kynect, Kentucky s Health Benefit Exchange kynector Training Program

Transcription

1 kynect, Kentucky s Health Benefit Exchange kynector Training Program September 2013

2 Contents 1. Overview of Purpose and Functions kynector Program Structure Exchange Basics Federal and State Operational Timelines 6 2. Overview of kynectors and Insurance Agents Insurance Agents kynector and Insurance Agent Participation Agreements Privacy and Security When Handling Personal Information The Health Insurance Portability and Accountability Act (HIPAA) Complaints, Grievances, and Disputes Public Programs Information Required to Determine Eligibility for Insurance Affordability Programs Citizenship/Lawful Presence State Resident Status Components of Eligibility for Insurance Affordability Programs Household Composition Income Determining Eligibility Overview of Public Programs Available in Kentucky Medicare Medicaid 20 Medicaid Managed Care Organizations KCHIP SNAP TANF (K-TAP) WIC Eligibility for Public Programs Medicare Eligibility Medicaid Under the ACA KCHIP Eligibility SNAP Eligibility 25 Page 1

3 TANF (K-TAP) Eligibility WIC Eligibility Qualified Health Plans (Health Insurance Plans) Individual Coverage Options and Qualified Health Plans (Health Insurance Plans) Insurance Coverage Levels and Health Insurance Plans Understanding Plans and Benefits Out-of-Pocket Maximums and Cost Sharing Reductions Tax Implications: Eligibility for a Premium Subsidy Other Insurance Programs Dental Insurance Other Consumer Scenarios Changes in Eligibility Special Enrollment (Pregnancy, Divorce, Marriage, Death, etc.) Enrollment Renewal Complex or Mixed Eligibility Grandfathered Plans Individual Responsibility Penalties & Exemptions Assisting with Application Mechanics Helping Consumers Correct Failed ID Proofing Resolving Verification Inconsistencies Assisting Consumers with Appeals Other Application Options: Applying via Paper Applications Understanding Eligibility and Facilitating Enrollment for the Small Business Owner Overview of the Small Business Health Options Program (SHOP) Program The Insurance Affordability Test COBRA Conversion Serving Kentucky s Population Sensitivity and Communications Training Sensitivity in Communication Communication Approach Understanding Customer Insurance Needs Risk Aversion 66 Page 2

4 Financial Impact Physical Health Identifying Local Healthcare Professionals Making and Receiving Referrals Understanding and Meeting the Needs of Underserved Populations kynector Resources Eligibility Determination Document Check List Important Phone Numbers Current Eligibility for Public Programs Facilitating Enrollment via SSP Applying online (learning how to use kynect) Using the Standardized Comparison Tool Glossary and Terms Basic health insurance concepts Annual Maximum Co-Insurance Error! Bookmark not defined Copay Deductible Effectuation Exclusive Provider Organization (EPO) Health Maintenance Organization (HMO) Health Savings Account (HSA) Kentucky Access Program (High-Risk Pool) Network Out-of-Pocket Maximums Preferred Provider Organization (PPO) Appendices 83 Page 3

5 1. Overview of kynect, Kentucky s Health Benefit Exchange The Health Benefit Exchange will operate as an online marketplace where individual Kentuckians and employees of small businesses can comparison shop for health insurance based on cost, benefits and quality. By the end of this section, you will be able to: 1.1 Identify the purpose and functions of kynect and the kynector program. 1.2 Comprehend the Office of the Kentucky Health Benefit Exchange (KHBE) s governing structure, operating model, and relationship with key stakeholders. 1.3 Understand how kynect will facilitate the implementation of the Affordable Care Act. 1.4 Recall important dates for both the State and Federal Exchange program plans and open enrollment. Page 4

6 1.1. Purpose and Functions The Commonwealth of Kentucky is implementing an integrated, web-based Health Benefit Exchange solution that fulfills the certification requirements set out by the Center for Medicare and Medicaid Services (CMS) and the Federal Government in response to the Patient Protection and Affordable Care Act (ACA). Throughout this document, the solution being implemented will be referred to as kynect. Health insurance companies, Kentucky consumers, kynectors, Insurance Agents, and Commonwealth employees will be able to access kynect through separate web-based portals. kynect allows user groups to view information they need and interact according to their role: consumer, insurance company, Insurance Agents, kynectors or Commonwealth employee. Through kynect, Kentuckians will be able to determine if they are eligible for premium tax credits or other public programs allowing for more affordable coverage. In order to help Kentuckians become aware of kynect, its purpose and its capabilities, the Office of the Kentucky Health Benefit Exchange (OKHBE) is conducting outreach through various marketing channels. Consumers may see advertisements on television, radio and billboards informing them of kynect kynector Program Structure The kynector program is under the purview of the Kentucky Cabinet for Health and Family Services (CHFS) and the Office of the Kentucky Health Benefit Exchange (OKHBE). Carrie Banahan, Executive Director of KHBE, oversees the kynector program, which is led by Vanessa Petrey, Program Lead. OKHBE also includes an advisory board made of 19 board members and is made up of the following subcommittees: Behavioral Health. Dental / Vision. Education / Outreach. Navigator / Insurance Agent. Qualified Health Plans (known to consumers as Health Insurance Plans). Small Employer Health Options Program Exchange Basics kynect will allow for easy comparison of available insurance plan options offered by participating issuers, based on price, benefits and services, and quality. In addition, individuals can use kynect to determine if they are eligible for new programs or subsidies to make insurance more affordable. These include programs such as premium tax credits or Medicaid expansion and the Kentucky Children s Health Insurance Program (KCHIP). Beginning in 2014, the ACA requires most individuals to have health insurance or be subject to tax penalities. However, that does not mean that every individual must buy a brand new plan. Some health plans in effect as of March 23, 2010 are grandfathered Page 5

7 under the law and will be considered qualified coverage, meeting the mandate to have health insurance beginning January Just as before the ACA passed, employers offering health insurance still have the freedom to change premiums, deductibles, co-pays, and network coverage. However, individual premium rates for health insurance offered through kynect are guaranteed for a one-year period of time Federal and State Operational Timelines Initial Open Enrollment Initial Open Enrollment is October 1 st 2013 to March 31 st Key dates for kynect are as follows: 1. October 1, 2013 to March 31, 2014: Initial open enrollment for 2014 coverage. 2. January 1, 2014: State Marketplaces must be up and running, qualifying individuals to enroll in the programs implemented by the Affordable Care Act. Small businesses, defined as businesses with 50 or fewer employees, may select the plans from kynect they wish to offer to their employees. 3. October 15, 2014 December 7, 2014: The annual open enrollment period occurs. 4. January 1, 2015: State Exchanges must be able to support themselves financially. 5. October 15, 2015 December 7, 2015: The annual open enrollment period occurs. 6. January 1, 2016: Small businesses, defined as businesses with up and including to 100 employees, may select the plans from kynect they wish to offer to their employees. 7. January 1, 2017: The now fully functional and self-supported Exchanges may choose to open enrollment to large businesses Initial Exchange Open Enrollment The initial open enrollment period begins October 1, 2013 and extends through March 31, For each new enrollment during this period, kynect will send a notice of enrollment to the given health insurance Issuer and await a fully-funded effectuation transaction, which will serve as confirmation that the consumer has been successfully enrolled in their selected health plan. During initial open enrollment, coverage start-dates will be as follows: Application Submitted Coverage Start Date 10/1/ /15/2013 1/1/ /16/2013 1/15/2014 2/1/2014 1/16/2014 2/15/2014 3/1/2014 2/16/2014 3/15/2014 4/1/2014 3/16/2014 3/31/2014 5/1/2014 Figure 1: Initial Open Enrollment Period Page 6

8 Annual Exchange Open Enrollment for Individuals In years following the first year of kynect, the open enrollment period for kynect will take place from October 15 December 7. Per regulation 45 CFR , in September 2014, consumers will be sent a Notice of Redetermination from kynect. The notice will ask consumers to inform OKHBE of any changes that have taken place that will result in changes in eligibility. kynectors will play an important role in helping consumers respond to the notice and change plans, if applicable. Why are future Open Enrollments important for kynectors? kynectors will need to be prepared to assist consumers with the plan renewal process. If the consumer does not want to change their plan and has agreed to automatic renewal, no action is required on the part of the kynector. The consumer will be passively enrolled in their current plan. However, the rates for plans may change so consumers may be inclined to adjust their plan l ti Knowledge Check: 1. What will kynect allow Kentuckians to do? 2. By what date must state Exchanges be up and running? 3. When does the initial open enrollment period end? Page 7

9 2. Overview of kynectors and Insurance Agents kynectors will play an important role in facilitating consumer and small business enrollment in a Health Insurance Plan (HIP), Insurance Affordability Program, or Small Business Health Options Program (SHOP) plan by assisting with the kynect application process. Section Goals: 2.1 Recall the three areas in which kynectors will offer services and the level of involvement each role can have with a consumer. 2.2 Recall the role of an Insurance Agent, how they interact with kynect, and how their level of involvement with a consumer differs from kynectors. 2.3 Recall the purpose of the Insurance Agent participation agreement, kynector participation agreement, Entity Administrator participation agreement, and the two primary rules of HIPAA that apply to the kynector program. Page 8

10 Key Duties kynectors will provide services in three areas: - Outreach - Education - Enrollment Federal Requirement The kynector program is Kentucky s adaptation of the Federal requirement for a Navigator program kynectors kynectors will help individuals and small businesses compare different coverage options available through kynect and facilitate enrollment. Overall, kynectors will offer services in the following three areas: Outreach attend community events to raise awareness about kynect, how kynectors can help with enrollment through kynect, and the services available through kynect. Education provide information to individuals and small businesses regarding health insurance, insurance affordability programs, Health Insurance Plan selection and other services available through kynect. Enrollment assist individuals, families, and small businesses with enrollment in Health Insurance Plans, public programs, and insurance affordability programs; and small business owners with online enrollment. kynectors will find a calendar of such events on healthbenefitexchange.ky.gov Federal Expectations and Regulatory Compliance for kynector programs Under the Affordable Care Act (ACA), the kynector program includes the Navigator Program, the In-Person Assistor Program, and the Certified Application Counselor Program. Specific rules and regulations for these programs are found in regulations 45 CFR and 45 CFR and 45 CFR Under the law, kynectors must: Facilitate selection of a Qualified Health Plan (QHP), also called a Health Insurance Plan (HIP), maintain expertise in eligibility, provide referrals to those consumers whom they cannot help, and provide services in a fair and impartial manner. Conduct outreach and education activities to help inform consumers of kynect, the ACA, and answer any questions they may have. Maintain impartiality and provide objective guidance to consumers, kynectors may not be health insurance issuers, stop loss issuers, subsidiaries of such issuers, lobby on behalf of issuers, or receive any compensation from issuers. Refrain from making eligibility determinations and selecting Health Insurance Plans for consumers or enrolling applicants into a HIP. Page 9

11 How do I learn more? Additional details can found on these topics: Topic Full Text of the Law Roles and Responsibilities Conflicts of Interest Location The full verbiage of the law can be found at Section of this training manual Section of this training manual Figure 2: Additional Information Three kynector Roles: Navigator, In-Person Assistors, and Certified Application Counselors The roles of Navigator, In-Person Assistor (IPA), and Certified Application Counselor (CAC) fall under the kynector program. The kynector roles of Navigator, CAC, and IPA are similar but have important differences in their roles and responsibilities: Role Responsibility Personal advising Level of involvement Oversight Navigator Cannot guide an individual towards a given plan May interact with individuals and businesses Kentucky Health Benefit Exchange Conflicts of Interest In-Person Assistor Cannot guide an individual towards a given plan May interact with individuals at home or in person Kentucky Health Benefit Exchange Figure 3: Role Comparison: Navigator, IPA, and CAC Certified Application Counselor Cannot guide an individual towards a given plan May interact with individuals in person, typically at a health provider location Kentucky Health Benefit Exchange, DMS, OKHBE Designated Employees A kynector must meet the conflict of interest standards as outlined in Appendix A. All kynector individuals and entities will have to attest to this information before they can begin acting in their role. kynectors must disclose their role when providing services to the consumer. An outline of what must be disclosed is set forth in Appendix B Performance Metrics Once kynectors are certified through kynect, they are required to submit metrics to OKHBE to provide updates on education, outreach, and enrollment activities: When: Once a month. Page 10

12 How: Metrics will be submitted to OKHBE via a provided metrics template. Who: The metrics template will be submitted to the OKHBE Performance Manager by the entity administrator. What: Appendix C provides a detailed listing of required performance metrics. Why: Metrics will be collected by the OKHBE to monitor entity progress and overall performance of the kynector program, and outreach and education activities. Did You Know? Insurance Agents will continue to be licensed and regulated by the Kentucky Department of Insurance and paid by insurance companies Insurance Agents Insurance Agents are licensed and regulated by the Department of Insurance (DOI). Insurance Agents are appointed by specific insurance companies to sell, solicit, and negotiate their products. Insurance Agent must be registered by the OKHBE to participate on kynect. A registered Insurance Agent may enroll individuals in a Health Insurance Plan offered through kynect Overview of the Insurance Agent Role The role of an Insurance Agent includes negotiating insurance contracts or policies, purchases, or sales in return for a fee or commission. Insurance Agents may not necessarily be appointed by all of the health insurance companies participating on kynect. Insurance Agents are paid commissions by the insurance company with which they are appointed. Insurance Agents represent a health insurance company to provide services for individuals or small businesses in the solicitation, negotiation, or procurement of insurance policies. Insurance Agents offer advice and work to match the health insurance needs of individuals or small businesses seeking coverage with the products and options available. Unlike kynectors, Insurance Agents may select and enroll consumers in Health Insurance Plans through kynect, and provide advice concerning a consumer s best plan choice. Similar to kynectors, Insurance Agents may help consumers apply for premium assistance. How do Insurance Agents impact my role as a kynector? Depending upon the needs of the consumer, Insurance Agents and kynectors will work together to provide a consumer-friendly shopping experience. In some instances, a kynector might refer a consumer to an Insurance Agent. Likewise, an Insurance Agent may refer a consumer to a kynector. For more detailed information regarding referrals, please see to section 7.4 of this document. Insurance Agent Referrals can go in both directions kynector Figure 4: Referral Flow Page 11

13 If I am working with important or personal consumer documents, I file them in a locked cabinet until I can safely dispose of them Regulatory Compliance for kynectors and Insurance Agents The following sections give an overview of required regulatory compliance for all kynectors and Insurance Agents kynector and Insurance Agent Participation Agreements kynectors and Insurance Agents must enter into a Participation Agreement with the OKHBE in order to participate. Please refer to Appendix D for the kynector and Insurance Agent Participation Agreements Privacy and Security When Handling Personal Information It is of the utmost importance and a legal requirement to always be aware of the privacy and security of handling personal information. While performing kynector duties, there is a high likelihood of being exposed to sensitive client information, or Personally Identifiable Information (PII). This personal information may include, but is not limited to: 1. Full name (if not common). 2. Date of birth. 3. Birthplace. 4. Social Security Number. 5. Genetic information. 6. Individual s health insurance policy number or subscriber ID number. 7. Any unique identifier used by a health insurer to identify the individual. 8. Any information in an individual s application and claims history, including any appeals records. kynectors must handle this information carefully, not leaving it in public places or areas where others may be able to access it. Discarding of Personally Identifiable Information should be by shredder, not a trash can or recycling bin The Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) is an overarching federal law which, in part, is intended to protect the privacy of healthcare information and protect against related fraud. According to the US Department of Health & Human Services, the Office for Civil Rights enforces the two overarching rules of the HIPAA: The Privacy Rule and the Security Rule. The Privacy Rule protects the privacy of personally identifiable health information (defined above in section 2.3.2). At the same time, the Privacy Rule is balanced so Page 12

14 that it permits the disclosure of personal health information needed for patient care and other important purposes. Did You Know? Tips to Comply With HIPAA 1. Do not store client information on your laptop, thumb drive, or other electronic device. Detailed information regarding storing of client information may be found in the kynector s contract, MOA, or participation agreement (as applicable). 2. Immediately report any breaches to the OKHBE. 3. If you must leave your laptop in the car, lock it in the trunk. 4. Be cognizant of who can overhear your conversation when providing in-person assistance. The HIPAA Security Rule sets national standards for the security of electronic protected health information and the confidentiality provisions of the Patient Safety Rule. The Rule specifies a series of administrative, physical, and technical safeguards for covered entities to use to assure the confidentiality, integrity, and availability of electronic protected health information. The Rule also contains a special confidentiality provision, which specifically protects identifiable information that is being used to analyze patient safety events and improve patient safety. The Office for Civil Rights enforces the two overarching rules of the HIPAA: The Privacy Rule and the Security rule. How does this apply to me? As a kynector, you must comply with HIPAA, the applicable participation agreement, and the safe handling of sensitive consumer information Complaints, Grievances, and Disputes Conflicts of interest differ from complaints, grievances, and appeals in the following way: Conflicts of interest are preventative in nature (i.e. are in place to help prevent future issues). Complaints, grievances, and appeals are reactive in nature (i.e. are in place to help mitigate issues coming from events that have already occurred). If a complaint is received or questionable or unacceptable practices are identified by the OKHBE regarding a kynector, a preliminary investigation of alleged unacceptable practice shall be conducted by OKHBE. Complaints may be made in regards to kynectors, Insurance Agents, the kynector program, or kynect. If the findings of a preliminary investigation show that the complaint is valid and justified, further action may be taken against the individual or entity in question by the OKHBE or the entity itself (if applicable). Complaints regarding issuers and insurance policies should be filed through the Kentucky Department of Insurance (DOI). kynectors may help consumers with this process. The DOI s website defines two types of complaints: consumer complaints and insurance fraud complaints. The DOI website outlines the process for filing each of Page 13

15 these types of complaints. For additional information, please visit: How does this apply to me? If an IPA (or other kynector) is found to be guiding consumers to a given health plan because they are being paid by an employee that works for the health insurance company, this will be noted as an abuse of their position. A complaint will be raised and an investigation will occur. If the complaint against the IPA is found to be valid, additional action may be taken by the OKHBE or the IPA s entity. Knowledge Check: 1. What are three key activities of kynectors? 2. What are the differences between Navigators, IPAs and CACs? 3. What is the relationship between Insurance Agents and kynectors? 4. Who regulates Insurance Agent? 5. List three tips for complying with HIPAA. Page 14

16 3. Public Programs Federal and state programs are in place to help individuals who may be vulnerable or underserved. By the end of this section, you will be able to: 3.1 Identify the bare minimum requirements an individual must meet when applying for public programs. 3.2 Distinguish between the various public programs available in Kentucky. 3.3 Assist in determining eligibility for these public programs. Page 15

17 3.1. Information Required to Determine Eligibility for Insurance Affordability Programs In order for individuals to participate on kynect, they must be a citizen/lawfully present, not be incarcerated, and be a resident of Kentucky. kynectors may be required to assist consumers in uploading verification documentation to be compliant with these minimum requirements. This applies to public programs as well as private Health Insurance Plans (see Chapter 4). In order for individuals to participate on kynect, they must be a citizen/lawfully present, not be incarcerated, and be a resident of Kentucky Citizenship/Lawful Presence Individual applicants must be either a citizen or be lawfully present in the United States in order to participate on kynect. If citizenship/lawful presence is not verified through Federal data sources, or there is a data mismatch error, the consumer can provide proper documentation within 90 days to complete the verification process. During the 90 day period a consumer will still be able to enroll in Medicaid (if qualified) or enroll in a health insurance plan with Advanced Premium Tax Credit benefits (if applicable). If after 90 days appropriate documentation is not provided, the consumer will receive a notice notifying the consumer of disenrollment if they already enrolled in a plan. Non-citizens/non-lawfully present applicants cannot enroll for coverage on kynect. Categories of lawful presence include but may not be limited to the following types of people: Legal permanent US resident. Qualified alien or non-immigrant under the federal Immigration and Nationality Act, Title 8 U.S.C. For the complete list of lawful presence qualifications, please see Appendix E. Social Security Numbers Citizenship/lawful presence status verification varies based on whether or not an individual has a Social Security Number (SSN), which will be verified via the Federal Data Hub. In order to apply for coverage through kynect, an applicant must have an SSN or his or her status will need to be verified through another of the trusted data sources including but not limited to The United States Social Security Administration or the Department of Homeland Security. Incarceration Status Individuals who are incarcerated are not eligible for insurance affordability programs (Medicaid, CHIP, APTC, CSR) or to purchase a Health Insurance Plan. (see below in the document for program descriptions and details). Incarceration status is expected to Page 16

18 Incarceration Status Using the Federal Data Hub, kynect will ensure that an individual is not incarcerated at the time he or she is applying for insurance. Eligibility Eligibility is based on two components: Household Composition and Income. be verified via external sources. However, if the data source is unavailable for any reason, kynect is to accept his or her attestation without further verification. Regardless of the data source test, an individual can attest to not being incarcerated. If there is a mismatch between the individual s attestation and the data sources, the applicant will be required to submit supporting documentation within 90 days to support their attestation of not having an incarceration status. Individuals who are pending charges are not considered incarcerated for the purposes of kynect and are still eligible for insurance affordability programs. Further, individuals under home incarceration are still eligible to participate on kynect State Resident Status In order to participate on kynect, individuals must be a resident of the state of Kentucky. States have the option to require further documentation to verify residency status, but are not required to do so. If there is a mismatch between the individual s attestation and the data sources, the applicant will be required to submit supporting documentation within 90 days to support their attestation. An OKHBE caseworker will verify the supporting documentation and deem the individual s residency status as acceptable. Kentucky does not have minimum length of residency requirements. 3.2.Components of Eligibility for Insurance Affordability Programs Eligibility is based primarily on two sets of information: household composition and income. kynect will use this information to determine the plans for which an individual is eligible. See Chapter 4 for specific information on Health Insurance Plans Household Composition Determining a household composition is essential to determining the eligibility of each person in the household. kynect will use the number of family members and their ages to determine if an individual is eligible for a specific program. A household is defined by an individual s tax filer status. If an individual filed his or her own taxes in the previous year, they are considered to be in their own household. If the individual had dependents claimed on their taxes, those dependents would also be counted in the same household as the individual. Similarly, if an individual is claimed as a dependent on someone else s taxes, he or she would be included in the other person s household and not have their own household. Note: Household does not mean family or those who live in a single home. The household composition is based solely on the applicant s tax filer status. Households may apply as separate individuals or as one household. However, filing status may affect effect the total benefits received Income Income (from all taxable sources) will be used to project the household s income for the upcoming plan year. When applying online, kynect will prompt an applicant to enter Page 17

19 Income Verification Kynect will verify an individual s income on the Federal Data Hub. projected income for each individual within the defined household for the coming plan year. kynect will then verify that the individual and household has entered the correct income amount via the Federal Hub. The Federal hub will use the SSN of an individual to match the individual to their previous year s reported income. If the difference between these two amounts (self-reported income and Federal Hub Income) varies by more than 10 percent the individual will be prompted to submit verification to kynect that his or her self-reported income should be used. Specific instructions on how to do this will be displayed on the screen (and will also be covered in Exchange System Training for kynectors). If the self-reported income and the Federal Hub income are within 10 percent of each other, the kynect-calculated Modified Adjusted Gross Income (MAGI) will be used to determine eligibility for insurance affordability programs. MAGI is the methodology that uses federal income tax rules and concepts to: Count income Determine household composition and family size Federal income tax rules and concepts of adjusted gross income (with some modifications) are used, but MAGI is not simply a number off a tax return. For a brief overview of the term MAGI, please refer to the Glossary of this Training Manual. Inaccurately reporting income can have two effects on consumers: Underreporting income may lead to larger Advanced Premium Tax Credit (APTC) benefits or improper Medicaid eligibility determination. o Improper Medicaid eligibility determination may cause someone who is not truly eligible to inadvertently qualify for Medicaid. o The APTC error will be reconciled when a consumer completes their taxes and the consumer may have to pay back the overpayment of APTCs received during the year. Overreporting income may cause a consumer to be determined as ineligible for Medicaid when they should in fact qualify. It may also lead to smaller APTC benefits. A tax filer will receive a tax credit for any underreporting of APTCs when they file their tax return. kynectors should instruct consumers to use caution when selecting the amount of APTC applied during the initial shopping period. If 100 percent of APTC is applied and an income increase occurs, the consumer may have to pay back the over applied APTC amount. Page 18

20 Determining Eligibility Based on household composition and income, kynect will determine the household s income level. Income level is measured as a percentage of the Federal Poverty Level (FPL). Please see Appendix F of this training manual for a table defining the income levels (as a percentage of FPL) for each household size. FPL will be updated and published on an annual basis in the Federal Register. This information will be reflected in kynect. This income level will determine whether an individual or household is eligible for insurance affordability programs. What can I do to help consumers? Because eligibility is based on the consumer s projected income and household size, kynectors can help by ensuring consumers have all the necessary information prior to starting an application. Documents to bring could include: Previous year s tax returns to determine tax filer status. Copies of W-2s received by everyone in the household. Information in regards to income from self-employment (if applicable). Information relating to changes in income. Other income-related documentation Overview of Public Programs Available in Kentucky Featured below is a list of public programs. These programs may be administered by the Federal government, state governments, or both. Though Medicare is a public program, I cannot apply through kynect Medicare Medicare is a federal entitlement program that provides health insurance for individuals 65 or older, individuals under 65 with certain disabilities, or individuals of any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). There are four major areas in the Medicare program: Part A: Hospital insurance program. Part B: Medical insurance program. Part C: Medicare advantage program. Part D: Outpatient prescription drug benefit. Note: Medicare is not a program that is available via kynect. It is included here to give a well-rounded overview of programs that kynectors may have exposure to while fulfilling their roles. If a consumer has questions regarding Medicare, please refer them to the DOI, State Health Insurance Assistance Program (SHIP), or an Insurance Agent for further assistance. Page 19

21 Please see section 8.2 for DOI and SHIP contact information Medicaid Medicaid was enacted in 1965 through amendments to the Social Security Act. Medicaid is a means-tested program that is jointly funded by the state and federal governments and managed by the states. Means-tested programs are those available only to individual with income below certain levels. Medicaid provides health coverage to low-income adults, pregnant women and children as well as individuals with disabilities. Individuals gain eligibility by meeting technical and financial requirements. Medicaid is jointly funded by state governments and the federal government. Every state establishes and administers its own Medicaid program and determines the type, amount, duration, and scope of services covered within broad federal guidelines. States are required to cover certain mandatory benefits and may choose to provide other optional benefits, as well. Medicaid Managed Care Organizations Most individuals enrolled in Medicaid will receive their services from a Managed Care Organization (MCO). Enrollment with an MCO will take place directly in kynect, in real time, as part of the consumer application process. Medicaid-eligible consumers, unless exempt from receiving, managed care, will be able to comparison shop both Health Insurance Plans (HIPs) and MCOs. Each household member will be directed to the options available to them by kynect. If a consumer enrolls in Medicaid and they are not exempt from managed care, they must enroll in an MCO. If the consumer does not select a MCO, kynect will select one for them automatically. Please note: Automatic selection will only apply to MCOs. Consumers will not be autoenrolled in Health Insurance Plans or SHOP plans KCHIP KCHIP stands for the Kentucky Children's Health Insurance Program, which provides health insurance for children. To qualify for KCHIP benefits, a child must be younger than 19, not have existing health insurance and whose family income is less than 213% of the federal poverty level, or 218% with the 5% Federal Poverty Level disregard. The program was enacted to provide healthcare to children facing barriers such as prohibitive cost and lack of access to coverage. Note: KCHIP will be available on kynect SNAP The Supplemental Nutrition Assistance Program (SNAP) offers nutrition assistance to low income individuals and families. According to the United States Department of Agriculture (USDA), households have to meet specific income tests unless all members are receiving benefits through Temporary Assistance for Needy Families or Supplemental Security Income (SSI). Most households must meet both gross and net income tests, but a household with an elderly person or a person who is receiving certain types of disability payments only has to meet the net income test. Households, Page 20

22 except those noted, that have income over the amounts listed below cannot get SNAP benefits. Household size Gross monthly income (130% of poverty)* Net monthly income (100% of poverty)* 1 $1,211 $931 2 $1,640 $1,261 3 $2,069 $1,591 4 $2,498 $1,921 5 $2,927 $2,251 6 $3,356 $2,581 7 $3,785 $2,911 8 $4,214 $3,241 Each additional $330 $429 member Figure 5: SNAP Qualifying Household Income Limits (Oct. 1, 2012 through Sept. 30, 2013) * Per the USDA, gross income means a household's total, non-excluded income, before any deductions have been made. Net income means gross income minus allowable deductions TANF (K-TAP) Temporary Assistance for Needy Families, also known as the Kentucky Transitional Assistance Program (K-TAP), is a federal assistance program that provides cash assistance to underprivileged families with dependent children. The funds are distributed through the United States Department of Health and Human Services. The law was enacted in 1997 and aims to provide support to families while helping them become self-sufficient, largely through employment efforts. There is a maximum of 60 months of benefits within a Kentucky resident s lifetime. Note: In the future, consumers may be able to enroll in SNAP, TANF (K-TAP), and other public programs via kynect. As this functionality is not currently available, please refer a consumer to the Department for Community-Based Services (DCBS) for enrollment information in these programs. The phone number for DCBS is found in section WIC The Special Supplemental Nutrition Program for Women, Infants and Children (WIC), is a program for supplemental food, healthcare referrals, and nutrition education for low-income pregnant, breastfeeding/non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. WIC provides: Nutrition education and services; Breastfeeding promotion and education; Page 21

23 A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services. The program aims to deliver the following benefits to qualifying and enrolled individuals: Improved Birth Outcomes and Savings in Healthcare Costs; Improved Diet and Diet-Related Outcomes; Improved Infant Feeding Practices; Immunization Rates and Regular Source of Medical Care; Improved Cognitive Development; Improved Preconception Nutritional Status; and Other various improved outcomes. Note: WIC is not available through kynect; however, the kynect system will ask if an individual wishes to be referred to the WIC program and kynectors may assist with those referrals Eligibility for Public Programs See below for specific details outlining eligibility requirements for public programs. Dual Eligibles Consumers who can receive both Medicare and Medicaid are considered dualeligibles Medicare Eligibility Generally, an individual is eligible for Medicare if they or their spouse worked for at least 10 years in Medicare-covered employment and they are 65 years or older and a citizen or permanent resident of the United States. If an individual is not 65 yet, they might also qualify for coverage if they have a disability or End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant). Additional information on Medicare eligibility can be found at Page 22

24 How can I help consumers who qualify for Medicare? kynectors will be expected to assist consumers who may be eligible for both Medicare and Medicaid benefits. The basic eligibility requirements for Medicare are listed above. However, because Medicare is not offered through kynect, the kynector must be able to direct the consumer (who is interested in receiving Medicare benefits) to the appropriate SHIP coordinator, who can help them apply. SHIP is a program formed to provide information, counseling and assistance to seniors and disabled individuals, their family members and caregivers. SHIP coordinators can be identified by visiting the following websites: or Insurance Agents may also assist consumers in determining if they are eligible for or require Medicare supplement insurance. Under the new Medicaid Expansion, Kentuckians whose income falls under 138% of the federal poverty line will be eligible for Medicaid Medicaid Under the ACA M edicaid Expansion for Low-Income Adults The Commonwealth of Kentucky has chosen to expand its Medicaid program by extending Medicaid benefits to adults who meet existing technical eligibility factors and whose income level is at or below 133 percent of the Federal Poverty Level (FPL). This means that individuals whose income is less than 1.33 times the national poverty line are income eligible for Medicaid benefits. Assets are not considered for this expansion population. In addition, the ACA implemented a 5 percent federal level disregard, if needed to gain Medicaid eligibility. If a consumer is not income eligible when comparing their household income to the established FPL limit the disregard will increase that threshold by 5 percent. This means that those with an income up to 138 percent of the federal poverty level are income eligible for Medicaid. The following example uses 138 percent as the maximum for Medicaid income eligibility. Page 23

25 Medicaid Eligibility Example: Facts An individual named John Smith is married to Joanie Smith. They have no dependents and are legally considered a two person household (based on their tax filing). John and Joanie would like to know if they are eligible for Medicaid. Their annual household MAGI income is $20,000. In 2013, the 100% FPL for a family of two is $15,510. Calculation To determine whether John and Joanie are eligible, John performs the following calculation: 100% FPL for a family of two in US Dollars x Maximum FPL to be eligible for Medicaid = Maximum Income for a family of 2 to be Medicaid Eligible $15,510 x 138% = $21,403 Conclusion John and Joanie s Income < Maximum Income for a Family of 2 to be Medicaid Eligible $20,000 < $21,403 John and Joanie are eligible for Medicaid. Additional Information: kynect will complete the official calculation to determine Medicaid Eligibility. kynectors will not be performing eligibility determinations. For complete FPL charts, please see Appendix F. Additional Information: Some Medicaid eligibility determinations (i.e. long-term care, waivers) may not be supported by kynect. For these examples, refer customers to local DCBS offices for more information. Medicaid for Children In addition to covering adults, Medicaid also provides coverage to children who are living in poverty. There are two kinds of Medicaid for children: Deemed eligible newborns: coverage for children born to mothers who received Medicaid at the time of birth, these newborns receive Medicaid from birth month through their 12 th month. Income is not a factor during this period of coverage Medicaid also covers children based on household income: o Under the age of 1 whose families MAGI income is not more than 195% FPL; o Under age 6 whose families MAGI income is not more than 142% FPL; and Page 24

26 o Under age 18, whose families MAGI income is not more than 109% FPL. Medicaid children are permitted to have other health insurance. Consider the following example: Family Member Income Level Medicaid? Reasoning Father, age % No The income is Mother, age % No greater than 138% of the FPL. Son, age 5 140% Yes Medicaid Expansion Yes, the family income is less than 142% FPL.. KCHIP KCHIP eligibility is determined by family income but only provides health insurance to the child in the family. Figure 6: Medicaid for Children Example Note: See Section 8.3 of this training manual for current Medicaid eligibility guidelines; these will no longer be in use for coverage and plans that begin in January KCHIP Eligibility KCHIP is a program for children younger than 19 who live in families with income between 142% and 213% of the FPL, or 218% with the FPL 5% disregard, that do not have private insurance. KCHIP will be offered through kynect.. Although KCHIP eligibility is determined by the family s household income, the program only provides insurance to children in the family. Note: Section 9.3 of this training manual outlines current KCHIP eligibility guidelines; these will no longer be in use for coverage and plans that begin in January SNAP Eligibility SNAP will not be offered through kynect during the first open enrollment period. However, it will still be important to for kynectors to know basic eligibility requirements to help assist and refer consumers who may be eligible. If questions arise about the program, kynectors may refer consumers to DCBS. Basic SNAP eligibility requirements in the State of Kentucky are as follows: 1. Citizenship 2. Work Registration 3. Resource Test 4. Income Test Page 25

27 The income and resource information can be found at SNAP and K-TAP SNAP and K- TAP will not be available through kynect in the first open enrollment period TANF (K-TAP) Eligibility Similar to SNAP, K-TAP will not be available through kynect during the first open enrollment period. However, kynectors should be aware of eligibility requirements for this program if the consumers have any preliminary questions. Beyond that, kynectors should refer the consumer to the Department for Community Based Services (DCBS). K-TAP provides a short-term cash benefit to families with children under the age of 18, or under age 19 if a full-time secondary student. Most adults who receive K-TAP must participate in a work activity. The K-TAP resource limit is $2,000 for a family. Please see the chart below for K-TAP income limits, Number of Family Members Monthly Gross Income Limits Maximum Payment Amounts 1 $742 $186 2 $851 $225 3 $974 $262 4 $1,096 $328 5 $1,218 $383 6 $1,340 $432 7 $1,462 $482 Figure 7: K-TAP Income and Resource Limits WIC Eligibility Most applicants who receive KTAP, SNAP or Medicaid are eligible for WIC. Applicants are eligible if: The applicant is pregnant or has a pregnant woman or infant in the family who receives Medicaid, or A member of the family receives KTAP, or The household income is at or below 185 percent of the federal poverty level. Individuals can also use the WIC prescreening tool to determine if they are eligible: Please refer to the following income guideline chart for the WIC program: Page 26

28 Figure 8: WIC Eligibility Knowledge Check: 1. What is KCHIP? 2. What percentage of the FPL must families be under to qualify for KCHIP? 3. In Kentucky, what percentage of FPL must families or individuals be under to qualify for Medicaid? Page 27

29 4. Qualified Health Plans (Health Insurance Plans) Under the Affordable Care Act, starting in January, 2014, Health Insurance Plans certified on kynect will provide essential health benefits (EHBs) and follow established limits on cost-sharing (such as deductibles, copayments, and out-of-pocket maximum amounts). By the end of this section, you will be able to: 4.1 List and explain the differences between the five different types of Health Insurance Plan available on kynect. 4.2 Compare Health Insurance Plans with other insurance options. 4.3 Describe the requirements to have dental coverage when purchasing a Health Insurance Plan. Page 28

30 4.1. Individual Coverage Options and Qualified Health Plans (Health Insurance Plans) The sections below outline the important features and key differences between the various Qualified Health Plans that are critical to know when helping consumers during enrollment. Please note: When interacting with consumers, please refer Qualified Health Plans (QHPs) as Health Insurance Plans (HIPs). For the purpose of this manual, QHPs will be referred to as HIPs Insurance Coverage Levels and Health Insurance Plans The Affordable Care Act (ACA) defines a Health Insurance Plan as an insurance plan that meets the criteria noted below: 1. Is certified by an Exchange. 2. Provides essential health benefits (EHBs): a. Ambulatory patient services; b. Emergency services; c. Hospitalization; d. Maternity and newborn care; e. Mental health and substance use disorder services, including behavioral health; f. Prescription drugs; g. Rehabilitative and habilitative services and devices; h. Laboratory services; i. Preventive and wellness services and chronic disease management; and j. Pediatric services, including oral and vision care. k. Additionally, may include oral and dental care. 3. Follows established limits on out-of-pocket spending (such as deductibles, copayments, and out-of-pocket maximums). 4. Meets other Commonwealth insurance and kynect requirements. For more details on these requirements, please see 900 KAR 10:010. These plans must be certified by each Exchange on which they are sold. In Kentucky, the Department of Insurance approves plan rates, forms, and networks and OKHBE certifies the plans before they are sold on kynect. Page 29