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38-2001. Insurance coverage for children; development of plan; provisions of coverage; powers and duties of the secretary of health and environment; program funding. (a) The department of health and environment shall develop and submit a plan consistent with federal guidelines established under section 4901 of public law 105-33 (42 U.S.C. § 1397aa et seq.; title XXI).

(b) The plan developed under subsection (a) shall be a capitated managed care plan covering Kansas children from zero to 19 years which:

(1) Contains benefit levels at least equal to those for the early and periodic screening, diagnosis and treatment program;

(2) provides for presumptive eligibility for children where applicable;

(3) provides continuous eligibility for 12 months once a formal determination is made that a child is eligible subject to subsection (e);

(4) has performance based contracting with measurable outcomes indicating age appropriate utilization of plan services to include, but not limited to, such measurable services as immunizations, vision, hearing and dental exams, emergency room utilization, annual physical exams and asthma;

(5) shall use the same prior authorization standards and requirements as used for health care services under medicaid to further the goal of seamlessness of coverage between the two programs;

(6) shall provide targeted low-income children, as defined under section 4901 of public law 105-33 (42 U.S.C. § 1397aa, et seq.), coverage subject to appropriations;

(7) shall provide coverage, subject to appropriation of funds and eligibility requirements, for children residing in a household having a gross household income (A) for 2009, at or under 225% of the 2008 federal poverty income guidelines and (B) for 2010 and subsequent years, at or under 250% of the 2008 federal poverty income guidelines; the participants receiving coverage shall contribute to the payment for such coverage through a sliding-fee scale based upon ability to pay as established by rules and regulations of the secretary of health and environment; and

(8) contains a provision which requires the newly enrolled participants with a family income over 200% of the federal poverty income guidelines to wait at least 8 months before participating in this program, if such participants previously had comprehensive health benefit coverage through an individual policy or a health benefit plan provided by any health insurer as defined in K.S.A. 40-4602, and amendments thereto. This waiting period provision shall not apply when the prior coverage ended due to loss of employment other than the voluntary termination, change to a new employer that does not provide an option for dependent coverage, discontinuation of health benefits to all employees, expiration of COBRA coverage period or any other situations where the prior coverage ended due to reasons unrelated to the availability of this program.

(c) The secretary of health and environment is authorized to contract with entities authorized to transact health insurance business in this state to implement the health insurance coverage plan pursuant to subsection (a) providing for several plan options to enrollees which are coordinated with federal and state child health care programs, except that when contracting to provide managed mental health care services the secretary of health and environment shall assure that contracted entities demonstrate the ability to provide a full array of mental health services in accordance with the early and periodic screening, diagnosis and treatment plan. The secretary of health and environment shall not develop a request for proposal process which excludes community mental health centers from the opportunity to bid for managed mental health care services.

(d) When developing and implementing the plan in subsection (a), the secretary of health and environment to the extent authorized by law:

(1) Shall include provisions that encourage contracting insurers to utilize and coordinate with existing community health care institutions and providers;

(2) may work with public health care providers and other community resources to provide educational programs promoting healthy lifestyles and appropriate use of the plan's health services;

(3) shall plan for outreach and maximum enrollment of eligible children through cooperation with local health departments, schools, child care facilities and other community institutions and providers;

(4) shall provide for a simplified enrollment plan;

(5) shall provide cost sharing as allowed by law;

(6) shall not count the caring program for children, the Kansas health insurance association plan or any charity health care plan as insurance under subsection (e)(1);

(7) may provide for payment of health insurance premiums, including contributions to a health savings account if applicable, and, in conjunction with an employer sponsored insurance premium assistance plan, may provide that supplemental benefits be purchased outside of the capitated managed care plan, if it is determined cost effective, taking into account the number of children to be served and the benefits to be provided;

(8) may provide that prescription drugs, transportation services and dental services are purchased outside of the capitated managed care plan to improve the efficiency, accessibility and effectiveness of the program; and

(9) shall include a provision that requires any individual to be a citizen or an alien lawfully admitted to the United States for purposes of establishing eligibility for benefits under the plan and to present satisfactory documentary evidence of citizenship or lawful admission of the individual. The criteria for determining whether the documentation is satisfactory shall be no more restrictive than the criteria used by the social security administration to determine citizenship. A document issued by a federally-recognized Indian tribe evidencing membership or enrollment in, or affiliation with, such tribe, such as a tribal enrollment card or certificate of degree of Indian blood shall be satisfactory documentary evidence of citizenship or lawful admission.

(e) A child shall not be eligible for coverage and shall lose coverage under the plan developed under subsection (a) of K.S.A. 38-2001, and amendments thereto, if such child's family has not paid the enrollee's applicable share of any premium due.

If the family pays all of the delinquent premiums owed during the year, such child will again be eligible for coverage for the remaining months of the continuous eligibility period.

(f) The plan developed under section 4901 of public law 105-33 (42 U.S.C. § 1397aa et seq., and amendments thereto) is not an entitlement program. The availability of the plan benefits shall be subject to funds appropriated. The secretary of health and environment shall not utilize waiting lists, but shall monitor costs of the program and make necessary adjustments to stay within the program's appropriations.

(g) Eligibility and benefits under the plan prescribed by subsection (b)(7) are not and shall not be construed to be entitlements, are for legal residents of the state of Kansas and are subject to availability of state and federal funds and to any state and federal requirements and the provisions of appropriation acts. If the secretary of health and environment determines that the available federal funds and the state funds appropriated are insufficient to sustain coverage for the income eligibility levels prescribed by subsection (b)(7), a lower income level shall be adopted and implemented by the secretary of health and environment, within the limits of appropriations available therefor, and all such changes shall be published by the secretary of health and environment in the Kansas register.

History: L. 1998, ch. 125, § 1; L. 1999, ch. 36, § 1; L. 2001, ch. 54, § 1; L. 2004, ch. 157, § 2; L. 2008, ch. 164, § 22; L. 2012, ch. 102, § 3; July 1.

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