Policy Appendix

The Appendix contains documents and materials that support all medical programs. Documents that were previously released to support a policy implementation have now been added to the Appendix list. It is noted that some documents do not have a form number. Only documents previously assigned are listed with a form number. Documents are sorted by the purpose of the item, not by the program for which it is used.

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Policy Appendix list

Releases of Information

Financial

Eligibility Processing

Review Processing

Worksheets

Alien Information

Application and Additional Information

Miscellaneous

Charts

Form #	Form Name
KC-6100	Medical Representative Authorization Form
KC-6100S	Formulario de Autorización del Representante Médico
KC-6200	Facilitator Authorization Form
KC-6200S	Formulario de Autorización del Facilitador
KC-6110	Authorization for Release of Protected Health Information
KC-6110S	Autorización para la Divulgación de Información Protegida de Salud

Form #	Form Name
F-8	Kansas Medical Standards 7-20
	Kansas Medical Standards 4-20
	Kansas Medical Standards 1-20
T-3	Life Estate Valuation Tables
T-4	Life Expectancy Tables
	Reasonable Compatibility Tool
	Acceptable Verification for Earned Income
KC-7000	300 Percent Income Chart 1-20
	300 Percent Income Chart 10-19
KC-7004	Countable Exempt Income Chart

Form #	Form Name
P-1	Medical Necessity
P-4	Kelley Blue Book User Instructions
P-14	Where to find Death Information on EATSS Records
KC-1100-JA	Family Medical Processing Eligibility Job Aid
KC-1500-JA	E&D Medical Processing Eligibility Job Aid
KC-1800-JA	SSP Application Job Aid 3-20
KC-7011	Resource Documentation Requirements
KC-7012	CE Dates for Aid Codes Chart
KC-7013	Tiered Verification Chart
	Communication Guide Medical to Non-Medical
KC-7014	MAGI Building IBUs – Flow Chart
KC-7015	MAGI Individual Budget Unit (IBU) Examples
	HCBS Termination Instructions
	Agency Cross Communication Guide
KC-7016	Applying the Income Rules for Children and Tax Dependents

Form #	Form Name
KC-1201	Family Medical Pre-Populated Review Form Instructions
KC-1601	E&D Pre-Populated Review Form Instructions
KC-7008	Skipped Review Chart
KC-7009	Pre-populated Review Processing Standards
KC-7017	Transitional Medical Scenarios
	Individuals Discontinued at Passive Review
	Medically Needy Late Review Guide
	Review Scenarios - Eligibility Policy Guidance

Form #	Form Name
W-2	Family Medical Spenddown Worksheet
W-3	E&D Spenddown Estimator Tool
W-4	TOP Worksheet
W-4.1	Applicant – Transfer of Property Calculator Instructions
W-4.2	Recipient – Transfer of Property Calculator Instructions
W-9	Transfer of Property Worksheet
W-10	Annuity Evaluation Worksheet
W-14	MediKan Eligibility Worksheet
W-15	VA Potential Benefits Checklist
W-16	Patient Liability Worksheet

Form #	Form Name
A-1	Immigrant status/Program Qualification chart
A-10	Systematic Alien Verification for Entitlements (SAVE) Handbook
A-11	INS Class of Admission Codes
A-12	Citizenship and Identify Verification for Medical Assistance and General Assistance

	Applications and Additional Information

	Families with Children
KC-1100	Medical Assistance Application for Families with Children
KC-1100S	Solicitud de Asistencia Médica para Familias con Niños (Application for Families with Children- Spanish)
KC-2100	Families with Children Brochure
KC-2100S	Asistencia Médica para Familias con Ninos (Families with Children Brochure – Spanish)
KC-2110	Helpful Hints for Families
KC-2110S	Consejos útiles para las familias (Helpful Hints for Families – Spanish)
	Elderly and Person with Disabilities
KC-1500	Medical Assistance Application for the Elderly and Persons with Disabilities
KC-1500S	Solicitud de Asistencia Médica para Personas Mayores de edad y Personas con Discapacidades (Medical Assistance Application for E&D– Spanish)
KC-1105	E&D Supplement to the KC-1100
KC-1105S	Suplemento de la Solicitud para KC-1100S (E&D Supplement to the KC-1000-Spanish)
KC-2500	Elderly and Persons with Disabilities brochure
KC-2510	Helpful Hints for E&D
KC-2510S	Consejos útiles para Ancianos y Discapacitados (Helpful Hints for E&D- Spanish)
	Medicare Savings Applications
ES-3100.8	Medicare Savings Program application
ES-3100.8S	Solicitud / Renovación Planes de Ahorro Medicare (MSP application- Spanish)
KC-2700	Medicare Savings Program Brochure
KC-2700S	Programas de Ahorro de Medicare (Medicare Savings Program Brochure-SP)
	Other Applications
ES-3100.1a	Correctional Facility Inmate- Qualifying Event
ES-3100.3	Certification of Need for Tuberculosis Treatment
ES-3100.7	Application for Medical Coverage – BCC
	Other Information
M-6	Medicaid Online Application Signature Page
M-7	Cover Letter for Unsigned Online Applications

Form #	Form Name
	Language Assistance Services
	OAH Frequently Asked Questions
	PRTF List
	Rights and Responsibilities English
	Rights and Responsibilities - Spanish
	User access for KEESM SSP Portal
	State of KS Voter registration form (online link)

Form #	Form Name
KC-6001	Administrative Roles Chart
KC-7004	Countable Exempt Income Chart
KC-7005	SSI Payment Status Codes
KC-7006	Eligibility Actions Following SSI Termination Chart
KC-7007	Standard Medical Aid Code Labels
KC-7010	Medical Hierarchy Chart
KC-7200	Document Types and Definitions Used for Imaging on Medical Cases