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Indiana Health Coverage Programs Family Tree. HP Provider Relations October 2010. 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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indiana health coverage programs family tree
Indiana HealthCoverage ProgramsFamily Tree

HP Provider Relations

October 2010

agenda
Agenda

Session Objectives

Indiana Health Coverage Programs

IHCP Team

Traditional Medicaid

Care Select

Hoosier Healthwise

Healthy Indiana Plan

Enrollment Broker

The “Tree”

Resources

Questions

objectives
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
define
Define

Indiana Health Coverage Programs

indiana health coverage programs
Indiana Health Coverage Programs

Indiana Health Coverage Programs

Traditional Medicaid

Hoosier Healthwise

Healthy Indiana Plan

Care Select

office of medicaid policy and planning
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
ihcp team1
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
ihcp team2
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
ihcp information
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

traditional medicaid fee for service1
Traditional Medicaid – Fee-for-Service

Traditional Medicaid- HP

Claims Processing

Customer Assistance

Provider Education

Web interChange

Provider Enrollment

traditional medicaid hp
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
traditional medicaid hp1
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

advantage health solutions ffs
ADVANTAGE Health Solutions – FFS

ADVANTAGE Health Solutions - FFS

Prior Authorization Traditional Medicaid Members

Restricted Card Program

Member Level

of Care

Medical Policy

Audit

Fax:

1-800-689-2759

advantage health solutions ffs1
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
fee for service
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
care select hp
Care Select – HP

Traditional Medicaid - HP

Care Select

Claims Processing

Administration Fee

CertificationCode Creation

Customer Assistance

Provider Education

Web interChange

care select hp1
Care Select – HP
  • Claims are processed by HP
  • Mixed reimbursement methodology
    • Fee for service, and
    • Administrative fee
      • per member per month
care select cmos
Care Select – CMOs

Care Select - Care Management Organizations

ADVANTAGE Health Solutions

MDwise

Provide Education

to Members About

Healthcare

Provide Prior

Authorization

for Enrolled

Members

Manage PMP

Panels

Demographics,

Scope of Practice

ManageRight Choices Program

Enroll Primary

Medical

Providers

care select care management organizations cmo
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
risk based managed care
Risk-Based Managed Care

Hoosier Healthwise

Risk-Based Managed Care

MDwise

www.mdwise.org

10 Delivery Systems

Managed Health Services

www.managedhealthservices.com

Anthem

www.anthem.com

risk based managed care1
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

risk based managed care2
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

risk based managed care3
Risk-Based Managed Care

Hoosier Healthwise Risk-BasedManaged Care

Claims Processing

Provider and Member Services

Panel Management

Prior Authorization for

Enrolled Members

Provider Contracting

risk based managed care4
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
healthy indiana plan1
Healthy Indiana Plan

Healthy Indiana Plan

MDwise

MHS

(effective January 1, 2011)

Anthem Blue Cross Blue Shield

Indiana Comprehensive Health

Insurance Association /

Affiliated Computer Services

(Enhanced Services Plan)

healthy indiana plan2
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
healthy indiana plan3
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)

enrollment broker1
Enrollment Broker

MAXIMUS Administrative Services

866-963-7383

Unbiased Member Education

Aids Member Selection of MCO,

CMO, and PMP

enrollment broker2
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
ihcp family tree diagram
IHCP Family Tree Diagram

Healthy Indiana Plan

Hoosier Healthwise

Risk-Based Managed Care

MDwise

MDwise

MHS

Anthem Blue Cross

Blue Shield

Anthem

Enhanced Services Plan

(ESP)

FSSA

OMPP

MAXIMUS

TraditionalMedicaid

Care Select

Managed Behavioral Health Organizations

HP

MDwise

MDwise (Care Select)

ADVANTAGE

(Care Select)

Advantage

Cenpatico

Behavioral Health

ACS

Magellan Health

Services

MHS

(effective 1/1/2011)

find help
Find Help

Resources Available

resources
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 7263Indianapolis, IN 46207-7263

Provider Relations field consultant