2693 Persons with Breast and Cervical Cancer(BCC) - Medicaid coverage is available to persons diagnosed with breast or cervical cancer through the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program if the requirements specified in this section are met. The general eligibility criteria of residency (2150), citizenship and alienage (2140), cooperation (2120) and SSN (2130) must be met. There are no financial criteria. Persons are eligible for the entire scope of Medicaid services, not just those related to treatment of the cancer.
2693.1 Screening Requirement - In order to be eligible under this category, a screening by the specific CDC program indicated above must be completed. Currently, Early Detection Works, with the Kansas Department of Health and Environment is the only CDC entity in Kansas. Regional case managers located in the county health departments are responsible for enrollment into Early Detection Works. Screening by an approved COC entity in another state will also meet this requirement. The Early Detection Works program applies certain eligibility requirements for entrance into the program. In 2006, only women ages 40-65 with incomes under 250% of poverty were eligible for Early Detection Works. Men are not eligible for the CDC screening. The case manager with the local health department is responsible for verifying enrollment into Early Detection Works by providing the eligibility worker with a copy of the approved Intake and Visit Summary document.
2693.2 Application Process - The Early Detection Works case manager is responsible for assisting the woman in the application process. The ES- 3100.7, Application for Medicaid Coverage, Breast and Cervical Cancer, has been developed for this purpose. Elements needed for the eligibility determination not available on the application (e.g., date of birth) shall be obtained from the Intake and Visit Summary.
It is expected that all applications shall be processed within 10 calendar days of receipt. Except for required verification (i.e., citizenship, identity or proof of alienage status) it is not necessary to verify the information reported on the application unless it appears questionable.
Eligibility is processed under the MS program. A Special Medical Indicator of BC (Breast and Cervical Cancer) shall be entered on the KAECSES PICK screen for each person eligible under this category. A one month base period is used.
Three month prior eligibility (see 7330 (2)) may be provided if all eligibility criteria are met, including the necessary screening referral from FREE to Know. In no event can coverage under this category begin prior to the first of the month in which the screening occurred.
2693.3 Uninsured Provision - The individual must be uninsured and she cannot be otherwise covered under any other form of creditable coverage, as defined by the Health Insurance Portability and Accountability Act, for treatment of breast or cervical cancer. Persons who have such coverage, including Medicare, are not eligible. If a person has coverage but is in a period of exclusion, such as a preexisting condition waiting period, or has exhausted the lifetime limit for treatment, creditable coverage for cancer is considered unavailable and the person may be eligible. A plan which covers cancer treatment but requires a high deductible be met IS considered available and would render the woman ineligible.
Persons eligible under other Medicaid groups are not eligible for coverage under this category, with the exception of spenddown coverage. A person meeting the criteria for another group must be placed in the other group and would not be eligible for coverage under this category until such eligibility ceased. A screening by the worker is required at the time of application. Persons may be eligible under this group while a disability decision is pending. If approved for SSI, coverage shall be switched given adequate notice requirements.
2693.4 Eligibility Period - Eligibility continues as long as the person is receiving treatment for breast or cervical cancer. The case manager is responsible for monitoring ongoing treatment with the individual’s physician or other medical provider(s) and notifying the eligibility worker when the course of treatment ends.
Cooperation with the review requirements of 9310 is required. Twelve month review periods shall be established for this group. The ES-3100.7 is used for the redetermination. Ongoing cancer treatment must be verified at review. Verification is requested, the ES-3822, Notice of Review Breast and Cervical Cancer, is included with each review application. This notice informs the beneficiary of the review and the requirement regarding ongoing cancer treatment. The beneficiary is responsible for obtaining verification of ongoing cancer treatment from the treating physician. The ES-3822A, Statement of Continuing Cancer Treatment is used to obtain information regarding treatment and care. Because the determination of ongoing cancer treatment is made by evaluating information on the form, the physician may submit additional information if necessary. The KDHE-DHCF Nurse/Program Manager for the BCC program makes the determination of ongoing cancer treatment.
Eligibility ends no later than the month following the month any of these requirements cease to be met, including reaching age 65, obtaining creditable coverage or the cessation of treatment. Eligibility may be established in another category if requirements are met. A new application will generally be required for this determination.
A BCC recipient who reports a pregnancy is continuously eligible per KFMAM 2300.
2694 AIDS Drug Assistance Program (ADAP) - Limited coverage is available for persons diagnosed with AIDS. Coverage is limited to payment of prescription drugs related to treatment of AIDS as provided in an ongoing formulary maintained by Health Care Policy. DCF has ultimate responsibility for the program, including budget and claims payments. However, eligibility policy and case processing are the responsibility of KDHE. EES staff are not responsible for the eligibility determination or case maintenance of these cases.
Eligibility information is captured on the KAECSS S system, as input by KDHE staff on the LIME screen. A program/person alert of AD (ADAP) will be set for persons determined eligible for ADAP. Eligibility information is then sent to the fiscal agent and is displayed on MMIS. Providers bill the MMIS for medications provided to the ADAP eligible client. Persons may be eligible for Medicaid or MediKan coverage as well as ADAP. Payment for claims is generally drawn from Medicaid funds, except when noted.
Persons may be eligible for one of three separate ADAP coverage groups: