HP Provider Relations October 2010 Indiana Health Coverage Programs Family Tree.

HP Provider RelationsOctober 2010

Indiana Health

Coverage Programs

Family Tree

Indiana Health Coverage Programs Family TreeOctober 2010

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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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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

DefineIndiana Health Coverage Programs


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Indiana Health Coverage Programs

Indiana Health Coverage Programs

Traditional Medicaid

Hoosier Healthwise

Healthy Indiana Plan

Care Select

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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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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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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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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

http://www.in.gov/fssa

http://www.indianamedicaid.com/

http://www.in.gov/legislative/iac/title405.html

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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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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


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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


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ADVANTAGE Health Solutions – FFSADVANTAGE

Health Solutions -

FFS

Prior Authorization

Traditional Medicaid Members

Member Level of Care

Fax: 1-800-689-2759

Medical PolicyAudit

Restricted Card Program


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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


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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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Care Select


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Care Select – HP Traditional Medicaid - HP

Care Select

Administration Fee

Customer Assistance

Provider Education

Web interChange

Certification Code Creation

Claims Processing


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Care Select – HP

– Claims are processed by HP

– Mixed reimbursement methodology

• Fee for service, and

• Administrative fee

per member per month


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Care Select – CMOsCare Select -

Care Management Organizations

ADVANTAGE Health

SolutionsMDwise

Manage PMPPanels

Demographics,Scope of Practice

Provide PriorAuthorizationfor EnrolledMembers

ManageRight Choices

Program

Enroll PrimaryMedical

Providers

Provide Educationto Members About

Healthcare


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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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Hoosier HealthwiseRisk-Based Managed Care


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Risk-Based Managed Care

Hoosier Healthwise Risk-Based Managed Care

MDwisewww.mdwise.org

Managed Health Serviceswww.managedhealthservices.com

Anthemwww.anthem.com

10 Delivery Systems


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– 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


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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

http://www.managedhealthservices.com/


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Hoosier Healthwise Risk-BasedManaged Care

Claims Processing

Provider and Member Services

Panel Management

Prior Authorization for Enrolled Members

Provider Contracting


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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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MDwise

Anthem Blue Cross Blue Shield

Indiana Comprehensive HealthInsurance Association /

Affiliated Computer Services(Enhanced Services Plan)

MHS (effective January 1, 2011)


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– 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


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– 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)

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Enrollment Broker


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Enrollment Broker

MAXIMUS Administrative Services866-963-7383

Unbiased Member Education

Aids Member Selection of MCO, CMO, and PMP


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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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IHCP Family Tree


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IHCP Family Tree DiagramFSSA

Traditional Medicaid

OMPP

MAXIMUS

MDwise (Care Select)

ADVANTAGE(Care Select)

HP

Advantage


MDwise

Anthem Blue Cross

Blue Shield

Enhanced Services Plan(ESP)

Care SelectHoosier Healthwise


MHS

Anthem

MDwise

Cenpatico

Behavioral Health

Magellan Health

Services

MDwise

Managed Behavioral Health Organizations

MHS(effective 1/1/2011)

ACS

Find HelpResources Available


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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

HP Provider Relations October 2010 Indiana Health Coverage Programs Family Tree.

Documents

Transcript of HP Provider Relations October 2010 Indiana Health Coverage Programs Family Tree.