kynector Program Training Manual

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

Contents 1. Overview of kynect, Kentucky’s Health Benefit Exchange 4

1.1. Purpose and Functions 5 1.2. kynector Program Structure 5

1.3. Exchange Basics 5 1.4. Federal and State Operational Timelines 6

2. Overview of kynectors and Insurance Agents 8

2.2. Insurance Agents 11

2.3.1. kynector and Insurance Agent Participation Agreements 12 2.3.2. Privacy and Security When Handling Personal Information 12

2.3.3. The Health Insurance Portability and Accountability Act (HIPAA) 12 2.3.4. Complaints, Grievances, and Disputes 13

3. Public Programs 15

3.1. Information Required to Determine Eligibility for Insurance Affordability Programs 16

3.1.1. Citizenship/Lawful Presence 16 3.1.2. State Resident Status 17

3.2. Components of Eligibility for Insurance Affordability Programs 17 3.2.1. Household Composition 17

3.2.2. Income 17 3.2.3. Determining Eligibility 19

3.3. Overview of Public Programs Available in Kentucky 19 3.3.1. Medicare 19

3.3.2. Medicaid 20 Medicaid Managed Care Organizations 20

3.3.3. KCHIP 20 3.3.4. SNAP 20

3.3.5. TANF (K-TAP) 21 3.3.6. WIC 21

3.4. Eligibility for Public Programs 22 3.4.1. Medicare Eligibility 22

3.4.2. Medicaid Under the ACA 23 3.4.3. KCHIP Eligibility 25

3.4.4. SNAP Eligibility 25

Page 1 kynect, Kentucky’s Health Benefit Exchange

3.4.5. TANF (K-TAP) Eligibility 26 3.4.6. WIC Eligibility 26

4. Qualified Health Plans (Health Insurance Plans) 28

4.1. Individual Coverage Options and Qualified Health Plans (Health Insurance Plans) 29

4.1.1. Insurance Coverage Levels and Health Insurance Plans 29 4.1.2. Understanding Plans and Benefits 31

4.1.3. Out-of-Pocket Maximums and Cost Sharing Reductions 31 4.1.4. Tax Implications: Eligibility for a Premium Subsidy 33

4.1.5. Other Insurance Programs 34 4.2. Dental Insurance 35

5. Other Consumer Scenarios 37

5.1. Changes in Eligibility 38

5.1.1. Special Enrollment (Pregnancy, Divorce, Marriage, Death, etc.) 39 5.1.2. Enrollment Renewal 40

5.2. Complex or Mixed Eligibility 41 5.3. Grandfathered Plans 41

5.4. Individual Responsibility Penalties & Exemptions 42 5.5. Assisting with Application Mechanics 43

5.5.1. Helping Consumers Correct Failed ID Proofing 43 5.5.2. Resolving Verification Inconsistencies 43

5.5.3. Assisting Consumers with Appeals 44 5.5.4. Other Application Options: Applying via Paper Applications 44

6. Understanding Eligibility and Facilitating Enrollment for the Small Business Owner 46

6.1. Overview of the Small Business Health Options Program (SHOP) Program 47 6.5. The Insurance Affordability Test 55

6.6. COBRA 56 6.6.1. Conversion 58

7. Serving Kentucky’s Population 62

7.1. Sensitivity and Communications Training 63

7.1.1. Sensitivity in Communication 63 7.1.2. Communication Approach 63

7.3. Understanding Customer Insurance Needs 65 7.3.1. Risk Aversion 66


7.3.2. Financial Impact 66 7.3.3. Physical Health 66

7.3.4. Identifying Local Healthcare Professionals 66 7.4. Making and Receiving Referrals 67

7.5. Understanding and Meeting the Needs of Underserved Populations 67

8. kynector Resources 71

8.1. Eligibility Determination Document Check List 71 8.2. Important Phone Numbers 71

8.3. Current Eligibility for Public Programs 73

9. Facilitating Enrollment via SSP 77

9.1. Applying online (learning how to use kynect) 77 9.2. Using the Standardized Comparison Tool 77

10. Glossary and Terms 78

10.1. Basic health insurance concepts 78

10.1.2. Annual Maximum 78 10.1.3. Co-Insurance Error! Bookmark not defined.

10.1.4. Copay 79 10.1.6. Deductible 79

10.1.7. Effectuation 80 10.1.8. Exclusive Provider Organization (EPO) 80

10.1.10. Health Maintenance Organization (HMO) 80 10.1.11. Health Savings Account (HSA) 80

10.1.13. Kentucky Access Program (High-Risk Pool) 81 10.1.17. Network 81

10.1.18. Out-of-Pocket Maximums 82 10.1.20. Preferred Provider Organization (PPO) 82

11. Appendices 83


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.


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.

1.2. 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.

1.3. 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


under the law and will be considered “qualified coverage,” meeting the mandate to have health insurance beginning January 2014. 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.

1.4. Federal and State Operational Timelines 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.

1.4.1. Initial Exchange Open Enrollment The initial open enrollment period begins October 1, 2013 and extends through March 31, 2014. 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 10/1/2013 – 12/15/2013 1/1/2014 12/16/2013 – 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

Initial Open Enrollment is October 1st 2013 to March 31st 2014.

Initial Open Enrollment


1.4.2. 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 155.330, 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?


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.


2.1. 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.

2.1.1. 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 155.210 and 45 CFR 155.205 and 45 CFR 155.215. 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.

Federal Requirement

The kynector program is Kentucky’s adaptation of the Federal requirement for a Navigator program.

Key Duties

kynectors will provide services in three areas: - Outreach - Education - Enrollment


How do I learn more? Additional details can found on these topics:

Topic Location Full Text of the Law The full verbiage of the law can be found at

http://www.healthcare.gov/law/index.html Roles and Responsibilities Section 2.1.2 of this training manual

Conflicts of Interest Section 2.1.3 of this training manual Figure 2: Additional Information

2.1.2. 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 Navigator In-Person Assistor

Certified Application Counselor

Personal advising

Cannot guide an individual towards a

given plan


given plan


given plan

Level of involvement

May interact with individuals and

businesses

May interact with individuals at home

or in person

May interact with individuals in person, typically at a health

provider location

Oversight Kentucky Health Benefit Exchange

Kentucky Health Benefit Exchange

Kentucky Health Benefit Exchange,

DMS, OKHBE Designated Employees

Figure 3: Role Comparison: Navigator, IPA, and CAC

2.1.3. Conflicts of Interest 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

2.1.4. 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.


http://www.healthcare.gov/law/index.html

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.

2.2. 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.

2.2.1. 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.

Figure 4: Referral Flow

Insurance Agent

kynector

Referrals can go in both directions

Insurance Agents will continue to be licensed and regulated by the Kentucky Department of Insurance and paid by insurance companies.

Did You Know?


2.3. Regulatory Compliance for kynectors and Insurance Agents The following sections give an overview of required regulatory compliance for all kynectors and Insurance Agents.

2.3.1. 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.

2.3.2. 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.

2.3.3. 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

“If I am working with important or personal consumer documents, I file them in a locked cabinet until I can safely dispose of them.”


that it permits the disclosure of personal health information needed for patient care and other important purposes.

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.

2.3.4. 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

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.

Did You Know?

“The Office for Civil Rights enforces the two overarching rules of the HIPAA: The Privacy Rule and the Security rule.”


these types of complaints. For additional information, please visit: https://insurance.ky.gov/static_info.aspx?static_id=1.

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.


https://insurance.ky.gov/static_info.aspx?static_id=1

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.


3.1. Information Required to Determine Eligibility for Insurance Affordability Programs

3.1.1. 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

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.”


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

3.1.2. 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.

3.2.1. 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.

3.2.2. 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

Using the Federal Data Hub, kynect will ensure that an individual is not incarcerated at the time he or she is applying for insurance.

Incarceration Status

Eligibility

Eligibility is based on two components: Household Composition and Income.


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.

Kynect will verify an individual’s income on the Federal Data Hub.

Income Verification


3.2.3. 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.

3.3. 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.

3.3.1. 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.

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.

“Though Medicare is a public program, I cannot apply through kynect.”


Please see section 8.2 for DOI and SHIP contact information.

3.3.2. 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 auto-enrolled in Health Insurance Plans or SHOP plans.

3.3.3. 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.

3.3.4. 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,


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 member $429 $330

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.

3.3.5. 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 8.2.

3.3.6. 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;


• 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.

3.4. Eligibility for Public Programs See below for specific details outlining eligibility requirements for public programs.

3.4.1. 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 http://www.cms.gov.

Consumers who can receive both Medicare and Medicaid are considered dual-eligibles.

Dual Eligibles


3.4.2. Medicaid Under the ACA

Medicaid 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.

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: http://chfs.ky.gov/dail/ship.htm or www.medicare.gov.

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.”


http://chfs.ky.gov/dail/ship.htm

http://www.medicare.gov/

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 12th 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

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.


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 30 140% No The income is greater than 138% of the FPL. Mother, age 30 140% No

Son, age 5 140% Yes –

Medicaid Expansion

Yes, the family income is less than 142% FPL..

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 2014.

3.4.3. 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 2014.

3.4.4. 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

KCHIP

KCHIP eligibility is determined by family income but only provides health insurance to the child in the family.


The income and resource information can be found at www.fns.usda.gov

3.4.5. 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

3.4.6. 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: http://wic.fns.usda.gov/wps/pages/start.jsf. Please refer to the following income guideline chart for the WIC program:

SNAP and K-TAP

SNAP and K-TAP will not be available through kynect in the first open enrollment period.


http://wic.fns.usda.gov/wps/pages/start.jsf

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?


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.


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.

4.1.1. 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.

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.


Metal Level and Catastrophic Plans There are four standard metal level “tiers”: Bronze, Silver, Gold, and Platinum. An additional Catastrophic level plan is available for those meeting special circumstances.

Aside from those qualifying for a Catastrophic level plan, Bronze is the minimum level of coverage required by law. The four metal level plans are designed such that on average, for a given level, the health plan pays a certain percentage of healthcare expenses for the average population. This percentage paid by the plan is called actuarial value. The following table shows the actuarial values associated with each metal level. These are defined by the ACA and must be adhered to by all plans sold on kynect.

Coverage Level

Actuarial Value (+/- 2%) The Impact on the Standard Consumer

Bronze 60% - Generally higher premiums as actuarial value increases - Generally lower deductibles as actuarial value increases - Generally lower copays and coinsurance rates as actuarial value increases, and generally has a higher premium

Silver 70% Gold 80%

Platinum 90%

Figure 9: ACA Plan Coverage Levels – Actuarial Values

The Catastrophic plan is available only for:

• Individuals under the age of 30 at the beginning of the plan year; • Individuals with a hardship; or

o In order to purchase a catastrophic plan due to hardship, individials must show proof of hardship (which includes a certificate of exemption) Please see Appendix G for more information on hardship criteria.

• Individuals without affordable coverage.

o In order to purchase a catastrophic plan due to lack of affordable coverage, individials must show proof of hardship (which includes a certificate of exemption).

If these qualifications are met, individuals may purchase a Catastrophic plan with the coverage level set at the Health Savings Account (HSA) current law levels. However, 3 primary care visits will be exempt from the plan’s deductible. This plan is available only in the individual market. Details on exemptions may be found in section 5.4.

Catastrophic plans provide lower premiums and higher cost sharing, and are available to some consumers.

Catastrophic Plans


4.1.2. Understanding Plans and Benefits As noted above, there are four broad categories (Bronze, Silver, Gold and Platinum) of

plans that consumers may choose to purchase. The main difference between these tiers is the amount the consumer will spend on receiving care versus the amount that the insurance company will spend on providing care.

This should not be confused with the benefits offered through the plans themselves. The benefits for each plan are defined by each individual issuer. Aside from essential health benefits, there are no set benefit levels for each plan tier. Therefore, two plans within the same metal level may have very different sets of benefits. These two plans, while different in the sets of benefits they provide, may cost the same amount to the consumer. Similarly, two plans of different metal levels may have similar benefits. The difference between the two plans would be in how much the consumer would spend on receiving these benefits and how much the issuer would spend.

To better understand the costs associated with a plan, refer to Sections 4.1.3 (Out-of-Pocket Maximums and Cost Sharing Reductions) and 5.1.4 (Tax Implications).

4.1.3. Out-of-Pocket Maximums and Cost Sharing Reductions All individuals and / or households that buy coverage via kynect will have a cap (maximum amount) placed on their total possible out-of-pocket spending. This out-of-pocket spending includes deductibles, copays and coinsurance (please see the glossary for definitions of these terms) that will be paid by the individual. There

How do I help a consumer compare various plans?

kynect will have a plan comparison tool that will allow the consumer to view multiple plans side-by-side, simulating a shopping experience. The comparison tool will outline the costs associated with each plan, the benefits that the consumer will receive, and provide links to the issuer’s provider network. The issuer’s website will also include a Summary of Benefits and Coverage document that details a given plan’s coverage options, insurance products, and more.

As a kynector, you will help a consumer compare each plan based on these factors (plan benefits, cost, and healthcare needs). When choosing a plan, the consumer must weigh his healthcare needs with costs associated with each plan.

Note: Recall that while kynectors can assist a consumer in comparing plans, they may not choose or recommend the plan for the consumer. Out-of-pocket

maximums place a cap on the amount a consumer will spend on receiving care in the given plan year.

Out-of-Pocket Maximums

“When comparing plans, I need to understand my healthcare needs and how much I can spend on receiving care.”


are limits for consumers’ contribution toward these costs which are determined by the issuers when they design their plans. Out-of-pocket maximums referred to in this manual apply for essential health benefits only. Health insurance plans may have separate out-of-pocket maximums for non-essential health benefits, as well.

Cost Sharing Reductions (CSR)

Some of your customers may qualify for cost sharing reductions. These are a mechanism, in the form of subsidies paid directly to the issuer by the federal government, to reduce a consumer’s cost of the deductible, co-pay, and / or co-insurance. Based on the consumer’s relation to the FPL, the amount of cost sharing reduction the consumer receives will impact their plan’s effective actuarial value (see table below). CSRs provide health insurance cost sharing assistance for individuals who are not eligible for Medicaid but whose income is between 100% and 250% of the FPL. These are only available for Silver Plans purchased through kynect.

These reductions are meant to reduce the out-of-pocket costs. This cost sharing reduction is provided by placing a limit on the out-of-pocket expenses that a

consumer will pay based on their income level. This reduction in the cost-sharing effectively increases the actuarial value of the silver plan purchased by the consumer.

Below is a table that defines these values for consumers who purchase silver level plans.

What do Out-of-Pocket Maximums mean to the consumers that I help?

Out-of-Pocket Maximums are important to understand because they determine the most that a consumer will have to pay for healthcare in a plan year. Note that this out-of-pocket maximum is in addition to the premium that the consumer will pay. Consumers should use this as a point of consideration when comparing two similar plans.

Example:

Joe’s monthly premium is $40. His plan’s out-of-pocket maximum is $4000 for the plan year. In this plan year, Joe will pay no more than $4480 in that year for essential health benefits. This is because Joe will pay a premium of $40 per month ($40 x 12 months = $480 in premiums for the year). For all additional covered services, Joe will only pay up to $4000 in total. Payments that count toward this $4000 maximum are his deductible, co-insurance, and may include his co-pays. For a given plan, what is included in Out-of-Pocket Maximums will be defined in the plan’s Summary of Benefits and Coverage.

Please note: When interacting with consumers, please refer to CSR as “Special Discounts”. For the purpose of this manual, CSR will still be referred to as CSR.

Cost Sharing Reductions

Cost Sharing Reductions are only available for silver level plans purchased through kynect.


Income Effective Actuarial Value 100 - 150% FPL 94% 150 - 200% FPL 87% 200 - 250% FPL 73% Above 250% FPL 70%

Figure 10: Out-of-Pocket Maximum for Silver Plan Consumers Based on Income Level

All other metal level plans (Bronze, Gold and Platinum) will also have out-of-pocket maximums for each plan defined by the issuer. However, consumers will not receive assistance from the government on copays, coinsurance, and deductibles for these other metal level plans.

Consumers must qualify for a tax credit (described in 4.1.4 in order to qualify for CSR.

4.1.4. Tax Implications: Eligibility for a Premium Subsidy Under the Affordable Care Act (ACA), beginning in 2014, qualified individuals will be eligible to receive premium tax credits through kynect to help them purchase a Qualified Heath Plan. This includes individuals who are not eligible for Medicare,

Medicaid, or KCHIP and are not offered other coverage options. This payment assistance may be provided in advance (“advanced premium tax credit” (APTC) or taken as a tax credit at the time an individual files their income taxes. This credit is only available through kynect.

The amount of the credit is determined by comparing the federal poverty level (FPL), household income and the premium of the second-lowest cost Silver plan (plan price as applicable for the applicant’s household based on family composition, ages and geographic location).

It is important to note that the credit is based on the premium for a benchmark plan: the second-lowest cost Silver plan available on kynect. A consumer, who wants a higher tier (Gold or Platinum) plan, will not receive additional APTC for the premium cost exceeding that of a silver plan.

For consumers whose Silver plan premium amount exceeds the annual premium limit, the APTC amount equals the difference between the plan premium and annual premium limit.

APTC = Plan Premium – Annual Premium Limit .

Please note: When interacting with consumers, please refer to APTC as “payment assistance”. For the purpose of this manual, APTC will still be referred to as APTC.

“APTC could help me pay my plan premium. The amount of assistance I receive is based on my income level.”


Income Annual Premium Limit

Up to 138% FPL 2% of income 138 - 150% FPL 3 - 4% of income 150 - 200% FPL 4 - 6.3% of income 200 - 250% FPL 6.3 - 8.05% of income 250 - 300% FPL 8.05 - 9.5% of income 300 - 400% FPL 9.5% of income

Figure 11: Premium Limits for Consumers Based on Income

An interactive calculator for both payment assistance and Small Business Tax Credits (as seen later in this manual), please go to: http://healthbenefitexchange.ky.gov/Pages/Interactive-Calculator.aspx

4.1.5. Other Insurance Programs Veterans health benefits and TRICARE are not available via kynect. They are included here to inform kynectors of other options for the consumer they assist.

The programs noted below may meet minimum essential coverage requirements for many individuals. In this case, the fully covered individual will not be required to purchase additional coverage to meet the ACA mandate for individual minimum essential coverage.

Veterans Health Coverage The Kentucky Department of Veterans Affairs (KDVA) was established October 1st, 1998 and is charged with helping veterans and their families obtain all federal, state and local veterans benefits to which they are entitled. KDVA serves the veterans of the Commonwealth in three primary areas of

Example Consumer: Joe Smith

Joe is a single man with no dependents, earns an income at 144% of the FPL ($16,545), and is not offered affordable health insurance by his employer or any other source. If Joe were to purchase a Silver plan which has an annual premium of $1000 via kynect, his:

• Annual premium limit will be 3.5% of his income or .035 * $16,545 = $579.09.

• APTC = Plan Premium per year – Premium Limit = $1,000 - $579.09 = $420.91.

• Joe’s monthly premium owed = $579.09 / 12 = $48.26. If Joe were to purchase a Gold plan with plan premium of $2,000 per year, his APTC amount would still be $420.91. Joe would then be expected to pay the annual balance of $1,579.09 to meet the $2,000 plan premium amount, or $131.59 per month.

“I have TRICARE coverage; therefore I will not be required to buy a new plan on kynect.”


http://healthbenefitexchange.ky.gov/Pages/Interactive-Calculator.aspx

support: healthcare, benefits, and cemetery operations (similar to the US Department of Veterans Affairs). KDVA is committed to fulfilling its mission to help veterans, their families and survivors obtain the benefits they have earned as veterans. For more information, please refer to http://veterans.ky.gov.

TRICARE

Formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), TRICARE is a healthcare program that provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the military Reserves. These benefits include dental and health insurance. TRICARE operates within the United States Department of Defense Military Health System and makes up the civilian care component of the Military Health System (MHS).

4.2.Dental Insurance OKHBE regulations require individuals under the age of 21 to have pediatric dental essential health benefits. If an individual is under the age of 21 and does not otherwise have dental coverage (as a dependent on a family’s plan, under a Health Insurance Plan, etc.), he or she will be required to obtain dental insurance. There are two possible ways to purchase the pediatric dental essential coverage:

• By purchasing a stand-alone dental plan; or

• Selecting a Health Insurance Plan with dental coverage embedded in it.

Stand-alone dental plans may offer adult dental coverage in addition to the required pediatric dental coverage. However, not all plans in kynect will include pediatric dental coverage

Plans that include pediatric dental coverage are considered plans with “embedded” dental coverage. Managed Care Organizations (MCO) will always contain a pediatric dental benefit.

If a consumer with a household member under 21 selects a plan with embedded pediatric dental coverage, they will automatically meet the

requirement to have dental coverage. If they select a plan that does not have embedded pediatric dental coverage, they will be notified by kynect that they must purchase stand-alone dental coverage. This independent coverage will still be purchased in kynect. Stand-alone dental plan rates may be guaranteed or estimated. If the rate is estimated, the premium associated with the stand-alone dental plan may vary based on the consumer’s information.

Note: Premiums for standalone dental plans purchased before March 1st 2014 will not be eligible for APTC in first year of kynect. Any APTC that a consumer would have put toward their dental plan premium will instead be reflected in their tax return for 2014.

“I am 20, so I am required to purchase dental insurance and elected to purchase a plan that includes it.”


http://veterans.ky.gov/

4.2.1. Dental Insurance Out-of-Pocket Maximums Dental out-of-pocket maximums exist for children. For adults, however, out-of-pocket maximums may not apply to dental insurance. Consumers must examine an insurance plan’s schedule of benefits, brochures, or policy to determine if out-of-pocket maximums apply.

Knowledge Check: 1. What are the levels of Health Insurance Plans available on kynect?

How do they differ from one another? 2. What costs are associated with the purchase of health insurance?

Who is responsible for paying each of these? 3. What does APTC stand for and how does it assist consumers? 4. What group of individuals is required to purchase dental insurance

and what are two ways they can do so via kynect? 5. When working with consumers, what are the appropriate titles to use

for APTC and CSR?


5. Other Consumer Scenarios

Section Overview and Objectives

This section outlines scenarios that kynectors may not deal with day to day, but are still very important to know.

By the end of this section, you will be able to: 5.1 Understand when a consumer may need to change their coverage due to a change in eligibility.

5.2 Recognize cases of mixed or complex eligibility and know how to work with consumers in these situations.

5.3 Recall the groups that are exempt from the personal insurance requirement. 5.4 Comprehend the overall application mechanics.


5.1. Changes in Eligibility Consumer life changes may have a substantial impact on their options or plan choices. For this reason, kynectors may be needed to assist consumers outside of the open enrollment period. Generally, consumers are allowed a 30 day period to communicate their changes in circumstances to kynect. Some examples of life changes are shown in the table below:

Examples of Changes in a Consumer’s Life Examples of Changes in Eligibility

An increase in income raises the consumer’s relation to the federal poverty level from below 138% to above 138% FPL.

The consumer is now no longer eligible for Medicaid but may be eligible for a Health Insurance Plan with APTC.

A decrease in income lowers the consumer’s income level from above 138% to below 138%.

The consumer is now eligible for Medicaid. This situation is especially important due to the tax implications associated with the APTC.

Birth of a child. Household composition will change, affecting eligibility and potential subsidies.

Figure 12: Changes in Eligibility

kynectors will be expected to work with consumers to understand when any of these changes occur and how it will affect their coverage options. In addition, kynectors should focus on communicating the requirement to report changes that may affect their eligibility when they conduct outreach activities. This will inform the consumers ahead of time of potential events that could occur in the coming year.


5.1.1. Special Enrollment (Pregnancy, Divorce, Marriage, Death, etc.) Special enrollment periods follow certain qualifying events that require enrollment status changes for an individual or group of individuals. It is important for consumers to be aware of these triggering events and to understand that if a triggering event occurs, they may be required to adjust their health insurance.

Below is a list of potentially common qualifying events. For a complete list, please refer to regulation 900 KAR 10:030E(section 7):

• Death of primary subscriber: If a primary health insurance subscriber dies, action may be required by the dependents to maintain coverage.

• Loss of eligibility for Medicaid/KCHIP or newly eligible for SHOP coverage through a Medicaid/KCHIP waiver.

• Birth, adoption or placement for adoption.

• Marriage.

• Loss of minimum essential coverage.

• An individual completes a permanent move that results in access to new Health Insurance Plans.

• Issuer violation of contract provisions: An individual who demonstrates that the Health Insurance Plans in which the individual is enrolled violated a material

Why is this important to consumers?

Consider the following, example scenario:

A married couple has a 23 year old full-time student, who they claim as a dependent. The annual household income total is $75,000. Therefore, the household is at 384% of the FPL.

However, the child turns 24 during the year and is no longer a dependent for IRS tax purposes due to his age. The household size drops by 1. Because there are fewer people that make up the household, the household effectively increases to 484% of the FPL. At 484% of the FPL, the household income is too high to qualify for APTC or CSR. For more information on how household size relates to the percentage of the FPL, please see Appendix F: FPL Charts.

Because APTC is an advanced tax credit, the IRS will require that the household repays any additional APTC given while the household income is 484% of the FPL. This could result in a large amount of money having to be repaid by the consumers when they file their taxes.

Though kynectors may not offer tax advice, kynectors should bring up the possibility of APTC or CSR eligibility changing based on changes in the consumer’s life. This information may help consumers determine which plan they choose and how they choose to apply APTC benefits (if applicable).

Special enrollments may occur because of a number of factors. Depending on the triggering event, gaps in coverage may or may not be at risk of happening.

Special Enrollments


provision of its contract in relation to the enrollee may be eligible for special enrollment.

• An issuer does not renew (discontinues) a plan: If a plan is discontinued by a health insurance provider, affected consumers will be required to enroll in a new plan or program.

5.1.2. Enrollment Renewal Prior to the annual open enrollment period, an eligibility redetermination will be made. Consumers will be provided notice of the eligibility redetermination and upcoming open enrollment period. Prior to the eligibility redetermination, consumers will be required to authorize kynect to collect the data necessary to complete the determination. There will be a mechanism available for consumers to authorize the collection of this data for up to a period up to 5 years. When a consumer first enrolls in kynect, they will be asked to authorize this automatic eligibility determination.

If the consumer is determined eligible and does not take action to change their plan, at the time of annual open enrollment, the consumer will be passively (automatically) renewed in their current plan. However, if any changes are desired or if the consumer’s current plan is no longer available, the consumer must take action to change their plan selection. kynectors will be expected to help consumers in this renewal process.

kynectors must communicate that if the consumer does not give authorization (of any kind) to collect the eligibility determination data, they will not be eligible to renew their plan or select a new one. This will result in a termination of their coverage after their current plan expires.

Note that the premium and cost-sharing portions of the plan may change. In addition, there may be different plans offered through kynect while others may be decertified. kynectors should encourage individuals to verify that

Do special enrollments work the same way as open enrollment?

Special enrollments can happen at any time during the year. Each type of special enrollment has certain rules associated with it.

As a kynector, it will be your job to help the consumer transition from their old plan to their new plan. You can take the following steps to ensure that they have a smooth transition process:

• Ask the consumer to bring updated income information. • Ask the consumer to update their household composition. • Facilitate a referral (if applicable).

“I want to be able to renew my plan automatically. To do this, I gave kynect permission to connect the Federal Hub each year on my behalf.”


they are renewing the correct plan or may need to consider enrolling in a new plan if their current plan no longer suits their needs.

5.2. Complex or Mixed Eligibility Complex or mixed eligibility is when a household (see the Glossary for the definition of a household), has different people eligible for different programs. Specifically, there may be families where some individuals are eligible for Medicaid or KCHIP while others are not eligible for APTCs. kynect is able to determine eligibility for all insurance affordability programs.

As a kynector, your job will be the same as before: walk the consumer through the enrollment process. kynect will calculate the household’s MAGI income and determine eligibility based on this income and family size. If a household is eligible for APTCs and / or CSRs, the amount or level APTC / CSR will also be determined. After a determination of eligibility, individuals will be shown the available health plans they are

eligible to enroll in. If the consumer is Medicaid or KCHIP eligible, they will need to select a managed care organization (MCO). Those eligible for HIPs (with and without APTC / CSR) will be shown available plans in their service area. At this point, the complex or mixed eligible consumer(s) may compare plans and select the plan that meets their needs.

5.3.Grandfathered Plans Health plans in effect as of March 23, 2010 are grandfathered under the ACA and will be considered “qualified coverage”, meeting the individual mandate to have health insurance beginning in January 2014. Health Insurance plans purchased after March 23, 2010 are considered non-grandfathered plans and must meet all the requirements of the ACA, including the requirement to provide essential health benefits. The grandfathering of plans and the updating of benefits to meet EHB requirements may take place outside of the view of consumers.

In the rare event that a plan is not able to be conformed or is no longer considered grandfathered, consumers will be required to

How can I help a consumer with renewals?

As a kynector, there are two ways you can help a consumer with renewal:

1. Encourage the consumer to give kynect consent to connect with the Federal Data Hub each year for up to five years. This will allow kynect to automatically contact the Federal Hub each year (for up to five years based on the consumers’ choice), verify eligibility information, and renew the plan.

2. Walk the consumer through kynect’s renewal process and screens. This is encouraged for consumers who expect to have changes in their incomes or household compositions in the coming year.

“I live in a mixed eligibility household. I am enrolled in a plan but my children are enrolled in KCHIP.”


obtain insurance to be in compliance with the individual mandate. kynectors may need to help consumers understand how and why they must enroll in appropriate coverage.

5.4. Individual Responsibility Penalties & Exemptions Under the Affordable Care Act, by 2014, most individuals will be required to have health insurance. Those that choose to remain uninsured will be required to pay a federal tax penalty if they are not exempt.

The law allows for certain individuals to be exempt from the mandate to have health insurance by recognizing nine exemptions (see below). Eligibility for two of these exemptions – hardship exemption and religious conscience exemption – are to be determined exclusively by the state Exchanges. However, based on final rules, for applications received prior to October 15, 2014, the KHBE will rely upon The Department of Health and Human Services (HHS) to determine exemptions.

After October 15, 2014, the KHBE must receive the exemption application and issue an eligibility notice. A decision on whether the KHBE will make the eligibility determination for an exemption has not been made at this time. States have the option to rely on HHS to make the determination for exemptions.

Exemptions may be granted based on the following: 1. Religious conscience: The individual is a member of a religious sect that is

recognized as conscientiously opposed to accepting any insurance benefits. 2. Healthcare sharing ministry: The individual is a member of a recognized

healthcare sharing ministry. Health sharing ministries are entities that help share the cost of health insurance, without providing the insurance themselves.

3. Indian tribes: The individual is a member of a federally recognized Indian tribe.

4. No filing requirement: The individual’s household income is below the minimum threshold for filing a tax return. To find out if an individual is required to file a federal tax return, use the IRS Interactive Tax Assistant (ITA).

5. Short coverage gap: The individual went without coverage for less than three consecutive months during the year.

6. Hardship: OKHBE or another insurance Marketplace has certified that the individual has suffered a hardship that makes the individual unable to obtain coverage.

7. Unaffordable coverage options: The individual can’t afford coverage because the minimum amount for the premiums is more than 8 percent of household income.

8. Incarceration: The individual is in a jail, prison, or similar penal institution or correctional facility after the disposition of charges.

9. Not lawfully present: The individual is neither a U.S. citizen, a U.S. national, nor an alien lawfully present in the U.S.


For additional information, please see the following website: http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision.

5.5. Assisting with Application Mechanics The kynect application process has been built to be as simple as possible to use for both the consumer and an assisting kynector. However, in some sections the individual may require additional assistance from the kynector. This section outlines some anticipated areas where additional guidance or information may be needed.

5.5.1. Helping Consumers Correct Failed ID Proofing When a consumer creates their personal account on kynect, per federal law, their identity (ID) must be verified before they can complete their account registration and start using kynect. This step has been put in place to help prevent against ID fraud and / or stolen identity issues. ID proofing will be attempted first via the consumer’s credit information. For many consumers, this check will verify their identity and they will move

on to complete the registration process.

However, for some, this check will not be sufficient to verify their identity, and additional proof of ID will be required. Please be aware that when dealing with consumers who require additional ID proofing, they may be confused or agitated. It will be important to note that ID proofing is not required because they did anything wrong, but rather a necessary step to create an online account in kynect. Without this ID proofing, the system will not allow a consumer to start an application.

In the situation that a consumer’s ID check fails, consumer will be presented with three options to resolve the failure:

1. The consumer will see the ID Proofing company’s phone number on the screen (Experian’s 1-800 number). A consumer may dial this and ask for assistance directly with the company;

2. A kynector can help the consumer scan in paper documentation to prove their identity; or

3. A consumer may request that a kynector, Insurance Agent, DCBS employee, or Customer Service representative complete an application on the consumer’s behalf after the assister verifies the consumer’s identity. To do this, the assister may initiate an application through his or her own assister dashboard.

The consumer has up to 90 days to have their ID verified.

5.5.2. Resolving Verification Inconsistencies Similar to resolving failed ID proofing, kynectors will help resolve any issues arising from verification of the following:

• Citizenship / lawful presence.

• State resident status.

“As a consumer, I initially failed the ID confirmation check. However, I can work with a kynector in two ways to resolve this issue.”


http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision

http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision

• Incarceration status.

• Income levels.

This failed verification will primarily come from a discrepancy between the consumer and the “Federal Hub”. The Federal Hub is a central source of information that will house information about a given consumer’s profile that includes the items listed above. An example of a verification inconsistency may be as follows: A consumer recently lost their job. The Federal Hub has not been updated with this information, so it still indicates that the consumer is earning $36,000 per year. However, at the time of verification, the consumer is actually without a source of income.

In cases of verification inconsistencies, a kynector will guide the consumer through steps to correct their information. To correct their information, the consumer may submit supporting documentation in the following ways:

1. Scan (if applicable) and upload the documentation directly to kynect;

2. Refer the consumer to a DCBS office; or 3. Deliver the documentation to an OKHBE office.

It is important for kynectors to facilitate this process. For example, if they are helping a consumer apply for kynect in the kynector’s office and the consumer realizes that they need more documentation, the kynector should encourage them to gather the documentation, and make another appointment (if necessary) to bring it back and continue the process. If there is a long delay in the consumer filling out their application, the kynector should follow up with the consumer directly to lend any additional help needed.

5.5.3. Assisting Consumers with Appeals kynectors will not be responsible for handling the various appeal processes. kynectors may help the consumer by referring them to the appropriate agencies, or providing access to any necessary forms. Examples of appropriate agencies include DCBS, OKHBE, DOI, the CHFS Ombudsman, or a Customer Service Representative.

5.5.4. Other Application Options: Applying via Paper Applications Though paper applications will be rare, kynectors will be expected to help consumers fill out a paper application if access to a computer is unavailable or impractical. When performing outreach activities where consumers will be signing up via a computer, kynectors are also required to have a paper copy of the application in case there are any consumers that require it.

If a consumer is adamant about using a paper form and the kynector has access to a computer or Self Service Portal (SSP), a kynector should still utilize kynect registration tools to help determine the appropriate eligibility requirements and program qualifications.

In order to receive credit for completed paper application, a kynector must receive the paper application and enter the consumer’s information into the SSP and associate

kynectors can help consumers resolve verification inconsistencies by helping consumers scan and upload supporting documentation.

Verifications


themself with that consumer. Sending the paper application to OKHBE may not result in credit being given to the kynector for having completed the form.

Knowledge Check: 1. What is one scenario where a change in a consumer’s life will result in

a change in their eligibility? 2. What are three examples of special enrollment?

3. What is complex or mixed eligibility? 4. What are three approaches a consumer can take if their ID cannot be

verified by their credit information?


6. Understanding Eligibility and Facilitating Enrollment for the Small Business Owner

Small businesses can provide health plans for employees and may be eligible for tax credits through kynect, Kentucky’s Health Benefit Exchange,

By the end of this section, you will be able to: 6.1 Understand the Small Business Health Option Program (SHOP). 6.2 Understand the participation requirements and administration mechanics

of the program. 6.3 Help small business employers and employees navigate the SHOP

marketplace and make informed decisions regarding their coverage options.

6.4 Explain subsidies, penalties and premium tax credits associated with SHOP.


6.1. Overview of the Small Business Health Options Program (SHOP) Program

Through kynect, the Commonwealth of Kentucky will offer a Small Business Health Options Program (SHOP). This SHOP Exchange provides an additional way for small business owners (50 or fewer employees) to provide quality and affordable health insurance to their employees. The SHOP Exchange allows employers to offer Health Insurance Plans that are both of high quality and affordable to their employees.

The primary benefit for employers buying coverage through the SHOP marketplace is that they will be able to compare several standardized plans from various carriers on a single screen. This will help employers determine which plans are best for their employees without having to visit each issuer’s site alone. Employers may choose to offer plans from multiple issuers to their employees via SHOP.

As seen in section 1.4, as of January 1, 2014, small businesses are defined as businesses with 50 or fewer employees. As of January 1, 2016, small businesses are

defined as businesses with up and including to 100 employees. And as of January 1, 2017, Exchanges may choose to open enrollment to large businesses, defined as businesses with greater than 100 employees.

Please refer to regulation 900 KAR 10:020 for more detailed regulatory SHOP information regarding the information seen in this section.

6.2.Setting up a SHOP Marketplace kynect will support rolling enrollment in the SHOP market starting October 1, 2013. Rolling enrollment allows SHOP employers to set up their initial SHOP plan options for their employees at any point throughout the year. Employers are not required to follow the open enrollment dates that pertain to the Individual

Exchange.

Plans purchased through the SHOP market will be in effect for 12 months, regardless of when they were purchased – they are not bound by the calendar year. For example, if an employee’s plan is effective on May 1, the employee will be covered for 12 months, with coverage ending the following April.

Employees have 30 days after employers set up their SHOP market plans to choose and enroll in a plan. Employees will be notified by the SHOP exchange of upcoming enrollment dates. This entire process of setting up SHOP plan options through to the coverage effective date could take up to three months.

The following section outlines steps that an employer and employees will need to take when setting up a SHOP market and enrolling for benefits. The eligibility criteria for both employers and employees are also outlined in this section. The following is a high level diagram that summarizes these steps:

It can take up to 3 months for a small business to complete the SHOP Exchange process, from set-up to enrollment.

SHOP Initial Enrollment


Figure 13: Setting up a SHOP Market

6.2.1. Employer Setup Employers seeking health insurance coverage for their full-time employees must complete a single application and meet the following criteria:

• The principal business address is in the kynect service area (Kentucky). Or if the principal business address is not in Kentucky, the business has a worksite in Kentucky;

• The employer employs no more than 50 employees (larger employers are not allowed to purchase);

• The employer agrees to offer coverage to all full-time employees; and

• Contributes at least 50% of the employee’s single premium.

The role of a kynector in relation to the SHOP exchange will be twofold – 1. Help Employers:

a. Understand the eligibility requirements to participate in the SHOP marketplace.

b. Navigate the SHOP portal and help them make informed choices in selecting plans that are best suited for their employees.

c. Help employers take advantage of the Small Business Tax Credit program as a means of assistance for employee premium costs.

d. Understand the implications of not offering Health Insurance to their employees.

2. Help Employees: a. Understand the plan choices available through their employer.

b. Compare the plan benefits (including SHOP, individual plans and public programs) and select a Health Plan that best meets their needs.

Specific eligibility requirements must be met by both employers and employees to participate in SHOP.

Eligibility Requirements


Note: Full-time employees are defined as those who work, on average, at least 30 hours per week.

This attestation is followed by the employer completing an employer application, which captures basic information, including:

• Employer name (the name of the business owner or contact person for the group);

• Employer physical address, email address and phone number;

• Employer tax identification number (EIN);

• Primary worksite location;

• Legal company name; and

• Year of established.

Employers must also submit the most recent copy of the Quarterly Unemployment Wage and Tax Report (Form UI-3). In addition, the employer must have a minimum of 75% of their eligible employees participate in the SHOP market (or have valid opt-out reasons to decline coverage) in order to meet the minimum criteria. To help the employers determine how many full-time employees they have, kynectors can refer to guidance from the IRS: http://www.irs.gov/pub/irs-drop/n-12-58.pdf Note: Opt-out reasons are also known as “waivers”.

The employer will be accepted or rejected based on the confirmation of these criteria. If the employer’s application is rejected, there will be a 30 day adjustment period

where an employer can submit additional supporting documentation to verify eligibility.

6.2.2. Employee Setup Full-time employees are eligible to participate in SHOP if they are included in the employer’s roster and marked as active full-time employees. The employee roster that the small business owner submits must have the following information for each of their employees: Employee Name, Social Security Number, Date of Birth, and Tobacco Use (if known). If offered coverage, spouses and dependents are also eligible to participate.

The employee cannot be denied participation in the employer selected health plans even if he or she has outstanding obligations with the selected issuer. Employees enrolled through SHOP are not eligible for APTC or CSR subsidies. For more information on APTC and CSR subsidies, please refer to Chapter 4 of this manual.

Even though employees are offered SHOP plans, they can decline coverage and will be asked to submit a reason for declining coverage.

“As a small business owner, I must be sure to submit my payments on time or else our enrollment will be terminated.”


http://www.irs.gov/pub/irs-drop/n-12-58.pdf

6.2.3. Employer Choice of Plans & Employee Plan Selection

Employer Choice of Plans Once the employee roster is submitted, the employer may then select plans they wish to offer to their employees. The employer may select one or more plans, including plans from multiple issuers to offer to employees. They may also be at various metal levels. For additional information on the various metal levels, please see Section 4.1 of this manual. If multiple plans are offered to employees, the metal levels of the plans must be contiguous or “touching.” For example, an employer could choose to offer Silver and a gold plan to employees; but an employer could not offer a silver and a platinum plan to employees. For more information on SHOP rules, please see 900 KAR 10:020.

Employee Plan Selection After the employer selects plans that he or she wishes to offer, the employees have 30 days to select a plan for themselves (and their dependents) during the open enrollment period. While the employer must give employees at least 30 days to select a plan, a 15 day extension may be requested by the employer to give their employees more days to choose a plan. Therefore, an employee may have up to 45 days to select a plan. Employees who do not wish to choose an employer plan should submit a valid opt-out reason through the kynect system. Valid opt-out reasons will not be counted against the employer’s group participation requirement.

Setup Employer Group in System If the employer has met the requirements, a group enrollment record will be sent to the insurance companies for each plan selected by the Employer group.

6.2.4. SHOP Initial Premium Payment OKHBE, at the end of open enrollment, will validate that the Employer group has met the minimum requirements to participate in SHOP. If the Employer has met the minimum requirements, OKHBE will send an invoice for initial payment to the Employer on the 15th of a given month.

The Employer can pay kynect through:

• Online credit card payment or ACH, with an auto-pay option, or

As a kynector, you will need to guide the employer through the initial SHOP set-up.

After the employees of the small business enroll in a SHOP plan or provide their waiver, the employer will need to pay an initial plan premium. Small business owners may come back to you, their kynector, for help. Refer to Section 6.2.1 for assistance.


• Mail a check or cash to a Commonwealth of Kentucky lockbox facility – OKHBE will then retrieve and process the payments, matching the payments to the employer record.

Once the Employer makes this payment, OKHBE will initiate further processing with Health Insurers. It may take up to 5-7 days prior to complete this process.

6.3. SHOP Enrollment Periods This section outlines additional administrative and enrollment components of the SHOP program.

6.3.1. Ongoing Enrollments There are a few cases where an employee may enroll for coverage through their SHOP enrollment outside of the open enrollment period.

kynectors should be aware of the following situations if an employee of a small business would like assistance outside of open enrollment.

Special Enrollment

Outside of the employer’s open enrollment period, kynect will allow special enrollment for employees due to a change in status or qualifying event. For most triggering events, the special enrollment period is limited to 30 days from the date of the triggering event except when otherwise specified. However, the applicant should be able to specify when the special event took place, in order to determine the coverage effective date.

kynect will allow qualified employees to enroll in an employer plan as a result of any special enrollment-causing events. For a list of these triggering events, please see Appendix H. It is the responsibility of the employer or the employee to notify kynect of the qualifying event within 30 days of the event, in order to select a plan.

SHOP Limited Open Enrollment Period for Employers who do not meet the minimum requirements.

Beginning November 15, 2014, an employer who does not meet the minimum contribution or participation requirements, may still participate on the SHOP Marketplace if the employer applies during the annual limited open enrolment period of November 15th through December 15th.

An employer will have met the minimum requirements when:

• The employer is located in Kentucky (principle business office or primary worksite).

• The employer has 50 or fewer employees on their roster; • The employer agrees to pay at least 50% of the plan’s premium for an

employee; • 75% of their employees are enrolled in kynect or have valid opt-out

reasons to decline coverage. • The employer agrees to offer coverage to all full-time employees.

Kynect will allow special enrollment for employees due to a change in status or qualifying event.

Special Enrollment


Employee Additions for Newly Hired / Eligible Employees

An employee who is hired after the close of the employer’s open enrollment period or an employee who was in a waiting period at the time the employer’s plan took effect will be allowed to enroll in coverage during a special enrollment period.

The start of coverage for the additional employee will depend on when he or she enrolled for health benefits. The following table shows when an employee’s coverage will be effective.

Enrollment Date Coverage Start Date Example

1st – 15th of the Month 1st of the following month

Enrolled: March 10th Coverage Starts: April 1st

16th – 31st of the Month 1st of the second following month

Enrolled: March 20th Coverage Starts: May 1st

Figure 14: Employee Addition Information

Employee Updates and Changes

All employee changes must be reported to kynect via a kynector, the employer or employee directly. kynect will not accept changes to the employee data from issuers. Changes can be made in groups and do not need to be changed one at a time in kynect. kynect will record changes to Employer group information and transmit the changes to the Issuers. A kynector can input a change for the individual through the kynector’s assister dashboard. This is only possible if the individual has associated his or her application with that particular kynector.

If the individual chooses to disenroll from his/her current plan due to geographic coverage area, kynect will notify the individual, employer, Issuer, and CMS of the disenrollment. The individual can then enroll in a new plan if a special enrollment period applies.

Renewal Process Renewals for SHOP coverage happen on an annual basis during a 30 day period prior to the end of an Employer’s plan year. This period is called the employer annual election period. These will happen throughout the year because depending on when the Employer initially applied for coverage.

During the employer annual election period, an employer may change:

• The method by which the qualified employer makes QHPs available to qualified employees

• The employer contribution towards the premium of a qualified employee

• The QHP or QHPs offered to qualified employees

Employers do not have a passive renewal and are required to respond to renewal notifications. Failure to do so will result in termination from SHOP.

All employee changes must be reported to kynect from the employer or employee directly.

Employee Updates


Termination of Employee Coverage and Disenrollment

If, for any reason, an employer needs to terminate coverage for the small business, he or she must do it through kynect and provide proper notice to OKHBE. In accordance with the Insurance Code and the ACA, employers can initiate the termination of an employee’s coverage through kynect or the employer group’s coverage through kynect.

This can occur in three ways:

• Employers can willingly initiate and finalize employee termination from SHOP.

• kynect can initiate a termination if the employer is in violation of the Terms of Agreement of the SHOP Exchange.

• Employees can initiate their own disenrollment from the SHOP Exchange.

In the three above scenarios, kynect will send a notice of the termination request to any applicable issuers so that the issuer may terminate coverage in accordance with state and federal laws. In all termination or disenrollment situations, coverage for an employee’s dependents will be automatically terminated when the subscriber’s coverage is terminated from the same plan.

The following notifications may be sent due to disenrollment and termination of coverage:

• Upon termination of an employee, a notification is sent to the employee and issuers.

• Upon termination of an employer group, a notification is sent to the employer, employees, and issuers.

• kynect will send a notice of special enrollment to the individual so that the employee can enroll for benefits in the individual Exchange.

• Issuers are still required to provide any notices under state or federal law.

As a kynector, how can I help employees and employers with termination? • Help newly disenrolled employees navigate the Individual Market by

facilitating their enrollment in a Health Insurance Plan.

• Explain that these consumers may be eligible for a special enrollment period.

• Explain to the newly eligible consumers what they need to enroll via the individual market:

o Household composition.

o Projected Income for the coming year.


6.3.2. Employee Retroactive Coverage Recall that the special enrollment period is limited, in most instances, to 30 days from the date of the triggering event. The applicant should be able to specify when the special event took place, in order to determine the coverage effective date.

Retroactive coverage means that an applicant may gain or terminate coverage for an event that happened before or after the enrollment date. Birth, adoption, and death are examples of qualifying events that may require a retroactive enrollment or disenrollment. Other qualifying events do not require a retroactive enrollment or disenrollment.

The effective date of coverage in the case of a birth, adoption, or placement of adoption must be the day of the date of birth, adoption, or placement of adoption. Therefore, Issuers must ensure that coverage is effective on the date of birth, adoption, or placement for adoption.

kynect will support mid-month terminations in the case of death. The effective end date of coverage will be the reported date of death. Death should be reported within 60 days of its occurrence, although extenuating circumstances may be handled on a case by case basis.

6.3.3. Ongoing Payments Invoices are generated on the 15th of the month, with payment due by 1st of the following month. The payment courtesy period for the first payment is effective date plus 7 business days. For all subsequent payments, employers will have a grace period of 30 days prior to being terminated by kynect. The employer will receive notice of grace periods and termination via an invoice.

6.4. Subsidies, Penalties and Premium Tax Credits See below for information regarding SHOP subsidies, penalties, and premium tax credits.

6.4.1. Subsidies For Employees: The federal subsidies available on the individual market (Advance Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR)) are not available on the SHOP market.

For Employers: Small business tax credits are available as outlined in the next section.

6.4.2. Small Business Healthcare Tax Credit The Affordable Care Act does not require that small businesses provide health insurance. The ACA offers opportunities to receive tax credits for eligible small businesses that choose to provide insurance to their employees. This credit can be claimed for two years beginning in 2014 (or beginning in a later year) through SHOP.

“Due to the recent birth of my child, I may be able to utilize a special enrollment period to gain retroactive coverage.”


Details of the Tax Credit Program can be found on the IRS website.

6.4.3. Penalties Small businesses (50 or fewer employees) are not required to offer Health Insurance to their employees, so there are no penalties associated with not offering coverage.

Regardless of penalties, employers are still highly encouraged to offer coverage. The Tax credit program can help offset the cost of premiums for employees.

6.5. The Insurance Affordability Test An employee may choose not to purchase coverage on their employer’s SHOP marketplace if the insurance is unaffordable. Therefore, when the individual is comparing SHOP plans, he or she may wish to use a tool called the Insurance Affordability Test (IAT) to assist them in making this determination. Generally, if the employee’s share of the lowest cost plan’s annual premium is greater than 9.5% of their annual household income, it is considered “unaffordable”. The IAT allows consumers to understand if the SHOP plans offered via their employer are affordable given their financial situations. This test is only available in the SHOP market, and will not be available in the individual market. This tool is to be used as a guide and is not a final determination of affordability. A final determination of what is unaffordable can only be determined via kynect based on Federal rules.

As kynectors, you can help consumers better understand whether a Health Insurance Plan or SHOP plan is a better choice for them. Though there will be no screen in the system that allows consumers to compare SHOP plans and individual market Health Insurance Plans side-by-side, kynectors and consumers can help manually compare the various plan options.

Beginning in 2014, this tax credit increases to a maximum of 50% (35% for non-profits) and will be available to small businesses who meet the criteria listed below and who purchase coverage through kynect.

• Fewer than 25 full-time equivalent employees • Pay average annual wages below $50,000 • Contribute 50% or more toward your employees’ self-

only health insurance premiums

“As a small business owner, I may want to provide health insurance to my employees so I can take advantage of the Small Business Health Care Tax Credit.”


Declining SHOP Coverage kynectors must remind the consumer that APTC and cost-sharing reductions will not be available to them if they decline an affordable SHOP plan. In other words, the consumer must pay the full premium and meet all of their out-of-pocket maximums, deductibles and copays for any plan purchased on the individual market if they are declining a SHOP plan.

There may be some exceptions to this (for example, if a SHOP plan does not offer coverage in the consumer’s area or is unaffordable to the consumer). According the ACA and IRS Tax Code, an individual’s coverage may be deemed unaffordable if the consumer is expected to contribute more than 9.5% of his or her household income toward the cost of the plan. When a consumer attempts to buy a Health Insurance plan

on kynect, a check will be performed automatically to examine whether the individual has employer-sponsored insurance available and whether the ESI affordable.

Other valid reasons to decline coverage include:

• Covered through spouse’s insurance

• Covered through parents’ health insurance

• Over 65 and on Medicare

• Covered through Medicaid or CHIP

• Covered by another employer’s Health Insurance Plan

• Covered by TRICARE or other Veteran’s plan

• Covered by an individual health plan

• Don’t live in the health plan service area

• Have an exemption

If the consumer chooses to decline an unaffordable SHOP market plan offered, he or she may apply for a QHP. The individual may also apply for APTC or cost-sharing reductions. Note that APTC is not guaranteed and normal application processing rules apply. For additional information on facilitating appeals, please refer to Section 5.5.3 of this manual.

6.6. COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA), which came into law in 1986, provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. However, this coverage is only available when coverage is lost due to certain specific events. In addition, benefits are only continued when the total cost of the policy, plus an administration fee, is paid by the person electing to continue coverage.

To be eligible for COBRA coverage, an individual must have been enrolled in their employer's health plan when they were employed and the health plan must continue to be in effect for currently active employees. COBRA continuation coverage is available after certain events occur that would, except for the COBRA continuation coverage,

A consumer is generally no longer eligible for APTC if he declines a SHOP plan and selects a Health Insurance Plan.

Forgoing APTC


cause an individual to lose his or her healthcare coverage. These events include the following:

Events that entitle one to COBRA continuation coverage

Length of COBRA continuation coverage

Termination of employee's employment (except for gross misconduct) 18 Months (Former employee and covered dependents)

Reduction of the employee's hours 18 Months

(Former employee and covered dependents)

Death of a covered employee 36 Months

(Spouse and covered dependents)

Divorce or legal separation from the covered employee 36 Months (Spouse and covered dependents)

Employee becomes entitled to Medicare (Part A, Part B or both) 36 Months (Spouse and covered dependents)

Dependent child covered under plan ceases to be an eligible dependent under the plan 36 Months

Person considered to have total disability, according to the Social Security Administration 29 Months

Figure 15: COBRA Qualifying Events

Following these certain events, qualified beneficiaries are given an election period of at least 60 days during which each qualified beneficiary may choose whether to elect COBRA continuation coverage. This period is measured from the later of the coverage loss date or the date the COBRA Election Notice is provided.

COBRA continuation coverage begins on the date that healthcare coverage would otherwise have been lost by reason of a COBRA event. If an individual becomes disabled while under COBRA coverage, they may be entitled to continuing their coverage up to 11 additional months while paying additional premiums.

An individual covered under COBRA, as a former employee no longer receiving benefits, you will usually pay the entire premium amount of their former plan. This premium will be the combination of both the portion of the premium that they paid as an active employee and the amount of the employer contribution. In addition, there may be a two (2) percent administrative fee. While the combined premiums may be higher than when the individual was employed, they will still be paying group premium rates, which are usually lower than individual rates. However, some individuals eligible


for COBRA may be able to qualify for premium assistance through kynect at a lower cost to the individual.

6.6.1. Conversion (KRS 304.18-114) Conversion comes into play when an individual is not eligible or no longer eligible for COBRA or state continuation coverage. Conversion allows an individual to convert a former (or soon to be former) group plan into an individual plan that is very similar in terms of the benefits it gives to the individual. Conversion comes into play, for example, when a group policy is terminated and not replaced by a new policy. There is no time length related to insurance gained from conversion, but there is also no requirement to keep premiums at the level they were during the period of coverage under the group policy.

6.6.2. State Continuation (KRS 304.18-110) State Continuation is similar to COBRA coverage. It was enacted as a failsafe to make sure those who do not qualify for COBRA coverage still have the ability to continue coverage for a defined period of time after termination from a group. Per Kentucky state law, KRS 304.18-110, an individual and their dependent will be able to continue their group coverage upon termination from the group for up to 18 months if they meet the following criteria:

1. The individual has been covered by the plan or any plan that it replaced for at least three (3) months; or

2. The individual must notify the insurer and pay the premium at the group rate within 31 days after they receive a notice of their right to continue coverage.

The individual will remain insured for up to 18 months after the date that the insurance ended by termination of the individual from the group. After the end of the 18 month period, an individual will be allowed to convert to an individual plan that closely resembles the coverage they had through their continuation plan. Coverage may end early if one of two conditions are met:

1. The consumer does not make a timely premium payment to the insurer; or 2. The group policy is terminated and not replaced by another policy within 31

days.

If the group policy is terminated and replaced by another policy, the consumer will continue to have continuation coverage under the old policy. The timeline of coverage will continue uninterrupted.

In addition to the group member, the following parties are also eligible for continuation of coverage:

• A surviving spouse and children whose coverage under the group policy would end due to the death of the group member.

• A child who has been covered as a dependent under the plan has a right to continuation coverage upon reaching the plan’s age limit for dependent status.

• A former spouse and the children in the former spouse’s custody are eligible for continuation benefits when their status as dependents of the group member


ends. This status change would result from a court order dissolving the marriage.

On the effective date of termination from the group insurance policy, an individual does not need to be granted continuation of the policy if they are either eligible for Medicaid or eligible for a new group policy.

Please note: COBRA, conversion, and continuation rules and regulations are subject to change.


6.7. Summary Outlined below is a summary of what was discussed in the previous section:

Consumer Things You Can Help With

How Does it Benefit Them? How Can You Add Value? Resources

Employers (Small Business)

Plan selection and Evaluation

Select the right benefit plan package for their employees

Help employers understand the Plans available and benefits they offer.

Help employers compare plans and select a plan that best meets their needs. Help employers evaluate the benefit levels and options offered by each plan. Help employers balance costs and plan benefits.

On-going Administration

Continuing coverage to their employees

Help Employers understand the timelines and processes associated with Premium payments, employee additions and changes.

Section 6

Small Business Tax Credit Program

Offsets the cost of providing coverage to employees to some extent

Guide small business owners through the process of determining if they are eligible for a tax credit by helping the consumer fill out Form 8941.

http://www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-for-Small-Employers

Employees Plan Selection and Evaluation

Select a plan that best meets their needs

Help employees understand the plans offered on the SHOP portal by their employer and the benefit levels associated with each.

Section 6

Help employees compare costs and evaluate the benefits of electing to enroll in an employer subsidized plan on the SHOP portal vs. a federally subsidized plan on the Individual market

Standardized Summary Of Benefits (SBC’s) available for each plan

For more detailed charts in regards to the Small Business Health Tax Credit tables and Small Business Health Care Tax Credit Eligibility Tool, please see Appendix I and Appendix J, respectively.

60 kynect, Kentucky’s Health Benefit Exchange




Knowledge Check:

1. What is the goal of SHOP and who can benefit from it? 2. During what period of time is the initial SHOP open enrollment period? 3. What are the criteria that a small business must meet to qualify for the

Small Business Health Care Tax Credit? 4. Are federal subsidies available on the individual market (APTC and

CSR) available on the SHOP market? 5. What does COBRA provide?


7. Serving Kentucky’s Population

`

kynectors “will engage in locally-focused work … that is culturally and linguistically appropriate”. January 2013 HHS Guidance on Insurance Exchanges

By the end of this section, you will be able to: 7.1 Communicate with a diverse set of consumers in a culturally sensitive

manner. 7.2 Identify forms of outreach expected of kynectors.

7.3 Walk consumers through key personal factors to consider when selecting a plan.

7.4 Know when and how to refer a consumer to another kynector or Insurance Agent.

7.5 Name specific population segments that might be more likely to require assistance.


7.1. Sensitivity and Communications Training

7.1.1. Sensitivity in Communication While working with consumers in Kentucky, kynectors should use an approach that considers cultural and socio-economic differences in populations. This sensitivity is especially important when meeting consumers in their homes or other places of need. kynectors will be explaining insurance concepts that may be unfamiliar so patience will also be important. A kynector’s demeanor throughout the process can have a significant positive or negative impact on the consumer experience; a friendly and inviting mannerism will be the first step in establishing a position as a trusted member of the community.

7.1.2. Communication Approach Communication skills are of utmost importance when interacting with consumers who wish to enroll through kynect. Effective communication is much more than the ability to speak. It is also the ability to actively listen and understand others, to “read” and interpret body language and to know the best ways to convey information to the consumer. Below are some tips to keep in mind when interacting with consumers. These have been adapted from the University of California, Davis.

Being a better speaker:

• Be considerate. Don’t dominate the conversation. This is about helping the consumer.

• Speak clearly. Don’t mumble or talk in the opposite direction of the listener.

• Use words that you know the listener might understand. Not all consumers will have the same level of understanding regarding insurance terminology.

• Stay focused on the conversation. Doing something else while you are talking, such as typing or working on other things, sends a message to the listener that you don’t think the conversation is worthy of your full attention. This could inhibit the listener’s responses to what you say.

• Learn to “read” the listener. If the other person seems inattentive or uncomfortable, it is probably not a good time to lead the conversation. Find out what will make them more comfortable, and ease the discussion.

“As a kynector, I work on listening intently to a consumer to understand their background before taking them through the enrollment process.”


Being a better listener:

• Eliminate distractions. If you find it hard to concentrate because of your surroundings, the consumer might as well. If distractions are interfering with comfortably communicating with the consumer, think about ways to make the setting more open for dialogue.

• Make time to listen. If you are in a hurry or don’t have time, let the speaker know and schedule another time to talk.

• Practice reflective listening. Repeat what you think the speaker said to ensure you heard the speaker correctly. This is called “reflective listening” and it is identified by statements as “If I understand you correctly...” and ensures that both the speaker and the listener understand each another.

• Wait for the speaker to finish. Don’t interrupt, even when it’s apparent the person speaking is gathering his/her thoughts.

• Pay attention to what is being said. When someone is speaking, don’t spend that time preparing your remarks or working on a project – listen.

• Keep eye contact. Doing so shows that you are interested in what is being said, this may encourage the speaker to express him/herself more freely.

Effectively Working with an Interpreter:

• Do not use family members as interpreters unless requested by the consumer.

• Never use children under 18 as interpreters.

• Use “certified” interpreters whenever possible.

• Talk directly to the individual consumer (Do not talk about the consumer in the third person to the interpreter)

• Interpreter may be able to explain or clarify the communication, but interpreters shouldn’t be giving them their advice or opinions.

7.2. Conducting Outreach and Raising Awareness Conducting effective outreach and raising awareness will be vital to the success of the kynector program. OKHBE will be conducting outreach and raising public awareness through a variety of media. These include television advertisements, billboards, radio advertisements and more.

In addition to OKHBE’s marketing and outreach, kynectors must possess the ability to effectively communicate with consumers from a wide variety of social and economic backgrounds. Careful considerations must be made when determining how best to reach a group of consumers. There will not be a “one size fits all” solution, especially given the diverse Kentucky population.

kynectors should be pro-active in going to outreach events to handout materials and educate consumers. Here is a small list of examples of sources to reach groups of consumers:

One of the quickest ways to build trust with a consumer is to speak clearly and listen effectively.

Communicating Effectively


• County fairs.

• Charity events.

• Book clubs.

• Religious groups.

• PTA meetings.

• YMCAs.

• Home Education Association meetings.

• Union or employee Meetings.

• Local club meetings.

•Events hosted by OKHBE.

When conducting outreach and education activities, kynectors should consider the specific audiences that could attend each of these events. It’s best to send your intended outreach event list to OKHBE for review prior to committing to an event. The events should focus on helping Kentuckians understand what kynect is, how healthcare reform applies to them, and what kynectors can do to help them with their enrollment.

To help kynectors prepare for outreach events, OKHBE has provided several fact sheets that kynectors may pass out at events. Consumers can take these fact sheets home with them as well. These can be found on kynect: http://kynect.ky.gov, the Self-Service Portal. Additional marketing materials may also be requested through this website. OKHBE will determine the availability and cost for these materials on a case by case basis.

kynector entities may also create their own informational pamphlets, brochures and marketing materials. However, all additional materials created are required to be approved by OKHBE. For approval from OKHBE, please have the entity administrator send prototype materials to OKHBE. kynectors may only use their own materials after receiving written approval from OKHBE.

7.3. Understanding Customer Insurance Needs Understanding the insurance needs of each individual customer is critical to understanding how to help them navigate kynect and the associated health insurance options. kynectors will also be expected to help consumers understand how to calculate items like their personal premium costs and expenses via kynect by walking consumers through the pre-screening tools. When walking consumers through these tools, it is very important to remember that kynectors cannot be biased and suggest a specific plan.

Regardless of role, a kynector will use kynect’s tools and guidance documents to empower customers to come to an appropriate decision around their insurance needs. Additionally, a good understanding of the individual seeking insurance’s risk aversion, financial situation, and physical health will allow for more effective communication between both parties.

“As a kynector, I hope to find success in setting up outreach meetings at my local YMCA.”


http://kynect.ky.gov/

7.3.1. Risk Aversion One factor in helping a consumer understand the different options available is to help them think about how risk averse they want to be. In the context of selecting a health plan, generally a plan with higher cost-sharing (deductible / co-pay / coinsurance / out-of-pocket maximum) and lower premium would be attractive to someone who is willing

to “chance” that they will not require significant healthcare services in the year. Somebody who does not like the idea of having such a large unknown financial cost might be more inclined to pay a higher premium every month in exchange for fewer “surprises” by way of lower cost-sharing expenses.

7.3.2. Financial Impact Understanding the impact to a consumer’s finances is another consideration when comparing plans. Because of the larger cost-sharing for a plan with lower premium, a consumer should be able to pay their portion of the cost-sharing to the extent that they required healthcare services. A key question to ask the consumer is if they have the finances and discipline to set aside a pool of money to cover a higher potential out-of-pocket cost.

7.3.3. Physical Health Understanding one’s physical health is a final key consideration in selecting a health plan. Generally a healthier consumer might consider a plan with higher cost-sharing and lower premiums on the expectation that their requirements for healthcare services will be low.

7.3.4. Identifying Local Healthcare Professionals kynectors will also play a role in helping consumers find healthcare providers. kynectors are expected to proactively make themselves available to those

looking for local healthcare providers and also be familiar with healthcare care resources in the area.

An example of why this is important is as follows: Some rural areas of Kentucky have more limited healthcare options than urban areas. With limited options, it will be important to know which of the insurers are in network (defined in the Glossary section of this document) for a given Health Insurance Plan. This information will allow qualifying individuals to make important decisions regarding which Health Insurance Plan is right for them. This information must be presented in an impartial and unbiased way by those in the role of an In-Person Assistor or Navigator.

Another consideration in identifying local healthcare providers is whether a plan includes out of state providers within its network or not. For example: Consumers who travel frequently or live near the state borders might consider access to providers outside of the Commonwealth.

For the most up to date information on providers and specific plans and networks, please refer to the insurer’s website. kynect will have updates to this information every quarter. However, issuers will update their network coverage regularly. This will serve as the best resource for

“I was able to verify through kynect that my child’s pediatrician will accept my new plan.”

“As an unmarried and generally healthy consumer, I am considering a plan with lower premium and higher cost-sharing.”


consumers to find providers in their network.

For most up to date information on prescription drug formularies, visit the issuer’s website as well. Insurance Companies

There will also be a tool on the Self-Service Portal that will allow consumers to search for healthcare providers (physicians, clinics, etc.) in order to make an informed decision on which plan to purchase. The tool will allow consumers to search for providers. After searching for providers, consumers may then go to the insurance company’s website to verify that their chosen provider is in-network. This approach may also allow consumers to more quickly look at detailed information about what services certain insurers offer with their plans (i.e. what medications are covered).

7.4. Making and Receiving Referrals Making referrals is a required and important role for kynectors. In a kynector program, a referral should be made when a given kynector is unable to fulfill their responsibilities for a given individual seeking insurance. If the kynector cannot assist the consumer, they must find a suitable alternative resource to assist the individual in question.

Referrals may be made between kynectors, Insurance Agents, and other resources such as the Customer Service Representative or any other appropriate resource. As defined in the conflict of interest regulatory compliance requirements, a kynector may not continuously refer separate individuals to the same source (such as an Insurance Agent or IPA). Referrals should always be made in an unbiased manner, with the

consumer’s best interests in mind. Please see section 2.1.3 for further details regarding conflicts of interest and regulatory compliance.

An example of this is as follows: There is an individual who is deaf and communicates using American Sign Language (ASL). If a kynector cannot use or understand ASL enough to effectively communicate, it is the kynector’s duty to find a resource who can communicate effectively regarding kynect. For assistance with finding other entities, please have the entity administrator contact the kynector program lead.

kynectors may also receive referrals from those who are unable to assist consumers. For example, if an Insurance Agent has a consumer who does not want to purchase a plan, but is instead eligible for Medicaid, the Insurance Agent may choose to refer this consumer to a kynector. In this scenario, the

kynector, who should know about helping consumers enroll in Medicaid (see Section 3 of this training manual), will receive the referred consumer and facilitate their enrollment process.

7.5. Understanding and Meeting the Needs of Underserved Populations Kentucky is a culturally diverse area and includes sections of underserved and vulnerable populations. The ability to understand and meet their needs will be crucial to the success these populations attaining health insurance. Below, select groups of underserved populations are noted. Please refer to Appendix K and Appendix L for

If a kynector cannot clearly communicate or answer an individual’s question, they may refer that individual to a party that can help.

Referrals


detailed data regarding “high need” populations and a regional map. Please refer to Appendix M for a list of possible agencies and contacts that may be able to assist with the populations.

Population Region(s) Sensitivity Approach

Rural 4, 7, 8 Members of the rural population of Kentucky may have had little access to health insurance coverage in the past. Due to this, kynectors may need to invest additional time in explaining the basics of health insurance, the ACA, and how each individual is affected by the new laws, regulations, and kynect.

Homeless 3, 5 Members of the homeless population may be similar to the rural population in that they may have had little access to health insurance coverage in the past. The homeless population may also be less likely to reach out for assistance in enrolling in kynect. kynectors may need to invest additional time with outreach activities and in explaining the basics of health insurance, the ACA, and how each individual is affected by the new laws, regulations, and kynect. Communicating to homeless population may present special challenges. There may be facilities that members of the homeless population frequently access. These facilities may serve as a venue for communications. In addition, kynectors may need to use their own assister dashboards to help a homeless consumer apply for coverage. Homeless consumers may or may not have the requisite email addresses to begin an application.

Medicaid, Blind and Disabled

2, 4, 7, 8 Members of the Medicaid, blind, and disabled populations may qualify for more specialized types of coverage in comparison to the standard consumer. kynectors will be required to assist the members of this population with understanding how they will obtain and maintain the appropriate amount of specialized coverage. This may include referring the individual for a healthcare assessment and/or to the local DCBS office.


Population Region(s) Sensitivity Approach

Part-Time Workers

5 Part-time workers (working less than 30 hours per week) may be affected by the ACA in multiple ways, but most closely by how their employer chooses to adhere to ACA rules and regulations. To successfully assist the part-time worker population, kynectors and Insurance Agents will be required to understand the possible insurance options which a part-time worker qualifies.

Population Lacking Basic Prose Level Literacy

All Regions The population lacking basic prose level literacy may require a kynector or Insurance Agent to read the majority of kynect-associated information and application language aloud to the consumer. To make sure that the relationship between kynector or Insurance Agent and consumer runs smoothly, sensitivity around the consumer’s potential lack of literacy is important.

Households without a Person over the Age of 14 Who Speaks English Well

All Regions Members of the population who are in households without a person over the age of 14 who speaks English well may require kynectors or Insurance Agents who are able to speak the language of the individual in order to assist. In the event that a kynector or Insurance Agent does not know the language of the consumer, they may need to refer the consumer another resource who is able to clearly communicate with and assist the consumer. Writing down information in notes for the consumer may aid in communication.

Figure 16: Underserved Population Information


Knowledge Check:

1. What is one benefit of being a good listener and one benefit of being a good speaker?

2. What are three places a kynector may find success having outreach events?

3. Why is it important to understand a consumer’s financial situation? 4. Why are referrals so important to perform?

5. What are two potentially underserved areas of Kentucky’s population?


8. kynector Resources

8.1. Eligibility Determination Document Check List The following is a list of forms of documentation that may be required to determine eligibility. When applying via the SSP, the consumer will be told what kind of documentation will be accepted at each step in the process:

Information to Assist Determining Eligibility

• Government Issued ID.

If the consumer does not have a government Issued ID, they may also present one of the following documents in original form, not a copy:

• Birth Certificate.

• Social Security number- Social Security card (laminated cards not accepted).

• Proof of address- Utility bill, mortgage documents, rental agreements.

Other important documents that will help determine eligibility will include:

• W-2 or other document proving yearly earned income information.

• Documentation of unearned income (example: Survivors & Disability Insurance).

• Proof of marriage.

A complete list of necessary and acceptable documents is available on the Self-Service Portal.

8.2. Important Phone Numbers The number for Support Professionals to call a Customer Service Representative is 1-855-326-4650.

kynect’s TTY number is 1-855-326-4654.

Below are important resources for kynectors.


As stated earlier in the manual, kynectors or Insurance Agents may be presented with situations or questions from consumers that require a referral to another individual or organization. Below is a list of phone numbers for important departments or entities that may be utilized by kynectors or Insurance Agents in these cases. This is not a comprehensive list, but will serve as a starting point in many situations.

Contact Information for Overarching Groups / Services

Department or Entity Name Phone Number Website

Department of Insurance (DOI)

502-564-3630 (local) 800-595-6053

http://insurance.ky.gov/

State Health Insurance Assistance Program 877-293-7447 http://chfs.ky.gov/dail/ship.htm

CHFS Ombudsman 800-372-2973 800-627-4702 (TTY)

http://chfs.ky.gov/os/omb/

Department for Medicaid Services (DMS)

800-635-2570 http://chfs.ky.gov/dms/

Kentucky Access (note this program will not be open for new enrollments after December 2013)

866-405-6145 https://www.kentuckyaccess.com/index.cfm

Kentucky Prescription Assistance Program (KPAP)

800-633-8100 502 564-8966 (program manager)

http://chfs.ky.gov/dph/info/dpqi/KPAP.htm

Department for Community Based Services (DCBS) Each county will have its own DCBS office. Please refer to the website for more information.

502-564-3703 http://chfs.ky.gov/dcbs/

Center for Medicare & Medicaid Services (CMS)

(see website) http://www.cms.gov/

The Cabinet for Health and Family Services (CHFS)

502-564-3703 http://chfs.ky.gov/

Medicare (see website) http://www.medicare.gov/

State Health Insurance Assistance Program (SHIP)

877-293-7447 http://chfs.ky.gov/dail/ship.htm


http://insurance.ky.gov/


http://chfs.ky.gov/os/omb/

http://chfs.ky.gov/dms/

https://www.kentuckyaccess.com/index.cfm

https://www.kentuckyaccess.com/index.cfm



http://chfs.ky.gov/dcbs/

http://www.cms.gov/

http://chfs.ky.gov/

http://www.medicare.gov/


Contact Information for Overarching Groups / Services

Department or Entity Name Phone Number Website

Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

800-462-6122 502-564-3827 (local)

http://chfs.ky.gov/dph/mch/ns/wic.htm

Supplemental Nutrition Assistance Program (SNAP)

502-564-3440 http://chfs.ky.gov/dcbs/dfs/foodstampsebt.htm

Kentucky Transitional Assistance Program (K-TAP)

502-564-7050 http://chfs.ky.gov/dcbs/dfs/ktap.htm

COBRA (via Kentucky DOI)

502-564-5868 http://insurance.ky.gov/static_info.aspx?static_id=120&Div_id=16

Kentucky Health Benefit Exchange (kynect)

502-564-7940 http://healthbenefitexchange.ky.gov/Pages/home.aspx

Figure 17: Important Phone Numbers

8.3. Current Eligibility for Public Programs Current Medicaid Eligibility

Currently in Kentucky, individuals qualify for the Medicaid program if they fall under the income limits as seen in the following chart:

Size of Family Annual Adjusted Gross Income

Monthly Adjusted Gross Income

1 $2,600 $217 2 $3,200 $267 3 $3,700 $308 4 $4,600 $383 5 $5,400 $450 6 $6,100 $508 7 $6,800 $567

Figure 18: 2013 Medicaid Program Income Limits

The following are additional Medicaid program provisions:




http://chfs.ky.gov/dcbs/dfs/foodstampsebt.htm

http://chfs.ky.gov/dcbs/dfs/foodstampsebt.htm

http://chfs.ky.gov/dcbs/dfs/ktap.htm

http://chfs.ky.gov/dcbs/dfs/ktap.htm

http://insurance.ky.gov/static_info.aspx?static_id=120&Div_id=16



http://healthbenefitexchange.ky.gov/Pages/home.aspx

http://healthbenefitexchange.ky.gov/Pages/home.aspx

• A pregnant woman or a child* under age 1 will qualify if their family income does not exceed 185% of the official poverty income guidelines.

• A child born after September 30, 1983, who is age 6 or older but under 19 years old will qualify if their family income does not exceed 100% of the official poverty income guidelines.

• A child age 1 or over but under age 6 will qualify if their family income does not exceed 133% of the official poverty income guidelines.

• A “targeted low-income child*” as specified in regulation 907 KAR 1:011, Section 2(3)(h), will qualify if their family income does not exceed 150% of the official poverty income guidelines.

• A “targeted low-income child” as defined in regulation 42 U.S.C. 1397jj(b) will qualify if their family income does not exceed 200% of the official poverty income guidelines.

* A child means a person who is under the age of 18; or is under the age of 19, in high school or the same level of vocational or training school and expected to graduate before or during the month of his 19th birthday. Current KCHIP Eligibility Please see the following chart for current KCHIP income limits for 2013.

Number of Household Members

(include parents and children)* Total Monthly Family

Income (before taxes) Total Annual Family

Income (before taxes)

1 $1,915 $22,980

2 $2,585 $31,020

3 $3,255 $39,060 4 $3,925 $47,100 5 $4,595 $55,140

6 $5,265 $63,180 7 $5,935 $71,220 8 $6,605 $79,260

Figure 19: 2013 KCHIP Income Limits

Note: Income limits change annually based on the publication of the federal poverty levels (FPL). This table shows the 200 percent FPL guidelines. KCHIP Eligibility FAQs Q: If a parent voluntarily leaves a job, are his/her children immediately eligible for KCHIP benefits?


A: If a parent voluntarily leaves a job, the children are not immediately eligible for KCHIP. There will be a six-month waiting period.

Q: Is my child eligible for KCHIP if I have dropped health coverage? A: Your child may be eligible, depending on your income level. Contact your local DCBS office, or call (877)KCHIP-18 ((877) 524-4718) for more information.

Q: How long will it take to find out if my child is eligible? A: The local DCBS office has 30 calendar days from the date your application is processed to determine eligibility. Processing your application may take longer if any required information is missing, incomplete or inaccurate. However, coverage for children determined eligible for KCHIP begins on the date the application is received.

Please see Appendix N for a detailed KCHIP application checklist.

K-Tap FAQs Q: How do I apply for K-TAP?

A: A family may apply for K-TAP and other assistance at the local Community Based Services offices in the county where the family lives. For additional information about K-TAP, contact your local Department for Community Based Services office.

Q: What happens when a K-TAP person goes to work?

A: The K-TAP check does not always stop. The earnings may not be counted for two months. When the earnings are counted in the K-TAP case, certain deductions are allowed. A family member may also get help with things needed in order to keep working.

Q: What happens if K-TAP is discontinued due to work? A: The family may still get some help such as Medicaid or food stamp benefits. The family may get Work Incentive reimbursements for up to nine months. Child care assistance may be received as long as the family meets the guidelines for the Child Care Assistance Program.


8.4. Helping Consumers Determine if They Need Insurance

Figure 20: Insurance Determination Flow


9. Facilitating Enrollment via Self Service Portal

9.1. Applying online (learning how to use kynect)

9.2. Using the Standardized Comparison Tool

This section is currently serving as a placeholder for topics that will be covered in SSP system training, available in August 2013.


10. Glossary and Terms

10.1. Basic health insurance concepts Below is a limited list of basic but important healthcare terms and concepts. Examples 3.1.1 – 3.1.10 have been provided by www.healthcare.gov, though some examples have been changed for added clarity. Please refer to www.healthcare.gov/glossary for a more robust glossary of terms.

10.1.1. Advanced Premium Tax Credit (APTC) Under the Affordable Care Act (ACA), beginning in 2014, qualified individuals will be eligible to receive premium tax credits through kynect to help them purchase a Qualified Heath Plan. This payment assistance may be provided in advance (“advanced payment of premium tax credit” - APTC) or taken as a tax credit at the time an individual files their income taxes. This credit is only available through kynect.

Please note: When interacting with consumers, please refer to APTC as “payment assistance”.

10.1.2. Annual Maximum An annual maximum is a cap on the benefits your insurance company will pay or provide in a year while an insured person is enrolled in a given Health Insurance Plan. These caps are also sometimes placed on certain services, such as prescriptions, hospitalizations, number of visits, and more. After an annual limit is reached, the insured person must pay all other associated healthcare costs for the remainder of the year. For example, if a health plan’s annual maximum is $750,000, once the insurance company has paid out $750,000, they will stop providing benefits afterwards. However,

Common health insurance terms and items that are important to know.

By the end of this section, you will be able to:

10.1 Recall the definitions of important, basic healthcare terms and how they apply to consumers and the roles of kynectors and Insurance Agents.

10.2 Explain what a High Risk Pool is and when it is ending.


http://www.healthcare.gov/glossary

there are no limits placed on receiving benefits within an individual’s lifetime. This provision is mandated by the ACA.

Annual maximums do not apply to essential health benefits in terms of dollar limits allowed.

10.1.3. Coinsurance Co-insurance is an insured person’s share of the costs of a covered healthcare service. This is calculated as a percent of the allowed amount for the service. An insured person pays co-insurance on top of any deductibles owed. For example: If the health insurance or plan’s allowed amount for an office visit is $100 (and the insured person has met their deductible), a co-insurance payment of 20% would be $20. The other $80 is paid by the insured person’s health insurance or plan.

10.1.4. Copay Copay is a cost sharing system between the insured and the insurance company. The insured pays a predetermined flat fee required at the time any covered medical service is received. For example: Paying $20 for a doctor's office visit. The insurance company pays the cost of the service less the copay. There may be different copays depending upon the type of company or service provided.

10.1.5. Cost Sharing Reductions (CSRs) Some of your customers may qualify for cost sharing reductions. These are a mechanism, in the form of subsidies, to reduce a consumer’s cost of the deductible, copay, and / or coinsurance. CSRs provide health insurance cost sharing assistance for individuals who are not eligible for Medicaid but whose income is between 100% and 250% of the FPL. These are only available for Silver Plans purchased through kynect. CSRs are meant to reduce the out-of-pocket costs as opposed to APTC, which is a premium subsidy.

10.1.6. Deductible A deductible is the amount an insured person owes for healthcare services before their health insurance or plan begins to pay. For example: If your deductible is $500, you will owe $500 before your plan begins to pay for most services. If you have a deductible of $500, and an essential surgery costs $700, you would have to pay $500 (as your deductible) and your insurance would cover the rest ($200). If your surgery is $300, you would pay the full $300, and the insurer would pay $0. In addition, $200 of your deductible would still remain ($500 - $300). This is the amount you would have to pay for any future services within a plan year before the plan starts paying.

You only need to meet your minimum deductible once per year and a deductible may not apply to all services. Additionally, if a consumer switches plans in the middle of the plan year, the amount paid in the form of a deductible starts over and does not carry over to the new plan; the paid deductible amount would be $0. Even if you have not exhausted the deductible, some preventive care may still be covered.


Note: If the issuer offers more benefits than essential health benefits, a different deductible rule may apply. For more information on essential health benefits, please see section 4.1.1.

10.1.7. Effectuation Effectuation is a process by which a consumer’s coverage becomes effective (effective date of coverage).

10.1.8. Exclusive Provider Organization (EPO) An exclusive provider organization plan is a plan where services are covered only if an insured person goes to doctors, specialists, or hospitals in the plan’s network (except in an emergency). These networks tend to be smaller than those of an HMO.

10.1.9. Healthcare Provider Provider is a broad term used to define health professionals who provide healthcare services. In some situations, the term may be used to refer only to physicians. Often, however, the term also refers to other healthcare professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized healthcare services.

10.1.10. Health Maintenance Organization (HMO) A Health Maintenance Organization (HMO) is a type of Health Insurance Plan that limits coverage to services provided by a specific group of doctors. This group of

doctors will be doctors who work for, or are under contract with the HMO.

10.1.11. Health Savings Account (HSA) An HSA is a special medical savings account available to taxpaying citizens who are also enrolled in a High Deductible Health Plan. An individual enrolled in an HSA may contribute funds into the account during the year. The funds contributed to the account are not subject to federal income tax at the time of deposit and may only be used for qualified medical expenses. Funds roll over year to year if they are not spent in the current year.

How does this apply to me? As a kynector, it will be important to explain what a deductible is to a consumer. When choosing an appropriate health plan, the consumer should ideally understand all costs associated with a particular plan. Therefore, the deductible amount will be one of the cost factors to consider when making their plan selection.

An HSA is a specialized medical savings account.

Definition Knowledge


10.1.12. Insurance Affordability Programs Insurance affordability programs are federal and state public programs that are in place to help individuals who may be vulnerable or underserved. These programs include, but are not limited to, Medicaid, Medicare, KCHIP, SNAP, TANF (K-TAP), and WIC.

10.1.13. Kentucky Access Program (High-Risk Pool) The Kentucky Access Program is a High-Risk Health Insurance Pool (High-Risk Pool), which is a state-run program. It offers health insurance to residents who are considered uninsurable and unable to buy coverage in the individual market. More information regarding the Kentucky Access Program may be found by visiting: www.kentuckyaccess.com.

As mandated by the ACA, starting 1/1/2014, insurers will no longer be able to deny health insurance to individuals due to their health status. Because of this, the Kentucky Access program is being discontinued. The coverage through Kentucky Access plans will only be until December 31, 2013.

10.1.14. Managed Care Organization (MCO) MCOs are networks that provide services to Medicaid consumers. Eligible consumers will be able to comparison shop the various MCOs in their area, similar to how other consumers will comparison shop Health Insurance Plans and SHOP plans (if applicable).

10.1.15. Modified Adjusted Gross Income (MAGI) Modified Adjusted Gross Income (MAGI) will be the income that is used to determine eligibility for insurance affordability programs. MAGI factors in a

consumer’s estimated yearly income and other factors to come to a final adjusted income calculation.

10.1.16. Multi-State Plans (MSPs) Multi-state plans may be available on kynect. Multi-state plans are available through contracts between issuers and the Office of Personnel Management (OPM). Generally, OPM plans must comply with state law and in Kentucky, must offer at least two HIPs in the individual market, SHOP Exchange, or both.

10.1.17. Network A network is defined as a group of doctors, hospitals and providers that are under contract to provide services to insurance company customers for a discounted price. Provider networks can cover a large geographic area or a wide variety of healthcare services. Insured individuals typically pay less for using a network provider compared to an out of network provider.

“As a consumer, I am currently covered by the Kentucky Access plan. However, it is ending on December 31, 2013, so I will need to become covered under a new insurance program.”


http://www.kentuckyaccess.com/

10.1.18. Out-of-Pocket Maximums All individuals and / or households that buy coverage via kynect will have a cap (maximum amount) placed on their total possible out-of-pocket spending. This out-of-pocket spending includes deductibles, co-pays and co-insurance that will be paid by the individual. These limits are determined by the issuers when they design their plans. Additionally, out-of-pocket maximums are only applicable to essential health benefits. Payments for additional benefits received may not contribute to the maximum amount.

Note : Final out-of-pocket maximums will be set once a consumer is effectuated in a plan or program. Please see below for more details on effectuation.

10.1.19. Pre-Existing Condition Insurance Plan (PCIP) The Pre-Existing Condition Insurance Plan (PCIP) is a temporary program that is a part of the Affordable Care Act. The plan makes coverage available for individuals who have a pre-existing medical condition, have not had insurance for six months, and who are legal US residents. Like High-Risk Pools, the coverage from this plan will also only be available until December 31, 2013.

10.1.20. Preferred Provider Organization (PPO) A preferred provider organization (PPO) is a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. A PPO membership provides a discount below the regularly charged rates of given professionals who are partnered with a health organization. An individual may still use doctors, hospitals, and providers outside of their PPO network, but these will come at an additional cost.

10.1.21. Premium A premium is the amount that must be paid for a person’s health insurance or plan. Premiums are usually paid on a monthly, quarterly or yearly basis.

How does this apply to me? As a kynector, you may have to help consumers that are involved in High-Risk Pools or PCIPs understand that they will no longer have coverage as of 1/1/2014 and will have to enroll in a new plan via kynect or the outside insurance market to gain coverage before that date.

Knowledge Check: 1. What is an annual maximum and how does it differ from an out-of-pocket

maximum? 2. When are High Risk Pools ending and why? 3. What is a deductible? Provide an example of how they work.

PPOs and HMOs are often confused, but have subtle and important differences.

Definition Knowledge


11. Appendices

Appendix A: Conflicts of Interest Checklist

An individual serving in the kynector program, shall not: Applies to:

Employee Entity

Use or attempt to use his or her influence in any matter which involves a substantial conflict between his or her personal or private interest and his or her duties in the public interest.

X

Provide customers with biased or partial information about plans for which customers are eligible. X

Select a plan on behalf of consumers X

Use his or her official position to obtain financial gain for himself, herself, or any members of their immediate family. X

Use or attempt to use his or her official position to secure or create privileges, exemptions, advantages, or treatment for himself or herself or others in derogation of the public interest at large.

X

Disclose or use confidential information acquired in the course of his or her official duties as a Navigator or IPA to further their own interests, economic or otherwise.

X X

Receive direct or indirect payments from any health insurance issuer in connection with the enrollment of individuals or employees in a Health Insurance Plan (HIP) or non-QHP as explicitly prohibited by federal law.

X X

Receive compensation of any kind from another entity outside of the Kentucky Health Benefit Exchange for facilitating enrollment into health plans.

X X

Receive any commission or any compensation for referring enrollees to an issuer or Insurance Agent. X X

Receive varying compensation based on plans or insurer chosen by the enrollees. X X

Receive or have an immediate family member receiving an investment in any note or debt from an insurer, except as to policy loans. Similarly, insurers are prohibited from extending a substantial investment to an individual serving in the kynector

X X


An individual serving in the kynector program, shall not: Applies to:

Employee Entity

program or their immediate family member.

Work for or have any immediate family members who work for restricted entities or individuals. Restricted entities or individuals include: • A health insurance issuer; • A subsidiary of a health insurance issuer; • An association that includes members of, or lobbies on

behalf of, the insurance industry; or, • An individual or entity that receives any consideration

directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals or employees in a HIP or a non-HIP

• A provider entity (including, but not limited to, hospitals, clinics, and physician practices) that is directly owned by, a subsidiary of, or exclusively contracts with, a single insurer or its subsidiaries., except in cases where the provider can demonstrate that due to geography or other factors, there are significant limitations on available insurers with whom to contract

An entity with members who would otherwise create a conflict of interest can still potentially serve as a kynector or IPA as long as the specific members do not engage in kynector or IPA activities.1

X X

An entity serving in the kynector program, shall not:

Use or attempt to use its position to secure or create privileges, exemptions, advantages, or treatment for itself or others in derogation of the public interest at large.

X X

1 An entity with members who would otherwise create a conflict of interest can still potentially serve as a kynector as long as the

specific members do not engage in kynector activities. For example, Organization X may still be able to act as a kynector entity as long as insurers who are members of the organization do not participate in the kynector activities.


Appendix B: kynector Disclosures This section is currently a placeholder to be updated by OKHBE when kynector Disclosures are finalized.


Appendix C: kynector Performance Measures The following are expected performance measures for IPAs. OKHBE reserves the right to amend measures as needed to better evaluate the kynector program:

Performance Measure Grouping IPA

1. Coverage Model

# of Applications Started

# of Applications Completed (Medicaid Eligible)

# of Applications Completed (Health Insurance Plan Eligible)

Conversion rate: Applications Completed / Started (derived from system metrics)

Total Drive Time

# of locations that require driving

Ratio of Total Drive Time to Total Number of Hours spent on Enrollment Activities (derived)

2. Focus

# of Unique population segments targeted (of the OKHBE list of target segments)

# of Enrollment Related Contacts

# Hours spent on Enrollment Assistance

# of Outreach and Education Related Contacts

# of Referrals Sent and Type of Referral

# of Referrals Received

3. Outreach

# of Community Events attended for IPA Duties

# of Person Hours spent at Community Events

# of Office Hours held

# of Presentations made, both in office and at outreach events

# of Locations where outreach materials were disseminated

# of Appointments with Consumers

# of Direct (phone or in-person) Contacts with Consumers

# of Follow-Up calls made to Consumers

4. Operations # of Reported of privacy and security breaches


Performance Measure Grouping IPA

5. Talent Management

# of IPAs Trained and Certified

# of Enrollments per IPA Employee

Average Consumer Satisfaction Rating (see below)

6. Cost Effectiveness $ Funds used on Enrollment Activities

$ Funds used on Outreach Activities

7. Change Management Has the contractor communicated with its

employees within one week of receiving regulatory updates from OKHBE?

In order to measure Consumer Satisfaction Rating, contractors will be required to distribute the following Consumer Satisfaction Survey.

Question 1 = Not Satisfied, 5 = Very Satisfied

Would you consider recommending this person to a friend or family member?

1 2 3 4 5

Would you return to this person if you need assistance in the future? 1 2 3 4 5

Did you receive the information you were looking for from the person? 1 2 3 4 5

Were you able to understand the person when he/she explained the process and components of kynect?

1 2 3 4 5

Complaints are separate from the Consumer Satisfaction Survey and will also factor into the evaluation of contractors. The OKHBE is primarily responsibility for taking, recording, and investigating complaints, and contractors are expected to fully comply with all complaint investigations. Any complaints received by contractors must be forwarded to OKHBE within seven business days of receipt.


Appendix D: Participation Agreements for kynectors, Administrators, and Entities Shall be available shortly.


Appendix E: Defining Lawful Presence Lawfully present means an individual who is a non-citizen and who— (1) Is a qualified non-citizen, as defined in this section; (2) Is in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); (3) Is paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; (4) Belongs to one of the following classes:

(i) Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; (ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. 1254a, and individuals with pending applications for TPS who have been granted employment authorization; (iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Public Law 101–649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status; (vii) Granted an administrative stay of removal under 8 CFR part 241; (viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

(5) Is an individual with a pending application for asylum under 8 U.S.C.1158, or for withholding of removal under 8 U.S.C. 1231, or under the Convention Against Torture who—

(i) Has been granted employment authorization; or (ii) Is under the age of 14 and has had an application pending for at least 180 days;

(6) Has been granted withholding of removal under the Convention Against Torture; (7) Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J);

(8) Is lawfully present in American Samoa under the immigration laws of American Samoa;

(9) Is a victim of a severe form of trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Public Law 106–386, as amended (22 U.S.C. 7105(b)); or

(10) Exception. An individual with deferred action under the Department of Homeland Security’s deferred action for childhood arrivals process, as described in the Secretary of Homeland Security’s June 15, 2012 memorandum, shall not be considered to be


lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

* * * * * Non-citizen has the same meaning as the term ‘‘alien,’’ as defined in section 101(a)(3) of the Immigration and Nationality Act (INA), (8 U.S.C. 1101(a)(3)) and includes any individual who is not a citizen or national of the United States, defined at 8 U.S.C. 1101(a)(22).

* * * * * Qualified non-citizen has the same meaning as the term ‘‘qualified alien’’ as defined at 8 U.S.C. 1641(b) and (c). * * * * *


Appendix F: Federal Poverty Line (FPL) Charts (Up to 400% of FPL)

Family Size

Annual Federal Poverty Level Guidelines

100% 133% 138% 150% 200% 250% 300% 400%

1 $11,490.00 $15,281.70 $15,856.20 $17,235.00 $22,980.00 $28,725.00 $34,470.00 $45,960.00

2 $15,510.00 $20,628.30 $21,403.80 $23,265.00 $31,020.00 $38,775.00 $46,530.00 $62,040.00

3 $19,530.00 $25,974.90 $26,951.40 $29,295.00 $39,060.00 $48,825.00 $58,590.00 $78,120.00

4 $23,550.00 $31,321.50 $32,499.00 $35,325.00 $47,100.00 $58,875.00 $70,650.00 $94,200.00

5 $27,570.00 $36,668.10 $38,046.60 $41,355.00 $55,140.00 $68,925.00 $82,710.00 $110,280.00

6 $32,590.00 $43,344.70 $44,974.20 $48,885.00 $65,180.00 $81,475.00 $97,770.00 $130,360.00

7 $35,610.00 $47,361.30 $49,141.80 $53,415.00 $71,220.00 $89,025.00 $106,830.00 $142,440.00

8 $39,630.00 $52,707.90 $54,689.40 $59,445.00 $79,260.00 $99,075.00 $118,890.00 $158,520.00

Family Size

Monthly Federal Poverty Level Guidelines

100% 133% 138% 150% 200% 250% 300% 400%

1 $957.50 $1,273.48 $1,321.35 $1,436.25 $1,915.00 $2,393.75 $2,872.50 $3,830.00

2 $1,292.50 $1,719.03 $1,783.65 $1,938.75 $2,585.00 $3,231.25 $3,877.50 $5,170.00

3 $1,627.50 $2,164.58 $2,245.95 $2,441.25 $3,255.00 $4,068.75 $4,882.50 $6,510.00

4 $1,962.50 $2,610.13 $2,708.25 $2,943.75 $3,925.00 $4,906.25 $5,887.50 $7,850.00

5 $2,297.50 $3,055.68 $3,170.55 $3,446.25 $4,595.00 $5,743.75 $6,892.50 $9,190.00

6 $2,715.83 $3,612.06 $3,747.85 $4,073.75 $5,431.67 $6,789.58 $8,147.50 $10,863.33

7 $2,967.50 $3,946.78 $4,095.15 $4,451.25 $5,935.00 $7,418.75 $8,902.50 $11,870.00

8 $3,302.50 $4,392.33 $4,557.45 $4,953.75 $6,605.00 $8,256.25 $9,907.50 $13,210.00


Appendix G: Hardship Exemptions Federal regulations allow individuals to request an exemption from the shared responsibility or individual mandate for nine specified categories, Please see section ? for more information on the general exemption process. Individuals who apply and qualify for a “hardship” exemption may also be eligible for enrollment in a catastrophic plan.

Individuals who experience a hardship, such as applicants who have experienced financial or domestic circumstances or had “significant, unexpected increase in essential expenses that prevented him or her from obtaining coverage” may be eligible for an exemption. Circumstances such as homelessness, eviction, foreclosure, domestic violence, death of a close family member, bankruptcy, substantial recent medical debt, unexpected expenses due to caring for a family member, and disasters that substantially damaged the individual’s property may be considered a hardship. Hardship also includes:

• Individuals for whom a Marketplace/kynect projects that no offer of coverage that meets the minimum value standard will be affordable;

• Individuals who are ineligible for Medicaid solely based on a state’s decision not to implement the Medicaid expansion under the Affordable Care Act (This is not applicable for Kentucky);

• Individuals and families who are eligible for affordable self-only employer-sponsored coverage, but the total cost of employer-sponsored coverage for all the employed members of the family are unaffordable.

• Individuals who are not required to file an income tax return. The requirement to file a federal tax return depends on your filing status, age, and types and amounts of income. To find out if you are required to file a federal tax return, use the IRS Interactive Tax Assistant (ITA). ;

• Individuals who are Indians (as well as their spouses and descendants) who are eligible for services through an Indian health care provider.

• Other circumstances that prevent an individual from obtaining coverage under a qualified health plan.


http://www.irs.gov/uac/Do-I-Need-to-File-a-Tax-Return%3F

Appendix H: SHOP Special Enrollment Triggering Events Below is a list of potentially common SHOP-related special enrollment triggering events:

• Loss of eligibility for Medicaid/CHIP or newly eligible for SHOP coverage through a Medicaid/CHIP waiver – A qualified employee or dependent that becomes eligible for premium assistance under Medicaid or CHIP or loses eligibility for Medicaid or CHIP constitutes a triggering event, and the employee or dependent would have a 60-day special enrollment period to select a QHP.

• Birth, adoption or placement for adoption – A qualified employee or dependent that gains or becomes a dependent through birth, adoption or placement for adoption will become eligible for coverage, with coverage effective on the date of the birth, adoption or placement for adoption.

• Marriage – A qualified employee that marries is eligible to purchase coverage or switch coverage during a special enrollment period.

• Loss of minimum essential coverage – A qualified employee or dependent that loses “minimum essential coverage” is eligible for a special enrollment period. The regulations note that an individual or dependent will be eligible for a special enrollment period only if the coverage that is lost meets the requirements of minimum essential coverage. This definition excludes loss of coverage that is “substandard” or otherwise not considered minimum essential coverage.

• Permanent move that results in access to new QHPs – A qualified employee may be eligible for special enrollment if a permanent move results in their gaining access to new QHPs. This provision includes instances in which an individual is already enrolled in a QHP, but a permanent move results in additional QHPs – for which the individual was not previously eligible – that become available.

• Errors – A qualified employee whose enrollment or non-enrollment in a QHP is unintentional, inadvertent or erroneous, and is the result of an error, misrepresentation or inaction of an officer, employee or agent of kynect or the Department of Health and Human Services (HHS), as determined by OKHBE, may be eligible for special enrollment.

• Issuer violation of contract provisions – A qualified employee who demonstrates that the QHP in which the individual is enrolled violated a material provision of its contract in relation to the enrollee may be eligible for special enrollment.

• American Indian – A qualified employee identifying as an American Indian, as defined by the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month.

• Premium Assistance through KHIPP – A qualified employee or dependent who becomes eligible for premium assistance through the Kentucky Health Insurance Premium Payment Program (KHIPP) may be eligible for special enrollment.


• Exceptional circumstances – A qualified employee may be eligible for a special enrollment under “exceptional circumstances,” in accordance with guidelines issued by HHS and as determined by OKHBE.


Appendix I: Small Business Tax Credit Tables


Appendix J: Small Business Health Care Tax Credit Eligibility Tool

For an interactive tax credit calculator, please refer to: http://www.smallbusinessmajority.org/tax-credit-calculator/


http://www.smallbusinessmajority.org/tax-credit-calculator/

Appendix K: Underserved and Vulnerable Population Data Population Profile

The following table provides summary demographic statistics for each Medicaid region in Kentucky. This information will assist kynectors in preparing to assist Kentucky consumers. The respondent may apply to one (1), several, or all eight (8) regions. “High Need” populations highlighted in green by region indicate segments that have a greater need for enrollment assistance. kynectors are encouraged to be proactive in planning on how they will serve these High Need populations in the regions for which they are assisting.

# Population Segment Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8

General Demographic Information

1 Total Population 287,993 402,934 1,236,689 486,478 786,826 416,995 241,556 479,896

2 Households 98,659 152,145 493,748 195,071 335,285 159,321 97,457 188,279

3 Percent Uninsured 15.82% 15.08% 14.13% 17.30% 15.86% 13.12% 15.81% 16.10%

High Need Population Segments – Highlighted cells indicate “High Need” populations for each region

4 Rural Population 69,012 82,593 116,664 152,920 117,612 32,712 73,611 164,510

5 Homeless Population 263 388 1,909 437 2,094 645 267 598

6 Medicaid Blind and Disabled 9,534 16,867 38,797 29,028 30,774 10,642 17,082 55,862

7 Part-Time Workers 38,536 53,629 192,062 78,136 152,954 67,389 38,647 56,956



8 Population Lacking Basic Prose Level Literacy

35,677 52,245 117,198 73,346 88,014 41,156 34,703 80,322

9

Households without a Person over the Age of 14 Who Speaks English Well or Very Well

851 1,168 7,505 2,431 5,110 1,523 311 381

Additional Information

10 Household Density per Square Mile 27 30 93 26 61 133 24 27

11 Median Household Income $40,460 $40,940 $47,988 $35,363 $45,150 $56,433 $35,404 $29,191

12

Percent of Households at or Below 2.00 times the Federal Poverty Level

58.11% 58.42% 50.77% 64.37% 54.05% 43.87% 61.36% 67.17%



13

Projected Minimum Number of Households with at Least One Uninsured Person

19,056 24,103 70,117 34,220 51,892 20,979 14,873 29,971

14

Population with Direct Purchase Insurance (Individual Market)

10,711 11,819 58,907 14,518 38,105 17,100 3,432 7,404

15 Number of Employers with 50 or Less Employees

5,200 7,351 26,907 9,053 17,241 7,669 4,176 8,066


Appendix L: Map of Kentucky Regions


Appendix M: Additional Phone Numbers for Kentucky Organizations Below is a list of phone numbers that may assist kynectors or Insurance Agents in assisting specific populations within Kentucky.

Contact Information for Specialized Groups / Services

Department or Entity Name Focus Phone Number

Website

The Department of Labor COBRA population

502-564-3070 http://www.labor.ky.gov/Pages/LaborHome.aspx

Veteran’s Health Coverage

Veteran population

(see website) http://veterans.ky.gov/vahealthservices/Pages/default.aspx

TRICARE Veteran population

1-800-444-5445 (south region)

http://www.tricare.mil/Welcome/AboutUs/Regions/South.aspx

The Center of Excellence in Rural Health

Rural Population

855-859-2374 http://ruralhealth.med.uky.edu/

The Kentucky Outreach and Information Network (KOIN)

Rural Population

502-564-6786 ext. 3102

http://healthalerts.ky.gov/koin/Pages/default.aspx

Kentucky Housing Corporation

Homeless Population

800-633-8896 (KY only)

http://www.kyhousing.org/page.aspx?id=170

The Kentucky Medicaid Consortium

Medicaid, Blind, and Disabled Population

(see website) http://www.advocacyaction.net/Dot_page.asp?Dotid=55

The Department for Community Based Services


502-564-3703 http://chfs.ky.gov/dcbs/

The Department for Medicaid Services


800-635-2570 http://chfs.ky.gov/dms/

Kentucky Health Insurance Advocate (KHIA)


877-587-7222 http://insurance.ky.gov/home.aspx?div_id=16

The Arc of Kentucky Medicaid, Blind, and Disabled Population

800-281-1272 http://www.arcofky.org/

The Christian Appalachian Project


866-270-4CAP (4227)

http://www.christianapp.org/


http://www.labor.ky.gov/Pages/LaborHome.aspx

http://www.labor.ky.gov/Pages/LaborHome.aspx

http://ruralhealth.med.uky.edu/

http://ruralhealth.med.uky.edu/





http://www.advocacyaction.net/Dot_page.asp?Dotid=55



http://chfs.ky.gov/dcbs/

http://chfs.ky.gov/dms/

http://insurance.ky.gov/home.aspx?div_id=16

http://insurance.ky.gov/home.aspx?div_id=16

http://www.arcofky.org/




United 874K Disabilities Coalition


(see website) http://www.advocacyaction.net/Dot_page.asp?Dotid=56

The Aging Disability Resource Center (Under the CHFS Department of Aging and Independent Living)


(see website) http://chfs.ky.gov/dail/areaagenciesonaging.htm

Area Agencies on Aging (Under the CHFS Department of Aging and Independent Living)


502-564-6930 http://chfs.ky.gov/dail/

The CHFS Division of Developmental and Intellectual Disabilities


502-564-7702 http://dbhdid.ky.gov/ddid/

The Commonwealth Council on Developmental Disabilities


877-367-5332 http://chfs.ky.gov/ccdd/

The Kentucky Office for the Blind


800-291-8424 http://blind.ky.gov/Pages/default.aspx

The State Health Insurance Assistance Program


877-293-7447 http://www.chfs.ky.gov/dail/ship.htm

Burley Tobacco Growers Part-Time Workers

859-252-3561 http://www.burleytobacco.com/

Community Action Kentucky

Part-Time Workers

800-456-3452 http://www.communityactionky.org/

The Home Builders Association of KY

Part-Time Workers

800-489-4225 http://www.hbak.com/

The Kentucky Association of Manufacturers

Part-Time Workers

502-352-2485 http://www.kam.us.com/

Kentucky Cattlemen's Association

Part-Time Workers

859-278-0899 http://www.kycattle.org/

The Kentucky Horse Council

Part-Time Workers

859-367-0509 http://www.kentuckyhorse.org/

The Kentucky Retail Federation

Part-Time Workers

502-875-1444 http://www.kyretail.com/

The Kentucky Adult Education Division

Part-Time Workers

(see website) http://kentucky.gov/education/pages/adulted.aspx





http://chfs.ky.gov/dail/areaagenciesonaging.htm

http://chfs.ky.gov/dail/areaagenciesonaging.htm

http://chfs.ky.gov/dail/

http://dbhdid.ky.gov/ddid/

http://dbhdid.ky.gov/ddid/

http://chfs.ky.gov/ccdd/

http://blind.ky.gov/Pages/default.aspx

http://blind.ky.gov/Pages/default.aspx

http://www.chfs.ky.gov/dail/ship.htm

http://www.chfs.ky.gov/dail/ship.htm

http://www.burleytobacco.com/

http://www.burleytobacco.com/

http://www.communityactionky.org/

http://www.communityactionky.org/

http://www.hbak.com/

http://www.kam.us.com/

http://www.kycattle.org/

http://www.kentuckyhorse.org/

http://www.kentuckyhorse.org/

http://www.kyretail.com/

http://kentucky.gov/education/pages/adulted.aspx




The Kentucky Department of Agriculture

Part-Time Workers

502-564-4696 http://www.kyagr.com/

The Kentucky Office of Employment and Training

Part-Time Workers

502-564-7456 http://oet.ky.gov/

The Kentucky Chamber of Commerce

Part-Time Workers

502-695-4700 http://www.kychamber.com/

The Kentucky Adult Education Division


(see website) http://kentucky.gov/education/pages/adulted.aspx

The Kentucky Department of Education


502-564-4770 http://education.ky.gov/Pages/default.aspx

The Kentucky Chamber of Commerce


502-695-4700 http://www.kychamber.com/

The Kentucky World Language Association


(see website) http://kwla.wikispaces.com/

Asociación de Hispanos Unidos-Lexington Hispanic Association (AHU)


859-685-2178 http://www.ahuky.org/


http://www.kyagr.com/

http://oet.ky.gov/

http://www.kychamber.com/





http://education.ky.gov/Pages/default.aspx

http://education.ky.gov/Pages/default.aspx



http://kwla.wikispaces.com/

http://kwla.wikispaces.com/

http://www.ahuky.org/

Appendix N: Pre-ACA KCHIP Application Check List Individuals will be asked to send proof of documentation for any of the following that apply to their family:

1. For all applicants, send copies of health insurance cards (front and back). 2. For children born outside Kentucky, send proof of U.S. Citizenship such as a

birth certificate, U.S. Passport, or adoption papers. 3. For applicants who are not U.S. citizens, send proof of Permanent Resident

Cards (green cards) or other forms from U.S. Citizenship and Immigration Services

4. For all children, send proof of identity. If you are sending a U.S. Passport, a Certificate of Naturalization (DHS Forms N-550 or N-570), or a Certificate of U.S. Citizenship (DHS Forms N-560 or N-561) for items 2 or 3 above, you do not need to send proof of identity. Proof of identity can be: • A current state driver's license ; • School ID with photo; • Military Dependent ID with photo, issued by state, federal or local

government; • ID issued by state, federal, or local government with photo; • School record including report card, day-care, or nursery school record; or • Clinic, doctor or hospital record. If you cannot get any of these documents to prove the identity of children under age 16, an attestation may be signed instead

5. For children and their parents who have earned income, send copies of all pay

stubs from the last two (2) months or send a letter from the employer stating the amount that will be paid. If self-employed, send copies of last year's tax return and all schedule attachments. Step-Parents, Grandparents and other non-parent caregivers do not have to send this information.

6. For children and their parents who have unearned income, send proof of gross income (before taxes) for all money that is not from a job like Veteran's Benefits, worker's compensation, and alimony. Proof could be award letters. Step-Parents Grandparents and other non-parent caregivers do not have to send this information.

7. Proof of child care payments such as receipts, statements, etc. 8. Court order and proof of alimony or child support payments. This would include

payments being made or received by persons in the home. If it is paid through Child Support Enforcement, you must list as income but do not have to send proof.

9. In some cases, you may be able to get KCHIP/Medicaid coverage for the three (3) months before the application date. If you want to request coverage for the three (3) months before you apply, send proof of income for those months.

a. Please be advised, prior medical bills may not be covered in all situations.


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