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 Forms and Materials

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
	Authorization for Release of Protected Health Information
	Autorización para la Divulgación de Información Protegida de Salud
ES-3904	HIPAA Compliant Authorization to Disclose Information to KDHE

Form #	Form Name
F-8	Kansas Medical Assistance Standards –7/18
T-3	Life Estate Valuation Tables
T-4	Life Expectancy Tables
	Reasonable Compatibility Tool
	Acceptable Verification for Earned Income
KC-7000	300% Income Chart
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
	CE Dates for Aid Codes Chart
	Tiered Verification Job Aid
	Communication Guide Medical to Non-Medical
	MAGI Building IBUs – Flow Chart
	MAGI Individual Budget Unit (IBU) Examples
	HCBS Termination Instructions
	Agency Cross Communication Guide
	Applying the Income Rules for Children and Tax Dependents

Form #	Form Name
KC1200	Family Medical Pre-Populated Review Form Eligibility Processing Job Aid
KC1600	E&D Pre-Populated Review Form Eligibility Processing Job Aid
	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-4	SSA 40 Qualifying Quarters: User Instructions
-	Qualifying Quarters Document
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

Form #	Form Name
KC-1100-JA	Application Questions Job Aid
KC1500-JA	Application Questions Job Aid
M-6	Medicaid Online Application Signature Page
M-7	Cover Letter for Unsigned Online Applications
ES-3100.3	Certification of Need for Tuberculosis Treatment
ES-3100.7	Application for Medical Coverage – BCC
ES-3100.8	Medicare Savings Program application
ES-3100.8S	Medicare Savings Program application – Spanish
KC-1100	Medical Assistance Application for Families with Children
KC-1100S	Medical Assistance Application for Families with Children – Spanish
KC-1105	E&D Supplement to the KC-1100
KC-1105S	E&D Supplement to the KC-1100 – Spanish
KC-1500	Medical Assistance Application for the Elderly and Persons with Disabilities
KC-1500S	Medical Assistance Application for the Elderly and Persons with Disabilities – Spanish
KC-2100	Families with Children Brochure
KC-2100S	Families with Children Brochure – Spanish
KC-2110	Helpful Hints for Families
KC-2110S	Helpful Hints for Families – Spanish
KC-2120	Extra Services Highlights
KC-2120S	Extra Service Highlights – Spanish
KC-2500	Elderly and Persons with Disabilities brochure
KC-2500S	Elderly and Persons with Disabilities brochure – Spanish
KC-2510	Helpful Hints for E&D
KC-2510S	Helpful Hints for E&D – Spanish
KC-2700	Medicare Savings Program Brochure
KC-2700S	Medicare Savings Program Brochure – Spanish
	SSP Application Job Aid 7-17

Form #	Form Name
N/A	OAH Frequently Asked Questions

Form #	Form Name
KC-6001	Administrative Roles Chart
KC-7002	KDHE Approved Abbreviations Chart
KC-7003	Contractor State Interaction Chart – KDHE
KC-7003.1	Contractor State Interaction Chart – MX-ED
KC-7003.2	Contractor State Interaction Chart – MX-FM

Form Number	Effective	Form Name
F-8	4/2018	Medical Standard
F-8	4/2017	Medical Standard
F-8	4/2016	Medical Standard
F-8	4/2015	Medical Standard
W-9	7/2017	Transfer of Property Worksheet