SR 99-02 Dated 01/99

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

New Hampshire is entering a new era in providing medical coverage to its children under age 19. This change is made possible by the initiation of New Hampshire Healthy Kids, hereafter referred to as "Healthy Kids." Under the umbrella of Healthy Kids, medical coverage is available to children under the age of 19 either through:

 Healthy Kids-Gold (HKG), which replaces "Medicaid" as the name for medical coverage for all children under age 19 who meet eligibility criteria for existing medical assistance programs, or

 Healthy Kids-Silver (HKS), a new medical insurance program for children under age 19 previously ineligible for KidsCare PLUS because their income was in excess of program limits. HKS comprises two coverage groups, based on income and age:

 Children aged 1 to 19 with income greater than 185% but less than or equal to 300% of federal poverty income guidelines are potentially eligible for HKS medical insurance subsidized by the Department;

 Children under age 19 with incomes between 300% and 400% of federal poverty income guidelines are potentially eligible for unsubsidized medical insurance offered through the New Hampshire Healthy Kids Corporation (NHHKC).

Note: Although children in this latter income group are not covered under the Department’s medical assistance programs, they must be referred to NHHKC for review and follow-up with the families. The purpose of requiring these referrals is to provide a seamless program of medical coverage, with a sliding scale of premiums, regardless of the point of entry into Healthy Kids-Silver. See PROCEDURES section of this SR.

These types of coverage are described in greater detail in the POLICY and PROCEDURES sections of this SR. Unless otherwise specified in this SR, such as in PROCEDURES, references to "Healthy Kids-Silver" or "HKS" will mean children with income greater than 185% but less than or equal to 300% of federal poverty income guidelines. A summary of Healthy Kids medical coverage is also provided in chart form at the end of this SR.

Background

The Balanced Budget Act of 1997, Public Law 105-33, established a new Title XXI of the Social Security Act, the Children’s Health Insurance Program (CHIP). Title XXI provides states with funding for initiation and expansion of health coverage to uninsured children. This funding enables vulnerable children to have access to medical coverage at an early age, thus providing them with the opportunity for a healthy start in life.

It is estimated that there are 20,000 uninsured children in N.H. In response to this situation, the N.H. State Legislature, in 1993, created the N.H. Healthy Kids Corporation (NHHKC), a private nonprofit organization that increases the availability of comprehensive health and dental coverage for NH’s uninsured children. The NHHKC has now partnered with the DHHS to provide health insurance funded by the State's Title XXI CHIP program. This partnership will allow a significant number of NH's uninsured children to have access to health and dental benefits not previously available.

Beginning in early 1998, the Department of Health and Human Services planned two phases to implement expanded medical coverage for children. In preparation for these phases, DHHS and NHHKC initiated an intensive, coordinated outreach effort, beginning with public presentations and forums to receive input on the expansion, circulation of Title XXI State Plan drafts, and information to contract agencies and hospitals. Other outreach activities have continued throughout year.

The policy released in SR 98-21, effective May 1, 1998, reflects Phase I, which expanded medical coverage for children under age 1 whose net family income is over

185%, but less than or equal to 300% of the federal poverty income guidelines. With the release of SR 98-21, medical assistance under poverty level programs for children was renamed as KidsCare PLUS. SR 98-21 also released an expanded presumptive eligibility process which enabled qualified hospital and contract agency providers to make presumptive eligibility determinations for all KidsCare PLUS applicants.

This SR implements Phase II, effective January 1, 1999, providing health and dental insurance, through a mandatory managed care program underwritten by Blue Cross and Blue Shield of New Hampshire and Northeast Delta Dental, to children age 1 to age 19 with income between 185% and 300% of the federal poverty level. This coverage is referred to as "Healthy Kids-Silver" (HKS).

Forms Revisions

 Form 800P, formerly known as Application for Medical Assistance for Low Income Pregnant Women and Children, has been extensively revised, reformatted, and renamed as Application For New Hampshire Healthy Kids Medical Insurance and Medical Coverage For Pregnant Women. Form 800P will now be used for the mail in redetermination process in place of Forms 800C(PL), Cover Letter for Form 800R(PL), and Form 800R(PL), Application for Redetermining Eligibility for Assistance), which have now been obsoleted.

 Form 808P, Information Necessary to Support Your Medical Assistance Application, and its instructions have been revised accordingly.

 Form 800PE, formerly titled Notice of Presumptive Eligibility Decision, has been revised and retitled Notice of Presumptive Eligibility for Medical Coverage for Pregnant Women to reflect revised usage. This change is caused by the inclusion, on revised Form 800P, of a place for indicating children found to be presumptively eligible for Healthy Kids-Gold medical coverage.

 New Form 800S, Eligibility Status for Healthy Kids, is being released with this SR, and serves as an interim communication document between the Department and NHHKC, regarding the child’s eligibility status for HKS, until this interagency referral process becomes automated in New HEIGHTS, scheduled for April, 1999.

Healthy Kids Gold

Healthy Kids-Gold (HKG) includes all formerly Medicaid (Title XIX) eligible children under the age of 19, regardless of category. The name change from Medicaid to Healthy Kids-Gold does not affect eligibility criteria for the various existing programs or coverage for these children. Child under age 19 who are eligible for medical assistance under TANF, TANF-MA, Children’s Medical Assistance, Children with Severe Disabilities (CSD), Home Care for Children with Severe Disabilities (HC-CSD), Aid to the Needy Blind (ANB), Aid to the Permanently and Totally Disabled (APTD), foster care, adoption subsidy, and KidsCare PLUS are now eligible under the general umbrella of HKG. Children eligible for HKG can receive retroactive medical assistance, and those with eligibility based on a percentage of the poverty level (i.e., those previously covered under KidsCare PLUS) can be determined presumptively eligible by a qualified entity (i.e., a contract agency trained by DFA staff). Renaming of Medicaid for children to HKG is a positive step that removes the negative image often associated with Medicaid and represents a commitment to a unified program of available and affordable health care services to children.

Release of a New Hampshire Healthy Kids-Gold Medical Identification Card

In conjunction with the change to Healthy Kids-Gold, new plastic medical identification cards will be issued to all children under age 19 who are eligible for medical coverage. The new cards will be used in the same manner as the current green plastic identification cards. Office of Health Management (OHM) will send a client mailing the week of December 13, 1998, to all caseheads of Medicaid eligible children informing them of the name change and of the impending replacement of their chilidren’s green Medicaid cards with the new HKG card. A copy of this client mailing was also sent to District Offices on December 16, 1998.

A fascimile of the new MA identification card is provided below. There is no pictorial

logo on the card. The words, "New Hampshire Healthy Kids" are printed in blue. The word "Gold" is printed in gold. The underlining and the client’s name and ID number appear in black. All the text on side 2 appears in black. The cards are magnetically encoded and show the appropriate telephone numbes for use by clients and providers.

MA ID Card Inserts

The following text will be printed on an MA ID card insert when a HKG card is issued for a child under age 19.

STATE OF NEW HAMPSHIRE

HEALTHY KIDS-GOLD CARD

Individuals under the age of 19, previously enrolled in Medicaid, are now enrolled in a medical benefits program entitled Healthy Kids-Gold.

The enclosed Healthy Kids-Gold card replaces your current, green Medicaid card. Your medical benefits have not changed.

Please destroy your green Medicaid card and only use the new card.

A parent or responsible adult must immediately sign his/her name on the back of a child’s card (under age 18 only). Any person 18 years old should immediately sign his/her own card

Please carry this card with you at all times.

If your card is lost or stolen, call your case technician at the District Office which handles your case. If you have questions regarding the services provided under this program you may call Medicaid Client Services at 1-(800)-852-3345, ext. 4344.

The following text will be printed on an MA ID card insert when a HKG child is no longer eligible for HKG based on age, but remains eligible for medical assistance under Title XIX. For example, an 18 year old ANB or APTD child who turns age 19 would be issued the standard green MA ID card.

STATE OF NEW HAMPSHIRE

MEDICAID CARD

Individuals who turn 19 are no longer eligible for the Healthy Kids-Gold program. You have, however, been determined eligible for the New Hampshire Medicaid program.

The enclosed green Medicaid card replaces your current Healthy Kids-Gold card.

Please destroy your Healthy Kids-Gold card and only use the new card.

Please sign the back of the card immediately and carry this card with you at all times.

If your card is lost or stolen, call your case technician at the District Office which handles your case. If you have questions regarding the services provided under this program you may call Medicaid Client Services at 1-(800)-852-3345, ext. 4344.

Revised Policy for Infants with Income over 185%, But Less Than or Equal to 300% of the Federal Poverty Level

SR 98-21, effective May 1, 1998, released policy allowing KidsCare PLUS eligibility for infants under age 1 with net family income over 185% but no greater than 300% of the federal poverty income guidelines. This SR modifies the special eligibility requirement for these infants of being uninsured. This SR also reduces the income verification requirement for this infant group from the most recent 8 weeks to the most recent 4 weeks of income.

Revision of Policy Prohibiting Having Other Health Insurance

SR 98-21 stated that the special eligibility requirement of being uninsured currently or within the last 6 months for infants with income over 185%, but less than or equal to 300% of the federal poverty level, unless good cause exists, applied only at initial application. After careful review of the applicable federal statutes and consultation with the Healthy Care Financing Administration (HCFA), policy has been revised to make being uninsured a continuing eligibility requirement.

 Clients must report all changes in circumstances, including obtaining health insurance for their children subsequent to initial application.

 When other health insurance is reported or the District Office becomes aware that other health insurance for the child has been obtained, take action to terminate the child’s eligibility in accordance with advance notice period requirements. The child’s eligibility ceases at the end of the advance notice period.

Note: Good cause reasons for coverage within the last 6 months are the same for Healthy Kids Silver medical insurance and are detailed on pages 7-8 of this SR.

Revised Verification of Income Requirement

Verification of family income is less restrictive than standard verification. To verify wages, the District Office must require documentation for only the most recent 4 consecutive weeks of earnings rather than 8 weeks.

Healthy Kids Silver

Healthy Kids-Silver (HKS) is a new initiative to make affordable health and dental insurance available to most of NH’s 20,000 uninsured children. HKS will enable working parents whose income is too high to qualify for HKG to provide their children with coverage through a comprehensive managed care program with premiums as low as $20 per month per child. HKS represents a positive new partnership between the State of New Hampshire, the federal government, NHHKC and the Healthy New Hampshire Foundation, a recently formed charitable organization which is contributing funding for this expansion.

 HKS provides medical insurance coverage for certain uninsured children aged one to nineteen whose net family income is over 185%, but less than or equal to 300%, of the federal poverty income guidelines. Unsubsidized coverage is also available for children from birth to age 19 with income between 300% and 400% of federal poverty income guidelines. DFA will refer any children with incomes in excess of 300% to NHHKC for review and follow up with the families. There is no other DFA involvement after referral, unless the family’s income drops below 300% of federal poverty income guidelines.

 It provides health and dental care, underwritten by Blue Cross and Blue Shield of New Hampshire and Northeast Delta Dental, that emphasizes preventative and primary care services for children.

 HKS provides a slightly less comprehensive medical services program than does HKG, and also has eligibility restrictions such as payment of a premium and the prohibition of currently having or having had medical insurance within the past 6 months, unless good cause exists.

 Children eligible for HKS cannot be found presumptively eligible, nor is retroactive coverage available.

Eligibility Requirements for Healthy Kids Silver

To receive medical insurance under HKS, all children must meet basic eligibility requirements applicable to other categories of assistance, such as citizenship/alien status, New Hampshire residency, providing certain documentation, and not being an inmate in a public institution or institution for mental diseases.

Exceptions: For HKS, social security numbers (SSN) of children and parents are not required, but may be provided voluntarily. Verification requirements regarding citizenship and wages are less restrictive than normal processing procedures allow. See below.

Additional eligibility requirements that apply to HKS coverage are:

 Income Limit: over 185%, but less than or equal to 300%, of the Federal Poverty Level).

 Age Limit: Age 1 through age 18 (i.e., under age 19).

 Payment of Monthly Premiums: $20 per month per child if net family income is >185% but <250% of the federal Poverty Level, $40 per month per child if net family income is >250% but <300% of the federal Poverty Level, with a $100 per family premium limit.

Note: Unsubsidized HKS has a higher premium for the same coverage and services.

 No current health coverage nor health coverage within the last 6 consecutive months, unless good cause exists.

 Not eligible for HKG for reasons other than failure to provide verification.

Income Limits

To qualify for HKS based on income, the child’s net family monthly income must be greater than 185%, but less than or equal to 300% of the federal poverty level for the appropriate family size, as illustrated in the following table:

Resource Limit

There is no resource limit for HKS coverage.

Assistance Group Composition

When determining income eligibility for HKS children, use the budgetary unit methodology in Family Assistance Manual Section 611.04, but compare net monthly income to the appropriate income limits for this group as noted above.

Special Eligibility Requirement: Being Uninsured

Children are not eligible for HKS if they are currently insured, or were covered under private or public health insurance other than HKG (Medicaid) or coverage that is currently available through the NHHKC, within the 6 calendar months prior to the month of application, unless at least one of the following good cause reasons exists:

 The health insurance was terminated due to involuntary loss of employment;

 The health insurance was terminated due to voluntary quit of employment, and the voluntary quit occurred for any of the good cause reasons specified in FAM 315.03 and 808.31;

 Change of employment to an employer who does not provide dependent coverage;

 Death of the subscriber to the insurance policy;

 Discontinuation of coverage to all employees by the employer;

 Discontinuation of COBRA benefits after 18 months for job termination or 24 months after the death of the subscriber;

 The insurer closes its operation in New Hampshire; or

 An involuntary reduction in work hours that makes the subscriber ineligible for the employer’s plan.

The District Office is responsible for determining good cause. The applicant must present third party documentation of good cause for termination or discontinuance of health insurance.

Clients must report all changes in circumstances, including subsequently obtaining health insurance for HKS children. The child’s eligibility ceases at the end of the month in which other health insurance is obtained.

Special Ongoing Eligibility Requirement: Premium Payments

A monthly premium is required for each child eligible for HKS, unless good cause exists. The following applies to premium payments.

 The premium will be payable to NHHKC. NHHKC will contact the family and explain the premium process and requirements, collect and process the premium, determine good cause for failure to pay the premium, and notify the District Office when the premium has not been paid for 60 days without good cause.

 Payment is due by the last day of the month for the following month’s coverage.

 Eligibility begins no earlier than the first day of the month after the month in which eligibility for HKS medical insurance is determined.

 Failure to pay the premium for 60 days without good cause will result in termination of eligibility.

Good cause for failure to pay the premium exists when NHHKC determines that at least one of the following criteria is met:

 The recipient’s family experiences a temporary or unexpected loss or reduction of income which prevents the family from paying the premium; or

 The recipient’s family incurs an unexpected expense which prevents the family from paying the premium.

Amount of Premium Payment

The amount of the required premium differs based on the child’s net monthly family income limit. If net family income is greater than 185%, but less than or equal to 250% of the Federal Poverty Level, the required premium per child is $20 per month. If net family income is greater than 250%, but less than or equal to 300% of the Federal Poverty Level, the required premium per child is $40 per month. The maximum monthly premium per family is capped at $100 per month, regardless of the number of children receiving HKS.

The following chart provides income limits and the required premium amount.

Special Procedures: Requests for Fair Hearings for Termination Due to Nonpayment of Premium

Requests for fair hearings on the basis of closing due to nonpayment of premiums require special procedures.

 Upon receiving such a request, notify NHHKC so that a prehearing conference can be arranged between their representative and the client.

 If the issue cannot be resolved, notify NHHKC of the date and time of the hearing.

 NHHKC will represent the agency at the hearing.

5% "Cap" on Cost Share

Federal law requires that the total annual cost share (premiums, co-payments, etc.) required of families of HKS-eligible children may not exceed 5% of the family’s annual income. Since the families are responsible for tracking their own expenses against the 5% figure based on their annual income, and for notifying NHHKC when their "cap" has been reached, NHHKC will be responsible for informing HKS families of this limit, assisting them in tracking as needed, and ensuring that the family’s cost share is suspended when the "cap" is reached.

Application for Healthy Kids Silver

Application for HKS may be made on Application Form 800, Form 800H, Heights Application, or Form 800P, Application For New Hampshire Healthy Kids Medical Insurance and Medical Coverage For Pregnant Women. Per SR 98-36, District Offices are to provide, accept, and use Form 800P if the applicant is requesting only medical coverage for their children, or for a pregnant woman. The District Office determines basic eligibility and NHHKC manages and processes other aspects of the child’s health care coverage once a case has been referred. Neither presumptive eligibility determinations nor retroactive medical assistance are available for HKS.

 Applications for HKS must be processed according to normal processing procedures, and certain client information must be verified. A full eligibility determination must be conducted and an eligibility decision must be reached within 45 days of the application date.

 All face to face interviews at the District Office for initial eligibility and redeterminations for HKS are waived provided there is no other program involvement, such as food stamps or child care. Subsequent redeterminations must be conducted every 12 months, unless the District Office becomes aware of the need to schedule an earlier redetermination.

 All HKS-only recipients may participate in the mail-in redetermination process using Form 800P, Application For New Hampshire Healthy Kids Medical Insurance and Medical Coverage For Pregnant Women.

Initiation of HKS Coverage

HKS coverage is always full month, for each month for which a premium has been paid. Coverage begins no earlier than the first of the month following the month in which eligibility is determined, provided that all required enrollment documentation is completed with NHHKC by the 20th of the month in which eligibility is determined and full payment of the 1st month’s premium is received by NHHKC by the last business day of that month. If the above deadlines are not met, coverage begins the first of the month following the completion of enrollment and payment of the 1st month’s premium.

Termination of HKS Coverage

The policy below applies regarding termination of HKS coverage.

 Families whose HKS coverage ends during a month for any reason other than nonpayment of the required premium, and who have already paid the monthly premium for that month, remain eligible through the last day of the month for which a premium has been paid.

 Families determined by NHHKC to have failed to pay the required premium for 60 days without good cause must have coverage terminated effective the last day of the month in which the 60th day falls. NHHKC notifies the Department of non-payment of the premium on new Form 800S, Eligibility Status for Healthy Kids. Allow an Advance Notice Period.

Exception: Nonpayment of a required premium without good cause does not apply to pregnant teens until the 61st post partum day.

3 Month Lockout Due to Failure to Pay the Premium Without Good Cause

Once a child has been determined ineligible for HKS for failure to pay the premium without good cause, the child will remain ineligible for HKS for a period of 3 months following termination medical coverage. District Offices are responsible for manually monitoring this period, through Alerts, the Expected Change screen, or paper "ticklers," until New HEIGHTS is programmed for this condition.

Additional Eligibility Information for HKS

Verification requirements for HKS differ from standard verification in the areas of citizenship, social security numbers (SSN’s) and wages. These differences are addressed below.

 The District Office cannot require verification of citizenship if the parent declares that a child is a US citizen on the application. However, if the parent voluntarily furnishes documentation of the child’s citizenship, e.g., by providing a birth certificate to verify the child’s age, the District Office will accept it. If the parent declares that the child is not a citizen, the District Office must require documentation to verify the child’s alien status according to current policy.

Note: Current eligibility policy for noncitizens applies to HKS children. See FAM Part 305.

 The District Office cannot require furnishing of the child’s SSN or proof of application for an SSN as a condition of eligibility. However, if the parent voluntarily furnishes documentation of the child’s SSN, the District Office will accept it.

 Verification of family income is less restrictive than standard verification. To verify wages, the District Office must require documentation for only the most recent 4 consecutive weeks of earnings, rather than 8 weeks.

Six Months Minimum Coverage Under a Managed Care Plan

DFA currently confers a minimum of 6 months of continuous medical coverage, regardless of eligibility changes within the first 6 months of eligibility, to Medicaid and HKG recipients participating in existing voluntary managed care plans. Although HKS is a mandatory managed care plan, HKS children are eligible for the same minimum of 6 months continuous coverage except under the following conditions:

 The child reaches age 19;

 Eligibility was obtained due to fraud or false or misleading statements;

 The child becomes ineligible for HKS due to obtaining other medical insurance;

 The child becomes ineligible for HKS due to nonpayment of premium; or

 The child is no longer a resident of New Hampshire.

District Offices, however, must continue to act on any information that may affect eligibility, and take all appropriate actions to deny or terminate eligibility for HKS.

Referral of HKG Infants Turning Age 1 to HKS

Infants with incomes between 185% and 300% of federal poverty income guidelines and receiving HKG must be screened for potential HKS eligibility in the month prior to the month in which the infant’s 1st birthday occurs, and referred to NHHKC via new Form 800S for HKS enrollment. A new application is not required. District Offices must set up manual Alerts or Expected Changes in New HEIGHTS or "ticklers" until such time as the automated referral process is available (April, 1999), in order that referral is made in a timely manner to prevent any break in coverage for otherwise eligible children. See PROCEDURES section of this SR.

Referral of Children with Income Over 300% of federal poverty level for HKS Unsubsidized Coverage

District Offices that become aware of applicant or recipient children under age 19 (i.e., age 0 through age 18) with family income greater than 300% of federal poverty income guidelines must refer these children to NHHKC for exploration of HKS unsubsidized medical insurance. Referral is done using new Form 800S. See the PROCEDURES section of this SR and new Form 800S(i), Instructions for Form 800S.

Crossmatches

Since providing SSN’s is not mandatory for HKS, these children will not be matched with SSA, NHES, or other agencies’ databases.

FORMS REVISIONS AND NEW FORMS

Revised Form 800P, Application For New Hampshire Healthy Kids Medical Insurance and Medical Coverage For Pregnant Women, and its Instructions

Form 800P, Application For New Hampshire Healthy Kids Medical Insurance and Medical Coverage For Pregnant Women, has been extensively reformatted and revised. This form was previously referred to as Application for Medical Assistance for Low Income Pregnant Women and Children. Instructions to Form 800P have been modified accordingly.

Changes to Form 800P are noted below.

 The header has been updated and changed to show that the form is jointly used by the Department of Health and Human Services and the New Hampshire Healthy Kids Corporation.

 Page numbers have been added to the bottom of the form.

 The form size was previously 8.5 inches by 11 inches, with the text appearing vertically on the page. The form size is now 11 inches by 8.5 inches, with the text appearing horizontally across the page. The horizontal format results in more efficient use of space.

 The tear-off sheet provides the toll free telephone number for the NHHKC, and encourages clients to call if they need help in completing the application.

 The Rights and Responsibility section has been redesigned in table format and rewritten for the sake of readability and clarity.

 A question has been added to this form to ask the client to explain, if applicable, why medical insurance has been terminated within the last 6 months.

 An additional question has been added as to whether a child in the household is severely disabled.

 Space has been added for qualified entities to indicate a presumptive eligibility determination for applicants for Healthy Kids-Gold medical coverage.

Note: The redesign of Form 800P has, of necessity, made the Form applicable to more programs and more flexible in use. Therefore, District Offices must carefully review each Form 800P received to identify any information or documentation/verification required for that particular application. For example, while SSN’s are not required for HKS, they are still required for HKG and pregnant women’s coverage. Therefore, an application for coverage by a pregnant woman with income below 185% of federal poverty income guidelines and her 2 year old child, whose income is between 185% and 300%, would require provision of an SSN by the woman but not by the child.

District Offices and providers will receive an initial supply of Form 800P under separate cover.

Revised Form 800PE, Notice of Presumptive Eligibility for Medical Coverage for Pregnant Women, and its Instructions

Form 800PE, Notice of Presumptive Eligibility for Medical Coverage for Pregnant Women, formerly known as Notice of Presumptive Eligibility, has been retitled and revised to reflect its new usage only for presumptive eligibility determinations for pregnant woman. All references to KidsCare PLUS have been removed. Form 800PE(i) has been revised accordingly. This change in usage was done because revised Form 800P includes a space which allows the entry of presumptive eligibility information for children only. When Form 800P is revised in the future to include presumptive eligibility information on pregnant women, Form 800PE and its instructions will be obsoleted. Providers will receive an initial supply of revised Form 800PE under separate cover.

Revised Form 808P, Information Necessary to Support Your Medical Assistance Application

Form 808P, Information Necessary to Support Your Medical Assistance Application, has been revised to put New Hampshire NHHKC on the header line. The income verification section has been changed to indicate that 4 weeks of paystubs must be submitted instead of 8 weeks, which was a previous policy requirement for all programs. Form 808P(i), Instructions to Form 808P, has been revised accordingly. Providers will receive an initial supply of Form 808P under separate cover.

New Form 800S, Eligibility Status for Healthy Kids

New Form 800S, Eligibility Status for Healthy Kids, serves as an interim communication document between the Department and NHHKC, regarding the child’s eligibility status for HKS. This form contains basic identifying information about the child and caretaker relative. The District Office completes the top section to indicate that the child meets HKS eligibility requirements and provides the form to NHHKC. Section 2 is completed by NHHKC to indicate that the child has been enrolled or enrollment has been declined, by District Offices (along with Section 1) to refer children for unsubsidized HKS medical insurance, or by either the District Office or NHHKC to indicate a change in status or that a recipient child is no longer eligible for reasons other than termination of the premium payment. Section 3 is completed by NHHKC to inform the Department of nonpayment of premiums for 60 days without good cause. Form 800S(i), Instructions to Form 800S, is also being released by this SR. District Offices will receive an initial supply of Form 800S under separate cover.

FORMS OBSOLESCENCES

Forms 800C(PL), Cover Letter for Form 800R(PL), and Form 800R(PL), Application for Redetermining Eligibility for Assistance, and their instructions have been obsoleted. Form 800P will now be used for the mail in redetermination process for pregnant women, HKG coverage based on a percentage of the FPL, and HKS children. Children receiving HKG under the Home Care for Children with Severe Disabilities (HC-CSD, or "Katie Beckett," program) will now be sent Form 800, Application. Forms 800C(PL) and 800R(PL) are not mentioned in the Certificate of Destruction in this SR, because these forms are generally not kept at the District Office. However, if District Offices have any of these forms in their possession, they must destroy or recycle them upon receipt of this SR.

PROCEDURES

Even with the initiation of partial New HEIGHTS processing capabilities as of January 18, 1999, most eligibility determination processes for HKS will need to be manual until full automation of HKS eligibility and case management, scheduled for April 26, 1999. Until full automation, case technicians must manually perform the following aspects of eligibility determination for HKS:

1. Denial of eligibility for having medical insurance currently or within the prior 6 calendar months, and related manual Notices of Decision.

2. Determination of good cause for termination of medical insurance within the prior 6 calendar months, and related manual Notices of Decision.

3. Alerts that an HKS child is turning age 19.

4. Prior to January 18, 1999, computation of income eligibility (New HEIGHTS will be capable of performing this function as of January 18. See below.).

5. Referral of potentially eligible children to NHHKC, using Form 800S.

6. If informed by NHHKC via Form 800S that a child is ineligible due to nonpayment of the required premium, closing of the case, suppression of all HEIGHTS-generated Notices, and generation of an Alert related to the 3 month "lock-out" of eligibility.

Note: Many of the procedures outlined in this Section are still being finalized by New HEIGHTS. Most of those procedures, however, involve the availability of "shortcuts," such as "worker-selectable" messages available on the Program of Assistance screen, that will reduce some of the manual processing required at this time. District Offices will be receiving further information and instruction directly from New HEIGHTS staff.

There are no changes at this time to procedures associated with HKG.

NOD Requirements

Healthy Kids-Gold

No changes are being made to Notices associated with HKG medical coverage at this time. Current Notices will continue to use previous program terminology, e.g., PLC, Medical Assistance, PLP, etc., until all programming changes related to Healthy Kids medical coverage have been made.

Healthy Kids-Silver

In general, all NOD’s related to HKS eligibility will be the responsibility of NHHKC, including all openings and most closings. Therefore, until full automation of HKS in April, 1999, when processing HKS cases on New HEIGHTS, District Offices must suppress any New HEIGHTS-generated NOD’s associated with opening HKS cases, or with denial/closing for any reason other than failure to verify basic eligibility elements, such as age, residence, or income.

Exception: District Offices must provide a manual NOD when denying or closing an HKS application for current or prior medical insurance. The following is suggested text for a manual NOD for this action:

"The child(ren) listed below are not eligible for Healthy Kids-Silver medical insurance because they [are currently covered by other medical insurance] [were covered by medical insurance, other than Healthy Kids-Gold or a plan through the New Hampshire Healthy Kids Corporation, at sometime during the past 6 months and you did not have a good cause reason for that insurance ending]. You may reapply for Healthy Kids-Silver medical insurance when six months have past since the child(ren)’s last medical insurance coverage ended.

[Child(ren)’s Name(s)]"

Allow an Advance Notice Period.

Note: New HEIGHTS may have the above message available as a "worker-selectable" choice, precluding the necessity of creating a fully manual NOD for this purpose. If so, case technicians may set the child’s "request" field to "No" and then select the above message from the drop-down screen. New HEIGHTS will then produce an NOD containing the above message.

Interim Procedures for Processing of HKS Applications on New HEIGHTS

New HEIGHTS programming of HKS policy will occur in 2 phases. Phase 1, effective January 18, 1998, will allow HKS income eligibility to be computed, but all other eligibility elements, Notices (except where "worker-selectable" Notices may be available), etc., must be done manually. Full automation of HKS eligibility is scheduled to occur April 26, 1999.

Applications Received Prior To January 18

1. Process the application through Client Registration (CR) and Application Entry (AE) to generate an official Request For Assistance (RFA) and official filing date. Because current programming will apply Healthy Kids-Gold non-financial requirements to this children, the following procedures must be followed in order to avoid incorrect processing of HKS applications:

 Citizenship -- if the child is declared a citizen on the Application, choose a verification reason even if not verified. If declared a noncitizen, keep as unverified until verification of the child’s alien status is obtained.

 SSN -- if the number is not available, enter the current date in the good cause field and indicate that the applicant is cooperating.

 Medical Insurance -- select the new HKS insurance provider type. Set the verification field to Not Verified regardless of verification status.

 Indicate that the client is "cooperating" with Exploring Other Benefits.

 Enter only the most recent 4 weeks of income, if verified.

2. Run SFU and EDBC to ensure that the AG is not also eligible for any other programs.

3. If income was not previously verified, enter the most recent 4 weeks and rerun SFU and EDBC. Delete any income entries older than the most recent 4 weeks.

4. When the MA AG FAILS due to income, do not confirm the denial.

5. Record in the case file the child’s net monthly income as determined by New HEIGHTS and manually compare to the HKS limits.

6. Manually screen the application for indications of other health insurance.

7. If the net income is higher than 300% of federal poverty income guidelines, refer the child to NHHKC using Form 800S for evaluation of eligibility for unsubsidized HKS medical insurance. Confirm the denial, but do not allow any Notices of Decision to be generated. NHHKC will contact the family and notify them of any coverages for which they may be eligible.

8. If net monthly income is within the subsidized HKS limits (>185% but <300% of federal poverty) and all other eligibility criteria are met, set up a paper case file and create an Alert, Expected Change, or other form of "tickler" process to complete case processing on or about Jan. 18 (see below).

9. Contact the applicant family and request needed verifications. Allow 10 days to provide. Deny the application, using regular procedures, if the applicant fails to provide required verifications within the 10 day timeframe.

10. When the basic eligibility is established, and all required verification has been provided, complete Section 1 of Form 800S and fax to NHHKC.

On or about January 18:

1. Go into the New HEIGHTS case.

2. Navigate to the Program of Assistance screen, click the Medical Assistance tab, and click the Healthy Kids-Silver box.

3. Keep the HKS medical insurance provider set to "Not Verified," even if in reality the "no current medical insurance" criterion has been met. This will keep the case in pending status prior to notice that premiums have been paid.

4. Rerun SFU and EDBC, taking the case all the way to the Case Confirmation screen. Until HKC faxes back Form 800S notifying the case technician that the premium has been paid, DO NOT CONFIRM THE CASE.

5. When Form 800S is received notifying that premium payment has been made, reenter the case, navigate to the medical insurance screen, and change the HKS verification field to "Verified."

6. Rerun SFU and EDBC; if no other verifications are needed, the case should PASS and be ready to confirm.

7. Navigate to the Program of Assistance screen. In the Filing/Application Date field, enter the 1st of the month following the month in which the premium was paid (as indicated at Form 800S).

8. When confirming the case, suppress any Notice for the HKS assistance group.

Note: Do not allow any applications to remain in pending status for longer than 45 days. If NHHKC has not responded with Form 800S by the 40th day, contact NHHKC immediately by telephone (1-800-4NHCHIP) to resolve the issue. If verifications are still outstanding, deny the application for Failure to Provide Verifications using normal procedures.

New Applications On Or After January 18

1. Put the application through CR and AE.

 Citizenship -- if the child is declared a citizen on the Application, choose a verification reason even if not verified. If declared a noncitizen, keep as unverified until verification of the child’s alien status is obtained.

 SSN -- if the number is not available, enter the current date in the good cause field and indicate that the applicant is cooperating.

 Medical Insurance -- select the new HKS insurance provider type. Set the verification field to Not Verified regardless of verification status.

 Indicate that the client is "cooperating" with Exploring Other Benefits.

 Enter only the most recent 4 weeks of income, if verified.

2. Run SFU and EDBC to ensure that the AG is not also eligible for any other programs and to put the case into pending status for Medical Assistance.

3. Request all verifications required by policy.

4. When all verifications have been received, reenter the case.

5. Enter all missing information and verifications. Delete any income entries older than the most recent 4 weeks.

6. Rerun SFU and EDBC.

7. When the MA AG FAILS due to income, navigate to the Program of Assistance screen, click the Medical Assistance tab, and click the Healthy Kids Silver box.

8. Rerun SFU and EDBC. If the MA AG FAILS again because net income is higher than 300% of federal poverty income guidelines, refer the child to NHHKC using Form 800S for evaluation of eligibility for unsubsidized HKS medical insurance. Confirm the denial, but do not allow any Notices of Decision to be generated. NHHKC will contact the family and notify them of any coverages for which they may be eligible.

9. If net monthly income is within the subsidized HKS limits (>185% but <300% of federal poverty) and all other eligibility criteria are met, process the case to the Case Confirmation screen but do not confirm the case.

10. Complete Section 1 of Form 800S and provide to NHHKC. Until HKC faxes back Form 800S notifying the case technician that the premium has been paid, DO NOT CONFIRM THE CASE.

11. When Form 800S is received notifying that premium payment has been made, reenter the case, navigate to the medical insurance screen, and change the HKS Insurance provider to "Verified."

12. Rerun SFU and EDBC; if no other verifications are needed, the case should PASS and be ready to confirm.

13. Navigate to the Program of Assistance screen. In the Filing/Application Date field, enter the 1st of the month following the month in which the premium was paid (as indicated at Form 800S).

14. When confirming the case, suppress any Notices for the HKS assistance group.

Once the District Office refers a potentially eligible child to NHHKC for either subdized or unsubsidized HKS, NHHKC will follow up and issue a letter of eligibility to the child’s parent/caretaker relative, explain and collect required premiums, help the family select a Primary Care Physician, explain the 5% "cap", and answer any questions the family may have about the program, covered services, cost shares, etc. The District Office will be notified of the child’s subsidized HKS enrollment status on Form 800S.

Procedures for HKG Infants Turning Age 1

1. In the month prior to the month in which the child’s 1st birthday falls, screen the case to confirm that all HKS eligibility requirements are met.

2. Complete Sections 1 and 2 of Form 800S (see Form 800S(i), Instructions) and provide to NHHKC.

3. If NHHKC returns Form 800S with an enrollment date, create an Alert or Expected Change to process the HKS case the day prior to the child’s 1st birthday.

4. The day prior to the child’s 1st birthday, enter the Program of Assistance screen and click the HKS tab.

5. Run SFU and EBDC to case confirmation.

6. Navigate to the Program of Assistance screen. In the Filing/Application Date field, enter the 1st of the month following the month in which the premium was paid (as indicated on Form 800S).

7. When confirming the case, suppress any Notice for the HKS assistance group.

8. If NHHKC returns Form 800S with any other message, close the HKG case effective the child’s birthday. No ANP is required.

Note: District Offices must ensure that these cases are processed in a timely manner to avoid any break in coverage for otherwise eligible children.

Procedures for Children with Income in Excess of 300%

When District Offices encounter applicants or recipients with income in excess of 300% of federal poverty income guidelines, follow all steps above, including confirmation of the denial or closing, suppressing the Notice when the assistance group fails the income test for HKS. IT IS CRITICALLY IMPORTANT THAT NO NOTICES OF DENIAL OR TERMINATION FOR HKS BE SENT BY DISTRICT OFFICES TO THESE APPLICANTS OR RECIPIENTS. After denying or closing the case on New HEIGHTS, complete Sections 1 and 2 of Form 800S (see Form 800S(i), Instructions) and provide to NHHKC.

Procedures for Current NHHKC-Covered Children Eligible for HKS in January, 1999

Special procedures are in process for converting children currently receiving unsubsidized medical insurance thorough NHHKC who will qualify for Healthy Kids-Silver as of January 1, 1999. Concord District Office staff, in cooperation with NHHKC staff, are screening these cases, and arrangements are being made to have them keyed into New HEIGHTS. The appropriate District Offices will be notified of these cases but need not take any action on these cases at this time.

Procedures for HKS Children Inappropriately Opened Presumptively Eligible

In the event that a child is opened for HKG because a qualified entity determined the child to be presumptively eligible for HKG, but further income verification reveals that the child is not income-eligible for HKG but may be eligible for HKS, take the following actions:

1. Enter the verified income into New HEIGHTS.

2. Rerun SFU and EDBC. If the assistance group FAILS due to excess income, confirm the closing but do not allow the current NOD to be generated.

3. Prepare a Manual Notice of Decision. The following wording is suggested:

A medical provider originally found your child eligible for Healthy Kids-Gold medical coverage. We have reviewed that decision and have determined that your child does not meet all the requirements for Healthy Kids-Gold medical coverage because [DO must fill in the appropriate reason, e.g., failure to provide verification, income exceeds program limits, child does not meet citizenship requirements, etc.].

Exception: New HEIGHTS is developing a "worker-selectable" message for this situation. Further instructions on this alternative will be given to District Offices directly by New HEIGHTS staff.

4. Reactivate the case. At the Medical Assistance tab, click the Healthy Kids-Silver box.

5. Follow procedures for case processing and referral via new Form 800S to NHHKC.

IMPLEMENTATION

The revised policies in this SR are effective for all new applications, and Healthy Kids-Gold redeterminations, on or after January 1, 1999. Except for HKS-eligible children already receiving NHHKC services (see above), HKS services may begin no earlier than February 1, 1999 for families who meet all eligibility requirements and pay the February premium(s) within NHHKC timeframes.

CLIENT AND PROVIDER NOTIFICATION

Efforts have been ongoing throughout the past several months to make the general public aware of medical coverage through Healthy Kids. Examples of such notification included press releases and fliers, as well as a public presentation from Governor Shaheen. Outreach activities beginning this December include REECHH (Ready to Enroll Eligible Children in a Health Home), a community based effort in Manchester, Dover, Rochester and Littleton through the Bi-State Primary Care Association. This effort emphasizes a neighbor to neighbor approach towards insuring that eligible children are provided with medical coverage. As part of this process, training is provided to business and community groups who, in turn, can educate potential clients about Healthy Kids. Other outreach efforts throughout the state include promotional materials, videos, mailings and public service announcements, such as radio talk shows, presentations and newspaper articles. NHHKC’s statewide effort includes identification of potentially eligible clients and partnerships with health care centers, municipalities, hospitals, social service agencies, schools, child care centers and physicians. The New Hampshire Hospital Association is also participating in outreach activities.

A Provider notice regarding the change to Healthy Kids-Gold cards was placed in the Medicaid Bulletin in October and November by the Medicaid Administration Bureau (MAB). A specific Provider Notice created by MAB is scheduled to be mailed out on Thursday, December 17, 1998, by EDS to every Medicaid provider.

TRAINING

District Office Supervisors were introduced to the name change and implementation of of the new HKS medical insurance program via previous memoranda from the DFA Director, and were instructed to advise their staff about the changes. Supervisors also received this SR in draft form on December 18, 1998. District Office staff may direct New HEIGHTS procedural questions to onsite support staff or the New HEIGHTS Help Desk. DFA will provide District Offices and outreach agencies with initial supplies of new and revised forms and their instructions.

POSTING INSTRUCTIONS

* The fascimile should be posted in back of the Forms Manual with other forms which are designated only by alpha characters or description.

DISPOSITION

This SR must be retained until revised manual pages associated with Healthy Kids coverage are available. Revisions to the DFA On-Line Policy Manuals are scheduled to be completed for the February 1, 1999 release.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at http://www.state.nh.us/dhhs, effective February 1, 1999. Hard-copies of the SR and attachments will be distributed to NHHKC, hospitals, contract child care agencies, public health clinics, WIC, and Early Intervention agencies.

This SR, and printed pages with posting instructions, will be distributed under separate cover to all hard copy holders of the Family Assistance, Food Stamp, and Forms Manuals subsequent to their electronic release in February.

DFA/SJC:s

------------------------------------------------------------------------------------------------------------------CERTIFICATE OF DESTRUCTION

I hereby certify that all copies of Form 800P, dated August 1997, SR 97-31 and Forms 800PE and, 808P, dated May 1998 SR 98-21, have been destroyed upon receipt of Forms 800P, 800PE, and 808P, dated January 1999, SR 99-02.

Office Manager: _____________________ District Office: ______________________

Please return this to Stock Control, 6 Hazen Drive, upon receipt of new forms.

Healthy Kids-Medical Coverage Eligibility Summary