Medicaid (MA) and State Supplementation

Division of Family Support

OPERATION MANUALOMTL-526

Volume IVA

Table of Contents R. 4/1/18

MEDICAID 1000-1349

Introduction to Medicaid1000-1049

Non-MAGI MA Definitions 1010

Abbreviations and Acronyms 1015

Agency Responsibility 1020

Type of Assistance (TOA) 1030

Medicaid Benefits1050-1234

Medicare/Medicaid Recipients 1060

Co-Pay for Medicaid Recipients 1065

Disclosure of Information1235-1239

Disclosure of Information 1235

KYHealth Card1240-1249

KYHealth Card 1240

Use of Medicaid 1250-1349

Introduction to Managed Care 1340

Managed Care Enrollment 1343

Exempt/Non Exempt Managed Care Recipients 1346

CASE ACTION1350-1549

Application1350-1419

Application for Entitled Benefits 1350

Eligibility for Entitled Benefits 1353

Application After Denial of SSI Benefits 1360

Authorized Representative (AR) 1371

Non-MAGI MA Application/Interview Process 1372

Electronic Signature __1373

Applications for the Deceased 1374

Non-MAGI MA Documentation 1380

Case Decision1420-1479

Scope of Investigation 1420

Authorizing Benefits 1430

Special Circumstance Processing 1435

Electronic Case File 1440

Ongoing/Retroactive Medicaid 1450

Standards of Promptness 1470

Recertification/Interim Changes1480-1509

Non-MAGI Medicaid Recertifications 1500

Negative Action1510-1540

Timely Notice of Decrease/Discontinuance 1510

Reasons for Negative Action 1530

Misrepresentation and Fraud 1540

Out of State Inquiries1545-1549

Recipients Moving Into or Out of Kentucky 1547

TECHNICAL ELIGIBILITY1550-1749

General Requirements1550-1579

Introduction 1550

Enumeration 1560

SSN Applications 1562

Use of SSN 1568

Citizenship and Identity1570-1579

Citizenship and Identity Requirements for Adult MA Programs 1570

Adult MA Case Processing for Citizenship Verification 1575

Criteria for Qualified Aliens 1577

Emergency Time-Limited Medicaid 1578

Extension of Emergency Time-Limited Medicaid 1579

Residency1580-1659

Residency 1580

Placement by another State 1590

Prisons/Public Institutions 1600

Interruption of Public Institutional Status 1610

Home Incarceration 1615

Spouse Abuse Center 1620

Emergency Shelter 1630

Third Party Liability (TPL)1660-1689

Third Party Liability 1660

TPL and SSI 1680

Category Requirements1700-1749

Aged/Blind/Disabled 1700

FINANCIAL ELIGIBILITY1750-2799

Introduction1750-1769

Allocations, Allowances, and Standards 1750

Relative Responsibility1770-1849

Applicant with a Spouse 1770

Blind or Disabled Child Living With Parents 1810

Blind or Disabled Child Living Apart From Family 1820

Resources1850-2049

Overview of Resources 1850

Resource Limits 1860

Excluded Resources 1880

Long Term Care Partnership Insurance 1885

Annuities 1890

Life Expectancy Table 1900

Home Equity Plans 1930

Jointly Held Resources 1940

Lifetime Care Agreement 1960

Liquid Assets 1970

Eligibility Advisor (EA) 1971

Homestead Property 1975

Non-home Real Property 1980

Nonrecurring Lump Sum 1990

Trusts 2010

Consideration of Income from a Medicaid Qualifying Trust 2011

Established On or Before 8/1/93

Vehicles 2030

Overview of Burial Reserves 2031

Excluded Burial Spaces and Items 2033

Life insurance Policies 2036

Pre-Arranged Funeral Contracts 2037

Transfer of Resources2050-2119

Transfer of Resources 2050

Life Estate 2055

Life Estate Table 2056

Exceptions to Transfer of Resources 2070

Consideration of Transferred Resources 2080

Entering Transfer of Resources Disqualifications 2081

Special Procedures for Transfer of Resources by a Power

of Attorney/Legal Guardian 2105

SSI Recipients and Transfer of Resources 2110

Institutionalized/Community Spouse Resources2120-2179

Special Resource Considerations For an Institutionalized Spouse 2120

With a Community Spouse

Resource Assessment 2130

Community Spouse Resource Allowance Calculation 2135

Resource Eligibility Determination For Applicants with a 2140

Community Spouse

Patient Liability Transfer of Resources 2150

Additional Considerations 2160

Recertification/Interim 2170

Income 2180-2209

Overview of Income 2180

Income Rounding 2200

Unearned Income2210-2399

Annuities 2220

Adult MA: Child and Spousal Support 2230

Contributions 2240

Farm/Business 2250

Home Equity Plans 2260

Income Supplementation 2270

Loans 2290

Long Term Care Insurance 2310

Other Unearned Income 2320

Promissory Notes, Loans, Mortgages, Land Contracts 2330

Statutory Benefits 2340

SSI 2350

Earned Income2400-2464

Contract Employment 2410

Occasional and Commissioned Employment 2420

Other Earned Income 2430

Seasonal Employment 2440

Self-Employment 2450

Wages 2460

Electronic Income Verification (EIV) 2461

Nonrecurring Lump Sum2465-2469

Nonrecurring Lump Sum 2465

Excluded Income2470-2479

Excluded Income 2470

Deductions2480-2489

Deductions 2480

PASS2490-2559

Plan for Achieving Self Support (PASS) 2490

Calculating Income2560-2599

Technically Eligible Applicant 2560

Technically Eligible Applicant and Spouse 2570

Technically Eligible Applicant with Technically Ineligible Spouse 2580

Companion Cases2600-2649

Companion Cases Introduction 2600

Both Individual and Spouse are Technically Eligible 2610

Technically Eligible Individual with Technically Ineligible Spouse 2620

Spend Down2650-2799

Spend Down Process 2650

Establishing the Retro Spend Down Quarter 2670

Establishing the Current Spend Down Quarter 2671

Considering Medical Expenses in Spend Down 2720

Allowable Spend Down Medical Expenses 2730

Patient Liability for Individuals Otherwise Medicaid Eligible 2770

Consumer Directed Option (CDO)2800-2800

Consumer Directed Option (CDO) 2800

Supports for Community Living (SCL)2810-2899

Introduction to SCL2810-2829

SCL Waiver Program 2810

Michelle P. Waiver 2815

Technical Eligibility Requirements 2820

SCL Eligibility Determination2830-2899

SCL Eligibility Determination Procedures 2830

SCL Individual 2840

SCL Child 2850

SCL Individual with Non-SCL Spouse 2860

SCL Couple 2870

SCL Income and Resource Consideration 2880

SCL Case Action 2890

HOME AND COMMUNITY BASED SERVICES2900-2999

Introduction to HCBS2900-2919

HCBS Waiver Program 2900

Technical Eligibility Requirements 2910

HCBS Eligibility Determination2920-2999

Medicaid Eligibility 2920

HCBS Patient Liability 2930

HCBS Individual 2940

HCBS Child Living with Parent 2950

HCBS Recipient with Non-HCBS Spouse 2960

HCBS Recipient with HCBS Spouse 2970

HCBS Case Action 2980

Case Action 2990

OTHER WAIVER PROGRAMS3000-3049

Acquired Brain Injury Eligibility Determination3000-3029

ABI Waiver Program 3000

ABI Medicaid Eligibility Determination 3005

Acquired Brain Injury (ABI Patient Liability Determination) 3010

ABI Individual 3015

ABI Recipient with Non-ABI Spouse 3017

ABI Recipient with ABI Spouse 3020

ABI Income and Resource Consideration 3025

ABI Long Term Care (LTC) Waiver 3030

HOSPICE PROGRAM3050-3299

Introduction3050-3099

Scope of Program 3050

Hospice Rates 3060

Hospice Technical Eligibility Requirements 3070

Non-Institutional Hospice Procedures3100-3179

Non-Institutional Hospice Medicaid Eligibility 3100

Non-Institutional Hospice MA Effective Date 3110

Non-Institutional Hospice Patient Liability 3120

Non-Institutionalized Hospice Individual or Child Living with Parents 3130

Non-Institutionalized Hospice Couple 3140

Non-Institutionalized Hospice Applicant with Non-Hospice Spouse 3150

Non-Institutional Hospice Income and Resource Consideration 3160

Non-Institutional Hospice Case Action 3170

Institutional Hospice Procedures3180-3299

Institutional Hospice MA Eligibility Determination 3180

Institutional Hospice MA Effective Date 3190

Institutional Hospice Patient Liability 3200

Institutionalized Hospice Individual 3210

Institutionalized Hospice Child 3220

Institutionalized Hospice Individual with Non-Hospice 3230

Community Spouse

Institutionalized Hospice Couple 3240

Institutional Hospice Income and Resource Consideration 3250

Institutional Hospice Case Action 3260

LONG TERM CARE3300-3799

Introduction to LTC3300-3349

Who is Eligible for LTC Vendor Payment 3300

Special Procedures for LTC Applicants 3320

Case Action 3350-3449

SSI Recipient in LTC 3350

Patient Status Not Met 3380

QMB Recipient in LTC 3390

SSI/State Supplementation Recipient Institutionalized 3410

Medicare Recipient in LTC 3420

Medicare and Medicaid Recipient in LTC 3430

Income Calculation3450-3499

Cost of Care 3450

Countable Income 3460

Excluded Income for LTC/Waiver 3470

Deductions and Allowances 3480

Eligibility Determination3500-3649

Special Income Standard 3500

Qualifying Income Trust 3505

LTC MA Effective Date 3510

Interruption of Stay 3520

LTC Individual 3530

LTC Couple 3540

LTC Individual with Community Spouse 3550

LTC Blind or Disabled Child 3560

Spend Down for LTC 3580

Change in Status 3590

Effective Date of Vendor Payment 3610

Patient Status Determination3650-3699

Peer Review Organizations 3650

Peer Review Organization Initial Certification 3660

Peer Review Organization Denial 3670

Peer Review Organization Reconsideration 3680

Peer Review Organization Appeal 3690

ICF IID3700-3719

Privately Owned/Operated Facilities 3700

State Owned/Operated Facilities 3710

Money Follows the Person (MFP)3715-3719

Money Follows the Person (MFP) 3715

Estate Recovery3720-3799

Introduction to Estate Recovery 3720

DCBS Responsibilities 3730

NON-EMERGENCY MEDICAL TRANSPORTATION3800-4149

Introduction3800-3849

Non-Emergency Medical Transportation 3800

Non-Emergency Medical Transportation Brokers 3810

MEDICAID WORKS3900-4149

Medicaid Works Overview 3900

Medicaid Works Application 3910

Medicaid Works Substantial Gainful Activity (SGA) 3912

Medicaid Works Financial Eligibility 3920

Denial/Discontinuance Codes for Medicaid Works 3940

Medicaid Works Recertifications/Interim Changes/Untimely Changes 3951

PASS THROUGH4150-4299

Requirements4150-4209

Pass Through Overview 4150

Concurrent SSI/State Supplementation 4160

Disabled Adult Child 4180

Disabled Early Widows and Widowers or Disabled Surviving 4190

Divorced Spouses With No Medicare Part A

Financial Eligibility4220-4249

Resources 4220

Income Calculation 4230

Applicant with Eligible Spouse 4235

Applicant with Ineligible Spouse 4240

Pass Through for Individual Losing State Supplementation 4245

Case Action4250-4299

Pass Through Application Process 4250

Discontinuances 4260

Pass Through Individual Receiving Waiver or Hospice Services 4280

QUALIFIED DISABLED WORKING INDIVIDUALS4300-4399

QDWI4300-4399

Introduction 4300

General Information 4310

Technical Eligibility 4320

Financial Eligibility 4330

QDWI Effective Dates 4340

Interims/Recertifications 4350

LOW INCOME SUBSIDY (LIS)4390-4399

Medicare Part D 4390

LIS Medicare Savings Program 4395

QUALIFIED MEDICARE BENEFICIARIES4400-4549

Introduction to QMB4400-4419

Medicare Savings Program Overview 4400

Technical Eligibility4420-4449

Mail-In Applications for Medicare Savings Programs 4420

Technical Eligibility for Medicare Savings Program 4430

Financial Eligibility4450-4499

Resource Limits for Medicare Savings Program 4450

Income Limits for Medicare Savings Program 4455

Medicare Savings Program Income 4460

Medicare Savings Program Deductions 4470

Case Action4500-4549

Medicare Savings Program Case Actions 4500

QMB, SLMB, OR QI1 Effective Date 4515

Accretes, Deletes, and Restorations 4525

Ex-Parte with Medicare Savings Plan 4535

SUPPLEMENTAL SECURITY INCOME4650-4899

SSI Applications4650-4749

Duplicate Applications 4650

Entitlement 4655

Potential SSI Applications 4660

MA Eligibility for Deceased Applicants 4662

SSI Financial Standards 4670

SSI Financial Eligibility 4680

Institutionalized Applicants 4690

Residency 4710

MA Eligibility for SSI Recipients 4720

SSI Discontinuance4750-4899

Medicaid Eligibility Redetermination 4750

Exparte 4770

Cases Eligible after SSI Discontinuance 4820