Transcript Healthy KidConnect Phase III Winter 2009

Oregon Department of Human Services
Healthy KidsConnect
and January 1, 2010 Medical
Policy Changes
1
This Training Covers January 1,
2010 Medical Policy Changes
 Noncitizen requirement changes
 Citizenship/Identity documentation
requirements for CHIP
 American Recovery and Reinvestment Act
2
Changes for
January 1, 2010
 Healthy KidsConnect overview and eligibility
 OPHP’s (Office of Private Health Partnerships)
role in Healthy KidsConnect
 DHS/AAA worker’s role in Healthy KidsConnect
3
January 2010 Changes for
Noncitizen Children
 Several new groups of noncitizen children
now meet the noncitizen requirement
 Includes immigrants and non-immigrants
 To be eligible, noncitizen children under age
19 must fit specific classifications set forth
by the Immigration and Nationality Act (INA)
4
Expanded Noncitizen
Requirement for Children
 Example of new groups of immigrants
include:
– Children who are Permanently Residing Under
Color of Law
– An individual who is a child of a U.S. citizen
whose visa petition has been approved and who
has a pending application for adjustment of
status
5
Expanded Noncitizen
Requirements for Children
Continued
 Several classes of non-immigrants are also
included in the new groups. Examples of
non-immigrants are:
– A child of an individual with special immigrant
status under section 101(a)(27) of the INA
– A fiancé of a citizen, as permitted under section
101(a)(15)(K) of the INA
6
Noncitizen Children
 Children meeting the new noncitizen
requirements are potentially eligible for OHP
Plus program benefits.
 A one time report will be sent of current
CAWEM children.
 Workers will need to review each child’s
noncitizen status and, if eligible, convert to
OHP Plus effective January 1, 2010.
7
New NCS Need/Resource Code
 There is a new N/R item that will be used on
any person who is not an LPR or REF and
meets the noncitizen requirement
 The N/R item is NCS and the date will be C
 N/R NCS C
 The new NCS need/resource item should be
available January 15
8
Noncitizen Children Turning 19
 Children who turn 19 during their eligibility
period:
– A monthly report will be available of NCS and
LPR children turning age 19.
– Children who turn 19 and do not meet the
noncitizen requirement for adults, but are
determined eligible for MAA/MAF, OSIPM or
OPU will have a benefit package reduction to
CAWEM.
– A 10 day notice is still required.
9
Noncitizen Documentation
Requirements
 All noncitizens, regardless of age, need to
provide documentation of their status
 The document provided could depend on
how they were admitted into the US (court
papers, I-94, etc.)
 The document provided will indicate what
section of law the noncitizen was admitted
under or what class of admission they are
considered to be by INA
10
Documentation Requirements
 For all noncitizens, if documentation of the
noncitizen’s status is not available when initially
determining benefits, we can open medical and
pend the client to provide the documentation if
both of the following are true:
– The client knows what their status is and if needed,
what section of law they were admitted under and
– The declared status meets the noncitizen requirement
11
CIP & CIE Coding for noncitizens
 In February, the CIP and CIE need/resource
items will be available for noncitizens, too
 If the client does not provide noncitizen
documentation, the CM computer system
will automatically send a 10-day close notice
and end the noncitizen’s medical
 Just like citizens, when the medical ends,
the computer will add the CID case
descriptor
12
New SAVE Verification
Requirement
SAVE must be checked:
 At each certification to verify the status of
the noncitizen client
 Whenever a change in status is reported
 This is a new federal requirement.
13
Noncitizen Chart
 There are more than 90 specific
classifications within the non-immigrant
group
 The noncitizen worker guide NC-1 has been
updated in the Family Services Manual
 Compare the noncitizen’s documentation to
the chart and determine whether they meet
the noncitizen requirement
14
Iraq and Afghanistan Refugees
 Effective December 19, 2009 Afghan and
Iraqi SIV (special immigrants) who came to
the United States with a temporary refugee
status will now get full Medicaid or CHIP at
the end of the 6-8 months refugee period, if
otherwise eligible for a Medicaid program or
CHIP.
15
New CHIP Citizenship
Documentation
Requirement
 CHIP now requires Citizenship and Identity
documentation to be viewed and citizenship fields
updated in the Person Alias/Update screen
 Citizenship and Identity verification for CHIP will
follow our current Medicaid policy and procedures
 CIP and CIE need/resource items now apply to
CHIP children, too
16
Citizenship/Identity Example
New applicant, DOR 01/05/2010 children ages
4 & 8 (three in the need group)
 Two month income average is $2015
 Person Alias/Update screen viewed for
citizenship/identity; no verification is coded
 All other eligibility requirements have been met
except citizenship; the children were not born in
Oregon
What are the workers next steps?
17
Citizenship/Identity Example
Continued
 Pend for citizenship verification
 Code both children with a CIP C/D
and CIP N/R
 Open medical benefits for both children
 Based on income the 4 year old will be OP6
and the 8 year old will be CHP
18
American Recovery and
Reinvestment Act (ARRA)
The ARRA Making Work Pay tax credit is now
$33.00
 This exclusion amount applies to all DHS
medical program clients who have earned
income
 Exclude $33.00 from earned income for each
month of income used. Only one exclusion per
person with earned income per month
19
Simplified Making Work Pay
Credit Process
 Clients receiving SSI, SSD, SSB Railroad
retirement, Veterans disability and veterans
pension payments who also have earned
income will receive the same tax credit
amount
 Clients with multiple jobs receive only one
exclusion
 Self employed clients also qualify
20
ARRA
 This change to the ARRA applies to new
applicants or those at redetermination in
January
 Ongoing clients who received the ARRA
exclusion prior to January will not need any
updating until their next redetermination
21
An Overview
of
Healthy KidsConnect (HKC)
22
Healthy Kids
The goal of Healthy Kids is to provide
outreach and enrollment efforts so that all
children under age 19 are covered by medical
insurance in the state of Oregon with:
 Medicare
 Medicaid
CHIP
Healthy KidsConnect (HKC)
Healthy KidsConnect is part of Healthy Kids
23
Healthy KidsConnect (HKC)
Overview
 New way of issuing benefits
 Benefits include a subsidy for health
insurance premiums
 Subsidy amount depends on the family’s
income
 DMAP does not issue HKC benefits
 HKC eligibility is based on CHIP eligibility
24
DHS in Partnership with OPHP
DHS/AAA workers and the Office of Private
Health Partnerships (OPHP) are partners
in the Healthy KidsConnect (HKC) process for
children
25
Office of Private Health
Partnerships (OPHP)
 OPHP is part of the Family Health Insurance
Assistance Program (FHIAP)
 DHS staff will process initial eligibility for HKC
applicants and code CM case
 HKC eligibility is very similar to CHIP, but with a
higher income limit
 The CM system does an automatic referral to
OPHP
26
Office of Private Health
Partnerships (OPHP) Role
 OPHP will establish and maintain contracts
with health insurance carriers to provide
coverage similar to OHP Plus
 OPHP will be responsible for issuing
subsidies and reimbursements
 Once referred to OPHP, the family has 45
days to be enrolled and receive an HKC
subsidy or reimbursement
27
Healthy KidsConnect Overview
 HKC offers families a way to access
health insurance for:
– Non-CAWEM children under age 19, and
– Ineligible for any other DHS medical program,
and
– Income is at 201% or above, and
– Must be uninsured to qualify (just like CHIP)
28
HKC Income Standard
Healthy KidsConnect has two income ranges:
 At or above 201% up to 301%, and
 Income at 301% and above
 The standard chart now has a 301% column
29
New 301% Standard
 HKC benefits depend on the family’s income
 Families with income at or above 301% do
not qualify for HKC subsidies
 301% and above families can access HKC
insurance, but must pay the full premium
cost
30
31
Healthy KidsConnect Categories
Category 1: For families with income at or
above 201% up to 301% FPL who don’t have
insurance available through an employer
HKC will offer health insurance that can be
purchased for children through the Office of
Private Health Partnership
32
Healthy KidsConnect Categories
Continued
Category 1 = a subsidy program based on
the client’s income level
 Income from 201% through 250% FPL will
have approximately 90% of the insurance
premium paid by OPHP
 Income from 251% through 300% FPL will
have approximately 80% of the insurance
premium paid by OPHP
33
Healthy KidsConnect Categories
Continued
Category 2: For families with income at 201%
up to 301% FPL when the parent has
Employer Sponsored Insurance (ESI)
available for their children through an
employer, but the children are not covered
Category 2 = A portion of the family’s
premium payment is reimbursed
34
Healthy KidsConnect Categories
Continued
Employer Sponsored Insurance Reimbursement
Income from 201% through 250% FPL
 will have approximately 90% insurance
premium reimbursement by OPHP
Income from 251% through 300% FPL
 will have approximately 80% insurance
premium reimbursement by OPHP
35
Healthy KidsConnect Categories
Continued
Category 3: For families with income at or
above 301% FPL
This is a full pay category. The client will be
required to pay the full premium amount to
receive coverage for their children
36
Category 3, cont.
 Self-employed families who do not meet the
$10,000 business entity income test are also
category 3 clients
 The client will be required to pay the full
premium amount to receive HKC insurance
coverage for their children
37
Eligibility Process
for
Healthy KidsConnect (HKC)
38
Healthy KidsConnect Process
 When an applicant requests medical
benefits only and no companion case exists,
the application can be sent to OHP
Statewide Processing Center (5503) for
processing
 Applications with an adult age 60 or above
who are requesting medical will be sent to
the local SPD/AAA office
39
Healthy KidsConnect Process
Continued
The DHS/AAA branch worker will:
 Screen for MAA, MAF, EXT, OSIPM, OHP,
CEM and CEC medical programs following
current process
 Income at 201% or above
screen application for HKC
40
Healthy KidsConnect Eligibility
Continued
HKC Eligibility is the same as CHIP with
higher income limits
Children under age 19
No TPL now or in the last 2 months
(the 2 months can be waived)
No resource limit
41
Healthy KidsConnect Eligibility
Continued
HKC eligibility continued
 Cannot be CAWEM and be eligible for HKC
 Must document citizenship and noncitizen status
 Use current and previous month income
 Can use budget month income when not eligible
using two month average (can also float budget
month using current policy)
42
Healthy KidsConnect Eligibility
Continued
Date of request (DOR)
 Follow current date of request process when
determining HKC eligibility
 Give 45 days from the date of request to
complete the pend and eligibility
determination process
 If a redetermination BED code the case
43
Denials
 Once the pend process is complete if the
client does not meet eligibility requirements
for any DHS medical program…
– Example: Income is 225% and client has TPL
 ….the worker must send both a close or
denial notice and a DHS 462A notice for the
ineligible child
Reminder: TPL received in the last two months can
be waived in some situations
44
HKC Referrals
 Two kinds of referrals to OPHP
 HKC children are referred who qualify for CHIP but
have income at 201% or above up to 301%. They
are eligible for HKC subsidies or reimbursements.
− They are assigned a 12-month redetermination
period.
 Children are referred who qualify for CHIP but
have income at 301% or above. They must pay
entire HKC insurance premium
─ They are not assigned a redetermination
period.
45
HKC Referral Process
Once it is determined an applicant is
approved for a referral to get HKC insurance:
 either update an existing CM case or
 open a new CM case
(HKC cases can be combined with other
programs)
46
HKC Referral Process
Transfer the case online and shuttle/mail
application to OHP Statewide Processing
Center (5503)
An HKC cover letter should be attached to
applications being transferred to 5503
Do not fax application to 5503 – this will
cause problems with 5503’s imaging process
47
48
KCA Code – at 201% up to 301%
When it is determined a client is approved for an
HKC subsidy referral to OPHP, the KCA
(KidsConnect Approved) coding is used:
 For families with income at 201% up to 301%
KCA is a person-specific C/D and N/R that tells
the CM system to send the HKC referral to
OPHP
 The N/R date is used to give the client the 45
days + 10 days notice to complete the process
with OPHP
49
KCA Date
KCA (KidsConnect approved for at 201% up to
301% FPL)
The N/R date is determined by:
– The 45th day from the referral approval date
– If the 45th day is on or before the 15th code that
month, if after the 15th code the next month
50
KCR Code
 KCR (KidsConnect Redetermination) is
a N/R only and will be added to each child
with KCA coding (income at 201% up to
301% only)
 KCR is a redetermination date based on a
12 month eligibility period
 Do not count the first prorated month
51
Approval 201% - 301% No ESI
HKC approval with income at 201% up to 301%
with no ESI available:
 If at redetermination – and BED coded
– The BED code will need to be updated to match
the KCA N/R date
 C/D KCA and N/R KCA MM/YY
 N/R KCR MM/YY
52
Employer Sponsored Insurance
N/R Code
Income is at 201% up to 301%:
 Check for employee sponsored insurance
(ESI)
 If the ESI is available, but the child is not
receiving ESI, complete the 415H (Medical
Resources Form)
 If there is ESI code the case on each child
with a N/R ESP C
53
Approval 201% - 301% with ESI
HKC approval with income at 201% up to 301%
with ESI available but not receiving:
 If at redetermination – and BED coded
– The BED code will need to be updated to match the KCA
N/R date
 C/D KCA and N/R KCA MM/YY
 N/R KCR MM/YY
 N/R ESP C
Fax DHS 415H to OPHP at 503-373-7704 Attn: HKC
54
New KC3 Code
When it is determined a client is not eligible
for a subsidy or reimbursement, the HKC
referral to OPHP has KC3 coding:
 For families with income at or above 301%
or self-employed and don’t pass the
$10,000 test. KC3 is a person-specific C/D
and N/R that tells the CM system to send
the HKC referral to OPHP
 No subsidy, no reimbursement, no
redetermination date
55
Approval at or Above 301%
HKC approval with income at or above 301%
C/D KC3
N/R KC3 MM/YY
 The KC3 N/R date for a new applicant will be:
– The month after a client is approved for an HKC
referral
– The CM system will automatically close the
referral based on the KC3 end date
56
Close/Denial at or above 301%
If at redetermination – Following current
policy, close medical benefits with 10-day
notice and DHS 462A
 If time for 10-day notice close medical using:
– a COMPUTE action and change the medical
eligibility field to an end date:
(example E 01/31/2010)
 If no time for 10-day
– add a BED code for the following month to allow
for 10-day
57
Close/Denial at or above 301%
Notices:
If closing other benefits for the child at
redetermination:
 Send a (CMCNSUB) 10-day close notice and a
DHS 462A
If denying DHS medical for the child (new
applicant):
 Send a (CMDNSUB) denial notice and DHS 462A
58
HKC Need Group Coding
On UCMS use the # OHP field for coding the
number in the HKC need group
# OHP ______ (need group for HKC
includes the unborn(s))
59
New Coding Example – Income
at 201% up to 301%
 The worker determines the applicant is
approved for HKC on 02/01/2010
 The worker will determine the 45th day from
02/01/2010 which is 03/17/2010
C/D KCA
N/R KCA 04/2010
60
New Coding Example
Referral approval date is 02/01/2010, since
February is prorated, the KCR end date will
be:
N/R KCR 02/2011
61
New Income Code for HKC
This code is for all Healthy KidsConnect
income levels at 201% and above:
HPK is a N/R and can be on the same
case with a N/R of HPI
N/R HPK C 4000.00
62
CMUP view
63
CMUP View with ESI
64
The Worker has the CM Case Set
up and Eligibility Coded
What’s next?
65
HKC CM Case Opened
 Once an HKC case has been coded
(KCA,KC3) as approved for referral the CM
system sends the client a referral notice
 The CM system will also send information to
the Office of Private Health Partnerships
(OPHP) during overnight processing
66
OPHP Receives CM Update
OPHP receives the information and will:
 send the client a welcome packet
 assist the client in accessing health
insurance
 sends the medical start date to CM for KCA
clients
67
Medical Start Date
For KCA clients (at 201% up to 301%), the
HKC medical start date will be the first of the
month the child is enrolled through OPHP
The medical start date is updated
automatically by the CM system and OPHP
68
KidsConnect Enrolled (KCE)
When OPHP enrolls the client; the C/D KCA
and N/R KCA will auto update to:
 KCE (KidsConnect Enrolled)
 The KCE N/R date will match the KCR date
previously coded by the DHS/AAA worker
 No HKC coding or eligibility time frames will
show on MMIS
69
New Coding after OPHP
Enrollment
70
KCA Process Example
Adult and 3 children (US citizens)
Income $4135 (225% FPL) qualifies for subsidy
No ESI available
Family meets HKC eligibility - #OHP 04
A. Eligibility worker approves an HKC referral
1. Children have C/D KCA and N/R KCA MM/YY
2. Children have N/R KCR MM/YY
3. Adult has N/R HPK C 4135
Do not add medical start dates
71
KCA Process Example
Continued
B. CM system sends case information to
OPHP and worker transfers to 5503
C. OPHP receives the case information
D. OPHP determines HKC subsidy amount
E. OPHP does choice counseling with client
F. OPHP explains the premium billing
process
72
KCA Process Example
Continued
G. OPHP pays insurance premium to HKC
insurance carrier
H. HKC insurance carrier enrolls client
I. OPHP sends the enrollment start date
electronically to CM system
J. The CM system adds a medical start date
to the children and converts the C/D and
N/R to KCE (Healthy KidsConnect
Enrolled)
73
KCA Process Example with ESI
Follow the same process in the previous
example, except:
Fax a completed DHS 415H to OPHP
Code each child who has ESI available to
them with a N/R ESP C
74
Example of Coding at or above
301%
75
HKC Scenario 1
Dad, Mom and two children – DOR 01/15/2010
CEM redetermination – BED 03/2010
Pend information is reviewed on 01/30/2010.
The children meet HKC eligibility requirements
and are approved on 01/30/2010
2 month average $3859 – above 201% FPL, but
less than 301%
What steps will the worker take on this case?
76
HKC Scenario Answer
Coding on UCMS: # OHP 04 / Coding on CMUP:
 C/D KCA
 N/R KCA 04/2010 (the 45th day from the
approval date is 03/16/2010)
 Update the BED to 04/2010 (matches KCA date)
 N/R KCR 01/2011 (12 month eligibility period,
prorated month is not counted)
 N/R HPK C 3859.00
 Transfer case online and mail/shuttle application
to 5503
77
HKC Scenario 2
Dad and his child receiving EXT are at
redetermination. DOR 03/01/2010
2 month average $2651
ESI is available to the child but it is not being
received by the child
In determining eligibility for this case what
information does the worker need that is
different from the previous scenario?
78
HKC Scenario 2
The worker needs to have a complete DHS
415H from Dad and will fax the DHS 415H to
OPHP once eligibility is determined
The worker approves HKC on 03/15/2010
UCMS is coded with # OHP 02
What coding is still needed?
79
HKC Scenario 2 Answer
This is the
old EXT start
date
45th day from
approval date is
04/29/2010 –
after 15th roll to
next month
12 month
eligibility
period
80
Contacts
SSP Medical Policy Analysts
(GroupWise) SSP-policy,medical
 Joyce Clarkson
 Michelle Mack
 Carol Berg
 Christy Garland
 Vonda Daniels
 Julie Cherney
503-945-6106
503-947-5129
503-945-6072
503-945-6119
503-945-6088
503-947-2316
81
Contacts
Continued
 SPD Policy Analyst
 Michael Avery
503-945-6410
 Coding Contact
 Alma Estrada
 Lisa Stegmann
503-947-5304
503-945-6725
82
Contacts
Continued
 CAF SSP Medical Trainers
 Annette Aylett
 Heidi Wormwood
 Terry Kester
 Betty Silva
 LaDonna Lofland
 Glenda Short
 Christine Shaw
 Trevor Baker
503-373-7893
503-373-7885
503-373-7882
503-373-1754
503-373-7669
503-373-7818
503-373-7673
503-373-7402
83
OPHP Contact Numbers
 OPHP Phone number: 1-888-260-4555
 Fax number: 1-503-373-7704
 Email: [email protected]
84