How To Get A Medicaid Plan In Kentucky

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1 PRESUMPTIVE ELIGIBILITY FOR MEDICAID SERVICES Provider Certification Training Program 1

2 TODAY S OBJECTIVES INTRODUCE THE FEATURES & OBJECTIVES OF PRESUMPTIVE ELIGIBILITY (P.E.). HIGHLIGHT P.E. BENEFITS & ELIGIBILITY REQUIREMENTS. EDUCATE HOSPITAL OFFICES ON THE P.E. SCREENING & CONFIRMATION PROCESS. DEMONSTRATE THE ON-LINE PROVIDER ENTRY FORM. VERIFY LESSONS LEARNED. ANSWER QUESTIONS. 2

3 WHAT IS PRESUMPTIVE ELIGIBILITY? A PROCESS IN KENTUCKY WHICH EXPEDITES AN INDIVIDUAL S ABILITY TO RECEIVE TEMPORARY COVERAGE FOR MEDICAID SERVICES. 3

4 WHO IS AUTHORIZED TO CONDUCT A PATIENT S P.E. DETERMINATION? EMPLOYEES OF HOSPITALS THAT: HAVE COMPLETED THIS P.E. CERTIFICATION/TRAINING PROGRAM, AND ABIDE BY THE STANDARDS OF THE MEDICAID AGENCY REGARDING P.E., AND CURRENTLY PARTICIPATE IN THE MEDICAID PROGRAM, AND HAVE NOTIFIED MEDICAID OF THEIR ELECTION TO MAKE P.E. DETERMINATIONS, AND HAVE ACCESS TO THE INTERNET. 4

5 EXPECTED RESULTS PATIENTS CAN RECEIVE TEMPORARY COVERAGE PROVIDER PAYMENT ASSURED AS WELL AS FEDERAL FUND PARTICIPATION FOR KENTUCKY AVOID HEALTH RISKS TO PATIENT 5

6 WHAT SERVICES ARE COVERED UNDER P.E.?* Medicaid Covered Services Including: Hospital Pharmacy Emergency Room Services Physician Dental Lab X-Ray *For all groups EXCEPT pregnant women 6

7 RESTRICTIONS FOR PREGNANT WOMEN ONLY Only ambulatory prenatal care services delivered in an outpatient setting. These include: Services furnished by a primary care provider, a rural health clinic, a primary care center, or a federally qualified health care center; Laboratory services ; X-ray services; Dental services, excludes orthodontics; Emergency room services; Emergency and nonemergency transportation; Pharmacy services. Birthing expenses are not covered under PE. 7

8 DURATION OF COVERAGE EFFECTIVE IMMEDIATELY UPON RECEIPT OF P.E. IDENTIFICATION CARD. COVERAGE CONTINUES UNTIL: A MEDICAID APPLICATION IS FILED AND EITHER APPROVED OR DENIED OR ON THE LAST DAY OF THE SECOND MONTH AFTER DETERMINATION OF P.E., IF NO MEDICAID APPLICATION IS FILED. THE INDIVIDUAL CAN APPLY FOR FULL MEDICAID COVERAGE: ONLINE AT IN PERSON AT DEPARTMENT FOR COMMUNITY BASED SERVICES BY MAIL USING PAPER APPLICATION BY FAX USING PAPER APPLICATION BY PHONE CALLING CONTACT CENTER AT KYNECT ( ) 8

9 THE PRESUMPTIVE ELIGIBILITY PROCESS AT PATIENT S INITIAL VISIT: PATIENT APPEARS TO NEED FINANCIAL ASSISTANCE PATIENT COMPLETES INFO. FORM; MEETS FINANCIAL CRITERIA OFFICE SECURES P.E. CONFIRMATION OFFICE ENTERS PATIENT DATA VIA INTERNET OFFICE PRINTS P.E. CARD. 9

10 WHO CAN RECEIVE COVERAGE THROUGH P.E.? INDIVIDUALS WHO: ARE RESIDENTS OF THE COMMONWEALTH OF KY DO NOT CURRENTLY RECEIVE MEDICAID BENEFITS HAVE NOT BEEN APPROVED FOR P.E. BENEFITS DURING THE CURRENT CALENDAR YEAR* AND HAVE MONTHLY FAMILY INCOMES BELOW: 138% FOR ADULTS WITHOUT MEDICARE** 200% FOR PREGNANT WOMEN 200% FOR CHILDREN UNDER 1 147% FOR CHILDREN FROM % FOR CHILDREN *FOR PE FOR PREGNANT WOMEN, LIMITED TO ONE PE DETERMINATION PER PREGNANCY. **FOR ADULTS WITH MEDICARE, INCOME LIMIT IS 29%. 10

11 CATEGORIES OF ASSISTANCE ADULTS: INDIVIDUALS AGE 19 THROUGH 65. INCOME LIMIT DEPENDS ON WHETHER THE ADULT HAS MEDICARE. SEE PREVIOUS SLIDE. PREGNANT WOMEN: WOMEN WHO ARE PREGNANT. THE NUMBER OF UNBORN COUNT IN THE HOUSEHOLD SIZE FOR INCOME ELIGIBILITY. EXAMPLE: SINGLE WOMAN WITH UNBORN TWINS WOULD BE A HOUSEHOLD SIZE OF 3. CHILDREN: UNDER THE AGE OF 19. THE AGE OF THE CHILD WILL DETERMINE WHAT THE INCOME LIMITS ARE. FORMER FOSTER CARE: INDIVIDUALS 19 THROUGH 26 WHO RECEIVED MEDICAID DUE TO FOSTER CARE STATUS UNTIL THEY AGED OUT OF THE PROGRAM AT 18 OR 19 (DEPENDING ON STATE). NO INCOME LIMIT. 11

12 DETERMINING PATIENT ELIGIBILITY ASSIST THE PATIENT IN COMPLETING THE PATIENT INFORMATION FORM. ASSIST THE PATIENT IN CALCULATING MONTHLY FAMILY INCOME TO DETERMINE FINANCIAL ELIGIBILITY. 12

13 PATIENT APPLICATION LET S REVIEW IT NOW 13

14 DETERMINING FINANCIAL ELIGIBILITY ADULTS WITHOUT MEDICARE <138% and ADULTS WITH MEDICARE 29% 2013* P.E. FINANCIAL ELIGIBILITY FAMILY SIZE ANNUAL INCOME FOR INDIVIDUALS WHO DO NOT HAVE MEDICARE ANNUAL INCOME FOR INDIVIDUALS WHO HAVE MEDICARE <138% ANNUAL INCOME 29% ANNUAL INCOME 1 $15,856 $3,336 2 $21,404 $4,500 3 $26,951 $5,676 4 $32,499 $6,840 5 $38,047 $8,004 6 $43,595 $9,168 *FINANCIAL CRITERIA CHANGES ANNUALLY 14

15 DETERMINING FINANCIAL ELIGIBILITY PREGNANT WOMEN <200% 2013* P.E. FINANCIAL CRITERIA (UNBORN CHILDREN COUNT IN FAMILY SIZE) FAMILY SIZE ANNUAL INCOME 2 (MOM AND SINGLE PREGNANCY) $ $ $ $ $63180 *FINANCIAL CRITERIA CHANGES ANNUALLY 15

16 DETERMINING FINANCIAL ELIGIBILITY CHILDREN UNDER 1 <200% 2013* P.E. FINANCIAL CRITERIA FAMILY SIZE ANNUAL INCOME 1 $ $ $ $ $ $63180 *FINANCIAL CRITERIA CHANGES ANNUALLY 16

17 DETERMINING FINANCIAL ELIGIBILITY CHILDREN 1-5 YEARS OLD <147% 2013* P.E. FINANCIAL CRITERIA FAMILY SIZE ANNUAL INCOME 1 $ $ $ $ $ $46438 *FINANCIAL CRITERIA CHANGES ANNUALLY 17

18 DETERMINING FINANCIAL ELIGIBILITY CHILDREN 6-18 YEARS OLD <138% 2013* P.E. FINANCIAL CRITERIA 18

19 DETERMINING FINANCIAL ELIGIBILITY FORMER FOSTER CHILDREN THERE IS NO INCOME LIMIT FOR FORMER FOSTER CHILDREN 19

20 DETERMINING FAMILY SIZE WHEN CALCULATING FAMILY SIZE: Count The Patient Unborn Child/Children Dependent Children living with Patient Don t Count Unborn Child s Father if not married to Patient Dependent Children not living in home and not claimed on tax return Spouse Parents and Siblings under 19 including Step-Parents 20

21 DETERMINING FINANCIAL ELIGIBILITY INCOME SOURCES WHEN CALCULATING INCOME: CONSIDER THE FOLLOWING INCOME SOURCES: WAGES/PAYCHECKS SOCIAL SECURITY ANNUITIES ALIMONY CASH GIFTS PENSIONS CALCULATE MONTHLY INCOME BY: MULTIPLYING WEEKLY INCOME BY 4.33 MULTIPLYING BI-WEEKLY INCOME BY 2.16 MULTIPLYING SEMI-MONTHLY INCOME BY 2 ONLY COUNT THE INCOME OF: ADULT PATIENT AND SPOUSE PARENTS (IF PATIENT IS CHILD UNDER 19) 21

22 TO OBTAIN P.E. CONFIRMATION CALL THE DEPARTMENT FOR MEDICAID SERVICES HELP DESK (866) (8:00 AM 6:00 PM EASTERN) PROVIDE THE FOLLOWING: USER ID (FOUND ON TRAINING CERTIFICATE) MEDICAID PROVIDER ID PATIENT S SOCIAL SECURITY NUMBER IF AVAILABLE (NOT REQUIRED) PATIENT S LAST NAME & FIRST NAME PATIENT S DATE OF BIRTH PATIENT S CHOICE OF MCO RECORD 10-DIGIT CONFIRMATION NUMBER ISSUE A DENIAL LETTER IF HELP DESK DENIES ELIGIBILITY 22

23 ENTERING PATIENT INFORMATION then click on KYHealth Net Next Select Presumptive Eligibility under the Member Tab 23

24 Screen shot of KyHealthnet 24

25 PRINTING TEMPORARY P.E. CARD ONCE INFORMATION HAS BEEN ACCEPTED SYSTEM WILL PROMPT YOU TO PRINT THE TEMPORARY P.E. CARD. OBTAIN SIGNATURE OF HOSPITAL STAFF DETERMINING ELIGIBILITY. OBTAIN PATIENT SIGNATURE (PARENT OR GUARDIAN IF CHILD IS PATIENT). 25

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27 FINAL PATIENT INSTRUCTIONS SUMMARIZE BENEFITS. ANSWER ANY PATIENT QUESTIONS. ENCOURAGE IMMEDIATE APPLICATION FOR FULL MEDICAID. PURPOSE OF FULL MEDICAID APPLICATION. APPLY FOR FULL MEDICAID BENEFIT PACKAGE. APPLY FOR COVERAGE BEYOND THE TEMPORARY P.E. PERIOD. LINKAGE TO OTHER SERVICES. PATIENT EDUCATION. 27

28 AVAILABLE METHODS TO APPLY ONLINE. IN PERSON AT DCBS. OFFICE LOCATIONS: BY MAIL USING PAPER APPLICATION. BY FAX USING PAPER APPLICATION. BY PHONE BY CALLING CONTACT CENTER. 28

29 BOOKKEEPING & BILLING RETAIN ORIGINAL/SIGNED PATIENT INFORMATION FORM IN PATIENT S MEDICAL RECORD. UPDATE YOUR PRACTICE MANAGEMENT PATIENT DATABASE. BILLING PROCESS FOR P.E. IS THE SAME AS MEDICAID. REIMBURSEMENT FOR P.E. SERVICES P.E. CAN BE BILLED THE NEXT BUSINESS DAY FOLLOWING ELIGIBILITY DETERMINATION. 29

30 PRESUMPTIVE ELIGIBILITY & MANAGED CARE INDIVIDUALS WHO RECEIVE PRESUMPTIVE ELIGIBILITY WILL BE PLACED WITH A MANAGED CARE ORGANIZATON (MCO). THE MEMBER MAY SELECT AN MCO AT THE TIME OF APPROVAL. AN AUTO ASSIGNMENT WILL BE MADE IF NO MCO IS SELECTED AND WILL BECOME EFFECTIVE IMMEDIATELY. ANY MCO CHANGE REQUESTED AFTER THE DAY OF ISSUANCE WILL BE EFFECTIVE THE NEXT FEASIBLE MONTH. CHANGES TO MCO CAN BE MADE BY CALLING MEDICAID MEMBER SERVICES , 8 AM TO 5 PM. MEMBER ELIGIBILITY INFORMATION AND MCO ASSIGNMENT WILL BE AVAILABLE ON KY HEALTH NET THE DAY FOLLOWING THE INITIAL DAY OF ELIGIBILITY DETERMINATION. 30

31 LET S CHECK WHAT YOU VE LEARNED! 31

32 1. P.E. STANDS FOR: A. PHYSICAL ENDURANCE B. PRESUMPTIVE ELIGIBILITY C. PRENATAL ELIGIBILITY D. PHYSICIAN EXTENDER 32

33 1. P.E. STANDS FOR: A. PHYSICAL ENDURANCE. PRESUMPTIVE ELIGIBILITY C. PRENATAL ELIGIBILITY D. PHYSICIAN EXTENDER 33

34 2. TRUE OR FALSE ONLY CHILDREN CAN RECEIVE P.E. BENEFITS. 34

35 2. TRUE OR FALSE ONLY CHILDREN CAN RECEIVE P.E. BENEFITS. FALSE! 35

36 3. WHICH OF THE FOLLOWING SHOULD BE INCLUDED WHEN CALCULATING FAMILY INCOME? A. CHILD SUPPORT PAYMENTS B. PARENT S WAGES FROM A JOB SHE QUIT TWO MONTHS AGO C. SOCIAL SECURITY 36

37 3. WHICH OF THE FOLLOWING SHOULD BE INCLUDED WHEN CALCULATING FAMILY INCOME? A. CHILD SUPPORT PAYMENTS B. PARENT S WAGES FROM A JOB SHE QUIT TWO MONTHS AGO. SOCIAL SECURITY 37

38 4. RECITE THE NUMBER FOR THE P.E. HELP DESK

39 5. WHICH OF THE FOLLOWING FIELDS ARE REQUIRED WHEN ENTERING PATIENT INFORMATION IN THE ON-LINE SYSTEM? A. PATIENT S HOME ADDRESS B. PATIENT S DUE DATE (IF PREGNANT) C. PATIENT S DATE OF BIRTH D. ALL OF THE ABOVE 39

40 5. WHICH OF THE FOLLOWING FIELDS ARE REQUIRED WHEN ENTERING PATIENT INFORMATION IN THE ON-LINE SYSTEM? A. PATIENT S HOME ADDRESS B. PATIENT S DUE DATE (IF PREGNANT) C. PATIENT S DATE OF BIRTH. ALL OF THE ABOVE 40

41 CONGRATULATIONS! 41

42 QUESTIONS? 42