907 KAR 20:005. Medicaid technical eligibility requirements not related to a modified adjusted gross income standard or former foster care individuals

Link to law: http://www.lrc.ky.gov/kar/907/020/005.htm
Published: 2015

      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.)
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