2600 - REQUIREMENTS SPECIFIC TO THE MEDICAID AND MEDIKAN PROGRAMS

2610 General Program Information - Both Medicaid and MediKan benefits are provided to help cover the cost of health care for an individual. Medicaid is a federally regulated and state administered program which is jointly funded by the federal and state government. It covers the majority of the state's medical recipients including children, pregnant women, and the aged and disabled. MediKan is a totally state regulated and funded program and covers disabled individuals who do not qualify for Medicaid. Separate state-funded programs are also operated for TB eligibles and residents of an IMD (see section 8112.4) between 21 and 64 years old. Eligibility policy for the AIDS Drug Assistance Program is the responsibility of KDHE.

Both the Medicaid and MediKan programs provide payments for comprehensive medical care and services furnished either through managed care entities or by enrolled providers. Payments are limited based on the scope of their practice, as defined by state law, and within the scope of services covered through the specific program. Specific services for which payment can be made and the proper payment rate (including capitation rates for managed care) are established by the Kansas Department of Health and Environment – Division of Health Care Finance (KDHE – DHCF) and are reviewed and adjusted periodically. Information on covered services can normally be obtained from the provider. Each provider is given a policy and procedure manual providing instructions related to coverage and processing claims; additional information can be obtained by the provider from the fiscal agent or KDHE – DHCF. Establishing eligibility/ineligibility of applicants/recipients based on the policies established within the limitations set forth by the Code of Federal Regulations and the Kansas Administrative Regulations is the responsibility of the KanCare Clearinghouse and the DCF Regional Service Centers. Licensed or certified medical practitioners determine the necessity of specified medical services, subject to review and approval by KDHE – DHCF. Payments (either capitated payments or direct service payments) are made directly to the provider (vendor) of medical services rendered to individuals certified as eligible. A contracted fiscal agent is used to process medical claims. The current fiscal agent is HP Enterprise Services (HP)

Both medical programs are funded by the Kansas State Legislature through KDHE – DHCF, Title XIX of the Social Security Act authorizes federal financial participation (FFP) in medical payments for Medicaid covered individuals as well as specifies basic eligibility and service requirements. DCF receives funding from KDHE – DHCF for eligibility functions in the regional service centers. The income and resource methodologies of the TANF program affect Medicaid eligibility in the children and pregnant women categories while those methodologies of the SSI program affect the Medicaid eligibility in the aged and disabled categories. Financial eligibility rules are the same as those used in Medicaid program for nondisabled children. The MediKan program is authorized through state legislation as well as the Kansas Administrative Regulations.

2611 Medicaid - The Medicaid program is divided into two segments, the "categorically needy" and the "medically needy."

1. Categorically Needy - Those persons who are eligible for a cash benefit under the SSI program or who meet Family Medical guidelines comprise a good portion of the categorically needy. Children and pregnant women who, although ineligible for cash assistance, have incomes that fall below certain poverty level guidelines also are classified within this group.
   
   The categorically needy receive medical assistance either because their income falls within poverty or Family Medical income guidelines or as a result of SSI eligibility. Within the categorically needy segment are also those persons who are "deemed" to be receiving an SSI cash benefit or Family Medical although ineligible for one due to certain financial or non-financial factors. For Family Medical, this would include persons who become ineligible due to increased earnings or hours of employment or because of loss of the earned income disregards (12 months of TransMed benefits), persons ineligible for cash assistance because of requirements that do not apply to medical, and persons who do not receive cash benefits because of the recovery of an entire grant for overpayment purposes. For SSI, this would include persons qualifying based on the Pickle Amendment provisions and persons who qualify for 1619(b) status under the SSI program benefits because they are working but who retain disability.
   
   Coverage of the categorically needy is largely mandated by federal law with some limited options within each individual group. The categorically needy consists of both mandatory populations and optional populations.  
   
   
   1. Mandatory Groups - As a condition of receiving federal funds, certain groups must be covered under the Medicaid plan. These groups include:
      
      
      1. Persons meeting Family Medical criteria (including TANF recipients) as well as those deemed to meet the criteria.
         
         
      2. SSI recipients, including those deemed to be receiving SSI.
         
         
      3. Pregnant women and children under the age of 1 whose countable income does not exceed 166% of the federal poverty level.
         
         
      4. Children ages 1 through 5 whose countable income does not exceed 149% of the federal poverty level.
         
         
      5. Children ages 6 through 18 whose countable income does not exceed 133% of the federal poverty level.
         
         
      6. Children receiving federally funded foster care or adoption support payments.
         
         
      7. Persons eligible for restricted coverage under the Qualified Medicare Beneficiary program (QMB), any of the Low Income Medicare Beneficiary (LMB) programs, or Qualified Working Disabled (QWD) program.
         
         
      8. Special protected groups such as the Pickle Amendment, Disabled Adult Children, etc.
         
         
      9. Non-citizens meeting all eligibility criteria for any Medicaid program except for the citizenship/alienage provisions, under SOBRA.
         
         
   2. Optional Groups - Kansas has elected to cover the following optional groups under the Medicaid plan:
      
      
   2. 1. Persons receiving services under the State's home-and-community based services (HCBS) waiver or Program of All - Inclusive Care for the Elderly (PACE) and certain NF residents.
         
         
      2. Children who do not meet the age criteria of the poverty level programs reflected above and who are financially eligible for Family Medical. (This primarily includes children who receive only state-funded foster care or adoption support payments.)
         
         
      3. Children under the age of 21 in long term institutional settings or between the ages of 19 and 22 and in the HCBS/SED waiver.
         
         
      4. Persons with disabilities between the ages of 16 and 64 with earned income under the Working Healthy program.
         
         
      5. Persons diagnosed with and receiving treatment for breast & cervical cancer.
         
         
      6. Individuals under the age of 21 who were in foster care on their 18th birthday.
         
         
      7. Presumptive Eligibility for children under age 19.
         
         
2. Medically Needy - The medically needy segment is comprised of those persons, who while meeting the non-financial criteria of one of the categorically needy programs such as age or disability, do not qualify because of excess income or resources or, in the case of pregnant women and children, have income which exceeds the poverty level guidelines of either Medicaid or Title 21. Most persons in the medically needy group are obligated for a share of their medical costs through the "spenddown" process. Coverage of this group is optional under federal law. If a state chooses this option, it must cover pregnant women (including coverage of the 60 day postpartum period) and children. Kansas provides coverage for the following groups:
   
   
3. 1. Pregnant women
      
      
   2. Children up to age 18 or age 18 and working toward the attainment of a high school diploma or its equivalent
      
      
   3. Persons 65 years of age and older
      
      
3. Persons who are disabled or blind under SSA standards.

Medically needy coverage can also be provided to caretaker relatives of dependent children but Kansas does not currently provide for this.

2612 MediKan - The MediKan program provides coverage of certain health care costs for disabled adults who meet the eligibility requirements of 2640. MediKan is funded with all state funds. There is no federal fund participation in this program.

The following sets forth a description of some of the Medicaid categories and the MediKan program category and the eligibility criteria specific to each. Persons not meeting the criteria for any of these categories are not eligible for either program. Eligibility criteria for all other Medicaid categories as well as the State's Title XXI program, Title 21, can be found in the Kansas Family Medical Assistance Manual.