1 Healthy KidsConnect and January 1, 2010 Medical Policy Changes Oregon Department of Human Services

2  Noncitizen requirement changes  Citizenship/Identity documentation requirements for CHIP  American Recovery and Reinvestment Act This Training Covers January 1, 2010 Medical Policy Changes

3 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

4 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)

5 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

6 Expanded Noncitizen Requirements for Children  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 Continued

7 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.

8 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

9 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.

10 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

11 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

12 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

13 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.

14 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

15 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.

16 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

17 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?

18 Citizenship/Identity Example  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 Continued

19 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

20 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

21 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

22 An Overview of Healthy KidsConnect (HKC)

23 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 Healthy KidsConnect is part of Healthy Kids  CHIP  Healthy KidsConnect (HKC)

24 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

25 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

26 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

27 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

28 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)

29 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

30 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

31

32 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

33 Healthy KidsConnect Categories 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 Continued

34 Healthy KidsConnect Categories 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 Continued

35 Healthy KidsConnect Categories 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 Continued

36 Healthy KidsConnect Categories 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 Continued

37 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

38 Eligibility Process for Healthy KidsConnect (HKC)

39 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

40 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

41 Healthy KidsConnect Eligibility HKC Eligibility is the same as CHIP with higher income limits Children under age 19 Children under age 19 No TPL now or in the last 2 months No TPL now or in the last 2 months (the 2 months can be waived) No resource limit No resource limit Continued

42 Healthy KidsConnect Eligibility HKC eligibility continued Cannot be CAWEM and be eligible for HKC Cannot be CAWEM and be eligible for HKC Must document citizenship and noncitizen status Must document citizenship and noncitizen status Use current and previous month income 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) Can use budget month income when not eligible using two month average (can also float budget month using current policy) Continued

43 Healthy KidsConnect Eligibility 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 Continued

44 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

45 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.

46 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)

47 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

48

49 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

50 KCA Date KCA (KidsConnect approved for at 201% up to 301% FPL) The N/R date is determined by: –The 45 th day from the referral approval date –If the 45th day is on or before the 15 th code that month, if after the 15 th code the next month

51 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

52 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

53 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

54 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 Attn: HKC

55 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

56 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

57 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

58 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

59 HKC Need Group Coding On UCMS use the # OHP field for coding the number in the HKC need group # OHP ______ (need group for HKC # OHP ______ (need group for HKC includes the unborn(s))

60 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 45 th day from 02/01/2010 which is 03/17/2010 C/D KCA N/R KCA 04/2010

61 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

62 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

63 CMUP view

64 CMUP View with ESI

65 The Worker has the CM Case Set up and Eligibility Coded What’s next? What’s next?

66 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

67 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

68 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

69 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

70 New Coding after OPHP Enrollment

71 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

72 KCA Process Example 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 Continued

73 KCA Process Example 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) Continued

74 KCA Process Example with ESI Follow the same process in the previous example, except: Fax a completed DHS 415H to OPHP Fax a completed DHS 415H to OPHP Code each child who has ESI available to them with a N/R ESP C Code each child who has ESI available to them with a N/R ESP C

75 Example of Coding at or above 301%

76 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/ month average $3859 – above 201% FPL, but less than 301% What steps will the worker take on this case?

77 HKC Scenario Answer Coding on UCMS: # OHP 04 / Coding on CMUP:  C/D  C/D KCA  N/R KCA 04/2010 (the 45 th 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  Transfer case online and mail/shuttle application to 5503

78 HKC Scenario 2 Dad and his child receiving EXT are at redetermination. DOR 03/01/ 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?

79 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?

80 HKC 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

81 Contacts SSP Medical Policy Analysts (GroupWise) SSP-policy,medical  Joyce Clarkson  Michelle Mack  Carol Berg  Christy Garland  Vonda Daniels  Julie Cherney

82 Contacts  SPD Policy Analyst  Michael Avery  Coding Contact  Alma Estrada  Lisa Stegmann Continued

83 Contacts  CAF SSP Medical Trainers  Annette Aylett  Heidi Wormwood  Terry Kester  Betty Silva  LaDonna Lofland  Glenda Short  Christine Shaw  Trevor Baker Continued

84 OPHP Contact Numbers  OPHP Phone number:  Fax number: 