Hoosier Healthwise and Healthy Indiana
Plan ……… Now and Then
A 2011 guide to help you
understand Managed Care
Medicaid
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General Overview
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Office of Medicaid Policy and Planning released
a Request for Proposals (RFP) in February 2010
Proposals were submitted in May 2010 by
interested health plans
Invitations were made in June
MDwise, Anthem and Managed Health Services
(MHS) were selected
Currently in Readiness Review which is a
comprehensive review of all operational areas
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Highlight of New Contract
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Combine Hoosier Healthwise and HIP- family
friendly
Debit card for medical services (HIP) only
Offer comprehensive package of disease
management programs
Managed Care Entity (MCE) to complete
standardized Health Risk Screening (70% within
90 days)
MCE’s to do all PMP changes and auto
assignments of new members to PMP
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Topic
2010… Currently
Claims Payment:
Hoosier
Healthwise
(HHW) and
Health
Indiana Plan
(HIP)
Anthem processing guidelines are:
 HHW submit claims with YRH
prefix and RID number
 HIP submit claims with YRK prefix
and unique ID number
 www.anthem.com for complete
processing guidelines
MDwise claims processing guidelines
are:
 Adjudicated by MDwise (HIP) and
its delivery systems for Hoosier
Healthwise: See quick contact sheet
 HIP and HHW - submit claims
with RID number.
Managed Health Services claims
processing guidelines are:
 MHS follows IHCP claims
processing guidelines.
Claims Processing –
Managed Health Services
P.O. Box 3002
Farmington, MO 63640-3802
Claims Appeals –
Managed Health Services
P.O. Box 3000
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Farmington, MO 63640-3800
January 2011
Each MCE will be responsible for claims
payment;
Anthem HHW and HIP– same as it was for
previous contractual period
MDwise HHW and HIP- same as it was for
previous contractual period
Managed Health Services- no changes to
HHW processing. HIP claims will be
processed same as HHW. Member RID#
to be used. Same PO box as HHW
claims.
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Topic
2010… Currently
January 2011
Claims Filing
Limit
Contractually set by each Managed
Care Organization (MCE).
Claims filing for all Managed Care
Entities (MCEs) including behavioral
health will be 90 days.
Claims
Reimbursement
for HIP
Medicare rates or 130% of
Medicaid IHCP fee schedule.
No changes for 2011.
Claims Edits
Contractually set by each MCE.
Watch for upcoming HIP
Reimbursement Manual published by
OMPP.
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Each MCE will institute the National
Correct Coding Initiative (NCCI) edits
for claims adjudication. This began
October 1, 2010. Anthem HIP no
changes necessary.
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Topic
Appeals and
Grievances
2010… Currently
January 2011
Effective July, 1, 2010, denied services
from Medical Management such as
reduction of services – Prior
Authorization.
Effective July, 1, 2010, denied services from
Medical Management such as reduction of
services – Prior Authorization.
Providers will submit an appeal for
the denied services (not grievance).
Providers can submit an appeal on behalf
of the member (not grievance).
Providers will be able to submit an
appeal within 30 calendar days from
the denial.
Providers will be able to submit an appeal
within 30 calendar days from the denial.
There are no changes in how
providers submit medical claims
denials. Providers will submit a
dispute.
Members will file a grievance
(formerly known as a complaint) and
will have 30 calendar days to file.
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There are no changes in how providers
submit medical claims denials. Providers
will submit a dispute.
Members will file a grievance (formerly
known as a complaint) and will have 30
calendar days to file.
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Topic
Online Claims
Enhancements
2010… Currently
January 2011
Current online claims functions:
Anthem – www.anthem.com
Claims and billing
information/guidelines
Prior authorization requirements &
forms
Forms Library
Health Education
Claim Status
MDwise – www.mdwise.org
Billing guidelines
Prior authorization forms &
requirements
Member eligibility – HIP
Quick contact sheet- delivery systems
Managed Health Serviceswww.managedhealthservices.com
File claims directly (no charge)
Verify member eligibility and TPL
information
Check claim status
View payment history
Download and print EOB’s
Claim auditing tool
Future online claims functions:
Anthem- www.anthem.com
Claims and billing information /guidelines
Prior authorization requirements & forms
Forms Library
Health Education
Availity
MDwise- www.mdwise.org
Billing guidelines
Prior authorization form & requirements
Member eligibility – HIP & HHW
Quick contact sheet- delivery systems
Claims and prior authorization review
Special Programs
Member and Provider incentives
Managed Health Services –
www.managedhealthservices.com
Care Gap Alerts
Cost Estimator Assistant
POWER/HIP information
Electronic attachments (EDI)
Member Portal
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Topic
Prior
Authorization
2010… Currently
Each MCE develops and manages its
own medical/behavioral prior
authorization processes.
Anthem PA requirements forms:
Can be found on our website
www.anthem.com
January 2011
OMPP has mandated a universal PA form for
each of the MCE’s. This form will be used for
requesting PA for services for all programs for
all MCE’s.
Click here for new PA form
MDwise PA requirements:
MDwise is a delivery system model and
the delivery system forms can be found
under the provider tab for forms at
www.mdwise.org
MHS PA requirements: PA requirements
are listed on the MHS Quick Reference
Guide. PA forms are located on
www.managedhealthservices.com on the
provider tab under the resources section.
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Topic
Online PA
Enhancements
2010… Currently
January 2011
Current online PA functions:
Future online PA functions:
Anthem- PA forms and its requirements
can be found on our website at
www.Anthem.com. Online submission is
unavailable at this time
Anthem- PA forms and its requirements can
be found on our website at www.Anthem.com.
Online submission is unavailable at this time
MDwise-PA forms and its requirements
can be found on our website at
www.mdwise.org. Online submission not
available at this time.
Managed Health Services – PA’s can
be initiated online. Clinical must be
either faxed or called into a Nurse for
review.
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MDwise- PA forms and its requirements can
be found on our website at www.mdwise.org.
Online submission may be available by
delivery system.
Managed Health Services- Online PA
requests available. Process enhancement to
include attachments will be provided in 2011.
Online QRG available on line as tool/guide.
www.managedhealthservices.com
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Topic
Provider
Enrollment
2010… Currently
All providers must have an active IHCP
provider number on file to participate
with an MCE.
Anthem- Contract includes the base
agreement, amendments for the specific
product line and a provider maintenance
form (PMF) plus credentialing as
applicable.
January 2011
Each MCE will recontract with providers for a
new contractual period beginning January 1,
2011. OMPP has mandated a universal
enrollment form for each of the MCEs. This
form will be used for contracting all lines of
business (Hoosier Healthwise, HIP, and Care
Select).
Embed form here to click.
MDwise- Along with the provider
contract for the delivery system the
provider is contracting, a MDwise
specific supplemental cover sheet is
required.
Managed Health Services – Along
with the contract MHS requires a
supplemental form, a contract attestation
(if adding additional providers), and a
completed W-9. Providers who do not
wish to be contracted should complete a
Non-Par form.
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Topic
2010… Currently
Contracting
All MCE provider contracts for HHW and
HIP will terminate effective 12/31/10.
January 2011
Providers will be notified about recontracting by each MCE by the following:
Each MCE will be responsible for
re-contracting its own providers.
Anthem- Contracting conducted by
Anthem’s commercial contracting team.
MDwise- Contracting will be conducted by
MDwise and its delivery systems.
Manged Health Services- Contracting will
be conducted by MHS.
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Anthem- Anthem contracting will begin
4th quarter 2010.
MDwise- MDwise contracting will start in
the summer of 2010. MDwise delivery
system provider relation staff will reach
out to current and new providers.
Managed Health Services – MHS
contracting will start in the summer of
2010. Providers will receive their new
contract documents via the mail or from
their Providers Relations Specialist.
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Topic
Eligibility
Hoosier
Healthwise
2010… Currently
Currently members can select a provider or plan.
Hoosier Healthwise – If a member does not
select a provider within 30 days, one will be
assigned for them and after 90 days the member
will be locked into the MCE for the remainder of
their enrollment period. (lock – in)
Auto-assignment is currently done by Maximus.
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January 2011
Hoosier Healthwise – The member will select
the plan MCE (Anthem, MDwise or Managed
Health Services).
HHW Auto Assignment Logic
Members will be assigned:
-Assign to MCE after 14 days (9 days from
potential table)
- Assigned within MCE to PMP within 30 days
-Members assigned to previous MCE with 12
month look-back
-Family member’s MCE
-Hoosier Healthwise; Rotating Assignment
Exceptions to Application Choice
- Open Enrollment ( <2 months)
- Right Choices Program members
- If a member calls the enrollment broker to
request a change, that will trump application
selection
•If a PMP disenrolls from a MCE and goes to
another MCE, member WILL NOT follow
PMP
Plan changes:
90 days HHW with Open Enrollment 12
Topic
Eligibility
HIP
2010… Currently
HIP – The member currently selects the plan.
The plan then assigns the provider. MDwise
currently assigns the provider. Anthem does not
currently assign a provider.
January 2011
HIP – The member will select the MCE (Anthem,
MDwise, or Managed Health Services).
HIP Auto Assignment Logic
-Neediest Plan
-60 days HIP plan choice, prior to 1st payment
Exceptions to Application Choice
- Open Enrollment ( <2 months)
- Right Choices Program members
- If a member calls the enrollment broker to
request a change, that will trump application
selection
If a PMP disenrolls from a MCE and goes to
another MCE, member WILL NOT follow PMP
Plan changes:
*Please note that pregnancy services are not
covered for HIP members.
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Topic
2010… Currently
Online Eligibility
Enhancements
Current online Eligibility functions:
Future online Eligibility functions:
Anthem HIP: Eligibility can be
verified via myanthem at
www.anthem.com. PMPs can
download members assigned to
them in excel format
Anthem HIP: Eligibility can be verified
via myanthem at www.anthem.com.
PMPs can download members assigned
to them in excel format.
MDwise- Eligibility can be verified
for HIP member thru provider web
portal.
MDwise-Eligibility can be verified for
HIP and HHW members thru provider
web portal.
Managed Health Services – TPL
and Eligibility information can be
verified. PMPs can download
eligibility lists in excel format.
Managed Health Services -MHS Same
as current - Verification, PMP
assignment/eligibility listings available.
Will provide online PMP selection and
changes online in 2011.
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Topic
2010… Currently
Right Choices
Program (RCP)
Program is in place to safeguard against
unnecessary and inappropriate use of
services.
Members are locked in to one PMP, one
pharmacy, and one hospital.
PMPs are the gatekeepers for the
member’s services.
Members must be referred to specialists
by the PMP.
A member can be in the program for up
to 5 years.
There are no changes to the RCP program for
the contract year 2011.
Power Account
for HIP
The Power Accounts are currently
managed by MDwise and Anthem.
Members receive monthly statements
that summarize provider and pharmacy
services.
In the new contract year, each MCE (Anthem,
MDwise, and Managed Health Services) will
manage the member’s power account. Each
member will receive monthly statements that
summarize provider and pharmacy services.
Providers will also be able to conduct point of
service transactions for power accounts.
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Topic
2010… Currently
Behavioral
Health
Anthem- Magellan manages HHW Behavioral
Health and Anthem Behavioral Health
manages HIP
Anthem- Behavioral Health integrated with
medical and managed by Anthem Behavioral
Health. Contracting will begin 3rd Quarter
2010
MDwise- Contracting delegated to InteCare
(BH).
Behavioral Health Managed by MDwise
Providers must be credentialed
Provider must have active IHCP number
MDwise- Contracting delegated to InteCare
(BH)
Behavioral Health, managed by MDwise
Provider will sign new addendum.
Addendum will be sent out by email or mail.
Providers will have 30 days to return form.
No re-credentialing.
Online enhancements to come.
Managed Health Services - Contracting and
maintenance of the network is delegated to
Cenpatico. Cenpatico manages the behavioral
health network. All providers must be
contracted with Cenpatico separately and go
through Cenpatico’s credentialing process.
Managed Health Services- Contracting and
maintenance of the network is delegated to
Cenpatico. Cenpatico manages the behavioral
health network. All providers must be
contracted with Cenpatico separately and go
through Cenpatico’s credentialing process.
Current contracted providers will receive a
contract amendment and have any appropriate
required documentation returned to Cenpatico
within 45 days of receipt. Re-credentialing
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will not be required for existing providers.
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Topic
Pharmacy
2010… Currently
January 2011
Currently managed by HP.
Preferred Drug List (PDL) has the
approved drugs, please refer to the
below link:
http://provider.indianamedicaid.co
m/provider-specificinformation/pharmacy.aspx
Please refer to the PDL at the below link
for the most up to date approved list of
drugs and changes to the formulary:
* ALL lines of business
•ALL lines of business
http://provider.indianamedicaid.com/pr
ovider-specificinformation/pharmacy.aspx
•HIP Tier 2 and Tier 3
•The MCE HIP plans to administer
PBM
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Topic
Quality
2010… Currently
January 2011
Currently OMPP has targeted performance
measures for Hoosier Healthwise.
Anthem
Anthem has a Quality Assessment Improvement
Program which promotes best clinical practices
with focus on preventative health guidelines.
Anthem promotes a medical home model which
highlights the goal of member focused
preventative care. Methods include webinars,
general and targeted education to providers and
members which focus on adult/child preventative
services, including High Risk OB and Childhood
Obesity Initiatives.
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The targeted performance
measures will be changing for
2011 and each MCE will work
with the provider networks to
provide education and tools
around the new measures and
focus.
A program and targeted measures
are in place for HIP.
Each MCE will discuss upcoming
performance initiatives.
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Topic
2010… Currently
Quality Currently OMPP has targeted performance
Cont.
measures for Hoosier Healthwise.
MDwise
MDwise has a dedicated Network
Improvement Program (NIP) Team and
programs in place focused on Quality and the
performance measures. The Well – child
campaign, medical chart review, billing
education, and incentive programs were a large
focus for this year. (LJ will discuss tools and
resources here)
Currently there are no targeted performance
measures for HIP.
January 2011
The targeted performance
measures will be changing for
2011 and each MCE will work
with the provider networks to
provide education and tools
around the new measures and
focus.
A program and targeted measures
are in place for HIP.
Each MCE will discuss upcoming
performance initiatives
.
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Topic
Quality
Cont.
2010… Currently
January 2011
Currently OMPP has targeted
performance measures for Hoosier
Healthwise.
MHS
MHS provides PMPs with a quarterly
listing of performance metrics, complete
with a listing of members in need of
services. Annual HEDIS chart audits
take place during the first and second
quarters. MHS also conducts semiannual provider workshops to provide
billing education. Billing updates are also
communicated via the Provider Watch
and web updates.
The targeted performance measures will
be changing for 2011 and each MCE will
work with the provider networks to
provide education and tools around the
new measures and focus.
A program and targeted measures are in
place for HIP.
Each MCE will discuss upcoming
performance initiatives.
HIP-Currently there are no targeted
performance measures for HIP
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Topic
Disease
Management
HRS completion
within 90 days of
new enrollment
Annual
Assestmetments
Member
Stratification
2010… Currently
January 2011
Currently each MCE has targeted
disease management programs in
place for the member population
for HHW and HIP.
In the new contract year, each MCE will
be responsible for implementing 10
targeted disease management programs.
Anthem
Programs can be found on our
website www.anthem.com , which
consist of: Asthma, Diabetes,
Cardiovascular, Smoking Cessation,
Childbirth, Preventive Care for
Women & Children, & Kids Learn
Healthy Habits
Anthem
Programs can be found on the website
www.Anthem.com which consists of:
Condition Care of Asthma, DM, COPD,
CAD, CHF. Behavioral Health will be
integrated with Physical Health Care
Management, programs consisting of
CoDa, Maternal Depression, Bipolar
Disorder, Autism, and ADHD.
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Topic
2010… Currently
Disease
Management
Cont.
Currently each MCE has
targeted disease management
programs in place for the
member population for HHW
and HIP.
In the new contract year, each MCE
will be responsible for implementing
10 targeted disease management
programs.
MDwise
Program information can be
found on the website at
www.mdwise.org which
consists of asthma, diabetes,
and high risk pregnancy.
MDwise- MDwise will expand our
program requirements by
implementing seven additional
disease management programs per
the above requirements.
Health Risk Screening (HRS)
HRS completion
within 90 days of
new enrollment
Annual
Assestmetments
Member
Stratification
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Topic
Disease
Management
Cont.
HRS completion
within 90 days of
new enrollment
Annual
Assessments
2010… Currently
January 2011
Currently each MCE has targeted
disease management programs in
place for the member population
for HHW and HIP.
In the new contract year, each MCE will
be responsible for implementing 10
targeted disease management programs.
Managed Health Services
Asthma, COPD, Diabetes,
Pregnancy, and Lead.
Managed Health Services
Asthma, COPD, Congestive Heart
Failure, Chronic Kidney Disease, Bipolar disease, Perinatal depression,
ADHD,
Autism/pervasive developmental
disorder,
Lead, Coronary Artery Disease,
Depression, and Diabetes.
Member
Stratification
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Member updates and changes
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HHW: Members must be in their “ free change”
or Open Enrollment period for plan selection to
be honored
 Members
who lose eligibility <2 months will remain
locked-in
 Members who complete an application within 90 days
of annual enrollment period will start “ free change”
period
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HIP: Members may select different plan at
redetermination
 Members
may select a Managed Care Entity on their
application or through Maximus (enrollment broker)
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Current HIP and HHW Membership
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HHW
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Members Primary Care Physician (PMP) Health Plan will not change unless:
PMP contracts with a different Managed Care Entity- member follow PMP prior to
1/1/11
 PMP contracts with more than one MCE-member stays with current MCE
 PMP leaves Hoosier Healthwise- member stays In MCE and is assigned to a
new PMP
 Member may follow PMP to another MCE if member is outside of his/her free
change period by filing a “just cause” request
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HIP
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All members will receive a letter that indicates they will have an
opportunity to change plans for a 1/1/2011 effective date
 If no changes is received, a HIP member will stay with their
current plan
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Redetermination for HHW and HIP
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For Hoosier Healthwise and Healthy
Indiana Plan:
 MCE’s
will outreach to members to remind
them to renew eligibility
 Managed Care Entities will assist members in
gathering required documentation
 With HIP, failure to complete determination
results in loss of coverage for 12 months
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Thanks from your MCO… MCE’s
Questions?
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