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
October 2010
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
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Indiana Health Coverage Programs Family Tree
October 2010
Define
Indiana Health Coverage Programs
Indiana Health Coverage Programs
Indiana Health
Coverage Programs
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Traditional
Medicaid
Hoosier Healthwise
Healthy Indiana
Plan
Care Select
Indiana Health Coverage Programs Family Tree
October 2010
IHCP Team
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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
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Indiana Health Coverage Programs Family Tree
October 2010
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
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Indiana Health Coverage Programs Family Tree
October 2010
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
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Indiana Health Coverage Programs Family Tree
October 2010
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
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Indiana Health Coverage Programs Family Tree
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Traditional Medicaid
Fee-for-Service
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Traditional Medicaid – Fee-for-Service
Traditional Medicaid - HP
Claims Processing
Customer Assistance
Provider Education
Web interChange
Provider Enrollment
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Indiana Health Coverage Programs Family Tree
October 2010
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
Printed
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field consultants
publications
Long
Term Care audits
IHCP
Web site
Indiana Health Coverage Programs Family Tree
October 2010
Traditional Medicaid – HP
Traditional Medicaid population
– 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
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Indiana Health Coverage Programs Family Tree
October 2010
ADVANTAGE Health Solutions – FFS
ADVANTAGE
Health
Solutions - FFS
Prior Authorization
Traditional
Medicaid Members
Member Level
of Care
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Indiana Health Coverage Programs Family Tree
October 2010
Medical Policy
Audit
Restricted Card
Program
Fax:
1-800-689-2759
ADVANTAGE Health Solutions – FFS
ADVANTAGE Health Solutions – FFS
responsibilities:
– Prior authorization (PA) for Traditional
Medicaid fee-for-service
– Review of Traditional Medicaid fee-forservice claims that suspend for medical
policy audits
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Indiana Health Coverage Programs Family Tree
October 2010
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
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Indiana Health Coverage Programs Family Tree
October 2010
Care Select
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Care Select – HP
Traditional Medicaid - HP
Care Select
Claims Processing
Administration Fee
Certification Code Creation
Customer Assistance
Provider Education
Web interChange
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Indiana Health Coverage Programs Family Tree
October 2010
Care Select – HP
– Claims are processed by HP
– Mixed reimbursement methodology
• Fee for service, and
• Administrative fee
per
20
member per month
Indiana Health Coverage Programs Family Tree
October 2010
Care Select – CMOs
Care Select Care
Management
Organizations
ADVANTAGE
Health Solutions
Manage PMP
Panels
Demographics,
Scope of Practice
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Enroll Primary
Medical
Providers
Indiana Health Coverage Programs Family Tree
October 2010
Manage
Right Choices
Program
MDwise
Provide Prior
Authorization
for Enrolled
Members
Provide Education
to Members About
Healthcare
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
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Indiana Health Coverage Programs Family Tree
October 2010
Hoosier Healthwise
Risk-Based Managed Care
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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
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Indiana Health Coverage Programs Family Tree
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Risk-Based Managed Care
Managed Care Medicaid population
– 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
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Indiana Health Coverage Programs Family Tree
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Risk-Based Managed Care
Managed care organizations
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
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Indiana Health Coverage Programs Family Tree
October 2010
Risk-Based Managed Care
Hoosier Healthwise Risk-Based
Managed Care
Claims Processing
Provider and Member Services
Panel Management
Prior Authorization for
Enrolled Members
Provider Contracting
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Indiana Health Coverage Programs Family Tree
October 2010
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
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Indiana Health Coverage Programs Family Tree
October 2010
Healthy Indiana Plan
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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)
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Indiana Health Coverage Programs Family Tree
October 2010
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:
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•
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
Indiana Health Coverage Programs Family Tree
October 2010
Healthy Indiana Plan
Enhanced Services Plan (ESP)
– 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
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Indiana Health Coverage Programs Family Tree
October 2010
Enrollment Broker
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Enrollment Broker
MAXIMUS Administrative Services
866-963-7383
Unbiased Member Education
Aids Member Selection of MCO,
CMO, and PMP
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Indiana Health Coverage Programs Family Tree
October 2010
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
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Indiana Health Coverage Programs Family Tree
October 2010
IHCP Family Tree
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IHCP Family Tree Diagram
FSSA
OMPP
MAXIMUS
Traditional
Medicaid
Care Select
HP
Hoosier Healthwise
Healthy Indiana Plan
MDwise
(Care Select)
Risk-Based Managed Care
MDwise
MDwise
Managed
Behavioral Health
Organizations
MDwise
ADVANTAGE
(Care Select)
Advantage
Anthem Blue Cross
Blue Shield
ACS
Enhanced Services Plan
(ESP)
MHS
(effective 1/1/2011)
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Indiana Health Coverage Programs Family Tree
October 2010
MHS
Anthem
Cenpatico
Behavioral Health
Magellan Health
Services
Find Help
Resources Available
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 7263
Indianapolis, IN 46207-7263
– Provider Relations field consultant
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Indiana Health Coverage Programs Family Tree
October 2010
Q&A