Presumptive Eligibility

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Presumptive Eligibility is a process that allows qualified entities to determine if an individual can receive short-term Medicaid. It provides individuals with temporary Medicaid coverage while KanCare processes their application for Medicaid.

Facilities such as hospitals, clinics, health departments, schools, etc. can become a Qualified Entity. The facility will notify KDHE of its intention to make presumptive eligibility determinations by submitting a statement of interest. They agree to make presumptive eligibility determinations following KDHE policies and procedures. The qualified entity will assist individuals with the process of submitting the Medicaid application. During the medical application process, the qualified entity will help individuals understand and submit requested documents to KanCare. Qualified entities will be paid the Medicaid reimbursement rates while consumers are receiving Presumptive Eligibility Coverage.

To learn more about becoming a Qualified Entity, select the "Becoming a Qualified Entity" in the Links & Resources section below.

General Eligibility Requirements

General Eligibility Requirements can be defined as specific conditions which must be met for a consumer to be eligible for medical benefits.

Qualified entities can make presumptive eligibility determinations for Pregnant Women, Children, Former Foster Care, Breast or Cervical Cancer (BCC) patients currently receiving treatment, parents, and other caretakers. These consumers must be a resident of Kansas, a U.S. Citizen, or eligible Non-Citizen, and meet income guidelines.

To learn more about General Eligibility Requirements, select the "PE Specialist Training Documents & Materials” in the following sections.

Becoming a PE Qualified Entity

Medicaid providers must be trained and certified by the KDHE Division of Health Care Finance (KDHE-DHCF) prior to making Presumptive Eligibility (PE) determinations. In order to become certified, the Medicaid provider must fulfill the following requirements:

Complete and submit a Presumptive Eligibility Statement of Interest to KDHE-DHCF.
A Memorandum of Understanding (MOU) contract must be drafted, agreed to and signed by the entity’s CEO or executive director and the KDHE Secretary. An implementation plan will be agreed to and followed.
Each Entity must designate staff to complete the KanCare Presumptive Eligibility Training in order to conduct PE determinations at their facilities.

Qualified Entity Responsibilities

Presumptive Eligibility (PE) determinations are based on the self-attestation of the applicants. Entities are not allowed to require or request any documentation for verification during the PE application process.

PE specialists at the Qualified Entity are expected to do the following:

Review KMMS to ensure that applicants do not have active Medicaid coverage
Interview applicants to complete the PE application
Provide applicants with the eligibility results of their determination
Assist applicants in completing a KanCare application for ongoing coverage
Act as the facilitator for the consumer, receive and follow-up on correspondence requests made by the Clearinghouse
Track PE determinations completed at the entity

Forms & Documents for Providers

Presumptive Eligibility Overview PowerPoint (effective 8/16/2024) - PowerPoint presentation detailing the Presumptive Eligibility program.
Statement of Interest - Document to be completed by facilities interested in becoming Qualified Entities.
Qualified Entity Communication Protocol - This document is a contact directory designed to support qualified entities, featuring phone numbers, email addresses, and addresses for easy access to essential contact information.

Training Documents and Materials

Below is a list of documents that Presumptive Eligibility (PE) specialists at Qualified Entities can use for training and reference.

PowerPoint

Presumptive Eligibility Policy & Procedure (effective 3/27/2024) - Presentation that provides all of the fundamentals- What PE is, who is eligible, how to enroll applicants, and the business process from start to finish.

Charts

Below are helpful charts for new and existing PE specialists that can be utilized during the PE application process.

Who Can Apply for Individuals (effective 06/27/2023) - A chart that shows which individuals can apply for KanCare on behalf of each demographic category.
Income Conversion Chart - Illustrates the calculations used to convert income to a monthly amount.
KC-7004 Countable Exempt Income Chart - Illustrates if an income type is countable or exempt.
F-8 KS Medical Standards (effective 04/01/2024) - Provides the total countable income limits to be eligible for specified programs.
2024 MCO Benefits - English - Highlights extra services you can receive in KanCare per MCO.
- 2024 MCO Benefits - Spanish

Forms

Below are forms PE specialists will utilize while assisting applicants apply for coverage.

Pre-Screening Questions for Presumptive Eligibility - English (effective 04/01/2024) - A questionnaire to help determine if an applicant is potentially eligible for PE in both English and Spanish.
- Pre-Screening Questions for Presumptive Eligibility - Spanish
Immigration Job Aid- English (effective 08/04/2023) - Categories of applicants who are eligible or ineligible based upon their immigration status.
- Immigration Job Aid - Spanish
KC-6200 Facilitator Authorization Form - English - Allows the applicant to designate the PE specialists or QE the ability to assist in the application process.
- KC-6200 Facilitator Authorization Form - Spanish
PE Access and Change Request - Request or remove access for PE specialist(s).
Document Upload Portal - This is the manual for the Document Upload Portal, use the Document Upload Portal to upload documents to an existing case.