Kentucky Lock-In Program
- What is the Kentucky Lock-In Program?
- Why are members enrolled in KLIP?
- What does KLIP enrollment mean for a member?
- What can a member do to be removed from KLIP?
- How can a KLIP enrollee change his or her pharmacy provider or PCP?
- What should a KLIP enrollee do in case of an emergency?
- How long is a Humana – CareSource member enrolled in KLIP?
- Whom can an enrollee or health partner contact with questions?
- How does an enrollee see a specialist who is not his or her designated KLIP provider?
What is the Kentucky Lock-In Program?
KLIP is a program for Kentucky Medicaid members who need help managing their health care needs. It is intended to limit overuse of benefits and reduce unnecessary costs to Medicaid while providing an appropriate level of care for the member. Humana – CareSource® members who meet the program criteria will be locked in to:
- One primary care physician (PCP)
- One controlled substance provider, if needed
- One pharmacy
KLIP is required by the Kentucky Department for Medicaid Services.
Why are members enrolled in KLIP?
Humana – CareSource monitors claim activity for overuse of benefits and unnecessary costs in accordance with state and federal laws. A member is considered a candidate for KLIP if a review of the member’s claim activity reveals an unusually large number of claims for medically unnecessary treatment, services or medications. Such activity may include:
- More frequent than average use of health care services
- Visits to a number of different providers over the course of a year
- Trips to the emergency room for non-emergency services
- Reports of fraud, waste or misuse from one or more of the following:
- Office of the Inspector General
- Law enforcement
- Humana – CareSource
What does KLIP enrollment mean for a member?
Members enrolled in KLIP will continue to receive medically necessary, Medicaid-covered health care services. An enrollee is “locked in” to health care delivered by one PCP, one pharmacy and one controlled substance prescriber (when applicable). The KLIP enrollee’s dedicated PCP and pharmacy provide an improved level of care, due to direct access to the enrollee’s complete medical history. If a KLIP enrollee receives service or care from a pharmacy or health partner not approved as his or her “locked-in” provider, Humana – CareSource will not cover services rendered, and the incurred costs will be the responsibility of the enrollee.
Except in an emergency, an enrollee should contact his or her PCP before seeking care from other providers.
A Care Manager may be assigned to a KLIP enrollee. The Care Manager may contact and consult with the enrollee about Care Management services and other benefits available from KLIP.
What can a member do to be removed from KLIP?
If a member disagrees with placement in KLIP and wants to discontinue enrollment, appeals can be requested by:
- Calling 1-855-852-7005 (TTY: 1-800-648-6056 or 711)
- Faxing a written request to 1-855-262-9797
- Emailing a written request to firstname.lastname@example.org
- Mailing a written request to:
Humana – CareSource
Attn: Member Grievance and Appeal Specialist
P.O. Box 221529
Louisville, KY 40252-1529
How can a KLIP enrollee change his or her pharmacy provider or PCP?
A KLIP enrollee can only change his or her PCP, controlled substance prescriber or pharmacy once in a two-year period unless:
- The physician’s office or the pharmacy is closed or moves too far away for the enrollee to feasibly continue to receive care.
- The enrollee relocates and the current health partner is too far away for the enrollee to continue under that health partner’s care.
- The enrollee can no longer travel to the health partner for medical reasons.
- The enrollee switches coverage from another managed care plan (MCP) or from regular Medicaid, and the assigned pharmacy or PCP is not on our provider network.
- The enrollee has a medical need that requires a different PCP.
- The pharmacy or PCP is no longer included on the Humana – CareSource provider network.
- The pharmacy or PCP no longer wants to provide services to the enrollee.
What should a KLIP enrollee do in case of an emergency?
Emergency services are for medical problems serious enough that they must be treated immediately. If the KLIP enrollee thinks he or she has an emergency, he or she should call 911 or go to the nearest emergency room (ER). The enrollee should call his or her PCP after the ER visit in case follow-up care is needed.
If a KLIP enrollee is uncertain whether an ER visit is necessary, the enrollee can call his or her PCP or the Humana – CareSource 24-hour nurse advice line. The number is listed on all Humana – CareSource member cards. The enrollee’s PCP or the 24-hour advice line nurse can talk to the enrollee about the medical problem and will advise the enrollee what he or she should do.
If the enrollee has a pharmacy emergency, Humana – CareSource may approve use of a different pharmacy. Examples of pharmacy emergencies include:
- The assigned pharmacy does not have the drug the enrollee requires and waiting for restocking of the drug will harm the enrollee’s health.
- The enrollee cannot get to the pharmacy and the delay will harm the enrollee’s health.
Enrollees can call the 24-hour nurse advice line if they have a pharmacy emergency.
How long is a Humana – CareSource member enrolled in KLIP?
A member will stay enrolled in KLIP for 24 months. Before the end of the 24-month period, his or her claim history will be reviewed. The member will be notified of a decision on continued KLIP status. If Humana – CareSource makes the decision to keep the member in KLIP, we will notify the member of his or her right to a state hearing if the member chooses to contest the decision.
Whom can an enrollee or health partner contact with questions?
Please call Member Services or Provider Services at 1-855-852-7005 (TTY: 1-800-648-6056 or 711) for help.
How does an enrollee see a specialist who is not his or her designated KLIP provider?
Referred-to health partners who offer services to KLIP enrollees will:
- Sign a Kentucky Lock-In Provider Referral Form completed by the primary care physician or referring physician that is delivered by the enrollee.
- Submit the signed Kentucky Lock-In Provider Referral Form with the claim.