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Oregon Department of Human Services. Healthy KidsConnect and January 1, 2010 Medical Policy Changes. This Training Covers January 1, 2010 Medical Policy Changes. Noncitizen requirement changes Citizenship/Identity documentation requirements for CHIP American Recovery and Reinvestment Act.

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Healthy kidsconnect and january 1 2010 medical policy changes

Oregon Department of Human Services

Healthy KidsConnectand January 1, 2010 Medical Policy Changes


This training covers january 1 2010 medical policy changes

This Training Covers January 1, 2010 Medical Policy Changes

  • Noncitizen requirement changes

  • Citizenship/Identity documentation requirements for CHIP

  • American Recovery and Reinvestment Act


Changes for january 1 2010

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


January 2010 changes for noncitizen children

January 2010Changes 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)


Expanded noncitizen requirement for children

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


Expanded noncitizen requirements for children

Expanded Noncitizen Requirements for Children

Continued

  • Several classes of non-immigrants are also included in the new groups. Examples of non-immigrants are:

    • A child of an individual with special immigrant status under section 101(a)(27) of the INA

    • A fiancé of a citizen, as permitted under section 101(a)(15)(K) of the INA


Noncitizen children

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.


New ncs need resource code

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 NCSand the date will be C

  • N/R NCSC

  • The new NCS need/resource item should be available January 15


Noncitizen children turning 19

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.


Noncitizen documentation requirements

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


Documentation requirements

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


Cip cie coding for noncitizens

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


New save verification requirement

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.


Noncitizen chart

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


Iraq and afghanistan refugees

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.


New chip citizenship documentation requirement

New CHIP CitizenshipDocumentationRequirement

  • 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


Citizenship identity example

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?


Citizenship identity example1

Citizenship/Identity Example

Continued

  • Pend for citizenship verification

  • Code both children with a CIP C/D

    and CIP N/R

  • Open medical benefits for both children

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


American recovery and reinvestment act arra

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


Simplified making work pay credit process

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


Healthy kidsconnect and january 1 2010 medical policy changes

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


Healthy kidsconnect and january 1 2010 medical policy changes

An Overview

of

Healthy KidsConnect (HKC)


Healthy kids

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)


Healthy kidsconnect hkc overview

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


Dhs in partnership with ophp

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


Office of private health partnerships ophp

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


Office of private health partnerships ophp role

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


Healthy kidsconnect overview

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)


Hkc income standard

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


New 301 standard

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


Healthy kidsconnect categories

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


Healthy kidsconnect categories1

Healthy KidsConnect Categories

Continued

Category 1 = a subsidy program based on

the client’s income level

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

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


Healthy kidsconnect categories2

Healthy KidsConnect Categories

Continued

Category 2: For families with income at 201%

up to 301% FPL when the parent has

Employer Sponsored Insurance (ESI)

available for their children through an

employer, but the children are not covered

Category 2 = A portion of the family’s

premium payment is reimbursed


Healthy kidsconnect categories3

Healthy KidsConnect Categories

Continued

Employer Sponsored Insurance Reimbursement

Income from 201% through 250% FPL

  • will have approximately 90% insurance premium reimbursement by OPHP

    Income from 251% through 300% FPL

  • will have approximately 80% insurance premium reimbursement by OPHP


Healthy kidsconnect categories4

Healthy KidsConnect Categories

Continued

Category 3: For families with income at or

above 301% FPL

This is a full pay category. The client will be

required to pay the full premium amount to

receive coverage for their children


Category 3 cont

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


Healthy kidsconnect and january 1 2010 medical policy changes

Eligibility Process

for

Healthy KidsConnect (HKC)


Healthy kidsconnect process

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


Healthy kidsconnect process1

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


Healthy kidsconnect eligibility

Healthy KidsConnect Eligibility

Continued

HKC Eligibility is the same as CHIP with

higher income limits

  • Children under age 19

  • No TPL now or in the last 2 months

    (the 2 months can be waived)

  • No resource limit


Healthy kidsconnect eligibility1

Healthy KidsConnect Eligibility

Continued

HKC eligibility continued

  • Cannot be CAWEM and be eligible for HKC

  • Must document citizenship and noncitizen status

  • Use current and previous month income

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


Healthy kidsconnect eligibility2

Healthy KidsConnect Eligibility

Continued

Date of request (DOR)

  • Follow current date of request process when determining HKC eligibility

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

  • If a redetermination BED code the case


Denials

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


Hkc referrals

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.


Hkc referral process

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)


Hkc referral process1

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


Kca code at 201 up to 301

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


Kca date

KCA Date

KCA (KidsConnect approved for at 201% up to

301% FPL)

The N/R date is determined by:

  • The 45th day from the referral approval date

  • If the 45th day is on or before the 15th code that month, if after the 15th code the next month


Kcr code

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


Approval 201 301 no esi

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 KCAMM/YY

  • N/R KCRMM/YY


Employer sponsored insurance n r code

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 ESPC


Approval 201 301 with esi

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 KCAMM/YY

  • N/R KCRMM/YY

  • N/R ESPC

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


New kc3 code

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


Approval at or above 301

Approval at or Above 301%

HKC approval with income at or above 301%

C/D KC3

N/RKC3MM/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


Close denial at or above 301

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 E01/31/2010)

  • If no time for 10-day

    • add a BED code for the following month to allow for 10-day


Close denial at or above 3011

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


Hkc need group coding

HKC Need Group Coding

On UCMS use the # OHP field for coding the

number in the HKC need group

# OHP ______ (need group for HKC

includes the unborn(s))


New coding example income at 201 up to 301

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

  • The worker determines the applicant is

    approved for HKC on 02/01/2010

  • The worker will determine the 45th day from

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

    C/D KCA

    N/R KCA04/2010


New coding example

New Coding Example

Referral approval date is 02/01/2010, since

February is prorated, the KCR end date will

be:

N/R KCR02/2011


New income code for hkc

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 HPKC4000.00


Cmup view

CMUP view


Cmup view with esi

CMUP View with ESI


Healthy kidsconnect and january 1 2010 medical policy changes

The Worker has the CM Case Set up and Eligibility Coded

What’s next?


Hkc cm case opened

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


Ophp receives cm update

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


Medical start date

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


Kidsconnect enrolled kce

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


New coding after ophp enrollment

New Coding after OPHP Enrollment


Kca process example

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

  • Eligibility worker approves an HKC referral

    • Children have C/D KCA and N/R KCA MM/YY

    • Children have N/RKCRMM/YY

    • Adult has N/R HPKC4135

      Do not add medical start dates


Kca process example1

KCA Process Example

Continued

  • CM system sends case information to OPHP and worker transfers to 5503

  • OPHP receives the case information

  • OPHP determines HKC subsidy amount

  • OPHP does choice counseling with client

  • OPHP explains the premium billing process


Kca process example2

KCA Process Example

Continued

  • OPHP pays insurance premium to HKC insurance carrier

  • HKC insurance carrier enrolls client

  • OPHP sends the enrollment start date electronically to CM system

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


Kca process example with esi

KCA Process Example with ESI

Follow the same process in the previous

example, except:

  • Fax a completed DHS 415H to OPHP

  • Code each child who has ESI available to them with a N/R ESPC


Example of coding at or above 301

Example of Coding at or above 301%


Hkc scenario 1

HKC Scenario 1

Dad, Mom and two children – DOR 01/15/2010

CEM redetermination – BED 03/2010

Pend information is reviewed on 01/30/2010.

The children meet HKC eligibility requirements

and are approved on 01/30/2010

2 month average $3859 – above 201% FPL, but

less than 301%

What steps will the worker take on this case?


Hkc scenario answer

HKC Scenario Answer

Coding on UCMS: # OHP 04 / Coding on CMUP:

  • C/D KCA

  • N/R KCA04/2010 (the 45th day from the approval date is 03/16/2010)

  • Update the BED to 04/2010(matches KCA date)

  • N/R KCR01/2011 (12 month eligibility period, prorated month is not counted)

  • N/R HPKC 3859.00

  • Transfer case online and mail/shuttle application to 5503


Hkc scenario 2

HKC Scenario 2

Dad and his child receiving EXT are at

redetermination. DOR 03/01/2010

2 month average $2651

ESI is available to the child but it is not being

received by the child

In determining eligibility for this case what

information does the worker need that is

different from the previous scenario?


Hkc scenario 21

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?


Hkc scenario 2 answer

HKC Scenario 2 Answer

This is the old EXT start date

45th day from approval date is 04/29/2010 – after 15th roll to next month

12 month eligibility period


Contacts

Contacts

SSP Medical Policy Analysts

(GroupWise) SSP-policy,medical

  • Joyce Clarkson 503-945-6106

  • Michelle Mack 503-947-5129

  • Carol Berg 503-945-6072

  • Christy Garland503-945-6119

  • Vonda Daniels503-945-6088

  • Julie Cherney503-947-2316


Contacts1

Contacts

Continued

  • SPD Policy Analyst

    • Michael Avery503-945-6410

  • Coding Contact

    • Alma Estrada503-947-5304

    • Lisa Stegmann503-945-6725


  • Contacts2

    Contacts

    Continued

    • CAF SSP Medical Trainers

      • Annette Aylett 503-373-7893

      • Heidi Wormwood503-373-7885

      • Terry Kester 503-373-7882

      • Betty Silva503-373-1754

      • LaDonna Lofland503-373-7669

      • Glenda Short503-373-7818

      • Christine Shaw503-373-7673

      • Trevor Baker503-373-7402


    Ophp contact numbers

    OPHP Contact Numbers

    • OPHP Phone number: 1-888-260-4555

    • Fax number: 1-503-373-7704

    • Email: [email protected]


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