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transcript
Indiana Health Coverage Programs Family TreeOctober 2010
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Agenda
– Session Objectives
– Indiana Health Coverage Programs
– IHCP Team
– Traditional Medicaid
– Care Select
– Hoosier Healthwise
– Healthy Indiana Plan
– Enrollment Broker
– The “Tree”
– Resources
– Questions
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Objectives
At the end of this session, providers will be able to:
– Identify and discuss the roles of the major stakeholders of the IHCP
– Understand the populations served by the various IHCP programs
– Identify the basic services performed by the plans
– Access the resources to acquire important information
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Indiana Health Coverage Programs
Indiana Health Coverage Programs
Traditional Medicaid
Hoosier Healthwise
Healthy Indiana Plan
Care Select
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Office of Medicaid Policy and Planning
– The OMPP and CHIP Office:
• Determine rules and regulations (Indiana Administrative Code – IAC)
• Determine and approve reimbursement level
• Address cost containment issues
• Establish IHCP policies for better health outcomes
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IHCP Team
Indiana Family and Social Services Administration (FSSA):
– Office of Medicaid Policy and Planning (OMPP) and Children’s Health Insurance Program (CHIP) Office
– Contractors:
– HP – Fiscal Agent
– Pharmacy Benefit Manager
• Affiliated Computer Services (ACS)
– Care Select – Care Management Organizations:
• ADVANTAGE Health Solutions
• MDwise
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IHCP Team
– Hoosier Healthwise - Managed Care Organizations:
• Anthem
• Managed Health Services (MHS)
• MDwise
– Healthy Indiana Plan (HIP)
• Anthem Blue Cross Blue Shield
• MDwise
• Managed Health Services (as of January 1, 2011)
• Enhanced Services Plan
– Enrollment Broker
• MAXIMUS
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IHCP Information
Primary sources for information about the IHCP are found at:
– FSSA Web site at www.in.gov/fssa
– IHCP Web site at www.indianamedicaid.com
– IHCP Provider Manual
– IHCP provider monthly newsletters
– IHCP provider bulletins
– IHCP provider banner pages
– Indiana Administrative Code at www.in.gov/legislative/iac/title405.html
Note: The IHCP reference tools apply to fee-for-service/Traditional Medicaid, not the risk-based managed care delivery system
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Traditional Medicaid – Fee-for-Service
Traditional Medicaid - HP
Claims Processing
Customer Assistance
Provider Education
Web interChange
Provider Enrollment
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Traditional Medicaid – HP
– Reimbursement methodology: Fee-for-Service (FFS)
– HP responsibilities include:
• Act as processor and payer for Traditional Medicaid and Care Select claims
• Enroll providers into the Indiana Medicaid program and perform enrollment updates
• Maintain and update Web interChange
• Educate providers and members through various channels, including:
Written correspondence
Provider field consultants
Printed publications
Long Term Care audits
IHCP Web site
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Traditional Medicaid – HP
– Traditional Medicaid includes:
· 590 Program
· Medical Review Team Program
– The following are applicable to traditional Medicaid members:
• Spend-down
• Qualified Medicare beneficiary (QMB)
• Home health/hospice
• Long Term Care
• Right Choices Program
Traditional Medicaid population
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ADVANTAGE Health Solutions – FFSADVANTAGE
Health Solutions -
FFS
Prior Authorization
Traditional Medicaid Members
Member Level of Care
Fax: 1-800-689-2759
Medical PolicyAudit
Restricted Card Program
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ADVANTAGE Health Solutions – FFS
ADVANTAGE Health Solutions – FFS responsibilities:
– Prior authorization (PA) for Traditional Medicaid fee-for-service
– Review of Traditional Medicaid fee-for-service claims that suspend for medical policy audits
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Fee-for-Service
The FSSA administers the following functions:
– Surveillance and Utilization Review (SUR)
– Claims Analysis and Recovery
• Prepayment Review (PPR)
• Program Integrity (PI)
– Post-Payment Audits
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Care Select – HP Traditional Medicaid - HP
Care Select
Administration Fee
Customer Assistance
Provider Education
Web interChange
Certification Code Creation
Claims Processing
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Care Select – HP
– Claims are processed by HP
– Mixed reimbursement methodology
• Fee for service, and
• Administrative fee
per member per month
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Care Select – CMOsCare Select -
Care Management Organizations
ADVANTAGE Health
SolutionsMDwise
Manage PMPPanels
Demographics,Scope of Practice
Provide PriorAuthorizationfor EnrolledMembers
ManageRight Choices
Program
Enroll PrimaryMedical
Providers
Provide Educationto Members About
Healthcare
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Care Select Care Management Organizations (CMO)– Care Management Organizations (CMOs):
• MDwise
• ADVANTAGE Health Solutions
– The CMOs process all prior authorizations for members assigned to their respective organizations
– Right Choices Program, primary medical provider (PMP) enrollment, and panel maintenance is administered by the CMOs
– Members select a physician to serve as their PMP
– The PMP serves as a member’s medical home and gatekeeper for most medically necessary care
– The PMP is responsible for providing or authorizing most primary and preventive services, and for reviewing and authorizing necessary specialty care and hospital admissions
– Claims for specialist services require the certification code from the PMP
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Risk-Based Managed Care
Hoosier Healthwise Risk-Based Managed Care
MDwisewww.mdwise.org
Managed Health Serviceswww.managedhealthservices.com
Anthemwww.anthem.com
10 Delivery Systems
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Risk-Based Managed Care
– The Hoosier Healthwise Program provides coverage for healthcare services rendered to persons in the following aid categories:
• Children
• Pregnant Women
• Low-income families
– The member’s specific eligibility aid category determines his or her benefit package
Managed Care Medicaid population
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Risk-Based Managed Care
Three managed care organizations (MCOs):
– MDwise
• 1-800-356-1204 or www.mdwise.org
– Managed Health Services
• 1-877-647-4848 or www.managedhealthservices.com
– Anthem
• 1-866-408-6132 or www.anthem.com
Managed care organizations
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Risk-Based Managed Care
Hoosier Healthwise Risk-BasedManaged Care
Claims Processing
Provider and Member Services
Panel Management
Prior Authorization for Enrolled Members
Provider Contracting
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Risk-Based Managed Care
MCO responsibilities include:
– Act as processor and payer of claims for risk-based managed care (RBMC) members who are enrolled in their respective MCO
– Manage medical care through each MCOs’ network of contracted PMPs and specialists
– Manage PMP panels
– Assume financial risk for services rendered to members in its network
– Process prior authorizations and manage subrogation activities for their respective members
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Healthy Indiana Plan
Healthy Indiana Plan
MDwise
Anthem Blue Cross Blue Shield
Indiana Comprehensive HealthInsurance Association /
Affiliated Computer Services(Enhanced Services Plan)
MHS (effective January 1, 2011)
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Healthy Indiana Plan
– Healthy Indiana Plan (HIP)
• Health insurance program for uninsured Hoosier adults between ages 19-64
• Services became available January 1, 2008
– Eligibility Requirements: • Earn between 22-200 percent of the federal
poverty level (FPL)
• No access to employer-sponsored health insurance coverage
• Be uninsured for the previous six months
• Not be eligible for Medicaid
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Healthy Indiana Plan
– Applicants for HIP respond to a Health Screening Questionnaire
– Responses to the questionnaire are analyzed to determine the appropriateness for placement of the applicant for ESP-level services
– ESP services are targeted for HIP members who require medical care for complex conditions including:
• Certain cancers
• Organ transplant
• HIV/AIDS
• Aplastic anemia
• Certain blood diseases
– ESP-level members receive services from enrolled IHCP providers
• All IHCP-enrolled providers are eligible to serve ESP members
– Applicants who do not meet the standard for ESP-level services are permitted to choose coverage from one of the two plan insurers (2010)
– Applicants will have the choice of three plan insurers beginning 1-1-11
Enhanced Services Plan (ESP)
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Enrollment Broker
MAXIMUS Administrative Services866-963-7383
Unbiased Member Education
Aids Member Selection of MCO, CMO, and PMP
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Enrollment Broker
MAXIMUS Administrative Services
– Serves as an enrollment broker for
• Care Select
• Hoosier Healthwise
• Healthy Indiana Plan
– Provides choice counseling to eligible members to assist them with choosing a PMP that best meets their needs
– Facilitates initial member enrollment in the program, and performs member-initiated PMP changes
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IHCP Family Tree DiagramFSSA
Traditional Medicaid
OMPP
MAXIMUS
MDwise (Care Select)
ADVANTAGE(Care Select)
HP
Advantage
Healthy Indiana Plan
MDwise
Anthem Blue Cross
Blue Shield
Enhanced Services Plan(ESP)
Care SelectHoosier Healthwise
Risk-Based Managed Care
MHS
Anthem
MDwise
Cenpatico
Behavioral Health
Magellan Health
Services
MDwise
Managed Behavioral Health Organizations
MHS(effective 1/1/2011)
ACS
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Resources
– IHCP Web site at www.indianamedicaid.com
– FSSA Web site at www.in.gov/fssa
– IHCP Provider Manual (Web, CD-ROM, or paper)
– Customer Assistance• 1-800-577-1278, or
• (317) 655-3240 in the Indianapolis local area
– HP Provider Written Correspondence– P.O. Box 7263
Indianapolis, IN 46207-7263
– Provider Relations field consultant