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Quality Healthcare is at the Heart of What We Do Welcome to Home State Health Plan
Quality Healthcare is at the
Heart of What We Do
Welcome to Home State Health Plan
www.HomeStateHealth.com
2Quality Healthcare is at the Heart Of What We Do
Home State Health Plan
Dawn Lukacina, Provider Relations Specialist
Robbin Smith, Manager, Network Development & Contracting
www.HomeStateHealth.com
3Quality Healthcare is at the Heart Of What We Do
About Centene Corporation
• Established in 1984 in Milwaukee, Wisconsin • Headquartered in Clayton, MO• Employs approximately 8,700 individuals• Serves approximately 2.1 million Medicaid consumers • Serves government sponsored healthcare programs in
21 states• Contracts with over 190,000 physicians and 1,900
hospitals
www.HomeStateHealth.com
4Quality Healthcare is at the Heart Of What We Do
Home State’s Philosophy • Local Approach
Quality healthcare is best delivered locally. Local approach enables us to ensure accessible, high
quality and culturally sensitive healthcare services to our members.
Our care coordination model utilizes integrated programs administered by a local staff.
• Care Coordination / Service Delivery Promote a medical home for each member. Partner with trusted providers. Ensure consumers receive the right care, in the right
place, at the right time.
• Continuous Quality Improvement Achieve demonstrated improvement in consumer safety,
health, and satisfaction.
www.HomeStateHealth.com
5Quality Healthcare is at the Heart Of What We Do
Home State Health Plan OverviewHome State strives to provide improved health status, successful outcomes and member & provider satisfaction in a coordinated care environment.
Home State has been designed to achieve the following goals: • Ensure access to primary and preventive care services• Ensure care is delivered in the best setting to achieve an optimal outcome• Ensure members receive access to the right care at the right place and right time• Improve access to all necessary healthcare services• Encourage quality, continuity and appropriateness of medical care • Provide medical coverage in a cost-effective manner
www.HomeStateHealth.com
6Quality Healthcare is at the Heart Of What We Do
Claim Operations
• Initial Claims must be submitted within 180 calendar days from the date of service
• Corrected claims must be submitted within 180 calendar days from explanation of payment
• Home State’s Payer ID is 68069 with the following clearinghouses: Emdeon SSI Gateway Availity
• Claims may also be submitted via our Secure web portal
A complete list of Clearinghouses can be found on our Website at www.HomeStateHealth.com.
www.HomeStateHealth.com
7Quality Healthcare is at the Heart Of What We Do
Claim Operations
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8Quality Healthcare is at the Heart Of What We Do
Claim Operations
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9Quality Healthcare is at the Heart Of What We Do
Care Improvement Opportunities
Primary Care Opportunities Report (PCOR)
Same Day Transportation
Case Management
Member Incentive Program/Cent Account
Member Connections
17P/Alere
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10Quality Healthcare is at the Heart Of What We Do
PCOR Key Areas of Focus PCOR Area of Opportunity FQHC Potential Improvement Activities Home State Improvement ActivitiesNo PCP Visit Call Members directly to set appointments
o Use appointments to hit HEDIS/EPSDT Measures as well such as Well Child, Immunizations, Lead, PAP, Chlamydia
Transportation Provider Coordinationo Same day availableo Reimbursement option
PCP appointment outreach by CM and Member Serviceso Telephonic prioritized by OB and
risk levelo EPSDT calls and letterso Extensive Transportation benefit
communication
Asthma DX with No inhaler prescription
Call Members directly to set appointment for visit to include medication evaluation/action plan development
Refer to Home State for Asthma DM program
Asthma DM programo Includes environmental
assessment by RTo PFM/spacer
Lead Screening Call members to schedule a Visit Call Home State to request Home Visit for
blood draw
Extensive Lead outreach and follow up to monitor and coordinate re-testing
Emergent/Urgent Visits Call Members directly to set appointments Provide Member education regarding:
o After Care Hours/Processo Triage Services/Home State NurseWise
Triageo Transportation Benefitso What is a True Emergencyo Urgent Care Availability
Emergency Super Utilizer CM programo Outreach to all members with 3
or more visits in last 90 dayso CM enrollment as appropriateo PCP appointment coordinationo Education on transportation,
NurseWise, Urgent Care Centers, when to go to the ER
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11Quality Healthcare is at the Heart Of What We Do
HSHP Transportation Services
Medical Transportation Management
Home State contracts with MTM to provide non-emergency medical transportation for Home State members
Benefits include routine visits, same day PCP and OB visits for expecting mothers (effective 08/01/13), mileage reimbursement, urgent visits, hospital discharges, and multi-leg trips (i.e. trip to the pharmacy immediately following a covered appointment)*
MTM may be reached at 1-866-694-HOME (4663) or www.MTM-Inc.net www.mtm-inc.net
*Visit www.HomeStateHealth.com to view Covered Services and Guidelines
www.HomeStateHealth.com
12Quality Healthcare is at the Heart Of What We Do
Case Management
• Integrated Care Management Teams– Identify and engage high-risk members using a variety of tools– Identify barriers to compliance with treatment plans– Encourage PCP/health home approach, appropriate use of ER– Facilitate communication across medical and behavioral
specialties– Coordinate services, including transportation and referrals,
setting appointments– Extensive Care Planning /communication with providers/holistic
approach across medical and behavioral health disciplines– Discharge Planning and post discharge follow up
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Confidential and Proprietary Information
www.HomeStateHealth.com
13Quality Healthcare is at the Heart Of What We Do
Contact Care Management-We’re Here to Help
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Confidential and Proprietary Information
Please Contact Us for Assistance With:
• Asthma or Diabetes Management• Transportation Needs• Appointment Scheduling• Prenatal Case Management• DME needs• Behavioral Health Assistance/Substance Abuse Assistance
Home State Health Plan1-855-694-4663
Ask for Case Management When Prompted
www.HomeStateHealth.com
14Quality Healthcare is at the Heart Of What We Do
MemberConnections® Program
The MemberConnections ® Program is Home State’s outreach program designed to provide education to our members on how to access healthcare and develop healthy lifestyles in a setting where the feel most comfortable
Components of Home State’s MemberConnections Program:
• Community Connections (Connects Members to Community resources)
• Home Connections (Connects Members who are home bound to other resources)
• CentAccount ® (Promotes appropriate utilization of preventive services)
For more information call 1-855-694-HOME (4663) to speak with a Home State Case Manager or visit www.HomeStateHealth.com
www.HomeStateHealth.com
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Innovative: Member Incentive Program
Confidential and Proprietary Information 10
Piloted in South Carolina in 2008 Centene has over 400,000 active CentAccount
cards Outcomes:
• Reduction of ER utilization by 19% (South Carolina)
• Members aged 3-21 were 33% more likely to get an annual well visit (Indiana)
• Year end Case Management efforts to reduce non-compliance were 90% more effective when paired with a CentAccount reward (Indiana)
• Member visits to their PCP within 90 days of enrollment increased by over 20% (Indiana)
• Adult members who earned the annual well visit reward were 34% less likely to visit the ER, translating into a savings of $2.04 PMPM in ER costs (Indiana)
• Adolescent well visit rate increased 21% after 7 weeks (Georgia)
Promotes personal healthcare responsibility and ownership by offering financial incentives that are valued and appreciated by healthcare consumers
www.HomeStateHealth.com
16Quality Healthcare is at the Heart Of What We Do
Alere™ 17P Administration
Home State Health Plan and Alere are working together to help your patients:
adhere to your prescribed treatmentsavoid hospitalization improve outcomes
www.HomeStateHealth.com
17Quality Healthcare is at the Heart Of What We Do
Alere™ 17P AdministrationThe Alere™ 17P Administration Nursing and Care Management Service, in partnership with Home State Health Plan, promotes better understanding and adherence with the 17P treatment regime. This helps to avoid unnecessary hospitalizations
Stopping 17P early or not starting at all puts 17P eligible patients at higher risk for preterm delivery
97.5% injection interval compliance
Ready to start a patient? Call 800-999-2415 or visit alere.com.
www.HomeStateHealth.com
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ICD-10 Transition
The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. The structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full (www.cms.gov/ICD10)
ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:
• ICD-10-CM (for diagnosis coding) uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM• ICD-10-PCS (for inpatient procedure coding) uses 7 alphanumeric digits instead of the 3 or 4
numeric digits used under ICD-9-CM procedure coding. ICD-10 CM diagnosis and ICD-10 PCS procedure codes will be required on all inpatient claims with discharge dates on or after October 1, 2014.
ICD-10 CM diagnosis codes will be required on all professional and outpatient claims on October 1, 2014.
Note: Service dates or discharge dates prior to October 1, 2014 will require ICD-9 codes.
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ICD-10 Transition (cont’d)
Home State Health plan will be ICD-10 compliant by 10/1/2014. Providers must submit claims with codes that align with CMS and state guidelines:
• Claims may not contain a combination of ICD-9 and ICD-10 codes.• Claims must be submitted with ICD-10 codes if dates of service are post-
compliance date. • Claims must not be submitted with ICD-10 codes prior to compliance date.• Outpatient claims with from / through dates that span compliance date
must be split. • Inpatient claims that span the compliance date must be coded with ICD-10• Interim bills for long hospital stays (TOB: 112, 113, 114) are expected to
follow the same rules as other claims. If a provider submits a replacement claim (TOB: 117) to cover all interim stays, it is expected that the provider must re-code all diagnoses / procedures to ICD-10 since the replacement claim will have a discharge / through date post-compliance.
• All first-time claims and adjustments for pre-10/1/2014 service dates must include ICD-9 codes, even if claims are submitted post-10/1/2014.
www.HomeStateHealth.com
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ICD-10 Transition (cont’d)
• ICD-10 Implementation and Testing Approach• The health plan’s ICD-10 implementation approace aligns with
CMS guidance and recommended timeframes. • The health plan completed its ICD-10 assessment in 2011-2012
and plans to perform HIPAA compliance testing with providers, clearinghouses, vendors and state agencies beginning July, 2013.
• Providers that submit claims via EDI or are interested in submitting claims via EDI can test with the health plan. For questions, please contact the EDI service desk at 1-800-225-2573, ext. 25525 or [email protected].
• If you are interested in testing with the health plan, please go to the Home State Health Plan website tp://www.homestatehealth.com/providers/tools-resources/icd-10-training.
• Home State Health Plan will be providing training sessions in the future. Stay tuned to our website for session dates and times.
www.HomeStateHealth.com
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Conversion to CMS 1500 version 02/12
The National Uniform Claim Committee (NUCC) has approved the conversion to the 02/12 version of the CMS 1500 form. This change is being made to accommodate the additional reporting needs related to the implementation of ICD-10.Home State Health Plan will follow the implementation of this form as recommended by the NUCC. Specifically:
• January 6, 2014 – March 31, 2014: Home State Health Plan will accept the current version of the CMS 1500 form (version 08/05) AND will accept the new version of the CMS 1500 form (version 02/12).
• April 1, 2014: Home State Health Plan will ONLY accept the 02/12 version of the CMS 1500 form. Providers will be required to enter a “9” for ICD-9 or “0” for ICD-10 in the ICD Ind. located in box 21 of the 02/12 version of the CMS 1500 and box 66 on the UB 04. The claim will REJECT if the ICD Ind. field is left blank.
The above is date of submission sensitive and not date of service sensitive. For example, if a claim has a date of service of March 17, 2014 and is submitted on or after April 1, 2014, the claim must be submitted on the 02/12 version. While there are a number of changes from the 08/05 version to the 02/12 version, the notable change is that box 21 has added 8 additional lines for diagnosis codes.
Exchange products are affordable health insurance solutions for the low-income uninsured
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FPL
0% 100% 200% 300% 400%
Medicaid1
133% 300% 400%
Marketplace/Exchange
Basic Health
200%
CHIP2
3
4
Centene is a State solutions company and Exchange products bridge the gap between
Medicaid and Commercial solutions
Family of 5
Churn Impact Significant:
• 40% of adults experience disruption of Medicaid eligibility
within 6 months• After 1 year, 38% no longer
eligible & 16% lost eligibility & regained coverage
• By end of 4 years, 38% of adults experienced 4 or more changes
in eligibility
**Health Affairs study results
Exchange Solutions Address “Churn”Impact and Split Families
Value to Members:• Eliminate gap in coverage• No disruption to provider
relationships• No disruption to continuity of care
• Reduce split families
Value to Providers:• Insurance for previously uninsured
patients• No disruption to continuity of care
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Exchange Market OpportunityKey Considerations
• Long term view (3-5 years)• Potential enrollment• Medicaid market share• Product design – affordability key goal• Provider network
oNetwork Adequacy & reimbursementoEssential Community Providers
• Timing24
Federally Facilitated Marketplaces
State Based Marketplaces
Centene State Participation - 2014
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Branding
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Cost Sharing ReductionsBenefit Plan Example
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250%+ FPL
200-250% FPL 150-200% FPL 100-150% FPL
MedicalSubj to
Deductible Base Silver Silver Low Silver Med Silver HighMedical Deductible $3,000 $3,000 $500 $0Rx Deductible $1,000 $500 $100 $0Out of Pocket Maximum $6,350 $5,200 $2,250 $2,250Emergency Room Services Y $250 $150 $100 $100All Inpatient Hospital Services (inc. MHSA) Y $1000 per day $1000 per day $250 $100Primary Care Visit to Treat an Injury or Illness N $50 $20 $10 $5Specialist Visit N $75 $30 $20 $10Mental/BH and Substance Abuse Disorder Outpatient Services Y $250 $150 $50 $50Imaging (CT/PET Scans, MRIs) Y $150 $150 $50 $25Rehabilitative Speech Therapy Y $50 $50 $10 $10Rehabilitative Occupational and Rehabilitative Physical Therapy Y $50 $50 $10 $10Preventive Care/Screening/Immunization N $0 $0 $0 $0Laboratory Outpatient and Professional Services Y $50 $25 $10 $0X-rays and Diagnostic Imaging Y $50 $50 $10 $0Skilled Nursing Facility Y $200 $100 $100 $0Outpatient Facility Fee (e.g., Ambulatory Surgery Center) YOutpatient Surgery Physician/Surgical Services Y
DrugsGenerics N $10 $10 $10 $10Preferred Brand Drugs Y $50 $20 $20 $20Non-Preferred Brand Drugs Y $75 $50 $40 $40Specialty Drugs (i.e. high-cost) Y $250 $250 $250 $100
$250 $150 $50 $50
Implications for Provider Community
• Grace Period/Member Eligibility• Premium/Charitable Support to Individuals• Marketplace Enrollment• Impact on Employer Sponsored Insurance• Impact on Federal/State DSH payments• Payment Innovation
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