907 KAR 20:005.
Medicaid technical eligibility requirements not related to a modified adjusted
gross income standard or former foster care individuals.
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
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
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 redetermination 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 Medicaid 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 Medicaid 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. (Recodified from 904 KAR 1:011, 5-6-1986; Am. 13 Ky.R. 377;
9-4-1986; 1791; eff. 5-14-1987; 14 Ky.R. 1017; eff. 12-11-1987; 2112; eff.
6-22-1988; 15 Ky.R. 1318; eff. 12-13-1988; 1961; eff. 3-15-1989; 16 Ky.R. 2582;
eff. 6-27-1990; 17 Ky.R. 549; eff. 10-14-1990; 2543; eff. 3-12-1991; 18 Ky.R.
520; eff. 10-6-1991; 23 Ky.R. 3442; 3841; 4162; eff. 6-16-1997; 25 Ky.R. 438;
859; eff. 9-16-1998; 26 Ky.R. 1239; 1563; eff. 2-1-2000, 29 Ky.R. 2624; eff.
3-24-2003; 30 Ky.R. 107; 613; eff. 8-20-2003; 30 Ky.R. 107; 613; 1109; 1521;
eff. 1-5-2004; 33 Ky.R. 571; 1360; 1544; eff. 1-5-2007; 34 Ky.R. 1813; 2105;
eff. 4-4-2008; TAm eff. 7-16-2013; Recodified
from 907 KAR 1:011, 9-30-2013; 1148; 1752; 2147; eff. 4-4-2014.)