Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520, 205.6481-205.6497,
341.360,
42 C.F.R. 435, 403,
45 C.F.R.
233.100,
8
U.S.C. 1101,
1153(a)(7),
1157,
1158,
1182(d)(5),
1231(b)(3),
1253(h),
1522,
1612,
1613,
1622,
1641, 38 U.S.C. 101,
107,
1101,
1301,
1304,
5303A,
42 U.S.C.
402,
416,
423,
1382c,
1383c,
1395i,
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 any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the technical
eligibility requirements of the Medicaid Program except for individuals whose
Medicaid eligibility standard is a modified adjusted gross income or for former
foster care individuals between the ages of nineteen (19) and twenty-six (26)
who aged out of foster care while receiving Medicaid coverage. Individuals to
whom the technical eligibility requirements in this administrative regulation
apply include children in foster care; aged, blind, or disabled individuals;
and individuals who receive supplemental security income benefits.
Section 1. The Categorically Needy.
(1) An individual receiving Title IV-E
benefits, SSI benefits, or an optional or a mandatory state supplement shall be
eligible for Medicaid as a categorically-needy individual.
(2) The following classifications of persons
shall be considered categorically needy and eligible for Medicaid participation
as categorically needy:
(a) A child in a
foster family home or private child-caring facility dependent on a governmental
or private agency;
(b) A child in a
psychiatric hospital, psychiatric residential treatment facility, or
intermediate care facility for individuals with an intellectual disability
beginning with day thirty-one (31) of the child's stay in the psychiatric
hospital, psychiatric residential treatment facility, or intermediate care
facility for individuals with an intellectual disability;
(c) A child in a subsidized adoption
dependent on a governmental agency;
(d) A qualified severely impaired individual
as specified in
42 U.S.C.
1396a(a)(10)(A)(i)(II) and
1396d(q),
to the extent the coverage is mandatory in this state;
(e) An individual who loses SSI benefit
eligibility but would be eligible for SSI benefits except for entitlement to or
an increase in his or her child's insurance benefits based on disability as
specified in
42
U.S.C. 1383c;
(f) An individual specified in
42
U.S.C. 1383c who:
1. Loses SSI benefits or state supplement
payments as a result of receipt of benefits pursuant to
42 U.S.C.
402(e) or (f);
2. Would be eligible for SSI benefits or
state supplement payments except for these benefits; and
3. Is not entitled to Medicare Part A
benefits;
(g) A disabled
widow, widower, or disabled surviving divorced spouse, who would be eligible
for SSI benefits except for entitlement to an OASDI benefit resulting from a
change in the definition of disability;
(h) A child who:
1. Was receiving SSI benefits on August 22,
1996; and
2. Except for the change
in definition of childhood disability would continue to receive SSI benefits;
or
(i) A person with
hemophilia who would be eligible for SSI benefits except that the individual
received a settlement in a class action lawsuit entitled "Factor VIII or IX
Concentrate Blood Products Litigation".
(3) The classifications of persons listed in
this subsection shall be considered categorically-needy and eligible for
Medicaid participation as limited by the provisions of this subsection.
(a) A family which correctly received
Medicaid for three (3) of the last six (6) calendar months, and would have been
terminated from receipt of AFDC using AFDC methodologies in effect on July 16,
1996 as a result of new or increased collection of child or spousal support,
shall be eligible for extended Medicaid coverage for four (4) consecutive
calendar months beginning with the first month the family would have been
ineligible for AFDC.
(b) A family
which would have been terminated from AFDC assistance using the AFDC
methodologies in effect on July 16, 1996 because of increased earnings, hours
of employment, or loss of earnings disregards shall be eligible for up to four
(4) months of extended Medicaid.
(c)
1.
Except as provided in subparagraph 3 of this paragraph, an individual in an
institution meeting appropriate patient status criteria who, if not
institutionalized, would not be eligible for SSI benefits or optional state
supplement benefits due to income shall be eligible under a special income
level which is set at 300 percent of the SSI benefit amount payable for an
individual with no income.
2.
Except as provided in subparagraph 3 of this paragraph, eligibility for a
similar hospice participant or similar participant in a 1915(c) home and
community based waiver program for individuals with an intellectual disability
or the aged, blind, or disabled shall be determined using the method
established in subparagraph 1 of this subsection.
3. Eligibility of an individual in an
intermediate care facility for individuals with an intellectual disability (ICF
IID) or supports for community living for an individual with an intellectual
disability or a developmental disability waiver meeting appropriate patient
status criteria whose gross income exceeds 300 percent of the SSI benefit
amount shall be determined by comparing the cost of the individual's care to
the individual's income.
Section 2. 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 requirement, 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 rede-termination of continued eligibility;
2. A qualified alien 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. An alien
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. An alien
who is granted status as a Cuban or Haitian entrant pursuant to
8
U.S.C. 1522;
h. A battered alien 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
l. An Amerasian immigrant pursuant to
8
U.S.C. 1612(a)(2)(A)(v);
or
3. A qualified alien
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. An alien 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. An alien 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;
h. An Amerasian immigrant pursuant to
8
U.S.C. 1612(a)(2)(A)(v);
or
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 alien shall
be eligible for medical assistance as provided in this paragraph.
(a) The individual shall meet the income,
resource, and categorical requirements of the Medi-caid Program.
(b) The individual shall have, or have had
within at least one (1) of the three (3) months prior to the month of
application, an emergency medical condition:
1. Not related to an organ transplant
procedure; and
2. Which shall be 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)
1. Approval of eligibility shall be for a
time limited period which includes, except as established in subparagraph 2 of
this paragraph, the month in which the medical emergency began and the next
following month.
2. The eligibility
period shall be extended for an appropriate period of time upon presentation to
the department of written documentation from the medical provider that the
medical emergency will exist for a more extended period of time than is allowed
for in the time limited eligibility period.
(d) The Medicaid benefits to which the
individual is entitled shall be limited to the medical care and services,
including limited follow-up, necessary for the treatment of the emergency
medical condition of the individual.
(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) 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.
Section 3. The
Medically Needy Who Qualify Via Spenddown. A medically needy individual who has
sufficient income to meet the individual's basic maintenance needs may apply
for Medi-caid with need determined in accordance with the income and resource
standards established in
907
KAR 20:020 through
907
KAR 20:045, if the individual meets:
(1) The income and resource standards of the
medically needy program established in
907
KAR 20:020 and
907
KAR 20:025; and
(2) The technical requirements of the
appropriate categorically needy group identified in Section 1 of this
administrative regulation.
Section
4. Qualified Medicare Beneficiaries, Qualified Disabled and
Working Individuals, Specified Low-Income Medicare Beneficiaries, and Medicare
Qualified Individuals Group 1 (QI-1).
(1)
Coverage shall be extended to a qualified Medicare beneficiary as specified in
42 U.S.C.
1396a(a)(10)(E):
(a) Subject to the income limits established
in
907
KAR 20:020:
(b) Subject to the resource limits
established in
907
KAR 20:025; and
(c) For the scope of benefits specified for a
QMB in
907
KAR 1:006.
(2) A QMB shall:
(a) Be eligible for or receive Medicare Part
A and Part B benefits;
(b) Be
determined to be eligible for QMB benefits effective for the month after the
month in which the eligibility determination has been made; and
(c) Not be eligible for QMB benefits:
1. Retroactively; or
2. For the month in which the eligibility
determination was made.
(3) A qualified disabled and working
individual shall be eligible under Medicaid for payment of the individual's
Medicare Part A premiums as established in
907
KAR 1:006.
(4) A specified low-income Medicare
beneficiary shall be eligible under Medicaid for payment of the Medicare Part B
premiums.
(5) A Medicare qualified
individual group 1 (QI-1) shall be eligible for payment of all of the Medicare
Part B premium.
Section
5. Technical Eligibility Requirements. The technical eligibility
factors for an individual included as categorically needy under Section 1 of
this administrative regulation shall be as established in this section.
(1) The following shall meet the requirements
of a child in accordance with
907 KAR
20:001, Section 1(19):
(a) A child in foster care;
(b) A child in a private
institution;
(c) A child in a
psychiatric hospital;
(d) A child
in a psychiatric residential treatment facility; or
(e) A child in an intermediate care facility
for individuals with an intellectual disability.
(2) An aged individual shall be at least
sixty-five (65) years of age.
(3) A
blind individual shall meet the definition of blindness as contained in
42 U.S.C.
416 and
42
U.S.C. 1382c relating to Retirement,
Survivors, and Disability Insurance or SSI benefits.
(4) A disabled individual shall meet the
definition of permanent and total disability as established in
42 U.S.C.
423(d) and
42
U.S.C. 1382c(a)(3) relating
to RSDI and SSI benefits.
(5)
(a) Using AFDC methodologies in effect on
July 16, 1996, a family who loses Medicaid eligibility solely because of
increased earnings or hours of employment of the caretaker relative or loss of
earnings disregards may receive up to four (4) months of extended medical
assistance for family members included in the medical assistance unit prior to
losing Medicaid eligibility.
(b)
The family shall meet the eligibility and reporting requirements for the
benefit period established in this subsection.
(c) The benefit period shall begin with the
month the family would have become ineligible for AFDC using AFDC methodologies
in effect on July 16, 1996.
1. To be eligible
for this transitional benefit period, the family shall:
a. Have correctly received Medicaid
assistance in three (3) of the six (6) months immediately preceding the month
the family would have become ineligible for AFDC using AFDC methodologies in
effect on July 16, 1996;
b. Have a
dependent child living in the home; and
c. Report earnings and child care costs no
later than the 21st day of the fourth month.
2. If the family no longer has a dependent
child living in the home, medical assistance shall be terminated the last day
of the month the family no longer includes a dependent child.
(6) An applicant who is
deceased shall have eligibility determined in the same manner as if the
applicant were alive to cover medical expenditures during the terminal
illness.
(7)
(a) 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 and the applicant is not
enrolled in a managed care organization.
(b)The effective date of Medicaid shall be
the first day of the month of eligibility.
(8)
(a)
Benefits shall be denied to a family for a month in which a parent with whom
the child is living is, on the last day of the month, participating in a
strike, and the individual's needs shall not be considered in determining
eligibility for Medicaid for the family if, on the last day of the month, the
individual is participating in a strike.
(b) A strike shall include a concerted
stoppage of work by employees (including a stoppage by reason of expiration of
a collective bargaining agreement) or any concerted slowdown or other concerted
interruption of operations by employees.
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 provided in Section 7 of
this administrative regulation;
(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 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 an institution for mental diseases, unless the individual has reached age
sixty-five (65).
(2) In
accordance with subsection (1)(c) of this section, if an individual is
receiving services in a mental hospital or psychiatric facility at the time the
individual reaches twenty-one (21) years of age and the services remain
medically necessary for the individual, the individual shall remain eligible
for the services until the individual reaches age twenty-two (22) years of
age.
Section 7.
Emergency Shelters or Incarceration Status.
(1) An individual or family group who is in
an emergency shelter for a temporary period of time shall be eligible for
medical assistance, even though the shelter is considered a public institution,
under the following conditions:
(a) The
individual or family group shall:
1. Be a
resident of an emergency shelter no more than six (6) months in any nine (9)
month period; and
2. Not be in the
facility serving a sentence imposed by the court, or awaiting trial;
and
(b) Eligibility for
Medicaid shall have existed immediately prior to admittance to the shelter or
it shall exist immediately after leaving the shelter.
(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 8. Application for Other Benefits.
(1) Except as provided in subsection (2) of
this section, as a condition of eligibility for Medicaid, an applicant or
recipient shall apply for each annuity, pension, retirement, and disability
benefit to which the applicant or recipient is entitled, unless the applicant
or recipient can show good cause for not doing so.
(a) Good cause shall be considered to exist
if other benefits have previously been denied with no change of circumstances
or the individual does not meet all eligibility conditions.
(b) Annuities, pensions, retirement, and
disability benefits shall include:
1.
Veterans' compensations and pensions;
2. Retirement and survivors disability
insurance benefits;
3. Railroad
retirement benefits;
4.
Unemployment compensation; and
5.
Individual retirement accounts.
(2) An applicant or recipient shall not be
required to apply for federal benefits if:
(a)
The federal law governing that benefit specifies that the benefit is optional;
and
(b) The applicant or recipient
believes that applying for the benefit would be to the applicant's or
recipient's disadvantage.
(3) An individual who would be eligible for
SSI benefits but has not made application shall not be eligible for
Medicaid.
Section 9.
Assignment of Rights to Medical Support. By accepting assistance for or on
behalf of a child, a recipient shall be deemed to have made an assignment to
the cabinet of any medical support owed for the child not to exceed the amount
of Medicaid payments made on behalf of the recipient.
Section 10. 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 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 the 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
11. Provision of Social Security Numbers.
(1) Except as provided in subsections (2) and
(3) of this section, an applicant or recipient of Medicaid shall provide a
Social Security number as a condition of eligibility.
(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 12.
Applicability. The provisions and requirements of this administrative
regulation shall:
(1) Apply to:
(a) Children in foster care;
(b) Aged, blind, or disabled individuals;
and
(c) Individuals who receive
supplemental security income benefits; and
(2) Not apply to an individual whose Medicaid
eligibility is determined:
(a) Using the
modified adjusted gross income standard pursuant to
907
KAR 20:100; or
(b) Pursuant to
907
KAR 20:075.
STATUTORY AUTHORITY:
KRS
194A.010(1),
194A.030(2),
194A.050(1),
205.520(3),
42 U.S.C.
1396a(a)(10), (r)(2),
1396b(f),
1396d(q)(2)(B),
1397aa