Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.520,
42 C.F.R.
435.530,
435.531,
435.540,
435.541,
435.906,
435.914,
435.916,
435.926,
42 U.S.C.
416,
423,
1382,
1396a, b, d
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 provisions relating to
determining initial and continuing eligibility for assistance under the
Medicaid Program except for individuals for whom a modified adjusted gross
income is the Medicaid eligibility income standard or former foster care
individuals who aged out of foster care while receiving Medicaid
coverage.
Section 1. 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, for the appropriate month of coverage, pursuant to:
1. This section;
2. Section 3 of this administrative
regulation; and
3. As established
in:
a.
907 KAR 20:005;
b.
907 KAR 20:020; and
c.
907 KAR
20:025.
(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
907 KAR 20:005,
907 KAR 20:020, and
907 KAR 20:025; 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 required 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 benefits 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
907 KAR 20:005,
907 KAR 20:020, and
907 KAR 20:025; and
(c) The applicant is excluded from managed
care organization participation in accordance with
907 KAR 17:010.
(4) Eligibility for qualified
Medicare beneficiary coverage shall be effective the month after the month of
case approval if technical and financial eligibility requirements were met as
established in
907 KAR 20:005,
907 KAR 20:020, and
907 KAR 20:025.
(5) Retroactive eligibility for benefits for
a specified low-income Medicare beneficiary benefits, Medicare qualified
individual group 1 (QI-1), or a qualified disabled and working individual shall
be effective no earlier than the third month prior to the month of application
if the individual meets technical and financial eligibility requirements as
established in
907 KAR 20:005,
907 KAR 20:020, and
907 KAR 20:025.
(6) An SSI-related recipient shall be
eligible for Medicaid benefits effective the month prior to the first month of
SSI payment if the individual:
(a) Is eligible
to be enrolled with a managed care organization in accordance with
907 KAR 17:010; and
(b) Meets Medicaid eligibility requirements
for that month.
(7) An
SSI-related recipient shall be retroactively eligible for Medicaid benefits
effective no earlier than the third month prior to the first month of SSI
payment if the individual:
(a) Is excluded
from managed care organization participation in accordance with
907 KAR 17:010; and
(b) Meets Medicaid eligibility requirements
for these months.
Section
2. Continuing Eligibility.
(1)
The recipient shall be responsible for reporting within thirty (30) days a
change in circumstances which may affect eligibility.
(2) 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.
Section 3. 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 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 SSI benefits;
2. Is age sixty-five (65) years or
over;
3. Has been determined to
meet the definition of blindness or permanent and total disability as contained
in 42 U.S.C.
1382c,
416, or
423 by either the Social Security
Administration or the medical review team;
4.
a. 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
b. Has not demonstrated any visible
improvement in condition;
5. Is receiving Retirement, Survivors, and
Disability Insurance benefits, federal black lung benefits, or railroad
retirement benefits based on disability as evidenced by an award
letter;
6. Is receiving Veterans
Affairs 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 benefits based on disability
during a portion of the twelve (12) months preceding the application month and
discontinuance was due to income or resources and 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)
1. 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
2. Has not
demonstrated any visible improvement in condition.
(4)
(a) A child who was receiving SSI 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 benefits, shall continue to meet the Medicaid
definition of disability.
(b) If a
redetermination is necessary, and in accordance with
923 KAR 2:470, 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.
Applicability. The provisions and requirements of this administrative
regulation shall not apply to an individual whose Medicaid eligibility is
determined:
(1) Using the modified adjusted
gross income as the income standard pursuant to
907 KAR 20:100; or
(2) Pursuant to
907 KAR
20:075.
21 Ky.R. 2590; 22
Ky.R. 294; eff. 7-26-1995; 23 Ky.R. 3642; 4167; eff. 6-16-1997; 25 Ky.R. 442;
864; eff. 9-16-1998; 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; 40 Ky.R. 1157; 1761;
2153; eff. 4-4-2014; Crt eff. 12-6-2019;
49
Ky.R. 2234; eff. 5/15/2023(EMERGENCY);
49
Ky.R. 2388; 50 Ky.R. 695; eff.
9/27/2023.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
42 U.S.C.
1396a
