Kan. Admin. Regs. § 129-6-54

Current through Register Vol. 43, No. 39, September 26, 2024

Section 129-6-54 - Financial eligibility for MAGI-excepted coverage groups

This regulation shall apply to all groups described in K.A.R. 129-6-34(c)(2), except that subsections (c) and (d) of this regulation shall not apply to any medicare beneficiary who meets the requirements of K.A.R. 129-6-86 or to any working disabled individual who meets the requirements of K.A.R. 129-6-87.

(a) Definitions. For purposes of this regulation, each of the following terms shall have the meaning specified in this regulation:

(1) "Client obligation" means the amount that the individual is required to pay towards the cost of care that the individual receives in a long-term care arrangement. Client obligation shall be based on the amount of applicable income that exceeds the income standard in the eligibility base period.

(2) "Eligibility base period" means the length of time used in the determination of financial eligibility. The length of the eligibility base period varies from one month to six months as specified in subsection (b).

(3) "Spenddown" means the amount of applicable income that exceeds the protected income level in the eligibility base period and that is available to meet medical costs.

(b) Eligibility base period.

(1) The base period shall be determined according to the following:

(A) For prior eligibility, the base period shall be the three months immediately preceding the month of application.

(B) Except for persons determined eligible under K.A.R. 129-6-85, the base period shall be one month for current eligibility.

(C) For persons determined eligible under K.A.R. 129-6-85, the base period shall be one month for persons in long-term care and six months for persons in independent living for current eligibility. A six-month base period shall be shortened in certain instances including when the recipient begins long-term care, becomes eligible for cash assistance, or dies.

(2) The base period shall begin on the first day of the month in which the application was received. Subsequent eligibility base periods for recipients shall begin on the first day of the month following the expiration of the previous base period. Each reapplication received outside of a previously established eligibility base period shall be treated as a new application without regard to any previous eligibility base period. However, if the reapplication includes a request for prior eligibility, the base period of prior eligibility shall not extend into a previously established eligibility base period.

(c) Financial eligibility for persons in independent living.

(1) The total of all applicable income in the eligibility base period, as determined in accordance with K.A.R. 129-6-111, shall be compared to the income standard, as specified in K.A.R. 129-6-103, for the base period. If the total applicable income is less than the income standard and the individual owns property that has value within the allowable limits, the individual shall be financially eligible for medical assistance. If the total applicable income exceeds the income standard, the individual shall be ineligible for medical assistance except for persons determined eligible under K.A.R. 129-6-73, 129-6-74, and 129-6-85.

(2) For determined eligibles under K.A.R. 129-6-73, 129-6-74, and 129-6-85, if the total applicable income exceeds the income standard and the individual owns property that has value within the allowable limits, the excess applicable income shall be the spenddown.

(A) Each applicant or recipient shall incur allowable medical expenses in an amount at least equal to the spenddown before becoming eligible for assistance. Medical expenses paid either voluntarily or involuntarily by third parties shall not be utilized to meet the spenddown, except for medical expenses paid by a public program of the state other than medicaid.

(B) A previously unconsidered increase in total applicable income during the current eligibility base period that results in an additional spenddown shall not alter the base period. The individual shall meet the additional spenddown during the eligibility base period before the individual becomes eligible or regains eligibility for medical assistance. A payment made through the program within the current eligibility base period shall not be considered an overpayment if a previously eligible individual fails to meet the additional spenddown within the current eligibility base period.

(d) Financial eligibility for persons in long-term care arrangements.

(1) Total gross income shall not exceed 300 percent of the payment standard for one person in the supplemental security income program as specified in K.A.R. 129-6-103(a)(13).

(2)

(A) If the person is eligible in accordance with paragraph (d)(1), the total of all applicable income in the eligibility base period, as determined in accordance with K.A.R. 129-6-111, shall be compared to the income standard, as specified in K.A.R. 129-6-103(b) for institutional arrangements and K.A.R. 129-6-103(c) for HCBS arrangements, for the base period. If the total applicable income is less than the income standard and the individual owns property that has value within the allowable limits, the individual shall be financially eligible for medical assistance. If the total applicable income exceeds the income standard and the individual owns property that has value within the allowable limits, the excess applicable income shall be the client obligation.

(B) If the person is not eligible in accordance with paragraph (d)(1), financial eligibility shall first be determined in accordance with subsection (c). If allowable medical expenses, including the cost of the long-term arrangement, are in an amount that is at least equal to the spend-down, a final determination of financial eligibility shall then be determined in accordance with paragraph (d)(2)(A), including application of the appropriate institutional or HCBS income standard as specified in K.A.R. 129-6-103(b) or (c). If allowable medical expenses are not in an amount that is at least equal to the spenddown, financial eligibility shall be determined in accordance with subsection (c).

(3) Each applicant or recipient shall incur allowable medical expenses in an amount at least equal to the client obligation before becoming eligible for assistance. Medical expenses paid either voluntarily or involuntarily by third parties shall not be utilized to meet this obligation, except for medical expenses paid by a public program of the state other than medicaid.

(4) Any increase in total applicable income during the current eligibility base period may result in financial in-eligibility or in additional obligation, but this increase shall not alter the base period. A payment made through the program within the current eligibility base period shall not be considered an overpayment if a previously eligible individual becomes ineligible because of an increase in total applicable income or fails to meet any additional obligation within the current eligibility base period.

(e) Allowable expenses. The following expenses shall be applied to a spenddown or client obligation if the individual provides evidence that the individual has incurred or reasonably expects to incur the expenses within the appropriate eligibility base period, or has incurred and is still obligated for expenses outside of the appropriate eligibility base period that have not been previously applied to a spenddown or obligation:

(1) Co-pay requirements;

(2) the pro rata portion of medical insurance premiums for the number of months covered in the eligibility base period regardless of the actual date of payment, past or future;

(3) any medicare premiums that are not covered by the department through the buy-in process. Premiums that are subject to the buy-in process shall not be allowable before completion of the buy-in process, even if the individual pays the premiums or the premiums are withheld;

(4) if medically necessary and recognized under Kansas law, all expenses for medical services incurred by the individual or a legally responsible family group member. Expenses for social services designated as medical services under the HCBS program shall be allowable under this paragraph for persons in the HCBS program. Expenses for routine supplies, as defined in K.A.R. 129-10-15a, and for institutional care if the individual does not meet nursing facility criteria through the level-of-care evaluation or reevaluation process as defined in K.A.R. 30-10-7, shall not be allowable under this paragraph; and

(5) the cost of necessary transportation by appropriate mode to obtain medical services specified in paragraph (e)(4).

Kan. Admin. Regs. § 129-6-54

Authorized by and implementing K.S.A. 2013 Supp. 65-1,254 and 75-7403; effective, T-129-10-31-13, Nov. 1, 2013; effective Feb. 28, 2014.