Iowa Health and Wellness Plan Overview • The Iowa Health and Wellness Plan is a new Medicaid program which began on January 1, 2014 to provide comprehensive health care coverage to low-income, uninsured Iowans ages 19 to 64. • Two options- Iowa Wellness (0-100% FPL) and Iowa Marketplace Choice Plan (101-138% FPL). • Marketplace Choice Plans: CoOportunity Health and Coventry Health Care of Iowa
Iowa Health and Wellness PlanHealthy Behaviors Program • To participate in the Healthy Behaviors Program and avoid paying a monthly contribution after the first year of coverage Iowa Health and Wellness Plan members must: 1) Get a wellness exam (annual physical) from a health care provider. 2) Complete a health risk assessment (HRA).
Wellness Plan Bonus • SCHC may earn an additional $10 per year for each Wellness Member when at least 50% of their assigned patients received a wellness exam.
Health Risk Assessment (HRA) • Iowa Medicaid has contracted with Treo Solutions to utilize the AssessMyHealthonline tool for completing member HRAs. • The Assess My Health tool allows providers to receive a report of the member’s results, from which a care plan can be developed. • A member with computer access can complete the assessment in 15 minutes (if healthy) up to 40 minutes (if very high needs and low computer literacy).
HRA Provider Reimbursement • SCHC will be eligible for a $25.00 payment for each member who completes the HRA with the assistance of the provider. The use of any other HRA tool will not be reimbursed by Iowa Medicaid. • The results of the HRA completed with the assistance of the provider are expected to be reviewed to create a care plan for the member.
HRA Workflow • Daily, IT will generate a list of Iowa Health and Wellness patients scheduled for visits the next day and send the list to the enrollment counselors (EC) in the morning. • EC will call patients on the list and explain the HRA and the advantages of completing it. • EC will schedule the patient to come in 30 minutes prior to appointment with provider to complete the HRA. • Upon patient’s arrival at the clinic, front desk will notify EC via EMR. • EC will take patient to the EC’s office. • EC will bring up the “Assess My Health” website (link on portal) and put in SCHC code OBC5Dand assist patient in completing HRA. • Once HRA has been completed, EC will print off two copies of the HRA report and give to patient. Patient will take report to provider visit that day.
HRA Workflow • Provider team will be notified that the patient is ready to be brought back to the provider room. • The results of the HRA completed are expected to be reviewed to create a care plan for the member. Care Management Plan form will be added after the Assessment and Plan form in all visit types to be used to document care plan. A quicktext has been created to assist in the documentation (.hra). • Provider (or nurse) will mark the appropriate box for CPT code and message in directive area will state the patient has completed HRA. • If EC was unable to meet with patient prior to patient being brought back to the exam room, case managers, nursing staff, and providers may need to assist patient completing HRA. • Medical records will confirm the chart has been marked appropriately in the directives area when indexing the HRA.
Preventive Services during follow up and sick visits • “Providers should assist members in completing their HRA prior to or during their annual preventive visit to complete their healthy behaviors.” • Oftentimes individuals are seen for follow up or “sick” visits. To the extent that any wellness visit components are included during the “sick” visit, they can count toward meeting the requirements of the preventive exam.”
Preventive Services during follow up and sick visits • Clearly state in HPI that patient is here for wellness exam in addition to presenting problem(s). • Nurse team will assist in reviewing self management goals and documenting specifics • In the Care Management Plan form, provider will use the Longitudinal Care Plan to provide instructions for patient. • Need to bill a level of care charge for presenting problems, administration and interpretation of HRA and wellness exam charge for these visits. • Billing will use modifier when submitting charges
Medically Exempt • Clear advantages for both patient and SCHC to move qualified patients from Iowa Health and Wellness (including marketplace plans) to Medically Exempt. • Medically exempt gives patients full Medicaid benefits, including significant mental health services.
Medically Exempt ‘Medically Exempt’ includes: • individuals with disabling mental disorders (including adults with serious mental illness) • individuals with chronic substance use disorders • individuals with serious and complex medical conditions, individuals with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living • individuals with a disability determination based on Social Security criteria
Medically Exempt Defined-Mental Health Individuals with disabling mental disorders, including at least one of the following: • Psychotic disorder • Schizophrenia • Schizoaffective disorder • Major depression • Bipolar disorder • Delusional Disorder • Obsessive-compulsive disorder • Identified to have a chronic behavioral health condition and
Medically Exempt Defined-Substance Use Individuals with chronic substance use disorder: • Diagnosis of substance use disorder, AND • Member meets the severe substance abuse disorder level on the DSM-V severity scale by meeting 6 or more diagnostic criteria, OR • Member’s current condition meets the medically-monitored or medically-managed intensive inpatient criteria of the ASAM criteria
Activities of Daily Living (ADLs) Patients with serious health conditions may be medically exempt if conditions limit ADLs. Examples of ADLs may include but are not limited to: • bathing and showering • bowel and bladder management • dressing, eating, feeding • functional mobility • personal device care • personal hygiene and grooming and/or toilet hygiene
Medically Exempt Defined-Health Conditions • Individuals with serious and complex medical conditions • Individuals with a physical disability • Individuals with an intellectual or developmental disability • Individuals with a disability determination through Medicare
Medically Exempt Workflow • Every Iowa Health and Wellness patient (including marketplace plan patients) should by assessed by the provider to determine if they qualify to be medically exempt. • If they may qualify, provider will fill out medically exempt form and give to enrollment counselor. • Provider team will create a care alert to document patient has applied for medically exempt. • Enrollment counselor will inspect form to ensure it is filled out correctly and fax to IME. • Form will be sent to medical records to input into EMR and then form will be sent to billing department. • Billing department will monitor IME reports and if patient is moved to medically exempt, registration will be updated to reflect change.