" is defined by
38
U.S.C.
101(2).