RELATES TO:
KRS
205.520,
42 U.S.C.
1396a(e)(14), (l)(1),
1396b(x),
9902(2),
42 C.F.R.
435.403,
435.406,
435.603,
435.926,
440.255
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 any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the provisions and
requirements for individuals whose Medicaid eligibility is determined using the
modified adjusted gross income as the income standard. The affected individuals
include children under the age of nineteen (19) years, pregnant women to 365
days postpartum, caretaker relatives, and adults under age sixty-five (65) who
do not have a dependent child under the age of nineteen (19) years and are not
otherwise eligible for Medicaid benefits.
Section
1. Applicability.
(1)
(a) The provisions and requirements of this
administrative regulation shall apply to individuals whose Medicaid eligibility
is determined using the modified adjusted gross income as the income
standard.
(b) An individual whose
Medicaid eligibility is determined using the modified adjusted gross income as
an income standard shall be an individual who is:
1. A child under the age of nineteen (19)
years, excluding a child in foster care;
2. A caretaker relative with income up to 133
percent of the federal poverty level established annually by the United States
Department of Health and Human Services pursuant to
42 U.S.C.
9902(2);
3. A pregnant woman, with income up to 195
percent of the federal poverty level established annually by the United States
Department of Health and Human Services pursuant to
42 U.S.C.
9902(2), including the
postpartum period to 365 days after delivery;
4. An adult under age sixty-five (65) with
income up to 133 percent of the federal poverty level established annually by
the United States Department of Health and Human Services pursuant to
42 U.S.C.
9902(2), who:
a. Does not have a dependent child under the
age of nineteen (19) years; and
b.
Is not otherwise eligible for Medicaid benefits; or
5. A targeted low income child with income up
to 150 percent of the federal poverty level established annually by the United
States Department of Health and Human Services pursuant to
42 U.S.C.
9902(2).
(2)
(a) If
an eligibility determination indicates that an individual's income exceeds 133
percent of the federal poverty level established annually by the United States
Department of Health and Human Services pursuant to
42 U.S.C.
9902(2), the department
shall apply an additional cushion of five (5) percent of the federal poverty
level toward the eligibility determination for the individual as described
pursuant to 42 U.S.C.
1396a(e)(14)(I)(i).
(b) If after the five (5) percent adjustment,
the individual's income is under the adjusted income threshold, the individual
shall meet the modified adjusted gross income standard.
(c) A pregnant person's federal poverty level
calculation pursuant to 42
U.S.C.
9902(2) shall be at
least two (2) and shall include the pregnant person and the number of children
expected to be delivered. Other members of the household shall be calculated
and included consistent with KAR Title 907.
(3) The provisions and requirements of this
administrative regulation shall not apply to an individual whose Medicaid
eligibility is determined using an eligibility standard that is not the
modified adjusted gross income.
Section 2. MAGI-based Methods. The department
shall use the MAGI-based methods established in
42 C.F.R.
435.603 to determine whether an individual
meets the Medicaid income eligibility requirements if the eligibility standard
is the modified adjusted gross income.
Section
3. Resources Not Considered. An individual's resources shall not
be considered for the purpose of determining Medicaid eligibility if the
eligibility standard is the modified adjusted gross income.
Section 4. Citizenship and Residency
Requirements.
(1) The citizenship requirements
established in 42 C.F.R.
435.406 shall apply.
(2) Except as established in subsection (3)
or (4) of this section, to satisfy the Medicaid:
(a) Citizenship requirements, an applicant or
recipient shall be:
1. A citizen of the United
States as verified through satisfactory documentary evidence of citizenship or
nationality presented during initial application or if a current recipient,
upon next redetermination of continued eligibility;
2. A qualified noncitizen who entered the
United States before August 22, 1996, and is:
a. Lawfully admitted for permanent residence
pursuant to 8 U.S.C.
1101;
b. Granted asylum pursuant to
8 U.S.C.
1158;
c. A refugee admitted to the United States
pursuant to 8 U.S.C.
1157;
d. Paroled into the United States pursuant to
8 U.S.C.
1182(d)(5) for a period of
at least one (1) year;
e. A
noncitizen whose deportation is being withheld pursuant to
8 U.S.C.
1253(h), as in effect prior
to April 1, 1997, or 8 U.S.C.
1231(b)(3);
f. Granted conditional entry pursuant to
8 U.S.C.
1153(a)(7), as in effect
prior to April 1, 1980;
g. A
noncitizen who is granted status as a Cuban or Haitian entrant pursuant to
8 U.S.C.
1522;
h. A battered noncitizen pursuant to
8 U.S.C.
1641(c);
i. A veteran pursuant to
38 U.S.C.
101,
107,
1101, or
1301 with a discharge
characterized as an honorable discharge and not on account of
alienage;
j. On active duty other
than active duty for training in the Armed Forces of the United States and who
fulfills the minimum active duty service requirements established in
38 U.S.C.
5303A(d);
k. The spouse or unmarried dependent child of
an individual described in clause i. or j. of this subparagraph or the
unremarried surviving spouse of an individual described in clause i. or j. of
this subparagraph if the marriage fulfills the requirements established in
38 U.S.C.
1304; or
3. A qualified
noncitizen who entered the United States on or after August 22, 1996, and is:
a. Granted asylum pursuant to
8 U.S.C.
1158;
b. A refugee admitted to the United States
pursuant to 8 U.S.C.
1157;
c. A noncitizen whose deportation is being
withheld pursuant to 8 U.S.C.
1253(h), as in effect prior
to April 1, 1997, or 8 U.S.C.
1231(b)(3);
d. A noncitizen who is granted status as a
Cuban or Haitian entrant pursuant to
8 U.S.C.
1522;
e. A veteran pursuant to
38 U.S.C.
101,
107,
1101, or
1301 with a discharge
characterized as an honorable discharge and not on account of
alienage;
f. On active duty other
than active duty for training in the Armed Forces of the United States and who
fulfils the minimum active duty service requirements established in
38 U.S.C.
5303A(d);
g. The spouse or unmarried dependent child of
an individual described in clause e. or f. of this subparagraph or the
unremarried surviving spouse of an individual described in clause e. or f. of
this subparagraph if the marriage fulfills the requirements established in
38 U.S.C.
1304;
i. An individual lawfully
admitted for permanent residence pursuant to
8 U.S.C.
1101 who has earned forty (40) quarters of
Social Security coverage; and
(b) Residency requirements, the applicant or
recipient shall be a resident of Kentucky who meets the conditions for
determining state residency pursuant to
42 C.F.R.
435.403.
(3) A qualified or nonqualified noncitizen
shall be eligible for medical assistance pursuant to
42 C.F.R.
440.255 and as provided in this subsection.
(a) The individual shall meet the income,
resource, and categorical requirements of the Medicaid Program.
(b) Coverage for the individual shall be:
1. Limited to the medical care and services
necessary for the treatment of an emergency medical condition or pregnancy of
the individual;
2. Not related to
an organ transplant procedure; and
3. For a medical condition, including severe
pain, in which the absence of immediate medical attention could reasonably be
expected to result in placing the individual's health in serious jeopardy,
serious impairment to bodily functions, or serious dysfunction of any bodily
organ or part.
(c) The
individual's coverage shall be recertified every twelve (12)
months.
(4)
(a) The satisfactory documentary evidence of
citizenship or nationality requirement in subsection (2)(a)1 of this section
shall not apply to an individual who:
1. Is
receiving SSI benefits;
2.
Previously received SSI benefits but is no longer receiving them;
3. Is entitled to or enrolled in any part of
Medicare;
4. Previously received
Medicare benefits but is no longer receiving them;
5. Is receiving:
a. Disability insurance benefits under
42 U.S.C.
423; or
b. Monthly benefits under
42 U.S.C.
402 based on the individual's disability
pursuant to 42 U.S.C.
423(d);
6. Is in foster care and who is assisted
under Title IV-B of the Social Security Act, which is codified as
42 U.S.C.
621 through
628b; or
7. Receives foster care maintenance or
adoption assistance payments under Title IV-E of the Social Security Act, which
is codified as 42 U.S.C.
670 through
679c.
(b) The department's documentation
requirements shall be in accordance with the requirements established in
42 U.S.C.
1396b(x).
(5) The department shall assist an applicant
or recipient who is unable to secure satisfactory documentary evidence of
citizenship or nationality in a timely manner because of incapacity of mind or
body and lack of a representative to act on the applicant's or recipient's
behalf.
(6)
(a) Except as established in paragraph (b) of
this subsection, an individual shall be determined eligible for Medicaid for up
to three (3) months prior to the month of application if all conditions of
eligibility are met.
(b) The
retroactive eligibility period shall begin no earlier than January 1, 2014 for
an individual who gains Medicaid eligibility solely by qualifying:
2. As an adult with income up to 133 percent
of the federal poverty level established annually by the United States
Department of Health and Human Services pursuant to
42 U.S.C.
9902(2), who:
a. Does not have a dependent child under the
age of nineteen (19) years; and
b.
Is not otherwise eligible for Medicaid benefits.
(7) The documentation of
citizenship requirements established in this administrative regulation shall
not apply to a noncitizen under nineteen (19) years of age who is lawfully
present in the United States of America.
(8) Except as established in subsection (9)
of this section, a noncitizen shall be considered to be lawfully present in the
United States of America if the individual:
(a) Is a qualified noncitizen;
(b) Is a noncitizen in a valid immigrant
status;
(c) Is a noncitizen who has
been paroled into the United States of America in accordance with
8 U.S.C.
1182(d)(5) for less than one
(1) year, except for an individual:
1.
Paroled for:
a. Prosecution; or
b. Deferred inspection; or
2. Pending removal
proceedings;
(d) Is a
noncitizen who:
1. Has been granted:
a. Temporary resident status in accordance
with 8 U.S.C.
1160 or
1225a;
b. Temporary protected status in accordance
with 8 U.S.C.
1254a or is an individual with a pending
application for temporary protected status who has been granted employment
authorization;
c. Employment
authorization under 8 C.F.R.
274a.12(c);
d. Deferred action status; or
e. An administrative stay of removal under 8
C.F.R. Part
241 ;
2. Is a
family unity beneficiary in accordance with
Section
301 of
Pub. L.
101-649 as amended, and 8 C.F.R. Part
236;
3. Is under deferred enforced
departure in accordance with a decision made by the President of the United
States of America; or
4. Is a
beneficiary of an approved visa petition who has a pending application for an
adjustment of status;
(e)
Is an individual with a pending application for asylum:
1.
b. For withholding of removal under
8 U.S.C.
1231; or
c. Under the Convention of Torture;
and
2. Who:
a. Has been granted employment authorization;
or
b. Is under the age of fourteen
(14) years and has had an application pending for at least 180 days;
(f) Is an individual who
has been granted withholding of removal under the Convention Against
Torture;
(g) Is a child who has a
pending application for special immigrant juvenile status as described in
8 U.S.C.
1101(a)(27)(J); or
(h) Is a victim of severe trafficking in
persons in accordance with the Victims of Trafficking and Violence Protection
Act of 2000 (
Public Law
106-386, as amended in
22 U.S.C.
7105(b)).
(9) An individual with deferred action under
the Department of Homeland Security's deferred action for the childhood
arrivals process shall not be considered to be lawfully present with respect to
any of the categories listed in subsection (8) of this section.
Section 5. Provision of Social
Security Numbers.
(1)
(a) Except as provided in subsections (2) and
(3) of this section, an applicant for or recipient of Medicaid shall provide a
Social Security number as a condition of eligibility.
(b) If a parent or caretaker relative and the
child, unless the child is a deemed eligible newborn, refuses to cooperate with
obtaining a Social Security number for the newborn child or other dependent
child, the parent or caretaker relative shall be ineligible due to failing to
meet technical eligibility requirements.
(2) An individual shall not be denied
eligibility or discontinued from eligibility due to a delay in receipt of a
Social Security number from the United States Social Security Administration if
appropriate application for the number has been made.
(3) An individual who refuses to obtain a
Social Security number due to a well-established religious objection shall not
be required to provide a Social Security number as a condition of
eligibility.
Section 6.
Institutional Status.
(1) An individual shall
not be eligible for Medicaid if the individual is a:
(a) Resident or inmate of a nonmedical public
institution except as established in subsection (2) of this section;
(b) Patient in a state tuberculosis hospital
unless he or she has reached age sixty-five (65);
(c) Patient in a mental hospital or
psychiatric facility unless the individual is:
1. Under age twenty-one (21) years of
age;
2. Under age twenty-two (22)
if the individual was receiving inpatient services on his or her 21st birthday;
or
3. Sixty-five (65) years of age
or over; or
(d) Patient
in a nursing facility classified by the Medicaid program as an institution for
mental diseases, unless the individual has reached age sixty-five
(65).
(2) An inmate shall
be eligible for Medicaid during the period of time the inmate is admitted to a
hospital if the inmate:
(a) Has been admitted
to a hospital;
(b) Has been an
inpatient at the hospital for at least twenty-four (24) consecutive hours;
and
(c) Meets the Medicaid
eligibility criteria established in this administrative regulation.
Section 7. Assignment of
Rights to Medical Support. By accepting assistance for or on behalf of a child,
a recipient shall be deemed to have assigned to the Cabinet for Health and
Family Services any medical support owed for the child not to exceed the amount
of Medicaid payments made on behalf of the recipient.
Section 8. Third-party Liability as a
Condition of Eligibility.
(1)
(a) Except as provided in subsection (3) of
this section, an individual applying for or receiving Medicaid shall be
required as a condition of eligibility to cooperate with the Cabinet for Health
and Family Services in identifying, and providing information to assist the
cabinet in pursuing, any third party who may be liable to pay for care or
services available under the Medicaid Program unless the individual has good
cause for refusing to cooperate.
(b) Good cause for failing to cooperate shall
exist if cooperation:
1. Could result in
physical or emotional harm of a serious nature to a child or custodial
parent;
2. Is not in a child's best
interest because the child was conceived as a result of rape or incest;
or
3. May interfere with adoption
considerations or proceedings.
(2) A failure of an individual to cooperate
without good cause shall result in ineligibility of the individual.
(3) A pregnant woman with income up to 195
percent of the federal poverty level established annually by the United States
Department of Health and Human Services pursuant to
42 U.S.C.
9902(2) shall not be
required to cooperate in establishing paternity or securing support for her
unborn child.
Section 9.
Application Process, Initial and Continuing Eligibility Determination.
(1) An individual may apply for Medicaid by:
(b) Applying over the telephone by calling:
1. 1-855-459-6328;
2. 1-855-306-8959 to speak to the DCBS Family
Support Call Center; or
3.
1-855-326-4654 if deaf or hearing impaired;
(c) Faxing an application to
1-502-573-2007;
(d) Mailing a paper
application to DCBS Family Support, P.O. Box 2104, Frankfort, Kentucky 40602;
or
(e) Going to the applicant's
local Department for Community Based Services Office and applying in
person.
(2)
(a) An application shall be processed
(approved, denied, or a request for additional information sent) within
forty-five (45) days of application submittal.
(b) Immediately after submittal if there is a
variance of ten (10) percent or more regarding income information reported by
the applicant versus information available from a trusted source or sources, a
request for additional information shall be generated for the applicant
requesting documentation to prove the applicant's income.
(c) If a trusted source indicates that an
applicant is incarcerated, a request for additional information shall be
generated requesting verification of the applicant's incarceration
dates.
(d) If an applicant fails to
provide information in response to a request for additional information within
thirty (30) days of the receipt of the request, the application shall be
denied.
(3)
(a) An annual renewal of eligibility shall
occur without an individual having to take action to renew eligibility, unless:
1. The individual's eligibility circumstances
change resulting in the individual no longer being eligible for Medicaid;
or
2. A request for additional
information is generated due to a change in income or incarceration
status.
(b)
1. If an individual receives a request for
additional information as part of the renewal process, the individual shall
provide the information requested within forty-five (45) days of receiving the
request.
2. If an individual fails
to provide the information requested within forty-five (45) days of receiving
the request, the individual's eligibility shall be terminated on the
forty-fifth day from the request for additional information.
(4) An individual shall
be required to report to the department any changes in circumstances or
information related to Medicaid eligibility.
Section 10. Continuous Eligibility for
Children.
(1) An individual who is younger
than nineteen (19) shall receive continuous eligibility, consistent with
42 C.F.R.
435.926.
(2) The continuous eligibility period for a
child recipient shall be for a period of twelve (12) months.
(3) A child's eligibility during a continuous
eligibility period shall only be terminated under the following circumstances:
(a) The child becomes nineteen (19) during
the continuous eligibility period;
(b) The child, or representative, voluntarily
requests that the eligibility be terminated;
(c) The child ceases to be a resident of the
Commonwealth;
(d) The agency
determines that the eligibility was granted due to:
1. Agency error; or
2. Fraud, abuse, or perjury attributed to the
child or representative; or
(e) The death of the child.
Section 11. Adverse
Action, Notice, and Appeals. The adverse action, notice, and appeals provisions
established in
907 KAR 20:060 shall apply to
individuals for whom a modified adjusted gross income is the Medicaid
eligibility income standard.
Section
12. Miscellaneous Special Circumstances.
(1) A person during pregnancy, and as though
pregnant through the end of the month containing the 365th day of a period
beginning on the last day of pregnancy, or a child under six (6) years of age,
as specified in 42 U.S.C.
1396a(l)(1), shall meet the
income requirements for this eligibility group in accordance with this
administrative regulation.
(2) If
an eligible child is receiving covered inpatient services, except for services
in a long term care facility or behavioral health services in an inpatient
facility on a long-term basis, on a birthday which will make the child
ineligible due to age, the child shall remain eligible until the end of the
stay for which the covered inpatient services are furnished if the child
remains otherwise eligible except for age.
(3) A child born to a woman eligible for and
receiving Medicaid shall be eligible for Medicaid as of the date of the child's
birth if the child has not reached his or her first birthday.
(4)
(a) A
parent, including a natural or adoptive parent, may be included for assistance
in the case of a family with a child.
(b) If a parent is not included in the case,
a caretaker relative or relatives may be included to the same extent the
caretaker relative would have been eligible in the Aid to Families with
Dependent Children program using the AFDC methodology in effect on July 16,
1996.
(5) For an
individual eligible on the basis of utilizing his or her excess income for
incurred medical expenses, the effective date of eligibility shall be the day
the spend-down liability is met.
(6) If a family member is pregnant, the
unborn child shall be considered as a family member for income determination
purposes.