The purpose of this memo is to implement the Presumptive Medical Disability (PMD) process and related policy changes. The new PMD process impacts both Medical Assistance and General Assistance. Several additional General Assistance policy changes are also included that make the GA and medical assistance programs more consistent. The effective date of these changes is September 1, 2006 and the new process is applicable to all applications received on or after this date. Except where indicated, ongoing General Assistance cases are subject to a PMD determination at the next annual review.

Because the implementation date of these changes is outside of the effective date of the next revision to the Kansas Economic and Employment Support Manual (KEESM), the changes are being implemented through this memo and have also been incorporated in the current draft of Revision 29, which will be effective October 1, 2006.

1. BACKGROUND

Federal Medicaid rules require an individual meet Social Security disability criteria in order to receive Medicaid based on disability. For administrative purposes, Kansas has relied on SSA to make the disability determination for many years. This strict limitation has resulted in cases pending many months, or even years, until a final determination is made. Although the MediKan program does provide a limited medical benefit package to those with the lowest incomes through the General Assistance program, it is funded entirely by state money. This makes the MediKan program costly to maintain and operate.

Although Medicaid rules require the SSA definition of disability be met, an option for the state to make internal disability determinations also now exists. Effective September 1, 2006 Kansas will implement this option with the Presumptive Medical Disability process. Adopting the PMD process will allow the state to make an internal disability determination for Medicaid, without waiting for the Social Security decision. Although the rules to make such decisions are strictly tied to SSA’s rules, the internal process is designed to issue a decision much quicker. This will allow those persons with the most severe disabilities to gain earlier access to Medicaid coverage. It will also allow some individuals who would otherwise receive state-funded MediKan to receive Medicaid, allowing the state to obtain additional federal funding and provide the beneficiary a broader range of services.

As with most federal programs, there are strict rules that must be followed when this option is implemented. Those rules and processes are outlined in this memo as well as the training material and the KEESM.

These same rules will also be applied in determining GA disability criteria. GA was intended to serve persons who would likely be eligible for Social Security disability. Application of the PMD process will result in a more objective assessment of cases in a manner that applies uniform standards and rules to the assessment of the individual’s disability claim.

The rules and processes of this implementation are outlined in this memo as well as the training material and the KEESM. New KAECSES information is available in the KAECSES User Manual.

2. DEFINITION OF PRESUMPTIVE MEDICAL DISABILITY
   
   Presumptive Medical Disability is essentially a process to determine disability. The PMD is actually composed of two separate determinations - a Presumptive Medicaid Determination and a Presumptive MediKan Determination. The Presumptive Medical Disability process brings both determinations into a single process.
   
   
   1. Disability - PMD primarily refers to the disability determination process. Persons seeking Medicaid coverage who have not been determined to meet SSA’s disability criteria and those seeking General Assistance/MediKan coverage receive a disability determination through the PMD process. PMD provides a single disability determination, first evaluating under Medicaid standards and then, if the beneficiary is not eligible, evaluating under MediKan standards (if other GA criteria are met).

   Tier 1 - The Medicaid determination continues to be based on Social Security criteria and the PMD process will use these standards when making decisions. For PMD, those who meet the SSA level of disability are considered Tier 1.

   The Tier 1 determination will evaluate if the impairment(s) meet or equal a listing described in Appendix 1 of CFR 404, Subpart P and will also consider the Medical-Vocational guidelines outlined in Appendix 2 of C.F.R. 404, Subpart P. This is essentially the Social Security definition.

   Tier 2 - For MediKan, the disability determination will use the same procedures as the Medicaid determination. This process involves an evaluation of the individual’s impairments related to their ability to work. To receive MediKan, the individual must be determined to have a severe impairment but, because of the person’s ability to work, the individual does not meet SSA criteria. Persons meeting this criteria are considered Tier 2.

   The Tier 2 determination considers the individual’s ability to perform past relevant work or adjust to other work. If a severe impairment does not exist, the individual does not meet Tier 2 criteria.

   2. Age - A PMD determination is only for individuals under age 65. Because Medicaid based on old age is available at age 65, a PMD is not necessary for persons in this age group. General Assistance cash is also available to persons age 65 without a separate PMD determination. A PMD determination is not necessary for persons eligible under another Medicaid category, such as MA CM. However, a PMD determination may be completed for a current eligible if coverage under the existing group is ending or if other services are sought which would require a disability determination.

   PMD is also applicable for children seeking coverage under a disability-related group. Because GA eligibility criteria restricts coverage to adults, only Tier 1 determinations will be applicable for children. The PMDT and DRT will use special SSA disability criteria for children when making the determination. A PMD determination will only be necessary when another category of Medicaid or HealthWave 21 isn’t available. A PMD determination is also appropriate when a child seeks services that are only available to persons with a disability determination.

   Example: 16-year old Kim receives HealthWave 21. Her mother has applied for HCBS PD waiver services for Kim. The PD waiver isn’t available with HealthWave 21 and Kim must be determined disabled in order to receive PD services. Because her access to services is limited without a disability determination, Kim is a good candidate for PMD.

   For both children and adult cases managed at the Clearinghouse, the case will be referred to the local SRS Service Center for PMD information and referral. Referral processing of all PMD-related eligibility is the responsibility of SRS. However, coordination will be necessary to ensure the referral is complete and accurate. These cases should be rare.

   3. Application - The PMD process requires consideration of several new disability-related eligibility factors prior to making a decision. The current application forms do not capture this information. A new form, the ES-3900, Tell Us If You Have Disability, has been created for use as an application addendum. It is recommended that the ES-3900 be included with existing supplies of current applications to ensure the new information is obtained timely. If the application comes into the office without the ES-3900, the form may be sent separately or the eligibility worker can call the applicant/recipient and ask the questions over the phone. Regional procedures will need to be established.
      
      
3. IMPACT OF PMD PROCESS ON ELIGIBILITY

Many policy and procedural changes impacting both GA and Medicaid are occurring as a result of the PMD implementation. It is important to understand the ultimate impact of these changes:

1. If an applicant or recipient meets Tier 1 criteria, he or she may receive GA cash and Medicaid OR Medicaid only.
   
   
2. If an applicant or recipient meets Tier 2 criteria, he or she may receive GA cash and MediKan coverage.
   
   
3. If a GA cash recipient does not meet either Tier 1 or Tier 2 criteria but cooperates with the PMDT and has a pending Social Security application, the individual may continue to receive GA cash and MediKan benefits. Cooperation with PMDT occurs at the next scheduled review, or earlier if the consumer requests a special PMD determination.
   
   
4. If a new applicant does not meet either Tier 1 or Tier 2 criteria, but cooperates with the PMDT and has a pending Social Security application, the individual is not eligible for GA cash or medical benefits. However, the application date is protected pending a final Social Security determination and is monitored by adding a pending MS program.

For purposes of this implementation, an individual is considered a GA recipient if he or she was receiving GA benefits on September 1, 2006 or had a pending application on August 31, 2006. Persons reinstated per KEESM 1423 following a break of less than 30 days retain recipient status. A GA applicant is an individual who applies for GA on or after September 1, 2006.

4. THE PRESUMPTIVE MEDICAL DISABILITY TEAM (PMDT)

The PMDT is a new unit within the Kansas Health Policy Authority charged with coordinating the completion of the disability determination for Presumptive Medical Disability. The unit is composed of a R.N./Unit Manager, a Disability Examiner, 5 Case Development Specialists and a Senior Administrative Support Specialist. All cases requiring a PMD decision must be referred to the PMDT. The responsibilities of the PMDT are listed below:

1. Development - The primary responsibility of the PMDT is to accept referrals from eligibility staff and develop/prepare the disability case for the Disability Review Team (DRT). The development process includes the following:
   
   
   • Conducting the Telephone Consultation
     
     
   • Requesting medical records from treatment sources
     
   • Obtaining work history and vocational information
     
     
   • Scheduling examinations when needed, including making arrangements for necessary and critical transportation to and from the examination
     
     
   • Obtaining information on other relevant factors for the decision
     
     
2. Kansas Legal Services Liaison - The PMDT will also serve as the primary liaison with KLS. All initial referrals and requests for withdrawal will go through the PMDT.
   
   
3. Central Data Base - A tracking and reporting system has been developed for capturing information relevant to the PMD. The PMDT is responsible for the system, called the PMDT Central Data Base. The data base is used as an aid to track the individual’s progress throughout the PMDT determination as well as capture information on the disabilities and impairments claimed by the applicant/recipient as well as those that are substantiated. Schedules for Telephone Consultations and consultative examinations will be recorded in the data base as will requests for medical records and reports from providers. The system will be used to create new reports for use by eligibility staff, as explained below. The PMDT is responsible for all data entry into the PMDT Central Data Base. SRS field staff will not have access to the system.
   
   
4. Communication - Communication between the PMDT and eligibility workers will be necessary. Communication protocols have been developed in order to facilitate these exchanges and clarify responsibility. Several forms have been developed to share pertinent information. These forms are mandatory and in some cases are considered official notification. For example, initial referrals, change reports and determination results are all reported on standardized forms.

There will be times when non-routine communication is necessary, or the worker needs to discuss a case with the developer. General emails or phone calls are appropriate in these instances.

1. E-Mail - A common e-mail box for the PMDT has been established. All email to the PMDT is sent to this common mailbox, rather than to individual email boxes.

The PMDT Mailbox is : PMDT@khpa.ks.gov

The PMDT will send communication directly to the eligibility worker, with a courtesy copy to a special SRS Regional Mailbox. The SRS region will be responsible for dispersing the information from this mailbox. The addresses for each regional mailbox are: PMDT@khpa.ks.gov

North East - PMDNER@srs.ks.gov

South East - PMDSER@srs.ks.gov

South Central - PMDSCR@srs.ks.gov

KC Metro - PMDKCR@srs.ks.gov

Wichita - PMDWIR@srs.ks.gov

West - PMDWER@srs.ks.gov

2. Telephone - A dedicated toll-free line has been established for calls coming to the PMDT. This line will be used for the Telephone Consultations as well as other incoming calls.

The PMDT toll-free number is: 1-888-547-2763 (1-888-KHPA-PMD). In Topeka, call 296-1849

The TTY number for the hearing impaired is (785) 296-2539.

3. Fax - A dedicated fax line has also been established for the PMDT. Eligibility workers must fax all initial referrals and other important documents to this number: The PMDT fax number is: (785) 296-1723.
   
   
4. Mail - All mail is sent to the PMDT at the following address:

   PMDT
   Kansas Health Policy
   Room 900-N, LSOB
   900 SW Jackson Street
   Topeka, KS 66612

5. The Disability Review Team (DRT) - As indicated earlier, the DRT is not technically a part of the PMDT. However, because the PMDT will communicate all information to the eligibility worker, the DRT is viewed as extension of the PMDT. The DRT is a team comprised of a disability examiner and a physician or psychologist. Once the PMDT has the file prepared and reviewed by the Disability Examiner, the case will be sent to the DRT for a final decision. Once the final disability decision is made, the case is sent back to the PMDT, who will notify the eligibility worker. The eligibility worker will not have any communication with the DRT. Communication will flow through the PMDT.

5. FINAL SSA DETERMINATION
   
   Application for Social Security benefits is a requirement for both General Assistance and disability-related medical assistance. Except for GA-RN [see item IX(A)(5)] individuals must have a current, pending application with SSA in order to receive, or continue to receive benefits. Verification of Social Security application is required and can usually be obtained from information on the TPQY or SDX. This can also be verified through a completed SSA-1610, a letter from SSA, or other collateral contact with SSA. A KLS referral alone no longer is considered adequate verification of a SSA disability application

A final determination by Social Security takes precedence over a determination made by the PMDT. A final determination is a decision for a disability-based benefit, either SSDI or SSI, in which the individual is either approved or has no further administrative appeal rights. Therefore, if the individual is denied SSDI/SSI benefits based on disability and fails to request an administrative appeal within the time frames allowed by SSA, the application is no longer valid for benefits and the decision becomes final.

Once a final determination has been made, eligibility under both programs must be redetermined. For persons who do not meet either Tier 1 or Tier 2 criteria medical assistance ends unless the individual qualifies under another medical program; General Assistance also ends.

6. CASES ELIGIBLE FOR PMD DETERMINATION

The PMD determination begins with a referral to the PMDT. All referrals must come from eligibility staff. Referrals received by the PMDT from outside sources will be routed to local eligibility staff. The eligibility worker is responsible for determining which cases to refer as well as the specific program involvement. The following process is used to make this determination:

1. The individual must have an active or pending medical assistance or General Assistance case. A referral shall not be sent before an application for benefits is received by the agency.
   
   
2. The individual must claim a disability that will last at least 12 months or result in death. The client’s statement of disability duration is sufficient to prompt a referral.
   
   
3. For Medicaid only applicants, do not refer persons with a final Social Security determination within the last 12 months unless the individual reports a new condition or a change in his or her disability. For persons who have not had a PMD determination, the client’s statement is sufficient to prompt a referral and no further verification is needed. If a determination has been completed in the past 12 months, the referral is made to the PMDT, with the Social Security history explained on the referral. Following the telephone consultation, the PMDT will determine if any change is sufficient to continue with the determination.
   
   Note that persons who’ve had a determination in the past 12 months may be referred for a GA/MediKan determination if under 24 months.
   
   
4. For GA applicants, do not refer for Tier 2 if other GA criteria are not met. Applicants with more than 24 months of General Assistance will not be able to receive GA and are therefore not potentially eligible for MediKan. However, these individuals may still be referred for a medical-only Tier 1 determination.
   
   
5. Do not refer cases where SSA will not make a determination due to a financial reason - such as spousal income or employment. These continue to be sent to DDS.
   
   
6. Do not refer individuals age 65 and over.
   
   
7. Any additional referrals necessary for the specific program are sent when the PMDT referral is sent. For example, referrals to the Working Healthy Benefit Specialist, KDOA for a LOC determination, the ILC or CDDO for an HCBS Assessment. It is critical to note on both referrals the ‘dual’ referral. In some cases, the other entity will be able to assist the individual with the disability determination process.

7. THE PMDT REFERRAL PROCESS
   
   Once the eligibility worker determines the case is to be referred to the PMDT, the next step is to gather information, complete paperwork and send the referral. In order for the case to be processed as quickly as possible, it is critical for the referral to be sent to the PMDT immediately. Neither GA cash nor medical assistance can be authorized until the PMDT makes a decision. The following protocol is used:
   
   
   1. Obtain a Client ID Number - Because all cases referred to the PMDT must have a Client ID Number prior to referral, the eligibility worker must ensure the case is registered within twenty four hours of the interview. If no interview will be completed, register the case within 24 hours of receipt.
      
      
   2. Schedule a Telephone Consultation (TC) - As part of the disability determination, the PMDT must complete a Telephone Consultation with the applicant. This is basically an interview with the applicant to obtain details relevant to the disability determination. The TC will collect information on the client’s medical status, medical history and work history. The Telephone Consultation must be completed as part of the PMDT process. Failure to complete the consultation will be considered non-cooperation and negative action may result.

   A third party may be allowed to complete the telephone consultation on behalf of the client, but only with the permission of PMDT. The applicant may choose to have others present during the TC. Case managers from the CMHCs, CDDOs and ILCs are encouraged to participate in the TC with the client.

   Prior to completing the TC, the client must be given a paper copy of the Telephone Consultation Guide. This is a list of the questions the client will be asked at the time of the TC. It is strongly suggested the client complete the form prior to the interview. The client can ask others to help complete the guide. The client may fax the guide to the PMDT prior to the appointment if he chooses.

   It is the responsibility of the eligibility worker to schedule the telephone consultation. This is usually done as part of the interview. The eligibility worker will contact PMDT reception and request an appointment for the TC. Preferably, the call will be made while the applicant is present to ensure availability. The worker will then note the time and date of the scheduled consultation as well as the assigned Developer, on the Telephone Consultation Guide. This is given to the client. The PMDT will also record the date and time in the Central Data Base. To help make sure appointments are not mixed up, the eligibility worker will also note the date and time of the TC on the initial referral.

   3. Obtain 3 Original, Signed Releases (ES-3904) - A special release of information will be necessary for the PMDT to obtain records from medical providers. These have been created especially for use by the PMDT. In rare instances, it may be necessary to obtain additional releases. The PMDT will request the eligibility worker assist with obtaining the additional releases. The form is the HIPAA Compliant Authorization to Disclose Information, the ES-3904.

   It is the responsibility of the eligibility worker to obtain these forms from the client as part of the interview. If a face-to-face interview is not completed, the forms are to be mailed to the individual with instructions to return as quickly as possible to the PMDT. A self-addressed envelope shall be included. These envelopes will be supplied by KHPA.

   Fax the forms to the PMDT along with the initial referral. Mail the original documents to the PMDT.

   4. Obtain SS Advocacy Information - For GA Only - All persons seeking General Assistance must have secured an advocate to assist with the Social Security application process. KHPA contracts with Kansas Legal Services to provide such advocacy for General Assistance recipients. However, an individual may elect to use another advocate.

   If the client wishes to use KLS, obtain an authorization of the election. This is done with the ES-3908, Disability Consultation/Representative Referral to Kansas Legal Services. The form includes an authorization acknowledging KLS’ involvement in the case. This form is faxed to the PMDT along with the referral form.

   If clients wish to use an advocate other than KLS, they will need to provide the name of the advocate and documentation that they have contacted the advocate regarding representation prior to approval.

   5. Social Security Referral - All persons seeking medical assistance under PMD or General Assistance must have an active Social Security disability application. If the individual indicates there is a pending SS application, verification must be provided (EATSS is the primary source).
      
      If there is no pending application, the individual is given the location and phone number of the closest Social Security office and instructed to apply. There are other options, including the SSA website (http://www.ssa.gov), to obtain additional information on the application process. The individual does not have to complete the application process prior to referral.
      
      
   6. Complete the ES-3901, Presumptive Medical Disability Team Referral - In order to complete the disability determination, the PMDT needs information on the client. This includes basic demographic information, Social Security application status, name and address of medical representative, etc. This information is provided to the PMDT with the initial referral. A special referral form, The Presumptive Medical Disability Team Referral (the ES-3901) has been developed for this purpose.

   The receipt of the ES-3901 initiates the PMDT determination. The PMDT will not start a determination until a referral has been received from eligibility staff. Although the telephone consultation is scheduled right away, it cannot be completed until the PMDT has a referral. Therefore, the referral must be sent prior to the scheduled telephone consultation.

   Complete all required fields on the ES-3901 - page 1 is mandatory. The PMDT needs the information in the required fields in order to complete the telephone interview.

   As part of the initial referral, the worker is also asked to note any observations regarding the individual’s physical and mental status/abilities. These observations can be useful for the disability team. Be as specific as possible with the observations. Examples of behaviors or limitations to note include:

   • mobility problems, including use of prosthetics or other equipment, missing limbs: walks with a cane, needed assistance to sit down, stand up, use the stairs
     
     
   • weight/appearance features: obese, underweight, pale, personal hygiene
     
     
   • mental confusion or illness: inability to follow directions, confused
     
     
   • visual or hearing : held paper very close to read, hard-of-hearing
     
     
   • other observations/information: coma, life-support , labored breathing

   The eligibility worker should also make note of any other barriers the PMDT may find important. Examples: transportation limitations (as the PMDT may be able to assist with transportation to necessary consultative examinations), previous SRS activity and involvement with other community programs.

   7. FAX to the PMDT - Fax the completed referral and all available forms to the PMDT. Again, this must be done prior to the telephone consultation.
      
      
   8. Mail Original Releases and KLS Referral to the PMDT.
      
      
   9. Reporting Changes - While the determination is pending it is critical for the PMDT and the eligibility worker to communicate important changes and new information that may impact either determination. If either party becomes aware of a change, the recipient of the information is to immediately report to the other entity. Examples include changes of address, living arrangement, and employment.
      
      The ES-3906, Notification of Changes and Final Decision Form, has been developed to serve as the primary communication tool between the entities for purposes of the PMDT determination. This form may be completed and emailed or faxed.
      
      If the eligibility worker determines the individual is not eligible for assistance due to a reason not related to disability, such as excess resources, the PMDT must be notified . Unless the determination has been sent to the DRT, the PMDT will terminate the disability determination process.
      
      
   10. Failure to Cooperate With the PMDT - Cooperation with the PMDT is a condition of eligibility. Failure to cooperate with the PMDT throughout any phase in the process may result in negative action. The following are specific examples of cooperation requirements:
       
       
       1. The Telephone Consultation - The individual must complete the telephone consultation with the PMDT. One appointment is initially scheduled. If the individual fails to contact the PMDT, the case will be referred back to the SRS eligibility worker for action. A second appointment will not automatically be scheduled. If the individual misses the consultation and requests a reschedule within 45 days of the initial application date, a new consultation shall be scheduled and the application reactivated. If PMDT scheduling prevents completing the TC within 45 days the application is still active if the client cooperates.
          
          Incomplete Telephone Consultations - If the applicant participates in the telephone consultation, but it cannot be completed due to lack of information available during the call, the applicant must be given the opportunity to supply information necessary to complete the TC. A request outlining the needed information will be sent from the PMDT to the client. The individual will be given 10 days to provide the information. If the applicant fails to respond to the request or provides incomplete information without an adequate response, the case is viewed as non-compliant. The case will be referred back to the eligibility worker for final action.
          
          
       2. Medical/Consultative Examination - If the PMDT determines there is a need for a medical examination, the individual must cooperate by keeping the appointment and completing any necessary follow-up requests. The PMDT contracts with specific medical practitioners to complete these examinations and the applicant may not be familiar with the provider. The PMDT will work with the applicant to the extent possible when scheduling the appointment. One reminder phone call will be made to the individual prior to the appointment. A second appointment will not automatically be rescheduled.
          
          
       3. Medical Records - The PMDT will rely heavily on medical records to make a determination. Records will be requested in nearly every case. Generally, the signed release will provide access to the records. However, the applicant may be asked to assist with the process on occasion. Cooperation with these requests is required.
          
          
8. PRESUMPTIVE MEDICAID DISABILITY

With the implementation of PMD, Medicaid coverage under disability-related groups will now be available to persons who have not yet been determined disabled by Social Security if they have been found to meet Tier 1 criteria and meet Social Security application requirements. For program purposes, a person who meets the PMD criteria is considered disabled according to Social Security standards. Instead of Social Security making the decision, KHPA is making the disability determination. Therefore, the PMD determination provides access to all disability-based Medicaid groups including: Working Healthy, HCBS, NF, and Medically Needy. Coverage is also available under a new SSI-related determination. All program rules continue to be applicable for the individual program. However, there are processing changes that differentiate a PMD determination from a ‘regular’ determination.

Persons do not need to receive General Assistance cash in order to receive Medicaid through PMD. Persons ineligible for GA due to the 24 month limitation, failure to meet interview requirements, etc. may still receive Medicaid coverage through a PMD determination.

As with General Assistance, the eligibility worker is responsible for initially reviewing the application or case for general eligibility requirements prior to sending a referral to the PMDT. Persons who are obviously ineligible are not referred to the PMDT.

1. Medicaid Coverage Under PMD - As indicated earlier, all applicable program rules continue to apply for persons determined disabled under the PMD process. All general, financial and non-financial rules are followed. Current processes and procedures are also used for the determination. Because it is necessary to track PMD determinations, additional procedures have been established for a PMD case. Case processing remains essentially the same, with specifics noted below. Processes for the new SSI-related group are very much like existing medical programs procedures.
   
   
2. SSA Application Status - Persons must have a Social Security disability application pending in order to receive coverage based on a PMD determination. Verification of Social Security status is required and must be received prior to initially authorizing Medicaid benefits. Failure to continue to cooperate with Social Security is a program violation and subject to negative action. See item V regarding a final SSA determination.
   
   
3. Prior Medical - Up to three months of prior medical is available if the onset date determined by the PMD provides for the three prior months. Current base period rules apply: One month base periods are used for LTC, Working Healthy or SSI-related coverage, a three month base is used for Medically Needy cases. To process, adjust the proration date on the MS program. All other program rules apply. However, coverage under a PMD determination must be on or after September 1, 2006. The application date must be protected if uncovered months remain in the prior period due solely to the effective date of implementation.
   
   
4. SSI-Related Coverage - One new program designation is also being implemented with the PMD process. A determination that essentially mirrors the SSI determination has been developed as a medical program option. The intent of the SSI-Related group is to provide medical assistance for persons who would otherwise qualify for SSI cash but are not eligible for GA. If eligible, coverage is provided without a spenddown. Although this is an SSI based determination, it is processed using the MS program on KAECSES.
   
   Program rules are very similar to those in the MS program. All general and non-financial eligibility criteria applicable to MS are applicable for the SSI-Related group. The following eligibility criteria apply:
   
   
   1. Financial Eligibility - For financial eligibility, the methodologies, exemptions and disregards applicable to the MS program apply. Countable resources cannot exceed the limit in 5130 and countable income for the appropriate household size and living arrangement cannot exceed the limit described in KEESM Appendix Item F-8 (note that a new Section 7 of this Appendix item has been created). If the countable income exceeds this amount, eligibility under another medical program can be considered. For example, for a single person in his own home, compare the countable income to the SSI program limit of $603.
      
      
   2. Assistance Plan - MS assistance planning rules are applicable.
      
      
   3. Base Periods - One month base periods are used.
      
      
   4. Changes - Eligibility under SSI-Related PMD continues as long as the requirements are met. Changes are effective the month following the month of the change.
      
      
   5. Reviews - Cases eligible for SSI-related PMD are subject to annual reviews.
      
      
   6. Other Program Requirements - Persons eligible under SSI-Related PMD are subject to the same rules as other PMD cases, including the Social Security application requirements. KAECSES processing procedures are applicable as described below.
      
      
5. Processing PMD Cases - All PMD cases are processed on the MS program. Special KAECSES coding has been implemented to assist the eligibility worker with the determination and to provide for additional data collection. More detail on these changes is outlined in Item X. The primary change is the creation of a new screen in KAECSES - PRDD. All individuals approved for coverage under PMDD must have a PRDD type code. This code identifies which specific medical program the individual is eligible for. Although current KAECSES processes will help the eligibility worker determine if the individual meets criteria, the results of the determination will be recorded on the new PRDD screen. This information will also be sent to MMIS to help establish the program the individual is covered under. Other program factors continue to be handled in the same manner. For example, the base period is established on SPEN according to current policy, long term care payments are authorized by completing the LOTC screen and notices of action are required. For long term care, Spousal Impoverishment rules apply. The program specific instructions follow:
   
   Working Healthy - The KAECSES medical program subtype must be = WH. Premiums are determined and documented as for a non-PMDD case. The applicable Special Medical Indicator must be entered on the PICK screen. If the individual is eligible, the PRDD type code = WH. The case is authorized on SPEN.

Adult Care Home/Institutional - When long term care budgeting is applicable on a case, the KAECSES medical program subtype must = AC. The PRDD type code = AC. LOTC must be completed. The case is authorized on SPEN using a Y in the CC override.

Home and Community Based Services (HCBS) - When HCBS budgeting is applicable on a case, the KAECSES medical program subtype must = HC. The PRDD type code = HC. LOTC must be completed. The case is authorized on SPEN using a Y in the CC override.

Medically Needy/Spenddown (including SOBRA spenddown) - No medical program subtype is needed for medically needy cases. The PRDD type code = SD, regardless of the size of the spenddown, including those with no spenddown. Spenddown processing under a PMD determination is exactly the same as under a ‘regular’ case. The spenddown amount will be sent to the MMIS and providers should bill the MMIS to reduce the spenddown. The case is authorized on SPEN.

SSI-Related Coverage - No medical program subtype is needed for these cases. The eligibility worker can rely on the KAECSES resource determination, as completed on MSRD, to determine if countable resources exceed the limits. However, for income the determination will be made based on information on the PRDD screen. The countable income and the total household size are displayed on the screen. The countable income is compared to the maximum allowable limits for the program and the income test is met if the countable income is not in excess of the limit. The limits are found in the KEESM, Appendix Item F-8. The PRDD type code = SI. The case is authorized on SPEN.

Any referrals for additional services, such as an HCBS request, a LOC request for NF placement, or WH Benefits Specialist notification, shall continue to be made as quickly as possible. Carefully note involvement on both referral forms.

6. Case Action Following PMDT Determination - Upon receipt of the results of the PMD determination, action is taken to approve, deny, close or pend the medical program. It is expected that all information necessary to process the case will be available, so processing should not routinely be delayed while awaiting additional information.

The following action is taken based on the results of the PMDT determination:

1. If Tier 1 criteria are met, the individual meets Medicaid disability standards and can receive Medicaid if other eligibility factors are met.
   
   
2. If the individual fails to Meet Tier 1, there is no eligibility under Presumptive Medicaid Disability. A formal denial notice is required, even if a protected filing date applies. Case action depends on the actual finding made by the PMDT:
   
   Tier 2 Approval - The individual meets MediKan disability standards. Unless he is also eligible for GA, there is no medical assistance eligibility under the PMD process. However, if there is an active SSA application on file, the medical assistance request shall pend a final SSA determination. No coverage can be given in the interim, but there is a protected filing date based on the request.

Neither Tier 1 Nor Tier 2 Approval - If the individual cooperated with the PMDT in determining the disability, but the disability criteria was not met and the individual has a pending application with Social Security, a protected filing date is established for Medicaid purposes and a final determination of eligibility will be made when SSA makes a final determination. For applications received on or after September 1, 2006 only, if the individual does not cooperate with the PMDT, the application date is not protected.

3. Notices - A notice of action must be sent notifying the client of the case action. Special approval and denial notices have been developed for PMD cases. These new Medicaid notices are found in the N series. A new series of notices - the D series - has been incorporated specifically for MediKan PMD cases (see item XIII below regarding notices). All PMD notices include a reminder about Social Security requirements.

All MS PMD approvals must be sent two notices. A standard notice about the PMD approval and a specific notice regarding program eligibility. For example, a client approved for Medically Needy with a PMD disability determination will be sent the N300 about the PMD approval, but would also receive a spenddown related notice, such as an N103 (MS approval with Spenddown Not Met).

4. Changes - All change reporting requirements apply to PMD determination as for ‘regular’ medical cases and appropriate action shall follow. For example, an ongoing PMD eligible sells his home. The proceeds are countable as a resource the following month. Other program processes are applicable as well. Examples include, rebudgeting for Working Healthy premiums every 6 months, adjusting patient liability due to non-covered medical expenses and allowing bills against an unmet spenddown.
   
   
5. Final Determination By Social Security - Eligibility must be redetermined once a final determination is made by SSA (see Item V above).

For persons found eligible by SSA, PMD involvement ends and the case is converted to regular medical. It is possible the category of medical could change. For example, a person could begin receiving SSI and would then be moved from an MS program to an SI program.

For persons found ineligible by SSA, the PMD case is closed. Timely and adequate notice is required. Medicaid coverage terminates unless the individual is eligible under another Medicaid group.

Even though the individual was found to be ineligible for SSD benefits, assistance provided based on a PMD determination is considered appropriate. The client is not expected to repay any medical benefits received while a PMD recipient.

For pending MS programs, the application is formally denied.

Note that negative action may be taken prior to the expiration of the individual’s time frame to file an appeal with SSA. If this occurs and the individual later supplies verification of a timely appeal, ongoing cases are reopened and applications are reactivated pending a final SSA determination.

Example: Ongoing PMD recipient John’s SSA application is denied for failure to meet disability criteria on 10-14-06. The Medicaid case is closed effective 10-31-06. On November 10, John submits verification he has requested an appeal of the denial from SSA. Because the SSA case has been reactivated due to the appeal request, the SSA decision is no longer considered final and John’s case is reopened.

6. KAECSES Procedures - When PMD coverage ends, involvement is terminated on KAECSES and the case is reprocessed to determine future eligibility. The action taken is dependent upon the SSA decision:
   
   
   1. For cases where participation in the MS program continues, PMD involvement must be closed on the PRDD screen. The MS program remains in open status and a Closure reason is entered while the case is in the benefit month of the closure. The case will no longer reflect PMD involvement and changes in the case are made the following month.

   Example: Willie is on the HCBS PD waiver and receives Medicaid based on a disability determined by the PDMT. He has a small pension of $400/month and doesn’t have a client obligation. On October 4 Willie is notified that Social Security has been approved. Willie calls to tell his worker right away. The worker takes the following action:

   1. Do not remove Medical program subtype of HC
      
      
   2. In the benefit month of November, enter the new income
      
      
   3. Go to MSID and then on to PRDD
      
      
   4. On the PRDD screen, enter the ‘CL’ action type and the closure reason in the ‘Closure Reason’ field. For Willie, this will be DA for SSA approved disability. PRDD will close effective 10/31/06.
      
      
   5. On the SPEN screen authorize, make note of the new client obligation and make sure the ‘CC Override’ is filled with a Y.
      
      
   6. Change the client obligation on LOTC
      
      
   7. Send appropriate notices

   2. For cases where MS participation ends, due to either a denial or a change in medical assistance categories, the MS program is closed on the MSED screen using an appropriate Closure reason code. Future eligibility may be reopened on the new program.
      
      Example: Billie’s Medicaid coverage is under the SSI-related group. On November 28 he notifies his worker that he has been approved for SSI benefits. An SI program must be opened and the MS program closed. The worker closes the MS program and opens an SI program effective the following months. Notices are created to inform Billie of the case action.
      
      
   3. KAECSES PRDD Denial/Closure Reasons - When action is taken to terminate PMD involvement and the MS program remains open, one of the following Closure reasons must be entered on the PRDD screen:

      CO - Failure to Cooperate
      
      DD - Disability Denied (for disability decision by the PMDT)
      
      ND- Not Disabled as determined by SSA
      
      65- Reached age 65 and PMD is no longer applicable.

9. GENERAL ASSISTANCE CHANGES
   
   Several policy and procedural changes are being implemented to support the new PMD process. Because of the link between General Assistance and Medicaid created by PMD, many of these changes were made to align the programs and make the PMD process easier to manage.
   
   
   1. GA Program Policy Changes
      
      
      1. ES-3151 “Statement of Disability” has been abolished. The client will be allowed to self declare disability by completing the ES-3900 “Tell Us About Your Disability” and responding “yes” to Questions 1, 4 and 5.
         
         
      2. The treatment of resource rules specific to the MS program, including Life Insurance (KEESM 5430(15)), Pensions (KEESM 5430(16)), vehicles (KEESM 5520) and Trusts as defined in KEESM 5600, are now applicable to GA. Current GA cases are evaluated under the new standards no later than the next review.
         
         
      3. The hardship criteria for GA has been changed. Only clients having an active ongoing Social Security application at the point that they reach the 24 month time limit will qualify for hardship.
         
         
      4. The GA provision that allows a client’s spouse to receive benefits if they act as a caregiver has been eliminated. If both individuals claim a disability, they both must be determined disabled by the PMDT in order to receive GA cash and MediKan benefits. If only one spouse claims a disability, there is no eligibility for GA. Therefore, a referral should be made to the PMDT for a Medicaid only/Tier 1 determination. Action related to this change would only occur at review or when the agency becomes aware of information that would result in a change in eligibility.
         
         
      5. GA RN will still be available to a client being discharged from Larned and Osawatomie State Hospitals, Rainbow Mental Health Facility, or released from the Larned Correctional Mental Health Facility subject to additional guidelines:
         
         
         • There is no eligibility for GA RN if more than 24 months of GA has been received.
           
           
         • The discharge plan developed by the hospital/facility will include preparation for a PMD determination. This includes a completed Telephone Consultation Guide, 3 signed PMDT/KHPA releases and a signed ES-3908, Referral to Kansas Legal Services, a PMD brochure and a contact with SSA regarding application for disability benefits. The hospital will assist the applicant in filing the GA and medical assistance application as quickly as possible once a discharge date is known. Following receipt of the application, the eligibility worker will complete the ES-3901, Presumptive Medical Disability Team Referral, and work with the applicant and hospital staff to schedule the telephone consultation. The hospital staff will assist the applicant during the telephone consultation if the individual is still a resident. If the applicant has been discharged, a referral to the designated CMHC for assistance will be made by hospital staff.
           
           If the life time limit has not been exceeded and the discharge plan is properly developed, a GA RN cash and medical case should be opened and a referral made to the PMDT. If PMDT has not notified the worker of a determination by the end of the GA RN eligibility period, convert the case to GA UA until the PMDT decision is received.
           
           
   2. GA Program Process Changes -
      
      
      1. When a client elects to utilize KLS as their advocate, the worker will no longer make a referral directly to KLS. Instead, once the consumer has signed the ES-3908, Disability Consultation/Representative Referral to Kansas Legal Services, the worker will forward the signed ES-3908 to the PMDT. The PMDT will forward the referral to KLS when it is determined to be appropriate.
         
         
      2. A KLS referral no longer serves as verification that the client has made application to Social Security. Verification that the client has made application to Social Security must be done prior to authorizing the case. Verification may be made in a number of ways. Examples include: EATSS, SSA 1610, or consumer notification, etc.
         
         
   3. GA Process Outline - An application received after September 1, 2006 should be processed in the following manner:
      1. When an applicant self-declares a disability, register a GA application within 24 hours of receipt, schedule applicant interview and request verifications. An MS program is also registered with a “Y” in the “Presumptive Disability” field.
         
         
      2. Determine that the applicant meets all general eligibility requirements, that the applicant has not received cash benefits in another state for any month that the applicant is applying for cash benefits in Kansas and that the applicant is not eligible for TAF benefits. If the applicant owns a vehicle, it must be registered in Kansas. Refer the individual to Social Security to initiate the application process.
         
         
      3. As part of the interview, the Presumptive Medical Disability Determination process should be explained to the applicant. Appropriate paperwork (outlined in the GA Application Check List Deskaid) should be provided to the applicant and routed as indicated.
         
         
      4. Determine if the applicant has previously received countable months of GA benefits. If they have received less than 24 months, then the applicant is eligible for a Tier 1 or Tier 2 determination. If the applicant has already received their 24 month life time limit, they will only be eligible for a Tier 1/ Medicaid only determination.
         
         
      5. When the PMDT decision is received, process the case based upon the PMDT determination.

      If approved for Presumptive Disability - Tier 1 Disability Level, open the MS program as per item VIII. Authorize the GA program with a subtype of PM. Enter OU under the “AM” field on the SEPA screen. Send the Presumptive Medicaid and GA cash approval notices.

      If approved for Presumptive Disability - Tier 2 Disability Level, the individual will receive GA cash and MediKan benefits and because there continues to be an active Social Security disability application, the MS case will continue to pend. Send the MediKan and GA cash approval notices.

      If it is determined that neither Tier 1 or Tier 2 eligibility criteria are met but the client’s SSA disability process is current and the client is cooperating with the process, the MS program continues to pend a final determination. If the SSA disability process is NOT current or the client is not cooperating with the process, the GA cash should be denied. Send the Presumptive Medicaid and GA Cash denial notices as appropriate.

10. KAECSES CHANGES/SYSTEM INFORMATION

Several KAECSES AE system changes have been made that support the Presumptive Medicaid Disability program and related policy changes. These include both on-line and report changes and are available starting September 5, 2006. Below is a summary of the changes:

ON-LINE CHANGES -

GA PM - Created a new GA program subtype of PM to use for those GA cases eligible for GA based on a Tier 1 disability determination by the PMD process. This new program subtype will allow only an ‘OU’ participation code for the AM program.

REAP/APMA - Added a new field on APMA and REAP to capture if the MS program being registered is going through the Presumptive Medicaid Disability process. The new field is titled PRESUMPTIVE DISABILITY and requires either an ‘N’ or ‘Y’ value when an MS program is being registered. Correct completion of this field is important as the system uses information in this field to identify MS Presumptive Medicaid Disability applications.

MSID - Added ‘GO TO PRESUMPTIVE DISABILITY?:’ field on MSID. The value defaults to ‘N’, but the new PRDD screen will display when the user presses enter after that value is changed to ‘Y’.

PRDD - The Presumptive Disability Determination screen is a new screen. This screen will come up after MSID when a ‘Y’ is entered in the GO TO PRESUMPTIVE DISABILITY field on MSID. Eligibility staff can next to PRDD when a case number and benefit month are entered on a menu screen.

PRDD is a multiple part screen. The top part calculates and displays the number in the household size, the household’s net income, and countable resources. This helps staff when determining if the family is eligible for Medicaid based on SSI income guidelines.

The bottom two-thirds of PRDD is for Presumptive Medicaid Disability approval, change, denial or closure actions. It functions much like the SUDD and LOTC screens in that it requires entry of the POA (position on app) number(s) before the rest of the fields open for entry or display existing data.

The eligibility worker can enter any of the four action types (AP for approval/changes; CL for closures; DE for denials; and DL for deletes). Based on the Action type, other fields open on the screen so required information can be entered. Once an action type is entered, it will not display the next time the screen is accessed.

The Closure/Denial Date is protected and populated by the system. Closure dates are the last day of a month and denial dates are the calendar day the denial action is taken. These dates do not display until the worker leaves the screen and returns to PRDD.

The PRDD Help Screen lists the Action types, Subsidy D types and Denial/Closure Reasons. The KAECSES code cards, page 17C, PRDD, also has the definition of the applicable codes.

MEBH/CAP2 - MEBH will display the Presumptive Medicaid Disability type (PRD IND) as entered on PRDD. CAP2 will have a ‘Y’ in the PRESM DIS: field for Presumptive Medicaid Disability MS cases.

MMIS - Daily and monthly medical eligibility records sent to the MMIS will include any Presumptive Medicaid Disability type entered on PRDD. The MMIS uses the Presumptive Medicaid Disability type, along with other information on the record, to determine the correct benefit plan. A Presumptive Medicaid Disability Indicator (PDI) has been added to the MMIS eligibility windows and will display the PRDD type received from KAECSES.

REPORTS -

Active Case Report - CR300 and 300A will display a ’Y’ in PRD column for all MS PMD cases.

Pending App Rept - MR660 and 660A will display a ‘Y’ in PRESUMPTIVE DISABILITY field for all pending MS PMD cases.

Statewide App Rept - A new statewide report has been created. The new report is the MR660D, ‘PENDING PRESUMPTIVE DISABILITY APPLICATIONS REPORT - STATEWIDE’. The report will list all pending GA programs where the program subtype is PM as well as all pending MS programs where the Presumptive Disability indicator is ‘Y’. The MR660D will be sorted in case name order, with Region and State totals to follow the detailed application listing. The SAR ID for this new report is SWW0483i-R10.

MISCELLANEOUS CHANGES -

Deauth Alert - All authorized Presumptive Medicaid Disability MS programs will deauthorize when the ‘roll to month’ is the 6th month before the review due month. A deauth alert will be created with the message reading 'DEAUTH-CHK SSA PRES DIS EXISTS'. Once the worker authorizes the MS program, the alert will be deleted. The purpose of the alert is to remind the worker to check the SSA disability application status.

MS, MA & CI - It is now possible to have a review period of greater than 12 months for

Review Dates - MA, MS and CI programs. This allows for prior medical to be processed without the system workaround of registering a review on RERE.

KAECSES Code - *MERE/SSDO code card, GA Vulnerability, page 2, add ‘M’ - MediKan.

Card Pen & Ink and remove ‘H’ - Cares for family member...

Changes - *PRDD code card, page 17C, add ‘DA’ - SSA Determined Disability as a new denial/closure reason.

11. KANSAS LEGAL SERVICES CONTRACT

Referrals to Kansas Legal Services for Social Security advocacy continue for General Assistance. The basic purpose of the KLS contract - to provide assistance and representation through the Social Security disability process - does not change with the implementation of PMD. However, there are several process changes.

As indicated in the August 1, 2006 memo (KLS Referral for General Assistance/MediKan Eligibles), KHPA is now the agency charged with contracting for advocacy. Because of this, all initial referrals will now be sent from KHPA. KLS will not accept referrals from SRS after September 1, 2006. Both SRS and KHPA will continue to directly communicate with KLS using the following basic guidelines:

• The PMDT will refer all cases.
  
  
• The PMDT will be responsible for notifying KLS of important actions related to the disability determination. These reports will be made when the client fails to cooperate with the PMDT or the individual does not meet either Tier 1 or Tier 2.
  
  
• SRS is responsible for notifying KLS of other actions or changes. For example, the GA case is closed because the client moved out of state or the client has moved into an NF. It is critical the worker continue to notify KLS of any eligibility changes - such as case closure.
  
  
• KLS will notify the PMDT, with a copy to the SRS Service Center, of issues they become aware of that could impact eligibility.

All General Assistance applicants will be officially referred to KLS when the initial referral to the PMDT is received. Those with private advocacy noted on the referral will be exempt from the referral requirements. KLS involvement begins immediately, as they will assist the individual with the Social Security application and subsequent activities. KLS will also assist the client with any necessary Social Security appeals.

Beginning with applications received on or after 09-01-06, the following process is used for General Assistance applicants. Referrals are not sent for Medical Assistance only applications:

1. As part of the initial interview, the eligibility worker is to explain the advocacy requirement for General Assistance and inform the applicant on the availability of free advocacy services through KLS. If SRS regions have elected to purchase advocacy services from another entity (e.g., Mentoring Works in the SouthEast Region), the choice of advocate is presented to the client. The client is also instructed to contact SSA for an initial appointment.
   
   If the client elects KLS, obtain a signed ES-3908 from the client. If the client elects a private advocate, documentation of representation is required.
   
   
2. On the initial referral to the PMDT, note the advocacy choice. If KLS is elected, fax the ES-3908 to the PMDT and send the original to the PMDT.
   
   
3. The PMDT will refer the case to KLS. KLS will contact the client and assist with making the Social Security claim, if an SSA application is not already pending.
   
   
4. KLS must be notified when the GA application is processed regarding the final decision:
   
   
   • If the PMDT determines the client does not meet necessary disability levels, the PMDT will notify KLS of the denial.
     
     
   • If the PMDT determines either the Tier 1 or Tier 2 level is met the case is referred back to SRS for a final eligibility decision. The eligibility worker is responsible for notifying KLS of the final decision (either approved or denied).
     
     
5. Ongoing communication with KLS will be the responsibility of both the PMDT and SRS. In general, SRS is responsible for notifying KLS when information becomes known that will impact KLS. For example, changes in address, living arrangement and income level.
   
   
6. KLS will communicate these types of changes directly to the eligibility worker, with the PMDT copied on the notification.
   
   
7. KLS will submit all requests to withdraw representation to the PMDT. These include requests due to non-cooperation with KLS for reasons such as failure to keep appointments, failure to report address changes ,etc. The PMDT may need to contact the eligibility worker for additional information prior to making the determination and will notify the worker of the decision. The eligibility worker may need to take negative action unless the client verifies involvement with another advocate.

12. CONVERSION OF CASES

All existing General Assistance cases and all pending medical assistance applications must be redetermined using the new policies. Two separate conversion processes have been established. Existing General Assistance cases, including those pending applications received prior to September 1, 2006, will be redetermined no later than the next scheduled review. Medical assistance applications pending a disability determination with no GA involvement are to be notified and given the opportunity for a PMD determination no later than October 31, 2006. Details regarding both processes are outlined below.

1. GA Cases - GA cases in open status prior to 09-01-2006 will be subject to PMDT determination at the point that the case comes due for it’s next review. At that point cooperation with the PMD determination is a mandatory condition of eligibility. In order to avoid overwhelming the PMDT with unnecessary referrals, the GA review will be processed prior to referring to the PMDT. Persons who do not comply with the GA review process will generally not be referred. However, the worker must evaluate the case to determine if there is still an active medical assistance application to consider.

Example: Millie fails the GA review because she has begun drawing a pension benefit from a previous employer. Although Millie is no longer GA eligible, she still wants to receive Medicaid. If Millie cooperates, a PMDT referral is made.

Persons ultimately found to meet Tier 1 criteria are potentially eligible for Medicaid. Persons found to be Tier 2 eligible continue to receive MediKan. Persons who do not fall into either criteria, but continue to cooperate with the SSA determination, also continue to receive MediKan. All of these are dependent upon passing other eligibility criteria.

1. PMD Prior Medicaid Determination - As part of any referral received on a GA review, the PMDT will consider an onset date 3 months prior to the month of review. This consideration will be made by the PMDT on every review and does not have to be specifically requested. If the PMDT finds the individual to meet Tier 1 or Tier 2 standards, the onset date will be noted on the notification back to the worker.

If the individual meets Tier 1, Medicaid coverage is given for three months prior to the month of review if the onset date determined by the PMDT is within this time frame, but not prior to 09-01-06. This is done on an MS program using the existing case number with the original application date. Because there is a pending Medicaid application for months prior to this which cannot be processed until a final SSA determination is made, an MS application is registered on a separate case number for tracking purposes. The application date is the date of the original GA or medical request.

If the individual meets Tier 2 or fails to meet either disability level, GA and MediKan continue if other program requirements are met, but the MS application continues to pend until a final SSA determination is made.

2. Process - Follow the guidelines below when processing a GA review:
   
   
   1. As part of the review, the client must be notified of the new PMD process. In addition to the ES-3820 (Notice of Eligibility Review - with the date and time of the interview), the ES-3905 (Important Information Notice Regarding Changes in General Assistance and Medical Eligibility) and the ES-3900 (Application Addendum) should be sent to the client at the same time the review is mailed.
      
      
   2. While waiting for the client to return the above material, the current status of the client’s SSA disability application and their cooperation with the process should be verified through one of the following methods: TPQY, Social Security contact or consumer verification.
      
      
   3. Verify the consumer is cooperating with either Kansas Legal Services or another advocate.
      
      
   4. As part of the interview, the Presumptive Medical Disability Determination process should be explained to the consumer. Appropriate paperwork (outlined in the GA Review Deskaid) should be provided to the consumer and routed as indicated.
      
      
   5. Once the interview is satisfactorily completed, reauthorize GA/UA for a 12 month recertification period and send review notices. The ES-3901, ES-3908 and ES-3904 are then faxed to PMDT.
      
      
   6. When the PMDT decision is received, process the case based upon the PMDT determination.
      
      
      • If approved for Presumptive Disability - Tier 1 Disability Level, open an MS case as described in item VIII. The GA case will remain open but the GA program subtype will be changed from UA to PM. Enter OU under the “AM” field on the SEPA screen.
        
        
      • If approved for Presumptive Disability - Tier 2 Disability Level, the individual will continue to receive GA cash and MediKan benefits and because there continues to be an active Social Security disability application, the MS case will continue to pend.
        
        
      • If it is determined that neither Tier 1 or Tier 2 eligibility criteria are met, but the client’s SSA disability process is current and the client is cooperating with the process, continue the GA cash and MediKan benefits and pend the MS. If the SSA disability process is NOT current or the client is not cooperating with the process, the GA cash and MediKan programs should be closed.

   Review Example: Example: Gary was approved for GA and Medical based on his original application date of February 9, 2006. His GA and MediKan review is due in January, 2007, so his case expires January 31, 2007. His review is completed and Gary continues to be eligible for GA. A referral is sent to the PMDT after the GA program is reauthorized. An MS program is registered at this time, if one is not already pending. The PMDT finds Gary meets Tier 1 level. Because this occurred at review, the PMDT developed an onset date three months prior, or October, 2006. An MS case is opened for Gary, effective 10-06. A second case number is used to register a pending MS, with an application date of 02- 09-06.

   3. Conversion of Cases Impacted by Other Policy Changes -

   GA Hardship - All hardship criteria except having an active SSA application have been eliminated. When a case in hardship status comes up for review, determine if the consumer has an active SSA application and they are cooperating with the process. If yes, proceed with process outlined above. If not, notify client they have 10 days to document that they have submitted an application for SSA disability. If the client cooperates, proceed with the process outlined above. If not, close case and send MediKan closure and GA cash Closure notices.

   Two-person GA/Caregiver Spouse - If both individuals claim a disability, proceed with the process outlined above, If only the PI claims a disability or if the PMDT determines only one of the two meets the presumptive disability standard and is at the Tier 1 - Medicaid level, open an MS case for the PI but close the GA cash and GA MediKan case. Send a Presumptive Medicaid approval notice to the qualifying Tier 1 case member and MediKan closure and GA cash closure notices to both the PI and the spouse.

   4. Request For Early PMD - Although existing GA cases are to be referred to the PMDT at the next review, consideration must be given to requests for a PMD determination prior to this date. The individual making the request must provide a reason for the early determination and the request is considered based on the individual circumstances. Requests for multiple referrals are not considered valid.

   The primary reason for an early referral is to receive a service that isn’t covered under MediKan, but is covered under Medicaid. For most MediKan recipients, there is little benefit to receiving Medicaid because the benefit packages are similar. However, examples include most LTC services and inpatient hospital stays. The local Medicaid liaison can assist with determining if a service or item is non-covered under MediKan but is covered under Medicaid.

   An early referral for an existing GA recipient shall include an explanation of the reason for the early referral in the ‘Comments’ section of the ES-3901.

2. MS/SI Applications Received Prior to 09-01-2006 - Unlike the GA conversion process, there is no scheduled phase-in for applications pending a disability determination. All current pending applications, including those which have been closed on KAECSES but still have a live protected filing date due to an SSA appeal of the disability finding, are eligible for a determination through PMD.

A PMD determination is not a mandatory condition of eligibility for these individuals. Although failure to cooperate with the PMD process will result in ineligibility for medical assistance applications received on or after 09-01-06, cooperation is not required for applications prior to this date. However, all applicants must be notified of the new process and the option to seek a PMD decision. The following procedure applies:

1. Notice - A notice informing the applicant of the PMD process must be sent for each pending case. A special notice, the N390, Disability Program Changes 09-2006, has been developed for this purpose. This initial notification must be completed by October 31, 2006 to all individuals who have pending medical assistance determinations based on disability. It is the responsibility of the eligibility worker to identify applicable cases and send the notice. Special reports to identify these cases are not being produced. The pending application should be reviewed to help identify the cases. If pending cases were closed due to local procedures, processes to identify these cases shall be developed locally.

The applicant is asked to notify the agency if he or she wishes to go through the PMD process. The questions on the ES-3901 have been incorporated into the N390 and the applicant is instructed to respond with the requested information.

2. Complete Pre-Referral Paperwork - If the applicant expresses interest in a PMD determination, the worker will request the forms and information necessary to complete an initial referral. The telephone consultation will be scheduled and Social Security application status must be verified.
   
   
3. Referral to PMDT - The referral to the PMDT is made by completing the ES-3901. To assist the PMDT, please ensure the Social Security Application portion of the referral is complete. The PMDT will then process the disability claim and inform the worker of the results.
   
   
4. Process MS Program - The MS case is processed following receipt of the final decision of the PMDT.

If the individual is found to meet Tier 1 criteria, the MS program is processed following the normal application procedures for a PMD case, including completion of the PRDD screen.

A finding of disability by the PMD is not valid prior to September 1, 2006. Since the protected filing date on these cases is prior to this date, the agency must continue to await the final decision by SSA before prior months can be processed. Because of this, a new MS case number should be used to register the application for purposes of protecting the filing date. The existing case number is used to process the PMD case.

5. Final Decision by SSA - When SSA makes a final decision, case action is required. For approvals, the case is moved from PMD status to ‘regular’ medical status. This is done by entering a valid indicator in the ‘closure’ field on the PMDD screen. The case is also rebudgeted beginning the month following the month of change.

Any months pending the Social Security determination due to the protected filling date must also be processed.

Note: Policy has been changed to allow movement to or from a PMD determination as a reason to break a 6 month base period.

Example: Bill applied for medical assistance on 06-07-2006. His application is still pending with SSA, so no medical decision has been made. He receives food stamps. The worker sends the V390 telling about PMD and Bill responds on 09-15-06. The PMDT then completes a disability determination on Bill and finds he meets Tier 1 criteria. Bill’s financial situation places him in the SI-related category, so he is eligible for Medicaid. The MS program is opened with an effective date of 09-01-06 on the existing case number. The application date is the date the PMD decision was requested or 09-15-06, with a 09-01-06 proration date. A new case number is used to register an MS application with the application date of 06-07-2006, this will be used to monitor the unresolved portion of this case.

In 11-06, Bill gets word he has been approved for SSD benefits of $800/month with an onset date of 01-2006. The case is then converted to a final MS program by closing the PMD on the PRDD screen. Because his income is over SSI limits, Bill is now eligible under the Medically Needy program. Because this involves going to or from a PMD status, the base period begins the month following the month of action, or 12-06.

The second case number is also processed for the medical period beginning with the protected filing date, or 06/06 - 08/06.

12. APPEALS

The PMDT will have primary responsibility for fair hearing requests related to a disability decision. However, it will be necessary for the eligibility worker to work with the PMDT in order to accurately represent both SRS and KHPA. Fair hearing requests which are not related to the disability determination continue to be the responsibility of eligibility staff.

The individual may request a fair hearing on a MediKan or Medicaid decision. The request must be received within the time frames outlined in the KEESM, which are different than those for Social Security disability appeals. When a disability-related request for a fair hearing is received, it is to be immediately sent to the Office of Administrative Hearings. Requests received directly by OAH will be referred to the PMDT. The PMDT will contact the worker regarding the case to assist in preparation for the hearing.

Where possible, the PMDT will process a reconsideration on the case. The reconsideration is basically an in-depth evaluation of the disability decision. Additional information may be needed from the client, such as work history and medical records. Additional medical releases may also be needed and assistance from the eligibility worker may be necessary.

If the original decision is upheld by the reconsideration, an appeal summary will be prepared by the PMDT. The eligibility worker will be responsible for providing the PMDT a summary of case activity along with copies of the relevant notices of action. This will be sent to OAH and a fair hearing will be scheduled. The eligibility worker will assist with making local accommodations for the appellant. The PMDT will present the SRS/KHPA case at the hearing.

If a secondary review of the original decision is requested, it is done by the KHPA State Appeals Committee

13. NOTICES

Because the new Presumptive Disability determination process allows a GA consumer to be eligible for either Medicaid or MediKan, it is no longer practical to issue combined cash/medical notices for this caseload. Therefore, separate notices will need to be sent to the consumer for cash and medical eligibility determinations. The GA cash notices will continue as G series notices. MediKan notices have been moved to a new D series.

For MS program, special PMD notices have been created. These are found in the N-series of notices, but are concentrated in the 300 section. Both approval and denial notices are included. The approval notices only address the PMD approval and do not provide information on the individual’s program eligibility. A separate notice must be sent for specific eligibility.

Because the existing GA caseload, including pending applications, are receiving coverage based on previous rules, existing notices will be retained for these cases as well as newly developed notices.

A complete list of notices will be sent through SRSTSC when available.

14. OTHER ISSUES
    
    
    1. Review Date Changes - To implement the Presumptive Medicaid Disability was to remove the 12 month review limit for determined medical programs (MA, MS and CI) has been removed. Beginning September 5, 2006 staff can enter a review limit up to 15 months. This is not a change to policy regarding the 12 month review limit. What this system change allows is the ability to do a longer review period when processing a medical application where the consumer requested prior medical. For those situations, staff no longer need to complete the system workaround by registering a review on RERE.
       
       Example: Ms Medicaid applies for MS on 8/15 and requests prior medical. Worker changes the benefit proration date to 05/01, processes the application and enters a review due date of 07/07 on SPEN. Prior to this system change, a 15 month review thru date could not be entered.
       
       
    2. Application Processing Time Frames - Because the medical determination requires a disability determination to be completed, the agency has 90 days to issue a timely decision to the individual. However, the GA processing time limit is still 45 days. Although all entities will strive to meet these processing guidelines, if total processing time exceeds 45 days, a Timeliness code must be entered on KAECSES. The special code currently used for this purpose, ‘CD’ (client disability pending) shall continue to be used for these situations.
       
       In order to ensure routine protection of the timely filing date, policy now requires all medical assistance applications to be registered and continue in pending status until a final Social Security decision is made. The application date used is the original date of application, for either GA or Medicaid, that would qualify as a protected filing date. The worker can choose to register an MS program or an SI program, depending on which benefits SSA indicates are pending.
       
       
    3. Third Party Involvement - Some applicants may find navigating the PMD process overwhelming and difficult. The existing General Assistance application process is well-known to many community advocates and social agencies, and is relatively straight-forward. Although the PMD process is very similar to Social Security’s process, it will take some time to learn the process and for it to become operational. It is very important that assistance for both applicants and recipients be available during critical phases of the PMD process.

    Neither SRS not KHPA have the capacity to assist every client through this process. We must rely on other agencies and advocates to provide this assistance. Therefore, education and training of local agencies is a key component to the success of the new PMDT process. SRS Regional Offices have primary responsibility for this task.
    
    A formal arrangement is currently being developed with the Community Mental Health Centers. Under the proposed arrangement, the CMHC would receive notification of an upcoming review for a current General Assistance recipient with the expectation the CMHC case manager would offer assistance throughout the process, including the telephone consultation. A special release would not be required for this type of arrangement because of the MediKan billing relationship with the CMHC. However, a release will be required for new applicants reporting medical health issues. Because most regions have developed special release forms with the local CMHC, no formal process is being developed for this phase.
    
    Central office will continue to work with other state-wide agencies and organizations to coordinate this type of assistance.

    4. Base Period Policy Change - Another policy change involves establishment of the Medically Needy base period when a case moves to or from PMD status. Current change reporting rules are applicable, with the change effective the month following the month of the change - or the second month following the change to allow for timely and adequate notice (see KEESM 9121.1 (5)). Where the change results in the case moving to PMD status or from PMD status, a new base period begins.

    For situations where a person is moving to PMD status, the base period begins the month of PMD eligibility. For situations where a person is moving from PMD status due to a final decision by SSA, the base period begins the month following the month PMD ends. The new policy will be especially important for cases currently pending, as PMD cannot be backdated prior to September 1, 2006. For new cases, the policy will impact base periods at both the beginning and end of a PMD period, as in following example:

    Example: Georgie was hospitalized with severe injuries incurred in a motorcycle wreck in May, 2007. He applies for medical assistance in June, 2007. He asks for prior medical, because he had problems with his diabetes and has medical bills. The case was sent to the PMDT, asking for a determination beginning March, 2007. The PMDT determines he meets Tier 1 criteria beginning May, 2007 but they cannot establish either Tier 1 or Tier 2 for March or April. His SSA application is pending for these months though, so there is a protected filing date.

    Because the initial month of PMD coverage ( May, 2007) falls into the prior period, there is a one month base established for May, 2007. The six month base begins June, 2007 and runs through November, 2007. A second six month base is established beginning December, 2007 and runs through May, 2008. In late January, 2008 Georgie receives word he has been awarded SS disability with an onset date of January, 2006.

    For the prior period, a two month base is established for the period of March-April, 2006. Since the PMD determination was completed for the month of May, 2006 and is part of an existing base period, there is no adjustment to the prior period.

    For the current period, action to change from PMD status to regular Medicaid is effective March, 2008 - as timely notice couldn’t be given for February. The current PMD base is shortened to end February, 2008. A new base is established for the period of March, 2008 - August, 2008 which also includes the new SSA award in the budget.

    5. Impact on Food Stamps -

    ABAWD Criteria - Persons who self-declare their disability on the ES-3900 (responding “yes” to questions 1 and 4 or 1 and 5) shall be regarded as exempt from the ABAWD provisions per KEESM 2521 (2). They shall also be exempt from Food Stamp work requirements per KEESM 3230 (3). If approved for presumptive disability as either a Tier 1 or Tier 2, the exemption shall continue until a final Social Security determination is made. If the person fails to meet either Tier 1 or Tier 2 qualifications, exempt status shall end beginning with the month following the month in which the determination is finalized allowing for timely and adequate notice. The person would then be subject to the ABAWD and work requirement provisions and continued eligibility determined. Benefits provided based on the original self-declaration would not be regarded as overpayments nor as ABAWD months.

    Entitlement to Special Household Status - Persons approved for presumptive disability under Tier 1 shall be considered as disabled for purposes of the Food Stamp Program, and entitled to the excess shelter deduction and the medical expense deduction. Once the Tier 1 presumptive determination is made, persons shall be coded with a Y in the DS/FS field on SSDO. Until this determination is made, the person is not entitled to special household status. Persons determined for a Tier 2 disability determination are not entitled to special household status.

    Reporting Requirements - Households in which all persons are being referred for a presumptive medical disability determination shall be considered simplified reporters for FS purposes (unless all household members are 60 or older in which case they are subject to change reporting). If a Tier 1 determination is made the person is considered disabled for FS purposes and the reporting requirements will change to a change reporter. Per KEESM 9120, a change in reporting requirements that results in the household changing from simplified reporting to change reporting shall be processed at the time of the next review or IR, whichever comes first. If the person(s) are determined for Tier 2 the household shall remain a simplified reporter (unless 60 or older).

CONCLUSION

The implementation of the new Presumptive Medical Disability process will result in significant process changes for those staff with General Assistance and disability-related Medical Assistance caseload responsibilities. Because of the increased workload, it is important to work as efficiently as possible. In the early phases of this implementation it will be critical to evaluate our process and to change or correct inefficiencies Both SRS and KHPA staff are interesting in receiving feedback on the process and regarding the impact the program is having on both staff and clients.

KHPA will make a select group of the PMD forms available to the SRS regional offices. An initial supply will be mailed, when available, and may be reordered through the SRS warehouse. Staff must locally reproduce forms until such time they are available. The current versions can be found in KEESM Revision 29 draft, scheduled to be effective October 1, 2006. Those forms which will be available through the warehouse are:

1. ES-3820, Notice of Eligibility Review
   
   
2. ES-3900, Tell Us If You Have a Disability
   
   
3. ES-3901, Presumptive Medicaid Disability Determination Referral Form
   
   
4. ES-3902, Presumptive Medical Disability brochure
   
   
5. ES-3903, Telephone Consultation Guide
   
   
6. ES-3904, HIPAA Compliant Authorization to Release Information to KHPA
   
   
7. ES-3905, General Assistance and MediKan Review Requirements
   
   
8. ES-3906, Presumptive Medicaid Disability Determination Notification of Changes and Final Decision Form
   
   
9. ES-3907, Disability Review Team Referral
   
   
10. ES-3908, Referral to Kansas Legal Services

If you have any questions, please contact one of the following:

For medical assistance, Jeanine Schieferecke, KHPA - (785) 296-8866

For General Assistance, Lewis Kimsey, SRS - (785) 296-0147

For the PMDT, Mark Votaw, KHPA - (785) 296-1849

For KAECSES and system issues - SRSTSC via GroupWise

Thank you for your hard work in making this project a success.

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