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Kentucky Cabinet – Medicaid Penalty Warning

Last Updated 11/9/22

CSW:

“We have reached the section of your application where a signature is required. Because your
application includes Medicaid, you must sign the Medical Penalty Warning Form. You can
choose to use voice signature or we can mail you the Medicaid Penalty Warning to sign and
return. A voice signature may allow for quicker processing. Would you prefer to use the voice
signature process now, or receive a form by mail?”

If client agrees to provide a voice signature, change the “Signature Type” to Voice Signature on the Sign
and Submit Page of the Worker Portal. The signature date will auto-populate. You must also indicate the
individual signing by voice.

Once you have completed all necessary information on the Sign and Submit page, you will then click
Voice Signature at the bottom of the Sign and Submit page to launch the Voice Signature popup. After
clicking Voice Signature, the following pop up window will appear. Once this box appears, follow the
script.

CSW:

“You are signing the Medicaid Penalty Warning for Case Number <state case number>.”

“Please listen carefully while a recorded statement is played. After it finishes, I will ask you a
question. If you answer yes to the question, your answer will serve as your signature on the
form. The following recording must be played all the way through and cannot be stopped. Are
you ready to begin?”

Once the client is ready to begin, select the primary language of the caller. The following options are
available in the drop down box for the Medicaid Penalty Warning: English, Spanish, Other. Once you
have selected the appropriate language and are ready to begin with the voice signature, click the “start”
button and the pre-recorded message will begin.

If the client doesn’t want to proceed with the voice signing the Medicaid Penalty Warning form, close the
pop-up by clicking the “X” in the top right hand corner. Change the Signature Type to “No Signature
Provided” and click Submit at the bottom of the Sign and Submit page. The MA-2 Form will be mailed to
the client for signature.
This document contains proprietary information of Language Services Associates, Inc. This information is intended solely for evaluation purposes.
Such proprietary information may not be used, reproduced, or disclosed to any other parties for any other purpose without the expressed written
consent of an officer of Language Services Associates, Inc.

Language Services Associates • 455 Business Center Drive - Suite 100 • Horsham, PA 19044 • 1.800.305.9673
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NOTE: If “Other” is chose, the pre-recorded message will be played in English and then must be read line
by line for the interpreter to translate the message. The language options for the MA2 form are different
from the language options for the application.

Important: DO NOT CLICK “Submit” when the pre-recorded message ends. If you do, the voice signature
will not be captured and will either need to be repeated or the form mailed for a written signature.

Once the pre-recorded message has finished playing, the CSW will state the following:

CSW:

“Please state your full name.”

“Do you understand that if you give false information, withhold information, fail to report changes
within 30 days, or allow someone else to use your KY Health card you may be subject to
prosecution for fraud, reduction or loss of Medicaid benefits, and may be required to repay the
dollar value of ineligible Medicaid benefits billed against your account?”

Client answers either “yes” or “no.” If client says “yes,” worker states for the recording:

“This recorded voice signature is for the Medicaid Penalty Warning form for Case Number
<verbalize case number>. I have recorded your voice signature. Please stay on the line with me
as I update the file.”

This document contains proprietary information of Language Services Associates, Inc. This information is intended solely for evaluation purposes.
Such proprietary information may not be used, reproduced, or disclosed to any other parties for any other purpose without the expressed written
consent of an officer of Language Services Associates, Inc.

Language Services Associates • 455 Business Center Drive - Suite 100 • Horsham, PA 19044 • 1.800.305.9673
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 www.LSAweb.com

At this point, you may click the “Submit” button. The Voice Signature pop-up will disappear and you will
be back on the Sign and Submit page. Click Submit at the bottom to submit the Medicaid Penalty
Consent signature.

If the client says “No,” worker states for the recording:

“Client has declined to capture a voice signature for the Medicaid Penalty Warning form for
Case Number <verbalize case number>. A paper copy of the Medicaid Penalty Warning is being
mailed for client’s signature. Your application cannot be processed without a signature on this
form. When you receive your Medicaid Penalty Warning Form in the mail, please review, sign
and return. Please stay on the line as I update the file. Thank you.”

Click the “Cancel” button to close out the voice signature pop-up and return to the Sign and Submit page.
The Signature Type will automatically change to “No Signature Provided.” Upon submitting the Sign and
Submit page, the MA2 Form will automatically be mailed to the client for signature.

Once the voice signature has been successfully submitted and the call has ended, only the voice
signature portion of the call will be uploaded to the Document Management System (DMS) to be
retrievable in the Electronic Case File (ECF) on the Apps/Renewal tab. It is important to note that it may
take up to 15 minutes for the voice signature to be retrievable in the ECF. In addition, the Interaction ID of
the recording will be automatically written to the case notes.

This document contains proprietary information of Language Services Associates, Inc. This information is intended solely for evaluation purposes.
Such proprietary information may not be used, reproduced, or disclosed to any other parties for any other purpose without the expressed written
consent of an officer of Language Services Associates, Inc.

Language Services Associates • 455 Business Center Drive - Suite 100 • Horsham, PA 19044 • 1.800.305.9673
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