hp provider relations may 2012 introduction to indiana health coverage programs

HP Provider Relations

May 2012

Introduction to

Indiana Health

Coverage Programs

Introduction to Indiana Health Coverage Programs May 20122

Agenda– What is Medicaid?

– Administration of Indiana Medicaid

– Indiana Health Coverage Programs (IHCP)

• Traditional Medicaid

• Care Select

• Hoosier Healthwise

• Children’s Health Insurance Program (CHIP)

• 590 Program

• Healthy Indiana Plan (HIP)

– References

– Questions


Objectives

– Provide a general overview of the Medicaid Program

– Discuss the general responsibilities of the State agencies and State contractors in regard to the administration of the IHCP

– Describe the major highlights of the IHCP including Traditional Medicaid, Care Select, Hoosier Healthwise, CHIP, 590 Program, and HIP

Learn What is Medicaid?


What Is Medicaid?– Medicaid is a federal and state funded

program, enacted in 1965 under Title XIX of the Social Security Act, which pays for the medical care of people who meet specific categorical nonfinancial, income, and resource requirements.

– Medicaid is an entitlement program, which means that any person who meets his or her state’s Medicaid eligibility criteria has a federal right to Medicaid coverage in that state.

• The state cannot limit enrollment in the program or establish a waiting list.

MEDICAID


Who Pays for Medicaid?

– The federal government matches state spending on Medicaid.

– Federal law outlines minimum requirements that all states’ Medicaid programs must fulfill.

• However, states have broad authority to define eligibility, benefits, provider payments, and other aspects of their programs.


Mandatory Groups

– Federal law requires that states cover certain “mandatory” groups of people who meet the state’s eligibility requirements to receive any federal matching funds.


Mandatory Benefits– Physician services

– Hospital services (inpatient and outpatient)

– Laboratory and X-ray services

– Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for individuals younger than 21 years old

– Federally qualified health center (FQHC) and rural health clinic (RHC) services

– Family planning services and supplies

– Pediatric and family nurse practitioner services

– Nurse midwife services

– Nursing facility services for individuals 21 years old and older

– Home health care for individuals eligible for nursing facility services

– Necessary transportation services


Optional BenefitsFederal law also permits states to cover many services designated as “optional” services, such as the following:

– Prescription drugs

– Hospice services

– Clinic services

– Durable medical equipment

– Vision services and eyeglasses

– Rehabilitation and other therapies

– Case management

– Care furnished by other licensed practitioners

– Transportation (above benefit limitations)

– Nursing facility services for individuals younger than 21 years old

– Dental services and dentures

– Intermediate care facility for the mentally retarded (ICF/MR) services

– Home and Community-Based Services (HCBS) Waiver Programs

– Inpatient psychiatric services for individuals younger than 21 years old

– Respiratory care services for ventilator-dependent individuals

– Personal care services


Indiana Health Coverage Programs

– In the state of Indiana, Medicaid services are offered to eligible Indiana residents through the IHCP.

– The IHCP is administered by the Office of Medicaid Policy and Planning (OMPP), which is under the Indiana Family and Social Services Administration (FSSA).

– The IHCP covers all the mandatory services and most of the optional services established by the federal government.

Indiana Medicaid

IndianaMedicaid

(IHCP)

11 Introduction to Indiana Health Coverage Program October 2011


Indiana Medicaid

12 Introduction to Indiana Health Coverage Programs May 2012

IHCP Payment Delivery System

– Providers are reimbursed for services rendered to members enrolled in IHCP based on the program in which the member is enrolled.

– The IHCP reimburses enrolled providers using the following three payment delivery systems:• Fee-for-service (FFS)

• Care Select

• Risk-based managed care (RBMC)


Fee for Service

– The FFS delivery system reimburses providers on a per-service basis.

– Providers bill services rendered to IHCP members directly to Hewlett-Packard (HP), the IHCP fiscal agent.



Care Select

– Care Select is similar to Traditional Medicaid in that payments for care are made on an FFS basis.

– In addition, a per-member, per-month administration fee is paid to primary medical providers (PMPs).

– Care Select operates as an FFS delivery system with a gatekeeper approach.

– Claims are submitted to HP for processing.



Risk-based Managed Care

– In the RBMC delivery system, the State pays each managed care entity (MCE) a monthly capitation fee based on the member’s category of service.

– This capitation fee covers the costs of care for most of the covered services incurred by Hoosier Healthwise members enrolled in the MCE network.

– Claims are processed and paid by the MCE in which the member is enrolled. • Exception: Claims for carved-out services, including but not limited to pharmacy and

dental services, are processed by HP and paid on an FFS basis.

– Providers should contact the MCE for specific claim payment and prior authorization (PA) policies and guidelines.


Describe Administration of Indiana Medicaid


Indiana Medicaid Administration

Division of Family

Resources (DFR)

OMPP

Indiana State

Department of Health (ISDH)

Division of Mental

Health & Addictions ( DMHA)

Division of Disability and

Rehabilitative Services( DDRS )

Division of Aging (DA )


Family and Social Services Administration

– The FSSA is the State agency responsible for social service and financial assistance programs.

– The FSSA includes the following five major service divisions:

• OMPP

• DFR

• DA

• DDRS

• DMHA


Office of Medicaid Policy and Planning

The OMPP is responsible for the following:

–Administering the IHCP at the State level, including the following functions:

• Medical policy development

• Program and contract compliance

• Contracting with MCEs

• Addressing cost containment issues

• Establishing IHCP policies

• Program reimbursement

• Program integrity, including claims analysis and recovery


Division of Family Resources

– The DFR, formerly known as the Division of Family and Children, is the division of FSSA responsible for processing applications and making eligibility decisions.

– The County Offices of the Division of Family Resources administer the IHCP at the local level.


Division of Aging

– The DA is the division of FSSA that operates the following programs:

• Two of the HCBS Waiver Programs

– Aged and Disabled (A&D) Waiver

– Traumatic Brain Injury Waiver

• Residential Care Assistance Program

• Nursing home Pre-Admission Screening Resident Review program

– Local Area Agency on Aging

• Handles the initial requests for waiver services

• Conducts nursing home pre-admission screenings


Indiana Medicaid State Contractors

State Contractors Involved in the

Administration of the Indiana Health

Coverage Programs (Indiana Medicaid)


State Contractor

– Serves as the State fiscal agent and as a liaison between the provider and member communities and the IHCP

– Manages the processing of claims (FFS)

– Processes a variety of financial transactions, including claim payments, voids, refunds, and accounts receivable

– Processes provider enrollment applications and updates existing provider records

– Provides training to the provider community through on-site visits, conferences, and workshops

– Provides member and provider customer assistance

HP Enterprise Services


State Contractor

– Traditional Medicaid or Care Select (FFS):

• Processes PA requests

• Reviews claims that suspend for medical policy audits

• Administers the Right Choices Program (RCP) for Traditional Medicaid and Care Select members

ADVANTAGE Health SolutionsSM


ADVANTAGE Health Solutions

– The RCP is designed to safeguard against the unnecessary or inappropriate use of Medicaid services.

– RCP case managers provide intensive member education, care coordination, and utilization management for members enrolled in the RCP.

– The member remains eligible to receive all medically necessary, covered services allowed by the IHCP when one of the following occurs:

• The service is rendered by one of the providers to whom the member is locked-in or restricted.

• The service is rendered by a specialist who has received a valid, written referral from the primary lock-in physician.

Right Choices Program


Right Choices Program– Effective January 1, 2010, any IHCP member participating in the IHCP (including

HIP) may be placed in the RCP.

– The RCP is administered by the health plan in which the member is enrolled.

Program Administered By Contact Information

Traditional Medicaid


1-800-784-3981

Care Select ADVANTAGE Health Solutions

1-800-784-3981

MDwise 1-800-356-1204 Hoosier Healthwise Managed Health Services

(MHS)1-877-647-4848

Anthem 1-866-902-1690, Option 3

MDwise 1-800-356-1204

HIP MHS 1-877-647-4848

MDwise 1-800-356-1204

Anthem 1-866-902-1690, Option 3


State Contractor

– Serves as the pharmacy benefit manager

• Responsible for the Drug Rebate Program

• Processes pharmacy-related PA requests

Xerox


State Contractor

– Myers and Stauffer is responsible for the following:

• Setting rates that affect claim pricing on certain types of claims (for instance, capital cost for inpatient claims)

• Setting flat fee rates for per diem services

• Auditing IHCP claim processing activities

Myers and Stauffer LC


State Contractor

– Entities authorized by the state of Indiana to operate a prepaid health care delivery plan (such as an HMO) on a capitated basis

• These entities arrange, administer, and process claims for the delivery of health care services to members who are enrolled in the Hoosier Healthwise Program.

– Administer the RCP for their members

Managed Care Entities

Managed Health Services

MDwise


State Contractor

– Provide a myriad of health services for members who are enrolled in Care Select

– Process PA requests

– Review claims that suspend for medical policy audits

– Administer the RCP

Care Management Organizations


MDwise


State Contractor

– Serves as an enrollment broker for the following:

• Care Select

• Hoosier Healthwise

• HIP

• Presumptive Eligibility for Pregnant Women

– Provides choice counseling for eligible members to assist them with choosing a health plan that best meets their needs

MAXIMUS Administrative Services

Explain Traditional Medicaid



– IHCP members enrolled in Traditional Medicaid are not assigned a PMP and do not need to enroll in any MCE to receive health-related services

– Services rendered to members

enrolled in Traditional Medicaid

are paid on an FFS basis



– Spend-down is a provision that allows a person whose income is more than the standard to receive assistance with medical bills under Medicaid.

– Spend-down works like an insurance deductible. Once the monthly spend-down amount is satisfied, Medicaid will pay for all other covered services for that month.

– The spend-down amount is determined by the DFR and is based on the member’s income and medical expenses.

– The member must pay the spend-down amount deducted from claims directly to the provider.

Spend-down



– Dually eligible members are individuals who are entitled to Medicare Part A and/or Part B and are eligible for Medicaid benefits.

• A Medicare beneficiary who is aged, blind, or disabled according to Medicaid’s standards and who meets the Medicaid income and resource eligibility rules can qualify for Traditional Medicaid.

Dually Eligible for Medicare and Medicaid



– A Medicare beneficiary who does not qualify for Medicaid following the established guidelines, may still qualify for Medicaid under one of the following categories designed for Medicare beneficiaries:

• Qualified Medicare Beneficiary (QMB)-Only

• QMB-Also

• QMB-Also with spend-down

– An individual must meet the following eligibility criteria to receive assistance with Medicare-related costs under the QMB program:

• Be entitled to Medicare Part A

• Be 65 years old or older or be younger than 65 years old and entitled to Medicare

Dually Eligible for Medicare and Medicaid



– Medicaid benefits are limited to payment of the member’s Medicare premiums, deductibles, and coinsurance for Medicare-covered services only.

• The member is only eligible for the premiums, deductibles and coinsurance for Medicare-covered services.

• Services not covered by Medicare are also not covered by Medicaid.

Qualified Medicare Beneficiary-Only Coverage



– Medicaid benefits include payment of the member’s Medicare premiums, deductibles, and coinsurance for Medicare-covered services.

– In addition, the member receives full Medicaid covered services (benefits).

– For QMB-Also with spend-down, the member receives full Medicaid covered services (benefits) after the monthly spend-down liability is met.

Qualified Medicare Beneficiary-Also Coverage



– Long-term care (LTC) services are available to IHCP members who meet the threshold of nursing care needs required for admission to or continued stay in an IHCP-certified nursing facility.

– The goal of the LTC program is to provide services in a setting other than an acute care wing of a hospital, enabling individuals whose functional capacities are chronically impaired to be maintained at their maximum level of health and well-being.

Long Term Care



– Patient liability is the monetary amount that a Medicaid resident must contribute toward his or her monthly care in a facility.

• The amount of patient liability is determined by the local county office of the DFR.

• The patient liability is deducted from LTC claims.

Long Term Care – Patient Liability



– The Hospice program provides services to IHCP members who are terminally ill.

• Hospice requires level of care (LOC) determination and a diagnosis of a terminal illness.

• A hospice provider must be Medicare-certified as a hospice provider prior to enrollment in the IHCP as a Medicaid provider.

Hospice



– Medicaid also offers additional nonmedical home and community-based services under waiver programs.

• Waivers are designed as an alternative to institutionalization.

• To qualify for waiver services, a person must first meet the LOC to receive services in an institution (hospital, nursing home, or ICF/MR) but choose to receive services in the community.

Waiver Programs



– Package E provides coverage of serious medical emergencies for undocumented immigrants and certain visitors to the United States who meet all other categorical and financial requirements.

• These members are only eligible for the following:

Labor and delivery until the mother is stable

Medical emergencies

A maximum of four-days supply of pharmacy services

• Nonemergency services may be billed to the member if a signed waiver was obtained prior to rendering services

Package E: Emergency Services Only

Define Care Select


Care Select

– Care Select is similar to Traditional Medicaid in that payments for care are made on an FFS basis.

– However, members are assigned to a PMP.

– An additional per-member, per-month administration fee is paid to PMPs.


Care Select

– As of October 1, 2010, Care Select changed from a care management program that covered an extensive group of aid categories to a disease management program with a focus on members with certain chronic conditions

– To participate in Care Select, members must meet the aid category criteria and have at least one of the health conditions covered by the program.

• Members can opt out of Care Select at any time and enroll in Traditional Medicaid instead.


Aid Categories Covered by Care Select

Care Select Aid Categorie

s

Aged

Ward of the State

Foster Care

Children/Adoptive Services

Care Select Aid

Categories

Blind

Aged

Disabled

Ward of the

State

Foster Care

Children/Adoptive Services


Health Conditions Covered by Care Select

– A member must also have one of the following conditions to be eligible for Care Select:

• Asthma

• Diabetes

• Congestive heart failure

• Hypertensive heart disease

• Hypertensive heart and kidney disease

• Rheumatic heart illness

• Severe mental illness

• Serious emotional disturbance

• Depression


Care Select

– Members select a health plan, also called a care management organization (CMO), to coordinate their health care services.

• MAXIMUS (an enrollment broker contracted by the State) can assist members in making a CMO selection.

– The CMO will assign a PMP.

– The PMP is responsible for the following:

• Providing or coordinating the member's care

• Providing most primary and preventive services and reviewing necessary specialty care and hospital admissions

Selecting a Health Plan and a Primary Medical Provider

Discuss Hoosier Healthwise


Hoosier Healthwise (Risk-based Managed Care Programs)

– The Hoosier Healthwise Program provides coverage for health care services rendered to the following aid category groups:

• Children

• Pregnant women

• Low-income families

– The specific eligibility aid category determines the benefit package.


Hoosier Healthwise

– Hoosier Healthwise follows an RBMC payment delivery system.

• As mentioned previously, in the RBMC delivery system, the State pays each MCE a monthly capitation fee based on the member’s category of service.

Risk-based Managed Care


Hoosier Healthwise

– within 30 days of their initial enrollment in Hoosier Healthwise, members select a health plan

• MAXIMUS (an enrollment broker contracted by the State) can assist members in selecting a health plan.

• After members enroll in a health plan, the health plan assists them in selecting a PMP.

• PMPs provide or authorize most primary and preventive care services.

Selecting a Health Plan and a Primary Medical Provider


Hoosier Healthwise

– MCEs arrange, administer, and pay (process claims) for the delivery of health care services to members who are enrolled in the Hoosier Healthwise Program.

– Each MCE is responsible for the following:

• Maintaining its own provider and member services units

• Paying claims for noncarved-out services

• Providing PA

Managed Care Entities

Managed Health Services

MDwise


Hoosier Healthwise

– CHIP, the State’s program created under Title XXI of the Social Security Act, provides health care coverage for children from birth through 18 years old using a buy-in option.

– Under CHIP, also known as Package C, the income limit is 250 percent of the federal poverty guidelines.

– Coverage is provided only to children who are ineligible for all other categories of the Hoosier Healthwise Program.

Children’s Health Insurance Program


Hoosier Healthwise

– Unlike the other Hoosier Healthwise programs, CHIP has cost-sharing requirements.

• A child determined eligible for Package C is made conditionally eligible pending a premium payment.

The child’s family must pay a monthly premium.

Only after the premium is paid is actual eligibility information transferred to IndianaAIM.

• Enrollment continues as long as premium payments are received and the child continues to meet all eligibility requirements.

Enrollment is terminated for nonpayment of premiums after a 60-day grace period.

Children’s Health Insurance Program – Cost-sharing Requirements


Early and Periodic Screening, Diagnosis, and Treatment

Early

Identifying problems early, starting at birth

Treatment

Diagnosis

Screening

Periodic

Doing physical, mental, developmental, dental, hearing, vision, and other screening tests

to detect potential problems

Checking children's health at periodic, age-appropriate

intervals

Performing diagnostic tests to follow up when a risk is

identified

Treating the problems found


Early and Periodic Screening, Diagnosis, and Treatment

– The EPSDT program, referred to as HealthWatch in Indiana, is a federally mandated preventive health care program designed to improve the overall health of eligible infants, children, and adolescents.

– The primary goal of the HealthWatch/EPSDT program is to ensure that all children in the IHCP receive age-appropriate, comprehensive, preventive services.

Describe 590 Program


590 Program

– The 590 Program is designed for residents of State-owned facilities under the direction of the FSSA, Division of Mental Health and Addiction, and Indiana State Department of Health.

– The 590 Program does not include incarcerated individuals.

– Members enrolled in the 590 Program are eligible for the full array of benefits covered by the IHCP (with the exception of transportation services).

• However, members do not receive a Hoosier Health Card.


590 Program

– All services provided on-site at the 590 Program facility are the financial responsibility of the facility.

• The 590 Program facility and all providers performing services must be enrolled in the 590 Program.

• Services provided to members enrolled in the 590 Program are reimbursed per claim, following an FFS payment delivery system.

– Billing for services includes the following:

• $150 or less Billed to the 590 Program facility

• Over $150 Billed to HP

• Over $500 Services require PA

Inform Healthy Indiana Plan


Healthy Indiana Plan

– HIP provides health insurance for uninsured adult Hoosiers between 19-64 years old whose household income is between 22 and 200 percent of the federal poverty level, who are not eligible for Medicaid.

• Eligible participants must be uninsured for at least six months and cannot be eligible for employer-sponsored health insurance.

• HIP is not an entitlement program; funding is limited.

• Pregnant women are not eligible for HIP services.

– Prescription drugs are limited to seven or nine fills per month; only four brands are allowed.

View The Indiana Health Coverage Programs Tree

65 Introduction to Indiana Health Coverage Program October 2011


FSSA

OMPP

MDwise

MHS

Anthem

Hoosier HealthwiseRisk-Based Managed Care

MAXIMUS

HP

590 Program

Healthy Indiana Plan

MDwise

Anthem Blue Cross

Blue Shield

Enhanced ServicesPlan (ESP)

Cenpatico

Behavioral Health

Anthem

MDwise

Managed Behavioral Health Organizations

FSSA = Family & Social Services AdministrationOMPP = Office of Medicaid Policy and PlanningMAXIMUS = Enrollment Broker

MHS


MDwise(Care Select)

Care Select

ADVANTAGE(Care Select)

Find Help References


References

– ADVANTAGE Health Solutionsadvantageplan.com

– Categories of Assistance (Indiana Client Eligibility System Program Policy Manual)in.gov/fssa/files/1600.pdf

– Anthemanthem.com

– Care Selectprovider.indianamedicaid.com/about-indiana-medicaid/member-programs/care-select.aspx

indianamedicaid.com/ihcp/BULLETINS/BT200723.pdf

in.gov/fssa/ompp/2546.htm

http://www.advantageplan.com/

http://www.in.gov/fssa/files/1600.pdf

http://www.anthem.com/

http://provider.indianamedicaid.com/about-indiana-medicaid/member-programs/care-select.aspx

http://provider.indianamedicaid.com/about-indiana-medicaid/member-programs/care-select.aspx

http://www.indianamedicaid.com/ihcp/BULLETINS/BT200723.pdf

http://www.in.gov/fssa/ompp/2546.htm


References– CHIP


– HealthWatch/EPSDT Provider Manual

provider.indianamedicaid.com/ihcp/manuals/epsdt_healthwatch.pdf

– FSSA/OMPP Glossary of Terms


– HIP

in.gov/fssa/hip

indianamedicaid.com/ihcp/Bulletins/BT200730.pdf


http://provider.indianamedicaid.com/ihcp/manuals/epsdt_healthwatch.pdf



References

– 590 Program Provider Manualprovider.indianamedicaid.com/ihcp/manuals/590_program_provider_manual.pdf

– Hoosier Healthwisein.gov/fssa/ompp/2544.htm

– Hospice Provider Manualprovider.indianamedicaid.com/ihcp/manuals/hospice_benefit_manual.pdf

– IHCPindianamedicaid.com/ihcp/index.asp


References

– IHCP Glossaryprovider.indianamedicaid.com/general-provider-services/ihcp-

glossary.aspx

– MHSmhsindiana.com

– MDwisemdwise.org

– Myers and Staufferin.mslc.com


References

– IHCP Provider Manualprovider.indianamedicaid.com/general-provider-services/manuals.aspx

– Title 405 Office of the Secretary of Family and Social Services Medicaid Covered Services and Limitations Rule in the Indiana Administrative Code (IAC) at 405 IAC 5state.in.us/legislative/iac/title405.html

– Medicaid Waiversin.gov/fssa/ompp/2549.htm

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