WELLCARE OF KENTUCKY YOUR GUIDE TO YOUR NEW HEALTH PLAN KY8CADBKT10874E_0000

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1 WELLCARE OF KENTUCKY YOUR GUIDE TO YOUR NEW HEALTH PLAN KY8CADBKT10874E_0000

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3 Hello Valued Member, Kentucky HEALTH is the Commonwealth s new health and wellness program. This handy guide describes some of the exciting changes in your new health plan. Please remember to keep this guide in your important papers. When you have questions, you can find some of the answers in here. You can also refer to your Member Handbook or go to WellCare of Kentucky has two Medicaid options: Original Medicaid; and Kentucky HEALTH Kentucky HEALTH improves your health by: Helping you take better care of yourself and involving you in your community Working with you on your health and helping you live a healthier life Giving you more control over your health care Most Kentucky HEALTH members will pay premiums or co-pays as a way to invest in their personal health. The Department for Medicaid Services (DMS) wants to help you understand how regular health insurance works, including things like: Making regular and on-time premium payments; Tracking deductibles; and Managing health care spending 3

4 Eligibility How does Kentucky HEALTH apply to me? It depends on how you are enrolled in Medicaid. You should have received a notice of eligibility that lets you know which type of enrollment you have with Medicaid. If you are enrolled in Kentucky HEALTH, you ll also get a letter that contains more details about your enrollment You might be affected by the changes in Kentucky HEALTH if you are: A Medicaid expansion adult (age 19 to 64) A Parent or caretaker of Medicaid children A former foster care member (up to age 26) Receiving Transitional Medical Assistance (TMA) A pregnant woman You are not affected by Kentucky HEALTH requirements if you are: A child enrolled in Medicaid or KCHIP (Kentucky Children s Health Insurance Program) A member enrolled in Medicare Over 64 years of age, blind or disabled A child in foster care A child involved in a subsidized adoption How will the services I receive change through Kentucky HEALTH? Good news! You can still get all current medical services. But the way you get those medical services might change. 4

5 Kentucky HEALTH members will be enrolled in one of two potential benefit plans, depending on their individual circumstances: State Medicaid Plan A benefit plan identical to the one provided to WellCare members before Kentucky HEALTH Kentucky HEALTH Alternative Benefit Plan (ABP) A benefit plan with services and benefits similar to what members would receive in a non-medicaid insurance plan. Kentucky HEALTH Alternative Benefit Plan (ABP) Some members will be enrolled in the Kentucky HEALTH ABP (see table) You will still get preventive and specialty medical services through WellCare Vision and dental benefits will be available through your My Rewards Account a special health savings account that lets you earn reward dollars for healthy activities Population Medicaid expansion adults (21+) Medicaid expansion adults (19-20) Medically Frail adults Former foster youth up to age 26 Pregnant women Parents and Caretakers Transitional Medical Assistance All other WellCare Members Changes in covered services Enrolled in ABP. Vision and Dental will now be covered by the (DMS) through the My Rewards account Enrolled in ABP. Vision and Dental benefits still provided by WellCare No changes No changes No changes No changes No changes No changes 5

6 My Rewards Account Kentucky HEALTH members are eligible for a rewards program. The My Rewards Account is offered to Kentucky HEALTH adults who Are pregnant, or Have paid a premium to gain access to the rewards account Members get rewards for completing certain activities. How do I receive rewards? You automatically earn money in your My Rewards Account when you: Go to the dentist for a cleaning Take your child in for a checkup Get a health screening or flu shot Complete other types of activities For a full list of activities, please go to <website> 6

7 What can I use My Rewards Account for? If you are eligible for a My Rewards Account, you may use it for enhanced benefits, such as approved fitness services or activities Medicaid expansion adults may also use the My Rewards Account for routine vision and dental services How do I get a My Rewards Account? Pregnant women are automatically enrolled in the My Rewards Account Other Kentucky HEALTH members can activate their My Rewards Account and keep the account active by paying their monthly premium When can I start earning rewards? There s good news if you are a Kentucky HEALTH member. You re already earning rewards! You get credit for any qualifying activities you completed with WellCare since Jan. 1, Check your My Rewards Account status and balance at citizenconnect.ky.gov 7

8 Cost Sharing: Investing in your Health As a Kentucky HEALTH member, you will likely pay either monthly premiums or co-pays. This lets you invest in your health. Monthly household premiums are between $1 and $15, depending on your income. Premiums cover your share of all WellCare covered visits for the month. You will not have to pay more no matter how many trips to the doctor. This chart shows you how cost sharing might affect you. Pregnant women are exempt from cost sharing. Member category Former Foster care, Medically frail All other non-pregnant adults who are Kentucky HEALTH members Benefits of paying monthly premiums You are enrolled in the My Rewards Account and can earn more benefits More benefits through the My Rewards Account You will not have to pay more regardless of the number of trips to the doctor Consequences for non-payment of premium You will not have access to a My Rewards Account for extra benefits The My Rewards Account is suspended Your benefits may be suspended if your income is over the federal poverty level. The Federal poverty level depends on household size, it could range from $12,140 for a single (individual) adult to $25,100 for 2 adults and 2 children (family of 4) If you are not suspended, you will have copays for all services Please remember to pay your premium. If you don t, you may lose your benefits or be enrolled in a plan with co-pays. A Co-pay is a set amount you will pay to get care. 8

9 There is a co-pay for all non-preventive services if your household income is below the federal poverty level and you did not pay your premium. The Federal poverty level depends on household size, it could range from $12,140 for a single (individual) adult to $25,100 for 2 adults and 2 children (family of 4). Co-pays vary based on the type of service. They can be more expensive than monthly family premiums. For example, you might pay: Benefit Co-pay Acute inpatient hospital admission $50 Outpatient hospital or ambulatory surgical center visit $4 Generic prescription drug $1 Brand name drug $4-$8 Emergency room for a nonemergency visit $8 Durable medical equipment $4 Office visit $3 Occupational and physical therapy $3 Speech-language pathology services $3 Laboratory, diagnostic or radiology services $3 For a full list of co-pays, please see your Member Handbook. You can also go to Cost sharing: Additional details If you do not pay your premium, your income level will determine if you: Have to pay a co-pay to keep your benefits or Lose coverage under Medicaid To learn more, please see your Member Handbook or go to How can I pay my premium? We ve made it easy for you to pay your premium. Many places will accept payment and there are lots of ways to pay: You can use cash, check, money order, <online at <website>>, or credit and debit card You can pay at retail locations, such as Walmart, Kroger, Check$mart and City National Bank You can call Customer Service to help you make your payment over the phone 9

10 What if I can t pay my premium? It s not always possible to pay your premium. Kentucky HEALTH understands that and provides temporary exemptions in some circumstances. You might be eligible for a temporary exemption if you: Are in the hospital; Experience a natural disaster; or Face certain personal circumstances You can find a complete list of exemptions in your Member Handbook. It is also available at Do you think you might qualify? Please call Customer Service at (TTY 711) Monday Friday, 7 a.m. to 7 p.m. or visit us at But you will need to upload the proof on the self-service portal at <website> or you can take the proof to your local Department for Community Based Services office. Don t forget: If you can t pay and don t qualify for an exemption, friends, neighbors, churches, providers or other charities can pay for you. Contact us to learn more. What if I don t know anyone who can help pay my premiums? We will try to find help for you. Please call our CommUnity Assistance Line (CAL) at (Video Relay ). We are here Monday through Friday from 9 a.m. to 6 p.m. Eastern Time What if I don t pay my premium? There is a penalty for not paying a premium. You can remove that penalty once per year. In order to remove a penalty. You have to: Pay two months of past due premiums; Pay one month of future premiums; and Complete a re-entry course <Placeholder for contact phone # or website> If you don t pay your premium, you enter a six-month penalty period, which could include: A suspension of benefits; or Enrollment in a co-pay plan (depends on your income) After six months, you can pay one month of premiums to re-enroll in a plan without co-pays. 10

11 Monthly Deductible Account statement and claim summary All Kentucky HEALTH members get a monthly Deductible Account and claim summary statement. This excludes pregnant women and children. Deductible Account: The Commonwealth of Kentucky wants you to be active in your healthcare. When you understand how the system works, you can make cost-conscious decisions. The Commonwealth of Kentucky will put $1,000 into your Deductible Account As you see providers for non-preventive services, money is taken out of your Deductible Account up to the first $1,000 Once you have received more than $1,000 in services, WellCare will continue to pay all of your medical claims. You will never get a bill for any covered services If you get less than $1,000 in services in a year, part of the unspent balance will be deposited into your My Rewards Account You can go to <website> or get a monthly statement that lets you: Review a summary of your claims Track your deductible balance and expense It is not a bill; you do not have to pay for any covered service The only effect on you is: You will get a monthly statement that explains your healthcare spending, and You can roll over a part of the unspent balance into a My Rewards Account at the end of the year 11

12 PATH Community Engagement PATH (Partnering to Advance Training and Health) Community Engagement can move you toward financial security. The 80 hours you complete each month in required activities builds and strengthens Kentucky s workforce. Kentucky HEALTH offers ALL beneficiaries access to community engagement and employment resources through its PATH Community Engagement Program. You can use PATH Community Engagement for job opportunities, job training, volunteer opportunities, and much more. And it s all free of charge! Do I have to participate in the PATH? Adult Kentucky HEALTH members must participate to stay eligible unless: They qualify for an exemption, or They already meet the requirements on their own What are the PATH Community Engagement requirements? You ll get a notice from Kentucky HEALTH that tells you when your requirements start, so you have time to prepare and find activities Completing PATH Community Engagement requirements will only take 80 hours of approved activities each month; PATH Community Engagement requirements will roll out across the state during 2018 Members who do not have to meet PATH Community Engagement requirements Pregnant women Medically Frail adults Former foster youth (up to age 26) Full-time students Primary caregiver of a dependent Employed full time (30 or more hours per week) 12

13 How do I complete my requirements? To register for PATH Community Engagement activities or report your PATH Community Engagement hours: Visit citizenconnect.ky.gov; or Call ; <TTY> <Monday Friday <X a.m. to X p.m.> <time zone> What types of activities meet my requirement? Some PATH Community Engagement activities that qualify are: Job skills training Job search activities Education related to employment General education (i.e. GED, community college) Vocational education/training Participation in Substance Use Disorder (SUD) treatment Subsidized or unsubsidized employment Community work experience Community service/public service Caregiving services for a non-dependent relative or other person with a chronic, disabling health condition What happens if I don t complete my hours? We want you to complete your PATH Community Engagement requirements. It s important to your success while you re a Kentucky HEALTH member. Meeting your requirements ensures that you keep your Medicaid benefits; your Medicaid benefits can be suspended or terminated if you don t meet your PATH Community Engagement requirements If your benefits are suspended, you can be reinstated by completing 80 hours of qualifying activities or completing a re-entry course If you do not meet the PATH Community Engagement requirement in a month you have an opportunity to make them up the following month before the suspension is in effect. The opportunity to make them up includes being current on all hours for the current month and either 13

14 1. Making up all deficit hours not completed in the prior month or 2. Completing a re-entry course. The option to take a re-entry course to avoid suspension or re-enter from suspension is only available once per benefit year. What if I can t meet my hours? Do you think you qualify for an exemption? You might just need to report a change to DMS and let them know you are a primary caregiver, full-time student or qualify for another exemption. Report changes to DMS at <phone or website> Your Member Handbook has a list of temporary exemptions. If you think you qualify, you can report it to Customer Service at (TTY 711) or visit You will need to upload the proof on the self-service portal at <website> or you can take the proof to your local Department for Community Based Services office. What if I don t qualify for an exemption, but still can t meet my hours? We offer a resource to help WellCare members meet PATH Community Engagement requirements. It s called WellCare Works. It can help you move toward meeting your life and career goals. Its features include: Completing online career assessments Learning about job interview tips, and You can complete these and many others at <website>. Receiving 1-on-1 job coaching We will also try to find help for you if you want to complete your requirements, but face other obstacles. Our CommUnity Assistance Line (CAL) can help with resources such as: Utility assistance Food banks Transportation Rental assistance Free and reduced-cost child care Would you like to learn more about our CommUnity Assistance Line (CAL)? Please call (Video Relay ). We have someone available to help you Monday through Friday from 9 a.m. to 6 p.m. Eastern. 14

15 Medically Frail Kentucky HEALTH includes a new category of eligibility called Medically Frail. If Kentucky HEALTH determines you are Medically Frail, you: Will continue to receive vision and dental coverage through WellCare; Can t lose your health coverage or be moved to a co-pay plan if you do not pay premiums Do not have to meet PATH Community Engagement requirements You might be eligible for this type of exemption if you have: A disabling mental disorder, including serious mental illness Chronic substance use disorder Serious and complex medical conditions A physical, intellectual or developmental disability that significantly impairs daily living You also might be eligible if you are chronically homeless. 15

16 How will WellCare notify me if I get this exemption? WellCare will monitor all of your doctor s visits and prescriptions If your medical history meets the Medically Frail requirements for Kentucky HEALTH, we will report that to DMS so that they can give you the appropriate exemption If your medical history shows that you come close to meeting the requirements, but don t fully qualify for the exemption, we will let you know what extra information we would need to report your qualifications to DMS Do you want to learn more about Medically Frail? Please see your Member Handbook or visit us at 16

17 Suspensions and Penalties Except for pregnant women and Medically Frail adults, Kentucky HEALTH members face new penalties if you: Fail to complete your annual recertification Fail to report a change in your circumstances to DMS Voluntarily withdraw from Medicaid coverage You can also be stopped from re-enrolling in Medicaid for 6 months if you get one of these penalties. How can I make sure I don t receive the new penalties? You want to make sure you aren t suspended and can re-enroll in Medicaid. Here s how to make it happen: Give your most recent address to DMS so you get any documents they send you Respond to any DMS requests for information or paperwork Report any changes of your circumstances to DMS. For example, if you decide to end your Kentucky HEALTH coverage you will not be able to re-enroll for six months. You will be able to re-enroll if the reason you end your coverage is you move out of Kentucky, gain other health insurance, or have a change in household income or size that caused you to become ineligible for Medicaid. You can also re-enroll before the end of the six months if you take a re-entry course. 17

18 What do I need to know about Premium Assistance? Kentucky HEALTH members who can use their employer s insurance may be able to use the Commonwealth of Kentucky s Premium Assistance program that will be coming in 2019; this will help pay for enrollment in your employer s plan If you enroll in Premium Assistance, you will no longer be a WellCare member Medically Frail members, pregnant women and children can use Premium Assistance Premium Assistance is required for expansion adults, parents and caretakers who have been enrolled in Kentucky HEALTH for 12 months, and who have the same employer for 12 months (if the plan is deemed cost effective) If you are eligible for Kentucky HEALTH, you may have the option or obligation to enroll in your employer s health plan instead of standard Medicaid consumer health plan option Kentucky HEALTH will reimburse you (less the required monthly Kentucky HEALTH premium amount) for the cost of your employer s plan You will have access to the benefits covered by your employer s plan AND any benefits covered by Kentucky HEALTH that may not be covered by your employer s plan You will also have access to the provider network of your employer s plan 18

19 MyWellCare Mobile App With our app, you ll have health information at your fingertips. The MyWellCare app on your smartphone or tablet lets you: Access your member ID card your member ID card Search for providers, quick care clinics and hospitals View Wellness Services View your Premium Payment and the due date So go ahead download MyWellCare today. It s free at Apple and Android app stores. To learn how to download the app, please see your Member Handbook. Other Important Info: At WellCare of Kentucky, we care about your health and well-being. Do you need more help or have any more questions? We re here for you. You can: Check your Member Handbook Visit Call Customer Service at (TTY 711) Monday to Friday 7 a.m. to 7 p.m. Eastern. Remember to tell Customer Service if you want to get text messages from us with reminders and information. 19

20 WellCare of Kentucky complies with all applicable federal civil rights laws. We do not exclude or treat people in a different way based on race, color, national origin, age, disability or sex. If English is not your first language, we can translate for you. We can also give you info in other formats. That includes Braille, audio and large print. Just give us a call toll-free. You can reach us at For TTY, call 711. Si el español es su lengua materna, podemos brindarle servicios de traducción. También podemos proporcionarle información en otros formatos, como braille, audio y letra de imprenta grande. Simplemente, llámenos sin cargo al Para TTY llame al 711.

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24 (TTY 711) Monday to Friday 7 a.m. to 7 p.m. Eastern Time CAD_10874E State Approved MMDDYYYY WellCare 2018