1 Kentucky HEALTH, which stands for Helping to Engage and Achieve - - PDF document

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Kentucky HEALTH, which stands for Helping to Engage and Achieve Long Term Help, is the Commonwealth’s new health and well-being program for non-disabled low-income adults on Medicaid. Approximately 88% of Passport’s membership will be impacted by Kentucky HEALTH. This program is designed to provide a commercial-like insurance experience by using 6 key components:

• 1. Cost Sharing where members will have premiums or copayments.
• 2. My Rewards Account where members will have the opportunity to earn funds for

completing certain activities and courses.

• 3. Deductible Account which will track members non-preventative services to show

the true cost of healthcare.

• 4. Community Engagement/PATH program encourages members to become involved

in their community and seek employment opportunities.

• 5. Education and Training provides courses members can take to clear penalties, to

earn funds for their My Rewards Account and to meeting their Community Engagement Requirements.

• 6. Premium Assistance which helps members gain access to a commercial primary

insurance through their employer. 2

The Kentucky HEALTH program consists of 2 benefits packages: the Alternative Benefit Plan, often referred to as the ABP, and the State Plan. The Alternative Benefit Plan is designed to provide individuals with a commercial insurance experience with cost sharing and deductible accounts. This benefit plan is aligned with Fee-For-Service Medicaid. Members will receive dental and vision benefits through their My Rewards Account with the exception of 19 and 20 year olds as they will continue to receive EPSDT services therefore will still have access to dental and vision services. Non-emergent medical transportation is also non-covered within the ABP. The Kentucky State Plan is consistent with current Medicaid benefits. Members will have cost sharing and deductibles. Members also have access to dental, vision via their MCO and non-emergent medical transportation via the State. 3

These populations listed are not impacted by Kentucky HEALTH and will not see any changes to their current benefits. These populations will also not be required to participate in cost sharing, community engagements or other aspects of the Kentucky HEALTH program. In essence, these populations will see no change. Members included in any waivers are not enrolled with MCO’s, they are strictly State Medicaid members. 4

The populations listed on this slide, as well as the next, are impacted by Kentucky

• HEALTH. Traditional Medicaid Adults are those that were eligible prior to expansion.

These members will receive the State Benefit Plan however, they will be subject to premiums or copays and have a Community Engagement Requirement. The Medicaid Expansion Adults will receive the ABP and will also be subject to premiums or copays and the Community Engagement requirement. 5

Pregnant Women and Children will be cost share exempt meaning they will not have premiums or copays and will also be exempt from Community Engagement

• Requirements. These members will see no change in benefits as they will receive the

State benefit Plan. Medically Frail Adults and Former Foster Care Children (up to age 26) will mirror the pregnant women and children population with the exception of being cost share

• ptional. While these members are not required to pay premiums or copays, they do

have the ability to opt-in to the premium plan if they wish to have access to My Rewards Account. Benefits for this population to have an active, funded My Rewards Account would be in the event they are no longer deemed Medically Frail or after age 26 for Former Foster Care they will enter the ABP/State Plan with a My Rewards Account safety net 6

Passport’s Kentucky HEALTH members will have the new Kentucky HEALTH insurance ID card which reflects the Kentucky HEALTH logo in the upper right corner. 7

Passport’s Kentucky HEALTH members can also be identified by their plan product code. This is a 4-digit code, known as the members Line of Business or LOB, that will indicate the Kentucky HEALTH plan the member is currently enrolled in. The chart you see on this slide is also in your folders. Please note the member LOB is specific to Passport Health Plan only. This is not something you will see on any other MCO portal or within HealthNet. If the 1st digit is a W this will indicate a Kentucky HEALTH member. The 2nd digit will indicate the type of member such as child, Former Foster Care, Medically Frail, etc. The 3rd digit will indicate if a member is retroactive or not as the O will indicate not retroactive while the R will show they are retroactive. The 4th digit will show the members cost share requirement. Notice the C will indicate they are copay required. These codes are listed in the members profile within the Provider Portal. It is important to utilize HealthNet as the source of truth for all member eligibility information such as effective date, etc. 8

Kentucky HEALTH introduces members to cost sharing aspects such as monthly premiums or copays. Members will NEVER pay both a premium and a copay. Monthly premiums range from $1-$15 and are based on the members FPL. Third parties such as family members, friends, etc. may make premium payments on behalf

• f members. Members can also pay their premiums in advance. For example, if their

monthly premium is $1, they are able to submit a $12 payment and be covered for the year. Members enrolled in the premium plan have access to My Rewards Account. Members are invoiced by their MCO and have 60 days from the date of invoice to make their premium payment. These can be made in person, by mail, over the phone or via the member portal. Households that are have members enrolled with different MCO’s will have to make a premium payment to EACH MCO. Households enrolled with the same MCO will make one premium payment. In the event a member does not make their premium payment on time they may be subject to a penalty. Members who are at or below 100% FPL will transition to the copay plan. They will also have their My Rewards Account suspended and receive a $25 deduction from the account. Members above 100% FPL will be suspended if they were an ongoing paying member and stopped making payments or disenrolled if they never 9

made their first premium payment. Members above 100% FPL will also have their My Rewards Account suspended and receive a $25 deduction from the account. Children, Medically Frail, Former Foster Youth (up to age 26) and Pregnant Women are exempt from any form of cost sharing however, Medically Frail and Former Foster Youth are able to opt-in to the premium plan if they want to have access to a My Rewards Account. 9

Members enter the copay plan due to failure to make their timely premium payments (if they are at or below 100% FPL) however, there are a few instances where members can come directly into the copay plan such as: Adult members transitioning into Kentucky HEALTH from non-MAGI Medicaid, Medically Frail members losing their Medically Frail status, members transitioning from pregnant to non-pregnant. Presumptive Eligible members and for members who age out. Any member on the copay plan has the ability to get back to the premium plan by clearing any penalties/paying back premiums. Copays are due at the time of service, for a list of copay required services and amounts please refer to the Kentucky HEALTH quick reference guide located in your folders. In the event a member is at or below 100% FPL and unable to make their copay, providers are prohibited from turning them away. Members who are above 100% FPL may be denied services for inability to make their copay. The Passport Provider Portal and Kentucky HealthNet will indicate if a member is above or below FPL so, it is imperative to check the members eligibility before each visit. If you recall, copay required members are identified by the last digit in their line of

• business. For example, if the members last digit of their LOB is a C, you know a copay

will be required for them based of the services being provided during that visit. 10

Copay plan members do NOT have access to their MY Rewards Account. During this time, it is suspended but, may become active again if they transition to the premium

• plan. Members are still able to complete My Rewards activities and earn funds into their

account while enrolled in the copay plan. Copays are deducted from provider claim reimbursement therefore providers should always attempt to collect the members copay. 10

ALL Kentucky HEALTH members will have a $1,000 deductible account that tracks the use of non-preventative services only. Members will not have to pay out-of-pocket to meet any deductible. Members will receive monthly statements showing their account balance and corresponding activity. Deductions from the deductible account are the Medicaid fee- for-service rates as paid to the provider. For example, if a member see’s a provider for a non-preventative visit and the amount paid to that provider is $50, the members deductible account will be deducted in the amount of $50. There is no penalty in the event the account is depleted. There is a 90-day runout period after the end of each year for submitted claims to be counted towards the members deductible. Once the 90-day period is over, members may request to transfer 50% of their remaining deductible account balance to their My Rewards Account, up to $500. The Deductible Account is a tracking mechanism to educate the member on the true cost of their healthcare habits. There is no action needed from the provider in regards to the members Deductible Account. 11

Now that we have covered several topics let’s take a moment to go over a few questions. 12

The My Rewards Account functions similarly to a Health Reimbursement Account and is available to anyone who is actively enrolled in the Premium Plan. Members can earn funds by completing My Rewards Account activities and certain PATH courses. There are also preventative services that have My Rewards funds tied to them such as getting a flu shot. Passport has completed a claims lookback to date of service 1/1/18 to capture any preventative services members may have complete. This information has been communicated to the state and the members MY Rewards Account has been credited accordingly. Members could begin intentionally earning My Rewards Account fund on 4/1 however, any earned funds earned cannot be used for services such as dental and vision until 7/1. In the event a member is moved into the copay plan, their My Rewards Account will be

• suspended. Funds for completed activities can will still be added to a suspended My

Rewards Account however, until the account suspension is lifted, these funds cannot be accessed. 13

As previously mentioned, the My Rewards Account can be used to pay for dental and vision services Registered Medicaid providers who have signed up for access to HealthNet are able to reserve funds up to 60 days prior to the date of service by entering applicable procedure codes and submitting a funds reservation request. If there are enough funds to cover the reservation, a confirmation number will be

• generated. If there are not enough funds, the reservation request will be denied.

Claims must be submitted within 30 days of the date of service indicated in the reservation request. My Rewards Account funds can only be used for services covered under Fee-For-

• Service. My Rewards funds cannot be used for services that are considered non-

covered per Medicaid. Services that are medical in nature will still be covered via the members MCO and NOT through their My Rewards Account. 14

Members who inappropriately use the emergency room for non-emergent visits can be subject to My Rewards penalties. Each non-emergent visit will result in an account

• deduction. The first visit will have a $20 deduction, the 2nd visit will have a $50 and 3 or

more visits will have a deduction of $75 for each visit. There are some exceptions to this:

• 1. If there is a behavioral health diagnosis present on the claim, it will NOT be treated

as a non-emergent visit and there will be no penalty applied to the members My Rewards Account.

• 2. If the member utilized the 24-hour Nurse Hotline 24 hours prior to the visit, it will

NOT be treated as a non-emergent visit and there will be no penalty applied. Members who do not have any non-emergent ER visits for one calendar year will accrue $100 in My Rewards Account funds. Note, this amount may be subject to change per DMS. 15

The Community Engagement program, known as PATH – Partnering to Advance Training and Health, encourages members to get involved in their community by volunteerism, public service, education and employment. Members in the PATH program are required to complete 80-hours of Community Engagement activities per month. Members will receive 90-days notice before their requirement officially begins. Once their requirement begins, members are required to report their hours by the 7th of the following month. All Kentucky HEALTH members are required to complete community engagement hours however, there are some exceptions: children, pregnant women, Medically Frail, primary caregivers of a tax dependent, full-time students, full-time employees working at least 120 hours/month and individuals meeting SNAP/KTAP requirements are exempt from the PATH program and will not have to complete any Community Engagement hours. Qualifying activities and courses range from job skills training to community service. Members can utilize the Citizen Connect portal to review their PATH requirements, see how many hours they have completed for the month and look for community engagement opportunities near them. The Citizen Connect portal will also allow members to submit their completed Community Engagement hours. 16

Northern Kentucky is leading the way for the Community Engagement/PATH program. Beginning on 7/1/18, Campbell County will be the first to have its members begin working towards their Community Engagement requirements. This requirement is being phased in across the Commonwealth through the end of 2018. The Paths 2 Promise counties shown in white and consist of Whitley, Knox, Clay, Bell, Leslie, Harlan, Letcher and Perry are exempt from the PATH requirement through 2018. 17

Education and Training courses are part of the PATH program. The Community Engagement module, Citizen Connect, will have both in-person and online courses members can sign-up for to accrue Community Engagement hours or funds for their My Rewards Account. There are also Education and Training re-entry courses that, when taken, will clear a member’s penalty. Members can log into Citizen Connect to view offered courses as well as sign-up for and complete them. 18

Now that we have covered several topics lets take a moment to go over a few questions. 19

The Premium Assistance program provides assistance in paying premiums for members who have access to an employer sponsored insurance plan. In order for members to receive this benefit, they must submit their employer sponsored insurance information via BeneFind for the state to review. If the plan is determined to be cost-effective, the member will be reimbursed by the State for their monthly employer sponsored insurance premium minus the members Kentucky HEALTH cost share requirement, such as their premium. At this point, State Medicaid will be the members secondary insurance as these members will not be enrolled with an MCO for their Medicaid benefits. 20

Members may be identified as Medically Frail in the event they have a disabling mental disorder, chronic substance use disorder, serious and complex medical conditions or

• ther physician, intellectual or developmental/mental disability. These conditions
• ftentimes affect a members ability to perform activities of daily living such as dressing,

bathing, toileting and eating. Members with HIV/AIDS as identified by the Ryan White Program or who are receiving RSDI are deemed Medically Frail without the need of MCO or provider attestation. Once approved, members are deemed Medically Frail for 12 months. 60 days prior to the end of their 12-month Medically Frail period, the member must obtain attestation to continue their Medically Frail status. Medically Frail members receive State Plan benefits and are cost share optional. These members may elect to pay a monthly premium in order to obtain a My Rewards Account. Medically Frail members will never be required to complete Community Engagement

• hours. They may choose to complete certain activities and/or courses to obtain My

Rewards Funds but, will not have to maintain hours in order to continue to receive benefits. 21

Completed attestation forms are submitted to Passport’s Care Connector team for review and scoring. The submission information is listed in the quick reference guide. Our Care Connectors utilize a standard, DMS approved scoring tool to score the attestation form. Members who have been identified via claims data as potentially Medically Frail will be sent to our Care Connector team for outreach and education. They will also assist the member in setting up doctor appointments to obtain the provider attestation. The Kentucky Medically Frail Clinician Attestation form will be available on our website but, has not yet been finalized by DMS. Any registered Kentucky Medicaid provider has the ability to submit the attestation form, this is not limited to a members primary care provider. Please note the Medically Frail section of your Quick Reference Guide indicates members may self-attest. This has been changed and is no longer valid. Members may call into our Member Services department to request Medically Frail status however, we will ultimately direct them member to their PCP to obtain provider attestation of their Medically Frail status. 21

Non-compliance with Kentucky HEALTH rules such as paying premiums on time, completing recertification on time, reporting changes that affect benefit status timely, meeting CE requirements may result in suspensions, penalties and lockout periods. Non-payment penalties for those that fail to make timely premium payments and are above 100% FPL may require a member to pay an past-due premiums as well as take a certified re-entry course. Members who do not meet their Community Engagement/PATH requirements may become suspended. To lift the suspension members must complete 80 hours of Community Engagement/PATH activities or take a certified re-entry course. Failure to report changes that may result in a member receiving Medicaid eligibility during technically ineligible months such as: income changes, address change and change in household size, may result in a 6-month suspension. Members can lift this suspension by completing a re-entry course. In the event a member feels as though they have been suspended or had a penalty applied they may appeal the decision. All suspension and penalty statuses will be communicated via all platforms such as the member self-service portal and the provider portal. 22

Kentucky HEALTH is very much an evolving program and Passport is committed to keeping our provider network as up to date on these changes as possible. Any and all changes and updates to this program as well as any of the materials you received today will be posted on our website. We encourage you to keep checking the Kentucky HEALTH section of our website under the Provider tab. If you wish to have your provider representative come to your office and provide more information to your staff, we are happy to do so! Please feel free to reach out to us to schedule a time that works for you. 23

For continuing education regarding Kentucky HEALTH we have included a list of Stakeholder Advisory Forums being held by DMS. These forums will provide updates in implementation, offer system demonstrations and answering questions from the

• community. For more information or to RSVP for one of these forums please email

KYHealthTeam@ky.gov. Passport is also educating our provider community across Kentucky until the end of

• May. In your folders are a listing of the next workshops, if you would like to attend

another location or, if some of your office staff were unable to make it today, please visit our website and register! We are also having 3 Kentucky HEALTH webinars. Friday May 18th and 25th we will hold a workshop webinar for those that were not able to attend in person. On June 27th we will offer one last webinar before the 7/1 Kentucky HEALTH go-live date. This webinar will allow us to provide any updates as well as answers questions you may have. To register for one of these webinars please visit our website, passporthealthplan.com and click on the Kentucky HEALTH 7/1/2018 link under the Provider section. 24

If you have any questions about the Kentucky HEALTH program, we are here to help! Our teams are able to assist you and answer any questions you may have. Please feel free to contact the above departments as well as your Provider Relations

• Representative. We have included a copy of our Meet the Team flyer in each of your

folders for your convenience. We strongly encourage you to utilize the Kentucky HEALTH website as it offers a wealth

• f knowledge regarding the program and is current with the latest updates, as we know

this program is still evolving! Passport will be in constant contact with our providers as we learn about any changes and updates to this program. One way we will do this is by eNews, within your folders you will find an eNews sign-up form. Please feel free to complete these forms and leave them on your table if you wish to receive eNews announcements from us! You can also register to receive eNews via our website. 25