Start Application: This section is in reference to the primary applicant. Just the fields unique to the primary applicant are included here.

Transcription

1 KDHE Medical Policy 1 Online s Eligibility Processing Job Aid June 23, 2015 This Job Aid is intended to provide instruction on the required elements of the online application. The system requires an answer for some application questions; however, the customer has the ability to submit an application with missing pieces of information. This Job Aid identifies when an answer left blank is acceptable and when additional follow-up is required. Note: questions to submit the application are marked with an asterisk *. verification policies still apply. Obtain verification as required in KEESM 1322, KFMAM 1325, or Policy Memo When a Leading has been answered Yes Follow-up s are presented and may be required. These will be outlined below with each question. For example, if a customer indicates they are self-employed, then it is necessary to obtain answers to all of the self-employment Follow-up questions. These instructions are intended as a guide and should not replace the prudent person principle. Start : This section is in reference to the primary applicant. Just the fields unique to the primary applicant are included here. First Name* Middle Name/Initial Last Name* Suffix (Jr., Sr., etc.) Maiden Name Date of Birth* Home Phone Number Message/Cell Phone Number Work Phone Number Is it ok to call you at work? Not Make sure it is valid. There are no edits preventing a future date, etc.

2 KDHE Medical Policy 2 Where are you applying from? Personal Address* I would like to learn that I have important information waiting for me at the message center through: Personal Address Line 1* Address Line 2 Not This is required to create an account. It will be used in the future for notices and other communications. Address fields are required for the Primary Applicant. Home, Home of friend or relative, Library, Internet café, DCF office, Health department, Mental Health Center, Community center, Clinic, Hospital, Other This will be used in the future to send notices through the message center instead of Postal Service mail. City* State* County* Drop-down list of US states and territories Drop-down list of Kansas counties ZIP Code* Are you applying for yourself?* Are you male or female?* Social Security Number If the person answers No to Are you applying for this person? a paragraph pops up with the CMS legal language. This question determines if this person is actually applying for services.

3 KDHE Medical Policy 3 Marital Status Maybe Not Displays if Yes to Are you applying for yourself? Married, Never Married, Divorced, Separated, Widowed, Common Law It may be necessary marital status for assistance planning purposes. Do any of the following apply to you? Please select all that apply Have you ever applied for Social Security Benefits? Do you want any of these specific services? Values display when answered Yes. 65 years of age or older Disability that will last at least 12 months or result in death Only if Disability that will last at least 12 months or result in death from above is checked If user selects Requesting help with nursing home care, home health care, or other long-term care, these values display If Yes, Other Name Used Information screen appears as the next screen. If Yes to Are you applying for yourself? Requesting help with nursing home care, home health care, or other long-term care Nursing Home, Home and Community- Based Services; PACE, WORK, Other institutional care Assume No if left blank These options drive other questions relating to E&D. This question can further assist you in determining the benefit being requested. Are you known by another name? Do you need help Assume No if left blank paying medical bills from the last 3 months? Are you pregnant? If Female and over the age of 10 and if Assume No if left blank Yes to Are you applying for yourself? Expected Due Date* If Yes to Are you Pregnant Assume 9 months from the Due Date Number of unborn If Yes to Are you Pregnant 1-8 Assume one if left blank children* Were you in Kansas If Yes to Are you applying for yourself? Assume No if left blank foster care on your and age is between 18 and 26 18th birthday? Who were you in the If Yes to Were you in Kansas foster JJA/Department of Corrections, DCF/SRS, custody of? care at the time of your 18th birthday? Tribal Authority, None of these What language do you Assume English if left blank speak at home?

4 KDHE Medical Policy 4 What language do you read at home? Do you have other communications needs? What is your race? (optional) Check all that apply. Are you Hispanic, Latino/a or Spanish origin? (optional) (check all that apply) Not If Yes to Are you applying for yourself? If Yes to Are you applying for yourself? White, Black or African American, American Indian or Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan Other Pacific Islander No not of Hispanic, Latino/a or Spanish origin, Yes Mexican, Mexican American or Chicano/a, Yes Puerto Rican, Yes Cuban, Yes another Hispanic Latino/a or Spanish origin Assume English if left blank What is your U.S. citizenship or noncitizen status* Have you delivered a baby in the last 3 months? Did you have emergency care in the last 3 months to save life, organs, or bodily function? If Yes to Are you applying for yourself? If Yes to Are you applying for yourself? and if other than U.S. Citizen If Yes to Are you applying for yourself? and if other than U.S. Citizen Lawful Permanent Resident (LPR, Nondocumented, Other Status, Refugee/Asylee, Sponsored Alien, Trafficking Victim, U.S. Citizen Assume No if left blank Assume No if left blank

5 KDHE Medical Policy 5 Choose your document type First Name (as it appears on your document) Non-citizen status must be verified. Non-citizen status must be verified. Not Only displays for non-citizen statuses other than non-documented Displays when a document type is selected Values: I-327 (Reentry Permit), I-551 (Permanent Resident Card), I-571 (Refugee Travel Document), I-766 (Employment Authorization Card), Certificate of Citizenship, Naturalization Certificate, Machine Readable Immigrant Visa (with Temporary I-551 Language), Temporary I-551 Stamp (on passport or I-94), I-94 (Arrival/Departure Record), I- 94 (Arrival/Departure Record) in Unexpired Foreign Passport), Unexpired Foreign Passport, US Passport, Visitor/Visa, I-20 (Certificate of Eligibility for Nonimmigrant Student Status), DS2019 (Certificate of Eligibility for Exchange Visitor Status), Other (select if document type not listed) This information may be needed to verify non-citizen status when unable to verify non-citizen status through the VLP or manual SAVE. entry when using the VLP Middle Name (as it appears on your document) Non-citizen status must be verified. Displays when a document type is selected entry when using the VLP Last Name (as it appears on your document) Non-citizen status must be verified. Displays when a document type is selected entry when using the VLP Date of Birth (as it appears on your document) Non-citizen status must be verified. Displays when a document type is selected entry when using the VLP

6 KDHE Medical Policy 6 Alien Number I-94 Number SEVIS ID Passport Number Not This field is displayed when one of the following document types is selected: I-327 (Reentry Permit) I-551 (Permanent Resident Card) I-571 (Refugee Travel Document) I-766 (Employment Authorization Card) Certification of Citizenship Naturalization Certificate Machine Readable Immigrant Visa (with Temporary I-551 Language) Temporary I-551 Stamp (on passport or I-94) This field is displayed when the I-94 (Arrival/Departure Record) document type is selected. This field is displayed when one of the following document types is selected: I-20 (Certificate of Eligibility for Nonimmigrant Student Status) DS2019 (Certificate of Eligibility for Exchange Visitor Status) Other (select if document type not listed) This field is displayed when one of the following document types is selected: Machine Readable Immigrant Visa (with Temporary I-551 Language) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) Unexpired Foreign Passport May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification

7 KDHE Medical Policy 7 Country of Issuance Visa Number Receipt Number Not This field is displayed when one of the following document types is selected: Machine Readable Immigrant Visa (with Temporary I-551 Language) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) Unexpired Foreign Passport This field is displayed when one of the following document types is being selected: Machine Readable Immigrant Visa (with Temporary I-551 Language) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) This field is displayed when the Temporary I-551 Stamp (on passport or I-94) document types is selected Drop-down list of countries May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification Naturalization Number Citizenship Number Document Expiration Date This field is displayed when the Naturalization Certificate document type is selected This field is displayed when the Certificate of Citizenship document type is selected This field is displayed when one of the following document types is selected: I-766 (Employment Authorization Card) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) Unexpired Foreign Passport May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification

8 KDHE Medical Policy 8 Other (please provide explanation) Not This field is displayed when one Other is selected as the document type May be needed for non-citizen verification People: This section is in reference to the applicant and all household members First Name* Middle Name Last Name* Suffix Maiden Name Date of Birth* Does this person live at the same address as you? Address Line 1 Address Line 2 City State Not If No to Does this person live at the same address as you? If No to Does this person live at the same address as you? If No to Does this person live at the same address as you? If No to Does this person live at the same address as you? Drop-down list of US states and territories Make sure it is valid. There are no edits preventing a future date, etc. If blank, assume the same address as the Primary Applicant. Look at this field along with Reason and Type of Facility (below) if the person is in the home.

9 KDHE Medical Policy 9 County ZIP Code Is this person away from the home for any of the following reasons? Reason* Where does this person live? Does this person live in any of these locations? Type of Facility* Not If No to Does this person live at the same address as you? and State is Kansas If No to Does this person live at the same address as you? If No to Does this person live at the same address as you? If Yes to Is this person away from the home for any of the following reasons? If Other to Reason If No to Does this person live at the same address as you? If Yes to Does this person live in any of these locations? Drop-down list of Kansas counties Work, School, Other. Shelter; Jail, Prison, or Correctional Facility; Psychiatric Hospital/Mental Institution; Assisted Living Facility; Hospital; Nursing Home; Drug/Alcohol Rehabilitation Center Assume No if left blank Name of Facility Date Entered Date Expected to Leave Are you applying for this person?* Is this person a male or female?* If Yes to Does this person live in any of these locations? If Yes to Does this person live in any of these locations? If Yes to Does this person live in any of these locations? This question determines if this person is actually applying for services.

10 KDHE Medical Policy 10 Social Security Number Do any of the following apply to you? Please select all that apply Has this person ever applied for Social Security Benefits? Does this person want any of these specific services? Is this person known by another name? Does this person need help paying medical bills from the last 3 months? Is this person Pregnant? Not If the person answers No to Are you applying for this person? a paragraph pops up with the CMS legal language. Values display when answered Yes. 65 years of age or older Disability that will last at least 12 months or result in death Only if Disability that will last at least 12 months or result in death from above is checked If user selects Requesting help with nursing home care, home health care, or other long-term care, these values display If Yes, Other Name Used Information screen appears as the next screen. If Yes to Are you applying for this person? If Female and over the age of 10 and if Yes to Are you applying for this person? Requesting help with nursing home care, home health care, or other long-term care Nursing Home, Home and Community- Based Services; PACE, WORK, Other institutional care Assume No if left blank. These options drive other questions relating to E&D. This question can further assist you in determining the benefit being requested. Assume No if left blank Assume No if left blank Expected Due Date* If Yes to Is this person Pregnant Assume 9 months from the Due Date Number of unborn If Yes to Is this person Pregnant 1-8 Assume one if left blank children* Was this person in If Yes to Are you applying for this Assume No if left blank Kansas foster care at person? and age is between 18 and 26 the time of their 18th birthday?

11 KDHE Medical Policy 11 Who was this person in the custody of? What is this person s race? (optional) Check all that apply. Is this person Hispanic, Latino/a or Spanish origin? Check all that apply. Not If Yes to Was this person in Kansas foster care at the time of their 18th birthday? If Yes to Are you applying for this person? If Yes to Are you applying for this person? JJA/Department of Corrections, DCF/SRS, Tribal Authority, None of these White, Black or African American, American Indian or Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan Other Pacific Islander No not of Hispanic, Latino/a or Spanish origin, Yes Mexican, Mexican American or Chicano/a, Yes Puerto Rican, Yes Cuban, Yes another Hispanic Latino/a or Spanish origin What is this person s U.S. citizenship or non-citizenship status* Has this person delivered a baby in the last 3 months? Did this person have emergency care in the last 3 months to save life, organs, or bodily function? If answer Yes to Are you applying for this person? If Yes to Are you applying for this person? and if other than U.S. Citizen If Yes to Are you applying for this person? and if other than U.S. Citizen Lawful Permanent Resident (LPR, Nondocumented, Other Status, Refugee/Asylee, Sponsored Alien, Trafficking Victim, U.S. Citizen Assume No if left blank Assume No if left blank

12 KDHE Medical Policy 12 Choose this person s document type First Name (as it appears on document) Non-citizen status must be verified. Non-citizen status must be verified. Not Only displays for non-citizen statuses other than non-documented Displays when a document type is selected Values: I-327 (Reentry Permit), I-551 (Permanent Resident Card), I-571 (Refugee Travel Document), I-766 (Employment Authorization Card), Certificate of Citizenship, Naturalization Certificate, Machine Readable Immigrant Visa (with Temporary I-551 Language), Temporary I-551 Stamp (on passport or I-94), I-94 (Arrival/Departure Record), I- 94 (Arrival/Departure Record) in Unexpired Foreign Passport), Unexpired Foreign Passport, US Passport, Visitor/Visa, I-20 (Certificate of Eligibility for Nonimmigrant Student Status), DS2019 (Certificate of Eligibility for Exchange Visitor Status), Other (select if document type not listed) This information may be needed to verify non-citizen status when unable to verify non-citizen status through the VLP or manual SAVE. entry when using the VLP Middle Name (as it appears on document) Non-citizen status must be verified. Displays when a document type is selected entry when using the VLP Last Name (as it appears on document) Non-citizen status must be verified. Displays when a document type is selected entry when using the VLP Date of Birth (as it appears on document) Non-citizen status must be verified. Displays when a document type is selected entry when using the VLP

13 KDHE Medical Policy 13 Alien Number I-94 Number SEVIS ID Passport Number Not This field is displayed when one of the following document types is selected: I-327 (Reentry Permit) I-551 (Permanent Resident Card) I-571 (Refugee Travel Document) I-766 (Employment Authorization Card) Certification of Citizenship Naturalization Certificate Machine Readable Immigrant Visa (with Temporary I-551 Language) Temporary I-551 Stamp (on passport or I-94) This field is displayed when the I-94 (Arrival/Departure Record) document type is selected. This field is displayed when one of the following document types is selected: I-20 (Certificate of Eligibility for Nonimmigrant Student Status) DS2019 (Certificate of Eligibility for Exchange Visitor Status) Other (select if document type not listed) This field is displayed when one of the following document types is selected: Machine Readable Immigrant Visa (with Temporary I-551 Language) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) Unexpired Foreign Passport May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification

14 KDHE Medical Policy 14 Country of Issuance Visa Number Receipt Number Not This field is displayed when one of the following document types is selected: Machine Readable Immigrant Visa (with Temporary I-551 Language) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) Unexpired Foreign Passport This field is displayed when one of the following document types is being selected: Machine Readable Immigrant Visa (with Temporary I-551 Language) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) This field is displayed when the Temporary I-551 Stamp (on passport or I-94) document types is selected Drop-down list of countries May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification Naturalization Number Citizenship Number Document Expiration Date This field is displayed when the Naturalization Certificate document type is selected This field is displayed when the Certificate of Citizenship document type is selected This field is displayed when one of the following document types is selected: I-766 (Employment Authorization Card) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport) Unexpired Foreign Passport May be needed for non-citizen verification May be needed for non-citizen verification May be needed for non-citizen verification

15 KDHE Medical Policy 15 Other (please provide explanation) Not This field is displayed when one Other is selected as the document type May be needed for non-citizen verification Parents Information Screen First name of parent #1 Last name of parent #1 First name of parent #2 Last name of parent #2 Who has Parental Control of this child?* Household Relationships screen* Maybe Maybe Maybe Maybe This screen will only display for children applying for coverage who are under the age of 19 when both parents have not already been identified as household members. Condition: fields are displayed dynamically based off of the household relationship page. Each person 19 and under and not married must have two parents. If only one parent is listed in the relationship table, one absent parent block is displayed. If there are no parents listed in the relationship table, two absent parent blocks are displayed. List of household members over the age of 18 or married It may be necessary to know parents names if needed for assistance planning purposes. It may be necessary to know parents names if needed for assistance planning purposes. It may be necessary to know parents names if needed for assistance planning purposes. It may be necessary to know parents names if needed for assistance planning purposes. This screen is laid out as a grid, where the user chooses relationship between each person on the application with others on the application. Contact applicant to obtain answer if something doesn t make sense. Format of screen: Mary Jones is the of Sally Jones

16 KDHE Medical Policy 16 Tax Information screen (primary applicant) CURRENT YEAR TA RETURN Based on your current situation, do you plan to file a Federal income tax return?* Will you file jointly with your spouse or partner?* Will you be claimed as a dependent on someone else s tax return?* Who will claim you on their tax return?* OTHER DEPENDENTS Can you claim a dependent(s) not listed on this application?* How many dependents not listed on this application can be claimed?* List the names of those dependents* Not If No to Based on your current situation, do you plan to file a Federal income tax return? If Yes to Will you be claimed as a dependent on someone else s tax return? If Yes to Based on your current situation, do you plan to file a Federal income tax return? If Yes to Can you claim a dependent(s) not listed on this application? If Yes to Can you claim a dependent(s) not listed on this application? Yes, No, Unknown Yes, No, Unknown List of all household members and Other 1-10 All questions are required and are asked for each person. These questions are important in creating tax households.

17 KDHE Medical Policy 17 Tax Information screen (household members) CURRENT YEAR TA RETURN Based on this person s current situation, do you plan to file a Federal income tax return?* Will this person file jointly with your spouse or partner?* Will this person be claimed as a dependent on someone else s tax return?* Who will claim this person on their tax return?* OTHER DEPENDENTS Can this person claim a dependent(s) not listed on this application?* How many dependents not listed on this application can be claimed?* List the names of those dependents* Not If No to Based on your current situation, do you plan to file a Federal income tax return? If Yes to Will you be claimed as a dependent on someone else s tax return? If Yes to Based on your current situation, do you plan to file a Federal income tax return? If Yes to Can you claim a dependent(s) not listed on this application? If Yes to Can you claim a dependent(s) not listed on this application? Yes, No, Unknown Yes, No, Unknown List of all household members and Other 1-10 All questions are required and are asked for each person. These questions are important in creating tax households.

18 KDHE Medical Policy 18 Job/Wages: This section has information for all jobs, including self-employment and unemployment. Leading s Does anyone in your household have a job?* Is anyone Self- Employed?* Is anyone getting unemployment benefits?* Job Detail Select a person* Employer Name Employer Address Employer Phone Number Start Date Date of Next Paycheck How often are you paid?* Are you paid hourly or do you have a set salary?* Not If Yes to Does anyone in your household have a job? Drop-down list of household members age 14 and older One time only, Every week, Every two weeks, Twice a Month, Once a month, Quarterly, Every year Hourly, Salary If Yes, ensure that details are provided in the follow-up questions.

19 KDHE Medical Policy 19 What is your gross pay amount (before deductions) for each check?* How much do you make an hour? (Include any shift differential or other increase to the base rate)* How many hours do you work per week?* Do you work overtime? How many hours of overtime do you work per week? How much do you make an hour for overtime? Maybe Maybe Not If Salary is selected If Hourly is selected If Yes to Do you work overtime? If Yes to Do you work overtime? Assume No if left blank Would be needed for a valid selfattestation in order to do a reasonable compatibility test. Income will be verified, may not require an answer to this specific question. Would be needed for a valid selfattestation in order to do a reasonable compatibility test. Income will be verified, may not require an answer to this specific question. Do you get tips? Assume No if left blank How much do you If Yes to Do you get tips? usually make in tips in each week?* Do you get Assume No if left blank commissions?

20 KDHE Medical Policy 20 How much do you make in commissions in an average month?* Not If Yes to Do you get commissions? Do you get bonuses? Assume No if left blank How much do you If Yes to Do you get bonuses? make in bonuses in an average year?* Do you have Assume No if left blank predictable income increases or decreases during a normal year because your income is from seasonal work such as working for a school system, tax preparation, roofing, construction or farming? What was your income last year? What do you expect your income from this job to be for the next 12 months? If Yes to Do you have predictable income increases or decreases during a normal year because your income is from seasonal work such as working for a school system, tax preparation, roofing, construction or farming? If Yes to Do you have predictable income increases or decreases during a normal year because your income is from seasonal work such as working for a school system, tax preparation, roofing, construction or farming? Income will be verified. May not require an answer for this specific question. Income will be verified. May not require an answer for this specific question.

21 KDHE Medical Policy 21 Do you have any expenses from your disability that allow you to work? Self-Employed Select a person What type of business is it? When did business start?* Were taxes filed on this income last year? What IRS form of schedule did you file to report this income? Reported Annual Gross Income* Reported Annual Gross Expenses* Is income expected to be the same this year? Not Condition: if Disability that will last at least 12 months or result in death was selected Condition: if Yes to Is anyone selfemployed? If Yes to Were taxes filed on this income last year? If Yes to Were taxes filed on this income last year? If Yes to Were taxes filed on this income last year? If No to Were taxes filed on this income last year? Drop-down list of household members age 14 and older Sole Ownership, Partnership, Corporation, S Corporation, Rental Schedule C, Schedule D, Schedule E, Schedule F, 4797, 1065, 1120S, Schedule K, Other Assume no if left blank Not required because will be known once verified Not required because will be known once verified Not required because will be known once verified Not required because will be known once verified. If answering No, the KC5150 form is required. Expected Annual Gross Income* Expected Annual Gross Expenses* If No to Is income expected to be the same this year? If No to Is income expected to be the same this year?

22 KDHE Medical Policy 22 Over the course of this year, what is your average monthly income? (Income may include gross receipts, sales of livestock, and crop insurance proceeds.)* Over the course of this year, what are your average monthly expenses? (Expenses may include car and truck expenses, chemicals and feed, commissions and fees, depreciation, insurance, mortgage, repairs and maintenance.)* Unemployment Benefits Select a person What is the weekly benefit amount?* What state is your unemployment claim with?* Not If No to Were taxes filed on this income last year? If No to Were taxes filed on this income last year? If Yes to Is anyone getting unemployment benefits? Drop-down list of household members age 14 and older

23 KDHE Medical Policy 23 Other Income: This section is for unearned income. Leading s Is anyone getting Social Security income?* Is anyone getting money from family, friends or others?* Not If Yes to Do any of the following apply to this person? (This person is age 65 or older, or will turn 65 in the next 2 months; This person has a disability that will last at least 12 months or result in death; This person needs help with nursing home care, home health care, institutional care or other long term care)

24 KDHE Medical Policy 24 Is anyone getting or going to get money from any of these?* Not Annuities, Trusts Contract sales Interest, Dividends, Investments Native American Per Capita Payments or Tribal Payments Oil Royalties/Mineral Rights Railroad Benefits Spousal Support Pensions/Other Retirements (i.e. KPERS) ~Cash Assistance (TANF), Foster Care Payments, or Adoption Assistance ~Child Support ~Educational Income/Scholarships/Loans ~Legal or Insurance Settlements or Court Actions ~Reimbursements, Refunds Veterans Administration Payments ~Veterans Administration(VA) Payments ~Work Program Training ~Worker s Compensation, Disability Does anyone get other income that is not listed above?* Social Security Income Select a person* If Yes to Is anyone getting Social Security income? Income types marked with this symbol (~) are not counted for MAGI programs. Drop-down list of all household members

25 KDHE Medical Policy 25 What is the amount of the monthly Social Security? Social Security Claim Number Not Verified through Interfaces Is this person getting Supplemental Security Income (SSI)? What is the amount of the monthly Supplemental Security Income benefit? Money from Family, Friends, or Others Select a person* How much?* How often?* From whom? Are you expected to pay this money back?* Income from Other Sources If Yes to Do any of the following apply to this person? (This person is age 65 or older, or will turn 65 in the next 2 months; This person has a disability that will last at least 12 months or result in death; This person needs help with nursing home care, home health care, institutional care or other long term care) and Yes to Is this person getting Supplemental Security Income (SSI)? Condition: if Yes to Is anyone getting money from family, friends or others? If Yes to Is anyone getting or going to get money from any of these? Drop-down list of all household members One time only, Every week, Every two weeks, Twice a Month, Once a month, Quarterly, Every year Verified through Interfaces Verified through Interfaces

26 KDHE Medical Policy 26 Select a person* Income Category* How often?* How much?* Not Drop-down list of all household members Cash Assistance (TANF), Foster Care Payments, or Adoption assistance Annuities, Trusts Contract sales Worker s Compensation, short-term Disability Educational Income/Scholarships/Loans Legal or Insurance Settlements or Court Actions Interest, Dividends, Investments Native American Per Capita Payments or Tribal Payments Oil Royalties/Mineral Rights Railroad Benefits Reimbursements, Refunds Veterans Administration (VA) Payments Pensions/Other Retirements (i.e. KPERS) Work Program Training Child Support Spousal Support One time only, Every week, Every two weeks, Twice a Month, Once a month, Quarterly, Every year

27 KDHE Medical Policy 27 Type of Cash Assistance (TANF), Foster Care Payments, or Adoption assistance Type of Annuities, Trusts What is the address of the property? Type of Workers Compensation, Short-term Disability Name of employer and/or law firm Is this person expecting to return to work?* Maybe Not If Cash Assistance (TANF), Foster Care Payments, or Adoption assistance is selected for Income Category If Annuities, Trusts is selected for Income Category If Contract sales is selected for Income Category If Worker s Compensation, short-term Disability is selected for Income Category If Worker s Compensation, short-term Disability is selected for Income Category If Worker s Compensation, short-term Disability is selected for Income Category Adoption Assistance Subsidy, Cash Assistance, Disaster/Emergency Assistance, Executive Volunteer Programs-SCORE and ACE, Foster Care and Permanent Custodianship, Foster Grandparents/Senior Volunteers, HUD Payments, Independent Living, Older American Act Payments, Refugee Resettlement Funds, Senior Health Aides/Companions, Tax Refunds/Rebates/Credits(EITC) Annuity, Trust Worker s Comp, Short-term Disability Depends on the rules of the program being determined. Not required because will be known once verified

28 KDHE Medical Policy 28 Did this disability cause reduced earnings? Maybe Not If Short-term Disability is selected for Type of Workers Compensation, Shortterm Disability Depends on the rules of the program being determined. What was this person s income last year? What does this person expect to make in the next 12 months? Type of Legal or Insurance Settlements or Court Actions Maybe Maybe Maybe If Yes to Did this disability cause reduced earnings? If Yes to Did this disability cause reduced earnings? If Legal or Insurance Settlements or Court Actions is selected for Income Category Life Insurance and Burial Proceeds, Death Benefits, Other Recurring Insurance Payments, non-exempt, Payments for Repair or Replacement of Property, Other Recurring Insurance Payments Depends on the rules of the program being determined. Depends on the rules of the program being determined. Depends on the rules of the program being determined. What is the source? Type of Interest, Dividends, Investments What is the source? Maybe Maybe Maybe If Legal or Insurance Settlements or Court Actions is selected for Income Category If Interest, Dividends, Investments is selected for Income Category If Interest, Dividends, Investments is selected for Income Category Dividends, Interest, Interest on Burial Fund, Life Insurance Dividends Depends on the rules of the program being determined. Depends on the rules of the program being determined. Depends on the rules of the program being determined.

29 KDHE Medical Policy 29 Type of Native American Per Capita Payments or Tribal Payments Not If Native American Per Capita Payments or Tribal Payments is selected for Income Category Native American Tribal Disbursements (includes casino profits), Bureau Indian Affairs Income, Indian Claims/Resettlement, Native American Payment s from Leases or Trusts of Individually or Tribal Owned Land Not required because will be known once verified Railroad claim number Type of Veterans Administration Payments VA Claim Number Type of Pensions/Other Retirements (i.e. KPERS) Type of Work Program Training If Railroad Benefits is selected for Income Category If Veterans Administration (VA) Payments is selected for Income Category If Veterans Administration (VA) Payments is selected for Income Category If Pensions/Other Retirements (i.e. KPERS) is selected for Income Category If Work Program Training is selected for Income Category Aid and Attendance, Unusual Medical Expenses (UME), Veterans Pension, VA Compensated Work Therapy, VA Monthly Housing Allowance, Veterans Disability Retirement/Pension Benefit, KPERS AmeriCorps/VISTA, College Work Study, Job Corps, VR Training Allowance/Incentive/Maintenance, WIA Earned, WIA Incentive or Training Allowance, Work Employment Program Payments Not required because will be known once verified Not required because will be known once verified Not required because will be known once verified Other Income Select a person* If Yes to Does anyone get other income that is not listed above? Drop-down list of all household members

30 KDHE Medical Policy 30 What Type?* How much? How often? Not Source of Income?* If Other is selected for What Type? Blood/Plasma, Lottery/Gambling Winnings, Strike Pay, Military Allotments, Other One time only, Every week, Every two weeks, Twice a Month, Once a month, Quarterly, Every year Not required because will be known once verified Depends on the rules of the program being determined. Not required because will be known once verified Depends on the rules of the program being determined.

31 KDHE Medical Policy 31 Expenses: Expenses Tab Leading s Does anyone in your home pay for any of the following? Does anyone in your home pay for Medical expenses? Does anyone in your home pay for Medicare coverage? Does anyone in your home pay for Other health insurance? Housing Costs Select a person* Not If Yes to Do any of the following apply to this person? (This person is age 65 or older, or will turn 65 in the next 2 months; This person has a disability that will last at least 12 months or result in death; This person needs help with nursing home care, home health care, institutional care or other long term care) If Yes to Does anyone in your home pay for any of the following? Rent Lot rent House Payment (Mortgage) Property taxes (if not included in house payment) Homeowner s insurance (if not included in house payment) Other housing costs Drop-down list of household members age 14 and older Assume No if left blank Assume No if left blank Assume No if left blank Assume No if left blank

32 KDHE Medical Policy 32 Housing Expense Type* How much does the household pay for this expense?* How often?* Medical Expense Select a person* Medical Expense Type How much is the expense? How often?* Who is it for? Describe the expense Not If Yes to Does anyone in your home pay for Medical expenses? Rent, Lot rent, House payment (Mortgage), Property taxes (if not in house payment), Homeowners insurance (if not in house payment), Other housing costs (such as Homeowner s association fees) Weekly, Every Other Week, Twice a Month, Monthly, Semi-Annually, Annually, One-Time Payment Drop-down list of all household members Unpaid medical bills still owed, Expense for household member not receiving assistance, Private pay nursing home expense, Non-covered medical expense, Durable Medical Equipment/Supplies, Medical Transportation, Prescriptions Weekly, Every Other Week, Twice a Month, Monthly, Semi-Annually, Annually, One-Time Payment Not required, but is required if an allowable expense. Not required, but is required if an allowable expense. Not required, but is required if an allowable expense. Not required, but is required if an allowable expense.

33 KDHE Medical Policy 33 Medicare Coverage Select a person* Medicare Claim Number* Medicare Part A, B, or D* Part A Start Date* Part B Start Date* Part B Premium Amount Part D Start Date* Part D Premium Amount Is this person only interested in the Medicare Savings Plan? Health Insurance Premiums Select a person* Not If Yes to Does anyone in your home pay for Medicare coverage? If Part A is selected for Medicare Part A, B, or D If Part B is selected for Medicare Part A, B, or D If Part B is selected for Medicare Part A, B, or D If Part D is selected for Medicare Part A, B, or D If Part D is selected for Medicare Part A, B, or D If Yes to Does anyone in your home pay for Other health insurance? Drop-down list of all household members Part A, Part B, Part D Drop-down list of all household members Not required, but is required if an allowable expense. Not required, but is required if an allowable expense.

34 KDHE Medical Policy 34 What type of health insurance premiums does this person pay? How much? How often? Begin Date Not Blue Cross Blue Shield of Kansas health insurance premium, Medicare Supplement health insurance premium, Long Term Care Insurance health insurance premium, Other health insurance premiums (Do not include Medicare) Values: Weekly, Every Other Week, Twice a Month, Monthly, Semi-Annually, Annually, One-Time Payment Not required, but is required if an allowable expense. Not required, but is required if an allowable expense. Not required, but is required if an allowable expense. Not required, but is required if an allowable expense. Is any of this expense paid by others? Not required, but is required if an allowable expense. How much is paid by others? Not required, but is required if an allowable expense.

35 KDHE Medical Policy 35 Resources: This section includes information about the Household s resources. Resources Tab Leading s Has anyone sold, traded, given away or changed ownership of any property such as a house or money, or any other property in the last 5 years? Does anyone own a home? Is anyone buying a home or other property such as land, buildings, or mobile homes? Does anyone own one or more of the motor vehicles listed below? Does anyone have any cash, stocks, bonds, or bank accounts? Maybe Not Condition: if Yes to Do any of the following apply to this person? (This person is age 65 or older, or will turn 65 in the next 2 months; This person has a disability that will last at least 12 months or result in death; This person needs help with nursing home care, home health care, institutional care or other long term care) Car, Truck, RV, Boat, Off-road vehicle, Mobile home, Camper, Trailer Cash, Checking, Savings, or Credit Union account, Certificate of Deposit (CD), Money Market Stocks/Bonds, Other Accounts If asking for LTC, is required. Assume No, if left blank.

36 KDHE Medical Policy 36 Does anyone have any retirement plans? Does anyone have any of these types of resources? Retirement Plans Select a person* Type of Retirement Plan* Current Value of Retirement Plans (i.e. Pension) Name of Bank or Company Account/Poli cy Number Address of Bank or Company Current value of IRA or Keogh or 401(k) Name of Bank or Financial Institution Not If Yes to Does anyone have any retirement plans? If Retirement plans (i.e. Pension) is selected for Type of Retirement Plan If Retirement plans (i.e. Pension) is selected for Type of Retirement Plan If Retirement plans (i.e. Pension) is selected for Type of Retirement Plan If Retirement plans (i.e. Pension) is selected for Type of Retirement Plan If IRA, Keogh, or 401(k) is selected for Type of Retirement Plan If IRA, Keogh, or 401(k) is selected for Type of Retirement Plan IRA, Keogh, or 401(k), Deferred Compensation Plan, Annuity, Other Retirement Plan Life Insurance, Life Estate, Burial/Funeral Plan, Oil/Mineral Rights, Trust Fund, Promissory Note/Contract Sales/Loans, Reverse mortgage, Business Property, Other resources Drop-down list of all household members Retirement plans (i.e. Pension); IRA, Keogh, or 401(k); Deferred compensation plan; Annuity; Other retirement plan

37 KDHE Medical Policy 37 Account/Poli cy Number Address of Bank or Financial Institution Current value of deferred compensation plan Name of Bank or Financial Institution Account/Poli cy number Address of Bank or Financial Institution Current value of Annuity Date Annuity purchased Account/Poli cy Number Address of Bank or Annuity Company Current value of other Retirement plan Name of Bank or Financial Institution Not If IRA, Keogh, or 401(k) is selected for Type of Retirement Plan If IRA, Keogh, or 401(k) is selected for Type of Retirement Plan If Deferred compensation plan is selected for Type of Retirement Plan If Deferred compensation plan is selected for Type of Retirement Plan If Deferred compensation plan is selected for Type of Retirement Plan If Deferred compensation plan is selected for Type of Retirement Plan If Annuity is selected for Type of Retirement Plan If Annuity is selected for Type of Retirement Plan If Annuity is selected for Type of Retirement Plan If Annuity is selected for Type of Retirement Plan If Other retirement plan is selected for Type of Retirement Plan If Other retirement plan is selected for Type of Retirement Plan

38 KDHE Medical Policy 38 Account/Policy number Address of Bank or Financial Institution Other Resources Select a person* Type of Resource* Face value of life insurance Cash surrender value Name of Insurance Company Account/Poli cy Number Address of Insurance Company Property value of Life Estate interest in any property Date Life Estate Created Not If Other retirement plan is selected for Type of Retirement Plan If Other retirement plan is selected for Type of Retirement Plan If Yes to Does anyone have any of these types of resources? If Life Insurance is selected for Type of Resource If Life Insurance is selected for Type of Resource If Life Insurance is selected for Type of Resource If Life Insurance is selected for Type of Resource If Life Insurance is selected for Type of Resource If Life Estate interest in any property is selected for Type of Resource If Life Estate interest in any property is selected for Type of Resource Drop-down list of all household members Life Insurance; Life Estate interest in any property; Burial/funeral arrangements, burial trusts, plots, or burial space; Contract for Care; Oil, mining, or mineral rights; Trust Fund; Reverse Mortgage; Promissory Note/Contract Sales/Loans; Business Property; Other Resources

39 KDHE Medical Policy 39 Name of Property owner Address of Property Current value of burial/funeral arrangements, burial trusts, plots, or burial space Name of Funeral Home or Bank Address of Funeral Home or Bank Current value of Contract for Care Not If Life Estate interest in any property is selected for Type of Resource If Life Estate interest in any property is selected for Type of Resource If Burial/funeral arrangements, burial trusts, plots, or burial space is selected for Type of Resource If Burial/funeral arrangements, burial trusts, plots, or burial space is selected for Type of Resource If Burial/funeral arrangements, burial trusts, plots, or burial space is selected for Type of Resource If Contract for Care is selected for Type of Resource Current value of oil, mining, or mineral rights Location of property Current value of Trust Fund Account/Poli cy number Name of Bank or Financial Institution If Oil, mining, or mineral rights is selected for Type of Resource If Oil, mining, or mineral rights is selected for Type of Resource If Trust Fund is selected for Type of Resource If Trust Fund is selected for Type of Resource If Trust Fund is selected for Type of Resource

40 KDHE Medical Policy 40 Address of Bank or Financial Institution Amount of Reverse Mortgage Date Received Do payments continue or are they one-time only? Amount of Promissory Note/Contract Sales/Loans Borrower s Name Amount repaid to date Current Value of Business Property Name of Business Property Address of Business Property Current value of Other Resources Not If Trust Fund is selected for Type of Resource If Reverse Mortgage is selected for Type of Resource If Reverse Mortgage is selected for Type of Resource If Reverse Mortgage is selected for Type of Resource If Promissory Note/Contract Sales/Loans is selected for Type of Resource If Promissory Note/Contract Sales/Loans is selected for Type of Resource If Promissory Note/Contract Sales/Loans is selected for Type of Resource If Business Property is selected for Type of Resource If Business Property is selected for Type of Resource If Business Property is selected for Type of Resource If Business Property is selected for Type of Resource

41 KDHE Medical Policy 41 Name of Resource Address of Resource Sold, Spent, or Given Away Property Select a person* What property? Not If Business Property is selected for Type of Resource If Business Property is selected for Type of Resource If Yes to Has anyone sold, traded, given away or changed ownership of any property such as a house or money, or any other property in the last 5 years? Drop-down list of all household members If asking for LTC, is required. Date ownership changed?* Value?* Given/Sold to? If asking for LTC, is required. Own Property Select a person* Is the property used as your home? If absent, do you intend to return to your home? Date expected to return to property Is this property used as rental or income producing property? If Yes to Does anyone own a home? Is anyone buying a home or other property such as land, buildings, or mobile homes? Drop-down list of all household members

42 KDHE Medical Policy 42 Property Type* Value Not Buildings, Land, Life Estate, Residential Property Amount Owed Is this property listed for sale? Name(s) of Property Owner(s) What is the address of the property? Motor Vehicle Select a person* Motor Vehicle Type* Year If Yes to Does anyone own one or more of the motor vehicles listed below? Drop-down list of all household members Car; Truck; Motorcycle; RV; Boat, Offroad vehicle, Mobile homes, Campers, Trailers Make Model License Number Estimated Value* Balance Owed Registered in Kansas?

43 KDHE Medical Policy 43 How do you use the vehicle? Cash, Stocks, Bonds, or Bank Accounts Select a person* Type of Resource* Total value of cash and/or uncashed checks Current value of Checking Account Name of Bank Account/Poli cy Number Address of Bank Is this a joint bank account? Not Condition: if Yes to Does anyone have any cash, stocks, bonds, or bank accounts? If Cash and/or un-cashed checks is selected for Type of Resource If Checking Account is selected for Type of Resource If Checking Account is selected for Type of Resource If Checking Account is selected for Type of Resource If Checking Account is selected for Type of Resource If Checking Account is selected for Type of Resource Home; Personal; Self Employment/Business/Self-sufficient; Transport Disabled Person; Transport Fuel/Water; Work, Seeking Employment, Training Drop-down list of all household members Cash and/or un-cashed checks, Checking Account, Business Checking Account, Savings Account, Electronic Debit Account, Care Home Resident Account, Individual Development Account (IDA), Learning Quest/529 ED ACCTS, Certificates of Deposit, Money Market Account, Stocks, Bonds, Other account

44 KDHE Medical Policy 44 What are the names on the account? Current value of Savings Account Name of Bank Account/Poli cy Number Address of Bank Is this a joint bank account? Not If Checking Account is selected for Type of Resource If Savings Account is selected for Type of Resource If Savings Account is selected for Type of Resource If Savings Account is selected for Type of Resource If Savings Account is selected for Type of Resource If Savings Account is selected for Type of Resource What are the names on the account? Current value of Business Checking Account Name of Bank Account/Poli cy Number Address of Bank Is this a joint bank account? If Savings Account is selected for Type of Resource If Business Checking Account is selected for Type of Resource If Business Checking Account is selected for Type of Resource If Business Checking Account is selected for Type of Resource If Business Checking Account is selected for Type of Resource If Business Checking Account is selected for Type of Resource What are the names on the account? If Business Checking Account is selected for Type of Resource