healthy kidsconnect and january 1, 2010 medical policy changes

11

Healthy KidsConnectand January 1, 2010 Medical

Policy Changes

Oregon Department of Human Services

22

Noncitizen requirement changesNoncitizen requirement changes Citizenship/Identity documentation Citizenship/Identity documentation

requirements for CHIPrequirements for CHIP American Recovery and Reinvestment ActAmerican Recovery and Reinvestment Act

This Training Covers January 1, This Training Covers January 1, 2010 Medical Policy Changes2010 Medical Policy Changes

33

Changes for Changes for January 1, 2010January 1, 2010

Healthy KidsConnect overview and eligibilityHealthy KidsConnect overview and eligibility

OPHP’s (Office of Private Health Partnerships) OPHP’s (Office of Private Health Partnerships) role in Healthy KidsConnectrole in Healthy KidsConnect

DHS/AAA worker’s role in Healthy KidsConnectDHS/AAA worker’s role in Healthy KidsConnect

44

January 2010January 2010 Changes for Changes for Noncitizen Children 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)

55

Expanded Noncitizen Expanded Noncitizen Requirement for ChildrenRequirement for Children

Example of new groups of immigrants Example of new groups of immigrants include:include:– Children who are Permanently Residing Under Children who are Permanently Residing Under

Color of Law Color of Law – An individual who is a child of a U.S. citizen An individual who is a child of a U.S. citizen

whose visa petition has been approved and who whose visa petition has been approved and who has a pending application for adjustment of has a pending application for adjustment of status status

66

Expanded Noncitizen Expanded Noncitizen Requirements for ChildrenRequirements for Children

Several classes of non-immigrants are also Several classes of non-immigrants are also included in the new groups. Examples of included in the new groups. Examples of non-immigrants are:non-immigrants are:– A child of an individual with special immigrant A child of an individual with special immigrant

status under section 101(a)(27) of the INA status under section 101(a)(27) of the INA – A fiancé of a citizen, as permitted under section A fiancé of a citizen, as permitted under section

101(a)(15)(K) of the INA 101(a)(15)(K) of the INA

Continued

77

Noncitizen ChildrenNoncitizen Children

Children meeting the new noncitizen Children meeting the new noncitizen requirements are potentially eligible for OHP requirements are potentially eligible for OHP Plus program benefits.Plus program benefits.

A one time report will be sent of current A one time report will be sent of current CAWEM children. CAWEM children.

Workers will need to review each child’s Workers will need to review each child’s noncitizen status and, if eligible, convert to noncitizen status and, if eligible, convert to OHP Plus effective January 1, 2010. OHP Plus effective January 1, 2010.

88

New NCS Need/Resource CodeNew NCS Need/Resource Code

There is a new N/R item that will be used on There is a new N/R item that will be used on any person who is not an LPR or REF and any person who is not an LPR or REF and meets the noncitizen requirementmeets the noncitizen requirement

The N/R item is NCSThe N/R item is NCS and the date will be Cand the date will be C N/R N/R NCSNCS CC The new NCS need/resource item should be The new NCS need/resource item should be

available January 15available January 15

99

Noncitizen Children Turning 19Noncitizen Children Turning 19

Children who turn 19 during their eligibility Children who turn 19 during their eligibility period:period:– A monthly report will be available of NCS and A monthly report will be available of NCS and

LPR children turning age 19. LPR children turning age 19. – Children who turn 19 and do not meet the Children who turn 19 and do not meet the

noncitizen requirement for adults, but are noncitizen requirement for adults, but are determined eligible for MAA/MAF, OSIPM or determined eligible for MAA/MAF, OSIPM or OPU will have a benefit package reduction to OPU will have a benefit package reduction to CAWEM. CAWEM.

– A 10 day notice is still required.A 10 day notice is still required.

1010

Noncitizen Documentation Noncitizen Documentation RequirementsRequirements

All noncitizens, regardless of age, need to All noncitizens, regardless of age, need to provide documentation of their statusprovide documentation of their status

The document provided could depend on The document provided could depend on how they were admitted into the US (court how they were admitted into the US (court papers, I-94, etc.)papers, I-94, etc.)

The document provided will indicate what The document provided will indicate what section of law the noncitizen was admitted section of law the noncitizen was admitted under or what class of admission they are under or what class of admission they are considered to be by INAconsidered to be by INA

1111

Documentation RequirementsDocumentation Requirements

For all noncitizens, if documentation of the For all noncitizens, if documentation of the noncitizen’s status is not available when initially noncitizen’s status is not available when initially determining benefits, we can open medical and determining benefits, we can open medical and pend the client to provide the documentation if pend the client to provide the documentation if bothboth of the following are true: of the following are true:– The client knows what their status is and if needed, The client knows what their status is and if needed,

what section of law they were admitted under andwhat section of law they were admitted under and– The declared status meets the noncitizen requirementThe declared status meets the noncitizen requirement

1212

CIP & CIE Coding for noncitizensCIP & CIE Coding for noncitizens

In February, the CIP and CIE need/resource In February, the CIP and CIE need/resource items will be available for noncitizens, tooitems will be available for noncitizens, too

If the client does not provide noncitizen If the client does not provide noncitizen documentation, the CM computer system documentation, the CM computer system will automatically send a 10-day close notice will automatically send a 10-day close notice and end the noncitizen’s medicaland end the noncitizen’s medical

Just like citizens, when the medical ends, Just like citizens, when the medical ends, the computer will add the CID case the computer will add the CID case descriptordescriptor

1313

New SAVE Verification New SAVE Verification RequirementRequirement

SAVE must be checked:SAVE must be checked: At each certification to verify the status of At each certification to verify the status of

the noncitizen clientthe noncitizen client Whenever a change in status is reportedWhenever a change in status is reported This is a new federal requirement.This is a new federal requirement.

1414

Noncitizen ChartNoncitizen Chart

There are more than 90 specific There are more than 90 specific classifications within the non-immigrant classifications within the non-immigrant group group

The The noncitizen worker guide NC-1noncitizen worker guide NC-1 has been has been updated in the updated in the Family Services ManualFamily Services Manual

Compare the noncitizen’s documentation to Compare the noncitizen’s documentation to the chart and determine whether they meet the chart and determine whether they meet the noncitizen requirementthe noncitizen requirement

1515

Iraq and Afghanistan RefugeesIraq and Afghanistan Refugees

Effective December 19, 2009 Afghan and Effective December 19, 2009 Afghan and Iraqi SIV (special immigrants) who came to Iraqi SIV (special immigrants) who came to the United States with a temporary refugee the United States with a temporary refugee status will now get full Medicaid or CHIP at status will now get full Medicaid or CHIP at the end of the 6-8 months refugee period, if the end of the 6-8 months refugee period, if otherwise eligible for a Medicaid program or otherwise eligible for a Medicaid program or CHIP. CHIP.

1616

New CHIP CitizenshipNew CHIP CitizenshipDocumentationDocumentation

RequirementRequirement CHIP now requires Citizenship and Identity CHIP now requires Citizenship and Identity

documentation to be viewed and citizenship fields documentation to be viewed and citizenship fields updated in the Person Alias/Update screenupdated in the Person Alias/Update screen

Citizenship and Identity verification for CHIP will Citizenship and Identity verification for CHIP will follow our current Medicaid policy and proceduresfollow our current Medicaid policy and procedures

CIP and CIE need/resource items now apply to CIP and CIE need/resource items now apply to CHIP children, tooCHIP children, too

1717

Citizenship/Identity ExampleCitizenship/Identity ExampleNew applicant, DOR 01/05/2010 children ages New applicant, DOR 01/05/2010 children ages

4 & 8 (three in the need group)4 & 8 (three in the need group)

Two month income average is $2015Two month income average is $2015

Person Alias/Update screen viewed for Person Alias/Update screen viewed for citizenship/identity; no verification is codedcitizenship/identity; no verification is coded

All other eligibility requirements have been met All other eligibility requirements have been met except citizenship; the children were except citizenship; the children were notnot born in born in Oregon Oregon

What are the workers next steps? What are the workers next steps?

1818

Citizenship/Identity ExampleCitizenship/Identity Example

Pend for citizenship verification Pend for citizenship verification

Code both children with a CIP C/D Code both children with a CIP C/D

and CIP N/Rand CIP N/R

Open medical benefits for both childrenOpen medical benefits for both children

Based on income the 4 year old will be OP6 Based on income the 4 year old will be OP6 and the 8 year old will be CHP and the 8 year old will be CHP

Continued

1919

American Recovery and American Recovery and Reinvestment Act (ARRA)Reinvestment Act (ARRA)

The ARRA Making Work Pay tax credit is now The ARRA Making Work Pay tax credit is now

$33.00$33.00 This exclusion amount applies to all DHS This exclusion amount applies to all DHS

medical program clients who have earned medical program clients who have earned income income

Exclude $33.00 from earned income for each Exclude $33.00 from earned income for each

month of income used. Only one exclusion per month of income used. Only one exclusion per

person with earned income per monthperson with earned income per month

2020

Simplified Making Work Pay Simplified Making Work Pay Credit ProcessCredit Process

Clients receiving SSI, SSD, SSB Railroad Clients receiving SSI, SSD, SSB Railroad retirement, Veterans disability and veterans retirement, Veterans disability and veterans pension payments pension payments who also have earned who also have earned incomeincome will receive the same tax credit will receive the same tax credit amount amount

Clients with multiple jobs receive only one Clients with multiple jobs receive only one exclusion exclusion

Self employed clients also qualifySelf employed clients also qualify

2121

ARRAARRA

This change to the ARRA applies to new This change to the ARRA applies to new applicants or those at redetermination in applicants or those at redetermination in JanuaryJanuary

Ongoing clients who received the ARRA Ongoing clients who received the ARRA exclusion prior to January will not need any exclusion prior to January will not need any updating until their next redeterminationupdating until their next redetermination

2222

An Overview An Overview

ofof

Healthy KidsConnect (HKC)Healthy KidsConnect (HKC)

2323

Healthy KidsHealthy Kids

The goal of Healthy Kids is to provide The goal of Healthy Kids is to provide outreach and enrollment efforts so that all outreach and enrollment efforts so that all children under age 19 are covered by medical children under age 19 are covered by medical insurance in the state of Oregon with:insurance in the state of Oregon with:

MedicareMedicare MedicaidMedicaid

Healthy KidsConnect is part of Healthy KidsHealthy KidsConnect is part of Healthy Kids

CHIP CHIP Healthy KidsConnect (HKC)Healthy KidsConnect (HKC)

2424

Healthy KidsConnect (HKC) Healthy KidsConnect (HKC) OverviewOverview

New way of issuing benefitsNew way of issuing benefits Benefits include a subsidy for health Benefits include a subsidy for health

insurance premiums insurance premiums Subsidy amount depends on the family’s Subsidy amount depends on the family’s

incomeincome DMAP does not issue HKC benefitsDMAP does not issue HKC benefits HKC eligibility is based on CHIP eligibilityHKC eligibility is based on CHIP eligibility

2525

DHS in Partnership with OPHPDHS in Partnership with OPHP

DHS/AAA workers and the Office of Private DHS/AAA workers and the Office of Private

Health Partnerships (OPHP) are partners Health Partnerships (OPHP) are partners

in the Healthy KidsConnect (HKC) process for in the Healthy KidsConnect (HKC) process for

childrenchildren

2626

Office of Private Health Office of Private Health Partnerships (OPHP)Partnerships (OPHP)

OPHP is part of the Family Health Insurance OPHP is part of the Family Health Insurance Assistance Program (FHIAP)Assistance Program (FHIAP)

DHS staff will process initial eligibility for HKC DHS staff will process initial eligibility for HKC applicants and code CM caseapplicants and code CM case

HKC eligibility is very similar to CHIP, but with a HKC eligibility is very similar to CHIP, but with a higher income limithigher income limit

The CM system does an automatic referral to The CM system does an automatic referral to OPHPOPHP

2727

Office of Private Health Office of Private Health Partnerships (OPHP) RolePartnerships (OPHP) Role

OPHP will establish and maintain contracts OPHP will establish and maintain contracts with health insurance carriers to provide with health insurance carriers to provide coverage similar to OHP Pluscoverage similar to OHP Plus

OPHP will be responsible for issuing OPHP will be responsible for issuing subsidies and reimbursementssubsidies and reimbursements

Once referred to OPHP, the family has 45 Once referred to OPHP, the family has 45 days to be enrolled and receive an HKC days to be enrolled and receive an HKC subsidy or reimbursementsubsidy or reimbursement

2828

Healthy KidsConnect OverviewHealthy KidsConnect Overview

HKC offers families a way to accessHKC offers families a way to access

health insurance for:health insurance for:– Non-CAWEM Non-CAWEM children under age 19, andchildren under age 19, and– Ineligible for any other DHS medical program, Ineligible for any other DHS medical program,

andand– Income is at 201% or above, and Income is at 201% or above, and – Must be uninsured to qualify (just like CHIP)Must be uninsured to qualify (just like CHIP)

2929

HKC Income Standard HKC Income Standard

Healthy KidsConnect has two income ranges: Healthy KidsConnect has two income ranges:

At or above 201% up to 301%, and At or above 201% up to 301%, and

Income at 301% and aboveIncome at 301% and above

The standard chart now has a 301% columnThe standard chart now has a 301% column

3030

New 301% StandardNew 301% Standard

HKC benefits depend on the family’s incomeHKC benefits depend on the family’s income

Families with income at or above 301% do Families with income at or above 301% do not qualify for HKC subsidiesnot qualify for HKC subsidies

301% and above families can access HKC 301% and above families can access HKC insurance, but must pay the full premium insurance, but must pay the full premium costcost

3232

Healthy KidsConnect CategoriesHealthy KidsConnect Categories

Category 1:Category 1: For families with income at or For families with income at or

above 201% up to 301% FPL who don’t have above 201% up to 301% FPL who don’t have

insurance available through an employer insurance available through an employer

HKC will offer health insurance that can beHKC will offer health insurance that can be

purchased for children through the Office of purchased for children through the Office of

Private Health PartnershipPrivate Health Partnership

3333


Category 1 = a Category 1 = a subsidy programsubsidy program based on based on the client’s income levelthe client’s income level

Income from 201% through 250% FPL will Income from 201% through 250% FPL will have approximately 90% of the insurance have approximately 90% of the insurance premium paid by OPHPpremium paid by OPHP

Income from 251% through 300% FPL will Income from 251% through 300% FPL will have approximately 80% of the insurance have approximately 80% of the insurance premium paid by OPHPpremium paid by OPHP

Continued

3434


Category 2:Category 2: For families with income at 201% For families with income at 201%

up to 301% FPL when the parent has up to 301% FPL when the parent has

Employer Sponsored Insurance (ESI)Employer Sponsored Insurance (ESI)

available available for their children through anfor their children through an

employer, but the children are employer, but the children are not not coveredcovered

Category 2 = A portion of the family’s Category 2 = A portion of the family’s

premium payment is reimbursed premium payment is reimbursed

Continued

3535


Employer Sponsored Insurance ReimbursementEmployer Sponsored Insurance Reimbursement

Income from 201% through 250% FPLIncome from 201% through 250% FPL will have approximately 90% insurance will have approximately 90% insurance

premium reimbursement by OPHPpremium reimbursement by OPHP

Income from 251% through 300% FPLIncome from 251% through 300% FPL will have approximately 80% insurance will have approximately 80% insurance

premium reimbursement by OPHPpremium reimbursement by OPHP

Continued

3636


Category 3:Category 3: For families with income at or For families with income at or

above 301% FPLabove 301% FPL

This is a full pay category. The client will be This is a full pay category. The client will be

required to pay the full premium amount to required to pay the full premium amount to

receive coverage for their childrenreceive coverage for their children

Continued

3737

Category 3, cont. Category 3, cont.

Self-employed families who do not meet the Self-employed families who do not meet the $10,000 business entity income test are also $10,000 business entity income test are also category 3 clientscategory 3 clients

The client will be required to pay the full The client will be required to pay the full premium amount to receive HKC insurance premium amount to receive HKC insurance coverage for their childrencoverage for their children

3838

Eligibility Process Eligibility Process

for for

Healthy KidsConnect (HKC)Healthy KidsConnect (HKC)

3939

Healthy KidsConnect ProcessHealthy KidsConnect Process

When an applicant requests medical When an applicant requests medical benefits only and no companion case exists, benefits only and no companion case exists, the application can be sent to OHP the application can be sent to OHP Statewide Processing Center (5503) for Statewide Processing Center (5503) for processingprocessing

Applications with an adult age 60 or above Applications with an adult age 60 or above who are requesting medical will be sent to who are requesting medical will be sent to the local SPD/AAA officethe local SPD/AAA office

4040

Healthy KidsConnect ProcessHealthy KidsConnect ProcessContinued

The DHS/AAA branch worker will:The DHS/AAA branch worker will:

Screen for MAA, MAF, EXT, OSIPM, OHP, Screen for MAA, MAF, EXT, OSIPM, OHP, CEM and CEC medical programs following CEM and CEC medical programs following current processcurrent process

Income at 201% or aboveIncome at 201% or above

screen application for HKC screen application for HKC

4141

Healthy KidsConnect EligibilityHealthy KidsConnect Eligibility

HKC Eligibility is the same as CHIP with HKC Eligibility is the same as CHIP with

higher income limitshigher income limits

Children under age 19Children under age 19

No TPL now or in the last 2 monthsNo TPL now or in the last 2 months

(the 2 months can be waived)(the 2 months can be waived)

No resource limitNo resource limit

Continued

4242


HKC eligibility continuedHKC eligibility continued

Cannot be CAWEM and be eligible for HKCCannot be CAWEM and be eligible for HKC Must document citizenship and noncitizen statusMust document citizenship and noncitizen status

Use current and previous month incomeUse current and previous month income

Can use budget month income when not eligible Can use budget month income when not eligible using two month average (can also float budget using two month average (can also float budget month using current policy)month using current policy)

Continued

4343


Date of request (DOR)Date of request (DOR)

Follow current date of request process when Follow current date of request process when determining HKC eligibilitydetermining HKC eligibility

Give 45 days from the date of request to Give 45 days from the date of request to complete the pend and eligibility complete the pend and eligibility determination processdetermination process

If a redetermination BED code the caseIf a redetermination BED code the case

Continued

4444

DenialsDenials

Once the pend process is complete if the Once the pend process is complete if the client does not meet eligibility requirements client does not meet eligibility requirements for any DHS medical program… for any DHS medical program… – Example: Income is 225% and client has TPLExample: Income is 225% and client has TPL

…….the worker must send both a close or .the worker must send both a close or denial notice denial notice andand a DHS 462A notice for the a DHS 462A notice for the ineligible childineligible child

Reminder: TPL received in the last two months can Reminder: TPL received in the last two months can

be waived in some situationsbe waived in some situations

4545

HKC ReferralsHKC Referrals

Two kinds of referrals to OPHP Two kinds of referrals to OPHP HKC children are referred who qualify for CHIP but HKC children are referred who qualify for CHIP but

have income at 201% or above up to 301%. They have income at 201% or above up to 301%. They are eligible for HKC subsidies or reimbursements. are eligible for HKC subsidies or reimbursements. −− They are assigned a 12-month They are assigned a 12-month redetermination redetermination period. period.

Children are referred who qualify for CHIP but Children are referred who qualify for CHIP but have income at 301% or above. They must pay have income at 301% or above. They must pay entire HKC insurance premiumentire HKC insurance premium── They are not assigned a redetermination They are not assigned a redetermination period. period.

4646

HKC Referral ProcessHKC Referral Process

Once it is determined an applicant is Once it is determined an applicant is

approved for a referral to get HKC insurance:approved for a referral to get HKC insurance:

either update an existing CM case or either update an existing CM case or open a new CM case open a new CM case

(HKC cases can be combined with other (HKC cases can be combined with other

programs)programs)

4747

HKC Referral ProcessHKC Referral Process

Transfer the case online and shuttle/mail Transfer the case online and shuttle/mail

application to OHP Statewide Processingapplication to OHP Statewide Processing

Center (5503)Center (5503)

An HKC cover letter should be attached toAn HKC cover letter should be attached to

applications being transferred to 5503applications being transferred to 5503

Do Do notnot fax application to 5503 fax application to 5503 – this will – this will

cause problems with 5503’s imaging processcause problems with 5503’s imaging process

4949

KCA Code – at 201% up to 301%KCA Code – at 201% up to 301%When it is determined a client is approved for an When it is determined a client is approved for an HKC subsidy referral to OPHP, the HKC subsidy referral to OPHP, the KCAKCA(KidsConnect Approved) (KidsConnect Approved) coding is used:coding is used:

For families with income at 201% up to 301%For families with income at 201% up to 301% KCAKCA is a person-specific C/D and N/R that tells is a person-specific C/D and N/R that tells the CM system to send the HKC referral to the CM system to send the HKC referral to OPHPOPHP

The N/R date is used to give the client the 45 The N/R date is used to give the client the 45 days + 10 days notice to complete the process days + 10 days notice to complete the process with OPHP with OPHP

5050

KCA DateKCA Date

KCA KCA (KidsConnect approved for at 201% up to (KidsConnect approved for at 201% up to 301% FPL)301% FPL)

The N/R date is determined by:The N/R date is determined by:– The 45The 45thth day from the day from the referral approval datereferral approval date– If the 45th day is on or before the 15If the 45th day is on or before the 15 thth code that code that

month, if after the 15month, if after the 15thth code the next month code the next month

5151

KCR CodeKCR Code

KCRKCR ( (KidsConnect Redetermination) KidsConnect Redetermination) is is a N/R only and will be added to each child a N/R only and will be added to each child with KCA coding (income at 201% up to with KCA coding (income at 201% up to 301% only)301% only)

KCR is a redetermination date based on a KCR is a redetermination date based on a 12 month eligibility period12 month eligibility period

Do not count the first prorated monthDo not count the first prorated month

5252

Approval 201% - 301% No ESI Approval 201% - 301% No ESI

HKC approval with income at 201% up to 301% HKC approval with income at 201% up to 301%

with with nono ESI available ESI available::

If at redetermination – and BED codedIf at redetermination – and BED coded– The BED code will need to be updated to match The BED code will need to be updated to match

the KCA N/R datethe KCA N/R date

C/D C/D KCAKCA and N/R and N/R KCAKCA MM/YYMM/YY N/R N/R KCRKCR MM/YYMM/YY

5353

Employer Sponsored Insurance N/R Employer Sponsored Insurance N/R CodeCode

Income is at 201% up to 301%:Income is at 201% up to 301%:

Check for employee sponsored insurance Check for employee sponsored insurance (ESI)(ESI)

If the ESI is available, If the ESI is available, but the child is not but the child is not receiving ESIreceiving ESI, complete the 415H (Medical , complete the 415H (Medical Resources Form)Resources Form)

If there is ESI code the case on each child If there is ESI code the case on each child with a N/R with a N/R ESPESP CC

5454

Approval 201% - 301% Approval 201% - 301% withwith ESI ESIHKC approval with income at 201% up to 301% HKC approval with income at 201% up to 301%

with ESI available with ESI available but not receivingbut not receiving::

If at redetermination – and BED codedIf at redetermination – and BED coded– The BED code will need to be updated to match the KCA The BED code will need to be updated to match the KCA

N/R dateN/R date

C/D C/D KCAKCA and N/R and N/R KCAKCA MM/YYMM/YY N/R N/R KCRKCR MM/YYMM/YY N/R N/R ESPESP CC

Fax DHS 415H to OPHP at Fax DHS 415H to OPHP at 503-373-7704 Attn: HKC503-373-7704 Attn: HKC

5555

New KC3 CodeNew KC3 CodeWhen it is determined a client is not eligible for a When it is determined a client is not eligible for a

subsidy or reimbursement, the HKC referral to subsidy or reimbursement, the HKC referral to OPHP has OPHP has KC3 KC3 coding:coding:

For families with income For families with income at or above 301% or at or above 301% or self-employed and don’t pass the $10,000 test.self-employed and don’t pass the $10,000 test. KC3KC3 is a person-specific C/D and N/R that tells is a person-specific C/D and N/R that tells the CM system to send the HKC referral to OPHPthe CM system to send the HKC referral to OPHP

No subsidy, no reimbursement, no No subsidy, no reimbursement, no redetermination dateredetermination date

5656

Approval at or Above 301%Approval at or Above 301%

HKC approval with income at or above 301%HKC approval with income at or above 301%

C/D C/D KC3KC3

N/RN/R KC3KC3 MM/YYMM/YY

The KC3 N/R date for a new applicant will be:The KC3 N/R date for a new applicant will be:– The month after a The month after a client is approved for an client is approved for an

HKC referralHKC referral– The CM system will automatically close the The CM system will automatically close the

referral based on the KC3 end datereferral based on the KC3 end date

5757

Close/Denial at or above 301%Close/Denial at or above 301%If at redetermination – Following current If at redetermination – Following current policy, close medical benefits with 10-day policy, close medical benefits with 10-day notice and DHS 462Anotice and DHS 462A

If time for 10-day notice close medical using:If time for 10-day notice close medical using:– a a COMPUTECOMPUTE action and change the medical action and change the medical

eligibility field to an end date: eligibility field to an end date:

(example (example EE 01/31/201001/31/2010))

If no time for 10-day If no time for 10-day – add a BED code for the following month to allow add a BED code for the following month to allow

for 10-dayfor 10-day

5858

Close/Denial at or above 301%Close/Denial at or above 301%

Notices:Notices:

If closing other benefits for the child at If closing other benefits for the child at redetermination:redetermination:

Send a (CMCNSUB) 10-day close notice Send a (CMCNSUB) 10-day close notice andand a a DHS 462ADHS 462A

If denying DHS medical for the child (new If denying DHS medical for the child (new applicant):applicant):

Send a (CMDNSUB) denial notice Send a (CMDNSUB) denial notice andand DHS 462A DHS 462A

5959

HKC Need Group CodingHKC Need Group Coding

On UCMS use the # OHP field for coding the On UCMS use the # OHP field for coding the

number in the HKC need groupnumber in the HKC need group

# OHP ______ (need group for HKC # OHP ______ (need group for HKC

includes the unborn(s))includes the unborn(s))

6060

New Coding Example – Income New Coding Example – Income at 201% up to 301%at 201% up to 301%

The worker determines the applicant is The worker determines the applicant is

approvedapproved for HKC on for HKC on 02/01/201002/01/2010

The worker will determine the 45The worker will determine the 45thth day from day from

02/01/2010 which is 02/01/2010 which is 03/17/201003/17/2010

C/D C/D KCAKCA

N/R N/R KCAKCA 04/201004/2010

6161

New Coding ExampleNew Coding Example

Referral approval date is 02/01/2010, sinceReferral approval date is 02/01/2010, since

February is prorated, the February is prorated, the KCRKCR end date will end date will

be: be:

N/R N/R KCRKCR 02/201102/2011

6262

New Income Code for HKCNew Income Code for HKC

This code is for all Healthy KidsConnect This code is for all Healthy KidsConnect

income levels at 201% and above:income levels at 201% and above:

HPKHPK is a N/R and can be on the same is a N/R and can be on the same

case with a N/R of HPIcase with a N/R of HPI

N/R N/R HPKHPK CC 4000.004000.00

6363

CMUP viewCMUP view

6464

CMUP View with ESICMUP View with ESI

6565

The Worker has the CM Case Set The Worker has the CM Case Set up and Eligibility Codedup and Eligibility Coded

What’s next?What’s next?

6666

HKC CM Case OpenedHKC CM Case Opened

Once an HKC case has been coded Once an HKC case has been coded (KCA,KC3) as approved for referral the CM (KCA,KC3) as approved for referral the CM system sends the client a referral noticesystem sends the client a referral notice

The CM system will also send information to The CM system will also send information to the Office of Private Health Partnerships the Office of Private Health Partnerships (OPHP) during overnight processing(OPHP) during overnight processing

6767

OPHP Receives CM UpdateOPHP Receives CM Update

OPHP receives the information and will: OPHP receives the information and will:

send the client a welcome packetsend the client a welcome packet

assist the client in accessing health assist the client in accessing health insuranceinsurance

sends the medical start date to CM for KCA sends the medical start date to CM for KCA clientsclients

6868

Medical Start DateMedical Start Date

For For KCAKCA clients (at 201% up to 301%), the clients (at 201% up to 301%), the

HKC medical start date will be the first of the HKC medical start date will be the first of the

month the child is enrolled through OPHPmonth the child is enrolled through OPHP

The medical start date is updated The medical start date is updated

aautomaticallyutomatically by the CM system and OPHP by the CM system and OPHP

6969

KidsConnect Enrolled (KCE)KidsConnect Enrolled (KCE)

When When OPHP enrolls OPHP enrolls the client; the C/D KCA the client; the C/D KCA

and N/R KCA will auto update to:and N/R KCA will auto update to:

KCEKCE (KidsConnect Enrolled) (KidsConnect Enrolled)

The KCE N/R date will match the KCR date The KCE N/R date will match the KCR date

previously coded by the DHS/AAA workerpreviously coded by the DHS/AAA worker

No HKC coding or eligibility time frames will No HKC coding or eligibility time frames will show on MMISshow on MMIS

7070

New Coding after OPHP New Coding after OPHP EnrollmentEnrollment

7171

KCA Process ExampleKCA Process ExampleAdult and 3 children (US citizens)Adult and 3 children (US citizens)Income Income $4135$4135 (225% FPL) qualifies for subsidy (225% FPL) qualifies for subsidyNo ESI availableNo ESI availableFamily meets HKC eligibility - #OHP Family meets HKC eligibility - #OHP 0404

A.A. Eligibility worker approves an HKC referralEligibility worker approves an HKC referral1.1. Children have C/D Children have C/D KCAKCA and N/R and N/R KCA KCA MM/YYMM/YY2.2. Children have N/RChildren have N/R KCRKCR MM/YYMM/YY3.3. Adult has N/RAdult has N/R HPK HPK CC 41354135

Do Do notnot add medical start dates add medical start dates

7272

KCA Process ExampleKCA Process Example

B.B. CM system sends case information to CM system sends case information to OPHP and worker transfers to 5503OPHP and worker transfers to 5503

C.C. OPHP receives the case informationOPHP receives the case information

D.D. OPHP determines HKC subsidy amountOPHP determines HKC subsidy amount

E.E. OPHP does choice counseling with clientOPHP does choice counseling with client

F.F. OPHP explains the premium billing OPHP explains the premium billing process process

Continued

7373

KCA Process ExampleKCA Process Example

G.G. OPHP pays insurance premium to HKC OPHP pays insurance premium to HKC insurance carrierinsurance carrier

H.H. HKC insurance carrier enrolls clientHKC insurance carrier enrolls client

I.I. OPHP sends the enrollment start date OPHP sends the enrollment start date electronically to CM systemelectronically to CM system

J.J. The CM system adds a medical start date The CM system adds a medical start date to the children and converts the C/D and to the children and converts the C/D and N/R to KCE (Healthy KidsConnect N/R to KCE (Healthy KidsConnect Enrolled)Enrolled)

Continued

7474

KCA Process Example with ESIKCA Process Example with ESI

Follow the same process in the previousFollow the same process in the previousexample, except:example, except:

Fax a completed DHS 415H to OPHPFax a completed DHS 415H to OPHPCode each child who has ESI available to Code each child who has ESI available to

them with a N/R them with a N/R ESPESP CC

7575

Example of Coding at or above Example of Coding at or above 301%301%

7676

HKC Scenario 1HKC Scenario 1

Dad, Mom and two children – DOR Dad, Mom and two children – DOR 01/15/201001/15/2010CEM redetermination – BED 03/2010CEM redetermination – BED 03/2010 Pend information is reviewed on 0Pend information is reviewed on 01/30/20101/30/2010..The children meet HKC eligibility requirements The children meet HKC eligibility requirements and are approved on and are approved on 01/30/201001/30/20102 month average 2 month average $3859$3859 – above 201% FPL, but – above 201% FPL, but less than 301%less than 301%

What steps will the worker take on this case?What steps will the worker take on this case?

7777

HKC Scenario AnswerHKC Scenario Answer

Coding on UCMS: # OHP Coding on UCMS: # OHP 0404 / Coding on CMUP: / Coding on CMUP: C/D C/D KCA N/R N/R KCAKCA 04/201004/2010 (the 45 (the 45thth day from the day from the

approval date is 03/16/2010)approval date is 03/16/2010) Update the Update the BEDBED to to 04/201004/2010 (matches KCA date)(matches KCA date) N/R N/R KCRKCR 01/201101/2011 (12 month eligibility period, (12 month eligibility period,

prorated month is not counted)prorated month is not counted) N/R N/R HPKHPK C C 3859.003859.00 Transfer case online and mail/shuttle application Transfer case online and mail/shuttle application

to 5503to 5503

7878


Dad and his child receiving EXT are at Dad and his child receiving EXT are at redetermination. DOR 03/01/2010redetermination. DOR 03/01/20102 month average $26512 month average $2651ESI is available to the child but it is ESI is available to the child but it is notnot being being received by the childreceived by the child

In determining eligibility for this case what In determining eligibility for this case what information does the worker need that is information does the worker need that is different from the previous scenario?different from the previous scenario?

7979


The worker needs to have a complete DHS The worker needs to have a complete DHS 415H from Dad and will fax the DHS 415H to 415H from Dad and will fax the DHS 415H to OPHP once eligibility is determinedOPHP once eligibility is determined

The worker approves HKC on 03/15/2010The worker approves HKC on 03/15/2010UCMS is coded with # OHP UCMS is coded with # OHP 0202

What coding is still needed?What coding is still needed?

8080

HKC Scenario 2 AnswerHKC Scenario 2 Answer

This is the old EXT start

date 12 month eligibility period

45th day from approval date is

04/29/2010 – after 15th roll to

next month

8181

ContactsContacts

SSP Medical Policy AnalystsSSP Medical Policy Analysts

(GroupWise) (GroupWise) SSP-policy,medical SSP-policy,medical Joyce Clarkson Joyce Clarkson 503-945-6106503-945-6106 Michelle Mack Michelle Mack 503-947-5129503-947-5129 Carol Berg Carol Berg 503-945-6072503-945-6072 Christy GarlandChristy Garland 503-945-6119503-945-6119 Vonda DanielsVonda Daniels 503-945-6088503-945-6088 Julie CherneyJulie Cherney 503-947-2316503-947-2316

8282

ContactsContacts

SPD Policy AnalystSPD Policy Analyst Michael AveryMichael Avery 503-945-6410503-945-6410

Coding ContactCoding Contact Alma EstradaAlma Estrada 503-947-5304503-947-5304 Lisa StegmannLisa Stegmann 503-945-6725503-945-6725

Continued

8383

ContactsContacts

CAF SSP Medical TrainersCAF SSP Medical Trainers Annette Aylett Annette Aylett 503-373-7893503-373-7893 Heidi WormwoodHeidi Wormwood 503-373-7885503-373-7885 Terry Kester Terry Kester 503-373-7882503-373-7882 Betty SilvaBetty Silva 503-373-1754503-373-1754 LaDonna LoflandLaDonna Lofland 503-373-7669503-373-7669 Glenda ShortGlenda Short 503-373-7818503-373-7818 Christine ShawChristine Shaw 503-373-7673503-373-7673 Trevor BakerTrevor Baker 503-373-7402503-373-7402

Continued

8484

OPHP Contact NumbersOPHP Contact Numbers

OPHP Phone number: 1-888-260-4555 OPHP Phone number: 1-888-260-4555 Fax number: 1-503-373-7704 Fax number: 1-503-373-7704 Email: Email: [email protected]@state.or.us

mailto:[email protected]

healthy kidsconnect and january 1, 2010 medical policy changes

Documents