Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 20 - Medicaid Eligibility › Section 907 KAR 20:001 - Definitions for 907 KAR Chapter 20

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				194A.005(1),
				205.8451(7),
				(9),
				304.14-640(4),
				311.550(12),
				314.011,
				620.020(5),
				20
				C.F.R. 416.2101, 42 C.F.R. 400.203,
				405.2401(b), 435.4, 438.2, 438.408, 447.280,
				8
				U.S.C. 1101(a)(15), (17),
				1641(b),
				(c), 38 U.S.C. 101(2),
				42 U.S.C.
				405(c)(2),
				670
								¢â,¬o 679c, 1395tt, 1396b(x)(3)(A), 1396d(a)(2)(A), (B),
				1396d(a)(9), 1396d(p)(1), 1396d(s), 1396l, 1396n(c), 1396p(d)(4)(B),
				1396r-5(g), 1396r(b), (c), (d), 1397aa to jj
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services, Department for Medicaid Services, has responsibility to
				administer the Medicaid Program.
				KRS
				205.520(3) authorizes the
				cabinet, by administrative regulation, to comply with a requirement that may be
				imposed or opportunity presented by federal law to qualify for federal Medicaid
				funds. This administrative regulation establishes the definitions for 907 KAR
				Chapter 20.
Section 1. Definitions.
(1) "1915(c) home and community based
			 service" means a service available or provided via a 1915(c) home and community
			 based services waiver program.
(2)
			 "1915(c) home and community based services waiver program" means a Kentucky
			 Medicaid program established pursuant to, and in accordance with,
			 42 U.S.C.
			 1396n(c).
(3) "ABD" means a person who is aged, blind,
			 or disabled.
(4) "Adult scale"
			 means the scale located in
			 907
			 KAR 20:020, Section 1(1), establishing Medicaid income
			 limits by family size.
(5)
			 "Advanced practice registered nurse" is defined by
			 KRS
			 314.011(7).
(6) "Adverse action" means:
(a) The denial or limited authorization of a
			 requested service, including the type or level of service;
(b) The reduction, suspension, or termination
			 of a previously authorized service;
(c) The denial, in whole or in part, of
			 payment for a service;
(d) The
			 failure to provide services in a timely manner; or
(e) The failure of a managed care
			 organization to act within the timeframes provided in
			 42 C.F.R.
			 438.408(b).
(7) "After the month of
			 separation" means the first day of the month that follows the month in which an
			 individual ceases living in the same household of a Medicaid eligible
			 family.
(8) "Aid to Families with
			 Dependent Children" or "AFDC" means an assistance program:
(a) In effect from 1935 through
			 1996;
(b) For children whose
			 families had low or no income; and
(c) Administered by the United States
			 Department of Health and Human Services.
(9) "Ambulatory prenatal care" means
			 health-related care furnished to a presumed eligible pregnant woman provided in
			 an outpatient setting.
(10)
			 "Appeal" means a request for review of an adverse action or a decision by an
			 MCO related to a covered service.
(11) "Applicant" means an individual applying
			 for Medicaid.
(12) "Authorized
			 representative" means:
(a) For a recipient or
			 applicant who is authorized by Kentucky law to provide written consent, an
			 individual or entity acting on behalf of, and with written consent from, the
			 applicant or recipient; or
(b) A
			 legal guardian.
(13)
			 "Baseline date" means the date the institutionalized individual was
			 institutionalized and applied for Medicaid.
(14) "Basic maintenance" means the amount of
			 income that may be retained by the applicant for living and personal
			 expenses.
(15) "Blind work expense"
			 or "BWE" means an SSI program option in which expenses a blind individual
			 incurs in order to earn income are deducted for an SSI eligibility
			 purpose.
(16) "Cabinet" is defined
			 by
			 KRS
			 194A.005(1).
(17) "Caretaker relative" means:
(a) An individual:
1. Who is the caregiver of a child;
			 or
2. On whose tax return the child
			 is listed as a dependent; and
(b) Who has one (1) of the following
			 relationships to the child:
1. A
			 grandfather;
2. A
			 grandmother;
3. A
			 brother;
4. A sister;
5. An uncle;
6. An aunt;
7. A nephew;
8. A niece;
9. A first cousin;
10. A relative of the half-blood;
11. A preceding generation denoted by a
			 prefix of:
a. Grand;
b. Great; or
c. Great-great; or
12. A stepfather, stepmother, stepbrother, or
			 stepsister.
(18) "Categorically needy" means an
			 individual with income below 300 percent of the supplemental security income
			 (SSI) standard who has been receiving hospice or 1915(c) home and community
			 based services for at least thirty (30) consecutive days.
(19) "Child" means a person who:
(a)
1. Is
			 under the age of nineteen (19) years;
2.
a. Is a
			 full-time student in a secondary school or the equivalent level of vocational
			 or technical training; and
b. Is
			 expected to complete the program before the age of nineteen (19)
			 years;
3. Is not self
			 supporting;
4. Is not a participant
			 in any of the United States Armed Forces; and
5. If previously emancipated by marriage, has
			 returned to the home of his or her parents or to the home of another
			 relative;
(b) Has not
			 attained the age of nineteen (19) years in accordance with
			 42 U.S.C.
			 1396a(l)(1)(D); or
(c) Is under the age of nineteen (19) years
			 if the person is a KCHIP recipient.
(20) "Community spouse" means the individual
			 who is married to an institutionalized spouse who:
(a) Remains at home in the community;
			 and
(b) Is not:
1. Living in a medical institution;
2. Living in a nursing facility; or
3. Participating in a 1915(c) home and
			 community based services waiver program.
(21) "Community spouse maintenance standard"
			 means the income standard to which a community spouse's otherwise available
			 income is compared for purposes of determining the amount of the allowance used
			 in the post-eligibility calculation.
(22) "Continuous period of
			 institutionalization" means thirty (30) or more consecutive days of
			 institutional care in a medical institution or nursing home or both and may
			 include thirty (30) consecutive days of receipt of a 1915(c) home and community
			 based service or a combination of both.
(23) "Countable resources" means resources
			 not subject to exclusion in the Medicaid Program.
(24) "DCBS" means the Department for
			 Community Based Services.
(25)
			 "Deemed eligible newborn" means an infant born to a mother who, at the time of
			 the infant's birth, was a Medicaid recipient.
(26) "Department" means the Department for
			 Medicaid Services or its designee.
(27) "Dependent child" means a biological
			 child, a step child, or a child gained through adoption, who:
(a) Lives with a parent in the community;
			 and
(b) Is claimed as a dependent
			 by either parent under the Internal Revenue Service Code.
(28) "Dependent parent" means a parent:
(a) Of either member of a couple;
(b) Who lives with the community spouse;
			 and
(c) Is claimed as a dependent
			 by either spouse under the Internal Revenue Service Code.
(29) "Dependent sibling" means a brother or
			 sister of either member of a couple, including a half-brother, half-sister, or
			 sibling gained through adoption, who:
(a)
			 Resides with the community spouse; and
(b) Is claimed as a dependent by either
			 spouse under the Internal Revenue Service Code.
(30) "Enrollee" means a recipient who is
			 enrolled with a managed care organization for the purpose of receiving Medicaid
			 or KCHIP covered services.
(31)
			 "Excess shelter allowance" means an amount equal to the difference between the
			 community spouse's verified shelter expenses and the minimum shelter
			 allowance.
(32) "Fair market value"
			 means an estimate of the value of an asset if sold at the prevailing price at
			 the time it was actually transferred based on:
(a) The most recent gross tax assessed value
			 of the property as stated by the local property valuation
			 administrator;
(b) An independent,
			 licensed appraiser; or
(c) The
			 price brought on the property at a public auction conducted by a licensed
			 auctioneer.
(33) "Family
			 alternatives diversion payment" means a lump sum payment made to a Kentucky
			 Transitional Assistance Program applicant:
(a)
			 To meet short-term emergency needs; and
(b) Pursuant to
			 921 KAR
			 2:500.
(34) "First month of SSI payment" means the
			 first month for which an SSI-related Medicaid recipient is determined to be
			 eligible for SSI payments.
(35)
			 "Foster care" is defined by
			 KRS
			 620.020(5).
(36) "Gross income" means non-excluded income
			 that would be used to determine eligibility prior to income
			 disregards.
(37) "Homestead" means
			 property:
(a) In which an individual has an
			 ownership interest; and
(b) That an
			 individual uses as the individual's principal place of residence.
(38) "ICF IID" means intermediate
			 care facility for individuals with an intellectual disability.
(39) "Impairment related work expense" or
			 "IRWE" means an SSI program option in which the United States Social Security
			 Administration deducts the cost of items or services an individual needs, due
			 to an impairment, in order to work.
(40) "Incapacity" means a condition of mind
			 or body making a parent physically or mentally unable to provide the
			 necessities of life for a child.
(41) "Income" means money received from:
(a) Statutory benefits (for example, Social
			 Security, Veterans Administration pension, black lung benefits, or railroad
			 retirement benefits);
(b) A pension
			 plan;
(c) Rental
			 property;
(d) An investment;
			 or
(e) Wages for labor or
			 services.
(42)
			 "Individual development account" means an account containing funds for the
			 purpose of continuing education, purchasing a first home, business
			 capitalization, or other purposes allowed by federal regulations or
			 clarifications that meet the criteria established in
			 921
			 KAR 2:016.
(43) "Institutionalized" means:
(a) Residing in:
1. A nursing facility;
2. An intermediate care facility for an
			 individual with an intellectual disability; or
3. A medical institution;
(b) Receiving hospice services;
			 or
(c) Receiving 1915(c) home and
			 community based services.
(44) "Institutionalized individual" means an
			 individual with respect to whom payment is based on a level of care provided in
			 a nursing facility and who is:
(a) An
			 inpatient in:
1. A nursing facility;
2. An intermediate care facility for
			 individuals with an intellectual disability; or
3. A medical institution;
(b) Receiving 1915(c) home and
			 community based services; or
(c)
			 Receiving hospice services.
(45) "Institutionalized spouse" means an
			 institutionalized individual who:
(a)
1. Is in a medical institution, intermediate
			 care facility for an individual with an intellectual disability, or nursing
			 facility;
2. Participates in a
			 1915(c) home and community based services waiver program; or
3. Is receiving hospice services;
(b) Has a spouse who is not an
			 institutionalized individual; and
(c) Is likely to remain institutionalized for
			 at least thirty (30) consecutive days while the community spouse:
1. Is not receiving hospice services;
			 and
2. Remains out of a medical
			 institution, nursing facility, intermediate care facility for an individual
			 with an intellectual disability, or 1915(c) home and community based services
			 waiver program.
(46) "KCHIP" means the Kentucky Children's
			 Health Insurance Program administered in accordance with
			 42 U.S.C.
			 1397aa through jj.
(47) "Kentucky Transitional Assistance
			 Program" or "KTAP" means:
(a) Kentucky's
			 version of TANF; and
(b) A money
			 payment program for children who are deprived of parental support or care in
			 accordance with
			 921
			 KAR 2:006.
(48) "Keogh plan" means a full-fledged
			 pension plan for self-employed individuals in the United States of
			 America.
(49) "Long-term care
			 partnership insurance" is defined by
			 KRS
			 304.14-640(4).
(50) "Long-term care partnership insurance
			 policy" means a policy meeting the requirements established in
			 KRS
			 304.14-642(2).
(51) "Managed care organization" or "MCO"
			 means an entity for which the Department for Medicaid Services has contracted
			 to serve as a managed care organization as defined by
			 42
			 C.F.R. 438.2.
(52) "Mandatory state supplement" is defined
			 by
			 42 C.F.R.
			 435.4.
(53) "Medical institution or nursing
			 facility" means a hospital, nursing facility, or intermediate care facility for
			 individuals with an intellectual disability.
(54) "Medically necessary" means that a
			 covered benefit is determined to be needed in accordance with
			 907
			 KAR 3:130.
(55) "Medically needy" is defined by
			 42 C.F.R.
			 435.4.
(56) "Medically-needy income level" or "MNIL"
			 means the basic maintenance standard used in the determination of Medicaid
			 eligibility for the medically needy.
(57) "Medicare Part A" means federal health
			 insurance that covers:
(a) Inpatient hospital
			 or skilled nursing facility services, including blood transfusions;
(b) Hospice services; and
(c) Home health services.
(58) "Medicare qualified
			 individual group 1 (QI-1)" means an eligibility category in which an individual
			 would be a qualified Medicaid beneficiary but for the individual's income
			 disqualifying the individual from being a qualified Medicare beneficiary due to
			 the circumstances established in
			 42 U.S.C.
			 1396a(a)(10)(E)(iv).
(59) "Minimum shelter allowance" means an
			 amount that is thirty (30) percent of the standard maintenance
			 amount.
(60) "Minor" means the
			 couple's minor child or the couple's minor individual older than a child who:
(a) Is under the age of twenty-one (21)
			 years;
(b) Lives with a community
			 spouse; and
(c) Is claimed as a
			 dependent by either spouse under the Internal Revenue Service Code.
(61) "Modified adjusted gross
			 income" or "MAGI" is defined by
			 42 U.S.C.
			 1396a(e)(14)(G).
(62) "Month of separation" means the month in
			 which an individual ceases living in the same household of a Medicaid eligible
			 family.
(63) "Monthly income
			 allowance" means an amount:
(a) Deducted in
			 the posteligibility calculation for maintenance needs of a community spouse or
			 other family member; and
(b) Equal
			 to the difference between a spouse's and other family member's income and the
			 appropriate maintenance needs standards.
(64) "NF" means nursing facility.
(65) "Nonqualified alien" means a resident of
			 the United States of America who does not meet the qualified alien requirements
			 established in
			 907
			 KAR 20:005, Section 2.
(66) "Non-recurring lump sum income" means
			 money received at one (1) time that is normally considered as income,
			 including:
(a) Accumulated back payments from
			 Social Security, unemployment insurance, or workers' compensation;
(b) Back pay from employment;
(c) Money received from an insurance
			 settlement, gift, inheritance, or lottery winning;
(d) Proceeds from a bankruptcy proceeding;
			 or
(e) Money withdrawn from an IRA
			 by an individual prior to the individual reaching the age at which a penalty is
			 not imposed for withdrawing the IRA, KEOGH plan, deferred compensation, tax
			 deferred retirement plan, or other tax deferred asset.
(67) "Nursing facility" means:
(a) A facility:
1. To which the state survey agency has
			 granted a nursing facility license;
2. For which the state survey agency has
			 recommended to the department certification as a Medicaid provider;
			 and
3. To which the department has
			 granted certification for Medicaid participation; or
(b) A hospital swing bed that provides
			 services in accordance with
			 42 U.S.C.
			 1395tt and
			 1396l,
			 if the swing bed is certified to the department as meeting requirements for the
			 provision of swing bed services in accordance with
			 42 U.S.C.
			 1396r(b), (c), and (d) and
			 42 C.F.R. 447.280.
(68)
			 "Old Age, Survivors, and Disability Insurance" or "OASDI" means the social
			 insurance program:
(a) More commonly known as
			 "Social Security"; and
(b) Into
			 which participants make payroll contributions based on earnings.
(69) "Optional state supplement"
			 is defined by
			 42 C.F.R.
			 435.4.
(70) "Other family member" means a relative
			 of either member of a couple who is a:
(a)
			 Minor or dependent child;
(b)
			 Dependent parent; or
(c) Dependent
			 sibling.
(71) "Other
			 family member's maintenance standard" means an amount equal to one-third (1/3)
			 of the difference between the income of the other family member and the
			 standard maintenance amount.
(72)
			 "Otherwise available income" means income to which the community spouse has
			 access and control, including gross income that would be used to determine
			 eligibility under Medicaid without benefit of disregards for federal, state,
			 and local taxes; child support payments; or other court ordered
			 obligation.
(73) "Patient status
			 criteria" means the patient status criteria established in
			 907
			 KAR 1:022.
(74) "Physician" is defined by
			 KRS
			 311.550(12).
(75) "Plan to Achieve Self Support" or "PASS"
			 means an SSI program option that enables a disabled individual receiving SSI
			 benefits to:
(a) Identify a work
			 goal;
(b) Identify training, items,
			 or services needed to reach the work goal; and
(c) Set aside money for installment payments
			 or a down payment for items needed to reach the work goal.
(76) "Presumptive eligibility" means Medicaid
			 eligibility determined:
(a) By a provider
			 authorized by
			 907 KAR
			 20:050 to make a presumptive eligibility
			 determination; and
(b) In
			 accordance with
			 907 KAR
			 20:050.
(77) "Provider" is defined by
			 KRS
			 205.8451(7).
(78) "Qualified alien" means an alien who, at
			 the time the alien applies for or receives Medicaid, meets the requirements
			 established in
			 907
			 KAR 20:005, Section 2(2)(a)2. or 3.
(79) "Qualified disabled and working
			 individual" is defined by
			 42
			 U.S.C. 1396d(s).
(80) "Qualified Medicare beneficiary" or
			 "QMB" is defined by
			 42
			 U.S.C.
			 1396d(p)(1).
(81) "Qualified non-citizen" is defined by
			 8
			 U.S.C. 1641(b) and
			 (c).
(82) "Qualified provider" means a provider
			 who:
(a) Is currently enrolled with the
			 department;
(b) Has been trained
			 and certified by the department to grant presumptive eligibility to pregnant
			 women; and
(c) Provides services of
			 the type established in
			 42
			 U.S.C. 1396d(a)(2)(A) or (B)
			 or 42 U.S.C. 1396d(a)(9).
(83) "Qualifying income trust" or "QIT" means
			 an irrevocable trust established for the benefit of an identified individual in
			 accordance with
			 42
			 U.S.C.
			 1396p(d)(4)(B).
(84) "Real property" means land or an
			 interest in land with an improvement, permanent fixture, mineral, or
			 appurtenance considered to be a permanent part of the land, and a building with
			 an improvement or permanent fixture attached.
(85) "Recipient" is defined by
			 KRS
			 205.8451(9).
(86) "Resource assessment" means the
			 assessment, at the beginning of the first continuous period of
			 institutionalization of the institutionalized spouse upon request by either
			 spouse, of the joint resources of a couple if a member of the couple enters a
			 medical institution or nursing facility, receives hospice services, or becomes
			 a participant in a 1915(c) home and community based services waiver
			 program.
(87) "Resources" mean cash
			 money and other personal property or real property that:
(a) An individual:
1. Owns; and
2. Has the right, authority, or power to
			 convert to cash; and
(b)
			 Is not legally restricted for support and maintenance.
(88) "Retirement, Survivors, and Disability
			 Insurance" or "RSDI" means an insurance benefit program:
(a) Managed by the United States Social
			 Security Administration;
(b) Also
			 known as Social Security Disability or Social Security Disability Insurance;
			 and
(c) That aims to provide
			 monthly financial support to individuals who have lost income due to
			 retirement, disability, or death of a family provider.
(89) "Rural health clinic" is defined by
			 42 C.F.R.
			 405.2401(b).
(90) "Satisfactory documentary evidence of
			 citizenship or nationality" is defined by
			 42 U.S.C.
			 1396b(x)(3)(A).
(91) "Significant financial duress" means a
			 member of a couple has established to the satisfaction of a hearing officer
			 that the community spouse needs income above the level permitted by the
			 community spouse maintenance standard to provide for medical, remedial, or
			 other support needs of the community spouse to allow the community spouse to
			 remain in the community.
(92)
			 "Social Security" means a social insurance program administered by the United
			 States Social Security Administration.
(93) "Social Security number" means a number
			 issued by the United States Social Security Administration to United States
			 citizens, permanent residents, or temporary working residents pursuant to
			 42 U.S.C.
			 405(c)(2).
(94) "Special income level" means the amount
			 that is 300 percent of the SSI standard.
(95) "Specified low-income Medicare
			 beneficiary" means an individual who meets the requirements established in
			 42 U.S.C.
			 1396a(a)(10)(E)(iii).
(96) "Spend-down liability" means the amount
			 of money in excess of the Medicaid income eligibility threshold to which
			 incurred medical expenses are applied to result in an individual's income being
			 below the income eligibility threshold.
(97) "Spousal protected resource amount"
			 means resources deducted from a couple's combined resources for the community
			 spouse in an eligibility determination for the institutionalized
			 spouse.
(98) "Spousal share" means
			 one-half (1/2) of the amount of a couple's combined countable resources, up to
			 a maximum of $60,000 to be increased for each calendar year in accordance with
			 42
			 U.S.C. 1396r-5(g).
(99) "Spouse" means a person legally married
			 to another under state law.
(100)
			 "SSI benefit" is defined by
			 20
			 C.F.R. 416.2101.
(101) "SSI essential person, spouse, or
			 nonspouse" means an individual necessary to an SSI recipient to enable the SSI
			 recipient to be self-supporting.
(102) "SSI general exclusion" means the
			 twenty (20) dollars disregard from income allowed by the Social Security
			 Administration in an SSI determination.
(103) "SSI program" means the United States
			 supplemental security income program.
(104) "SSI standard" means the amount
			 designated by the Social Security Administration as the federal benefit
			 rate.
(105) "Standard maintenance
			 amount" means one-twelfth (1/12) of the federal poverty income guideline for a
			 family unit of two (2) members, with revisions of the official income poverty
			 guidelines applied for Medicaid provided during and after the second calendar
			 quarter that begins after the date of publication of the revisions, multiplied
			 by 150 percent.
(106) "State plan"
			 is defined by
			 42 C.F.R.
			 400.203.
(107) "State spousal resource standard" means
			 the amount of a couple's combined countable resources determined necessary by
			 the department for a community spouse to maintain himself or herself in the
			 community.
(108) "Support right"
			 means the right of an institutionalized spouse to receive support from a
			 community spouse under state law.
(109) "Targeted low-income child" is defined
			 by
			 42 C.F.R.
			 457.310(a).
(110) "Temporary Assistance for Needy
			 Families" or "TANF" means a block grant program that:
(a) Succeeded AFDC; and
(b) Is designed to:
1. Assist needy families so that children can
			 be cared for in their own homes;
2.
			 Reduce the dependency of needy parents by promoting job preparation, work, and
			 marriage;
3. Prevent out-of-wedlock
			 pregnancies; and
4. Encourage the
			 formation and maintenance of two-parent families.
(111) "Title IV-E benefits" means
			 benefits received via Social Security Act Title IV, Part 3, which is codified
			 as
			 42
			 U.S.C. 670 through
			 679c.
(112) "Tobacco Master Settlement Agreement"
			 means an agreement:
(a) Entered into in
			 November 1998 between certain tobacco companies and states' attorneys general
			 of forty-six (46) states; and
(b)
1. That settled states' lawsuits against the
			 tobacco industry for recovery of tobacco-related health care costs;
2. That exempted the tobacco companies from
			 private tort liability regarding harm caused by tobacco; and
3. In which the tobacco companies agreed to
			 make various annual payments to the states to compensate for some of the
			 medical costs incurred in caring for individuals with smoking-related
			 illnesses.
(113) "Transferred resource factor" means an
			 amount that is:
(a) Equal to the average:
1. Monthly cost of nursing facility services
			 in the state at the time of application; and
2. Of private pay rates for semi private
			 rooms of all Medicaid participating facilities; and
(b) Adjusted annually.
(114) "Trust" means a legal instrument or
			 agreement valid under Kentucky state law in which:
(a) A grantor transfers property to a trustee
			 or trustees with the intention that it be held, managed, or administered by the
			 trustee or trustees for the benefit of the grantor or certain designated
			 individuals or beneficiaries; and
(b) A trustee holds a fiduciary
			 responsibility to manage the trust's corpus and income for the benefit of the
			 beneficiaries.
(115)
			 "Trusted source" means a source recognized by the federal government or
			 department as a reliable source for verifying an individual's
			 information.
(116) "Uncompensated
			 value" means the difference between the:
(a)
			 Fair market value at the time of transfer, less any outstanding loans,
			 mortgages, or other encumbrances on the asset; and
(b) Amount received for the asset.
(117) "Undue hardship" means that:
(a) Medicaid eligibility of an
			 institutionalized spouse cannot be established on the basis of assigned support
			 rights; and
(b) The spouse is
			 subject to discharge from the medical institution, nursing facility, or 1915(c)
			 home and community based services waiver program due to inability to
			 pay.
(118) "Valid
			 immigrant status" is defined by:
(a)
										8
			 U.S.C. 1101(a)(15);
			 or
(b)
										8
			 U.S.C.
			 1101(a)(17).
(119) "Veteran" is defined by
			 38
			 U.S.C. 101(2).