Iowa Health and Wellness Plan Healthy Behaviors Program

Iowa Health and Wellness Plan
Healthy Behaviors Program
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 Plan
Healthy 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
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
Health Risk Assessment (HRA)
• Iowa Medicaid has contracted with Treo Solutions
to utilize the AssessMyHealth online 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
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
• 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 OBC5D and 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
• 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
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 DefinedMental 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 DefinedSubstance 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 medicallymonitored 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
Medically Exempt DefinedHealth Conditions
• Individuals with serious and complex medical
• 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.
Billing Workflow
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