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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 optional. 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 1 st digit is a W this will indicate a Kentucky HEALTH member. The 2 nd digit will indicate the type of member such as child, Former Foster Care, Medically Frail, etc. The 3 rd 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 4 th 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 of 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
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