HIP HIP HOORAY! Healthy Indiana Plan

Presented by MDwiseOctober 19, 2010

HIPP0060 (09/10)

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Purpose of today’s discussion

HIP plan overview Covered services Preventive Services Prior Authorization HIP Tier 2 and 3 comparison HIP update 2011 Tools and Resources

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HIP

• January 2008 • The Healthy Indiana Plan was fully implemented• 20,000 applications received during the first

month• 10,000 Hoosiers enrolled by May 2008• Today- 46,000 Hoosiers enrolled in the plan

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Enrollment Funding

0

20000

40000

60000

80000

100000

120000

140000

HIP Enrollment

TotalFunding

ChildlessAdult

CurrentEnrollment

•HIP is funded for approximately 130,000 Hoosiers per year•Enrollment cap of 34,000 childless adults per year•This category has met it’s maximum capacity

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HIP Plan overview Coverage is focused on preventive services Power Account

• Medical expenses are paid out of the Power Account first until the $1,100 has been exhausted. After POWER account dollars are exhausted, it mirrors a commercial plan coverage.

Limit of $300,000 annually and $1,000,000 lifetime. Emergency services require a co-pay (refund to

member if admitted to the hospital). Coverage term is limited to 12 months ( member must

stay current with contribution payments). After the one-year term, members must be recertified

to continue in the plan for another 12 months.

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HIP Tier 2 and Tier 3

Healthy Indiana Plan

MDwise Tier 1

MDwise Tier 2

Tier 3 -MDwise Indiana Check UP

Comparison

Tier 1

No member deductible

Power Account contribution

Preventive Services 100% covered

ER co-pay required based on income

Pregnancy – not covered

50% employer contribution

RX www.indianapbm.com

Tier 2

Deductible

$1,100 member out of pocket expense

$25.00 Emergency Care co-payment

Preventive Services 100% covered

Pregnancy –not covered

Member’s RID will begin with H2

50% employer contribution

RX benefits Plans PBM

Tier #3

$1,200 member out of pocket expense

$0 Emergency Care co-payment

Preventive Services 100% covered

Pregnancy- not covered

Member’s RID or ID number will begin withH3

50% employer contribution

RX benefits Plans PBM

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HIP Covered Services

Comprehensive disease management Home health services, including case management Urgent care center services Preventive care services Family planning services Hospice services Substance abuse services Durable medical equipment Lead screening services for nineteen (19) and twenty (20)

year olds Hearing aids for nineteen (19) and twenty (20) year olds

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HIP Covered Services

Mental health care services Inpatient hospital services Skilled nursing facility services, subject to a 60-day

maximum Emergency room services, including non-emergent

services provided in an emergency setting Physician office services Diagnostic services, including pregnancy testing Outpatient services, including covered therapy

services * Note PE- Presumptive eligibility and NOP do not

apply to HIP

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Preventive care

MDwise will be encouraging members and requests that providers encourage members to receive appropriate age and gender preventive services, including:

• Annual physical• Colonoscopy

• Flu shot• Pap smear• Cholesterol testing• Mammogram• Chlamydia screening• Blood glucose screening• Tetanus-diphtheria booster• Lead testing, 19-20 year-old• Hearing Screening

•Unlimited preventive services Not subject to POWER Account

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Enhanced Service Plan ESP

HIP applicants are asked certain medical questions. These questions include, cancer, organ transplants, HIV,

AIDS, aplastic anemia, frequent blood transfusion, hemophilia, or other rare bloodstream diseases.

If answered yes, the approved applicant will be enrolled in the ESP which will allow for them to receive specialty services.

MDwise may refer to ESP during the first six months of active enrollment or at the end of a HIP member’s eligibility period.

ACS will process claims for ESP services.

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HIP and Pregnant Women

• Pregnant women are not eligible for HIP services• Pregnancy related services are non-covered • Physicians are encouraged to assist members to submit a

statement of pregnancy to the Division of Family Resources (DFR)

• The member’s HIP plan can also assist in the members reassignment

• HIP members who become pregnant are encouraged to contact the DFR to request re-assignment to Hoosier Healthwise (members are not automatically termed from HIP)• There will be no break in coverage

• Pregnant women may re-enroll in HIP following the pregnancy• ****See attachment in folder

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Reimbursement

MDwise will reimburse the provider of service at the current Medicare rates, or 130% of Medicaid rates, if the service does not have a Medicare reimbursement rate.

180 days claims filing (90 days in 2011)

• NOTE-Providers must be enrolled in the Indiana Health Coverage Program (IHCP) to participate in HIP, and be contracted with MDwise HIP.

• MDwise plan participation will be based on delivery system acceptance. (See quick contact sheet for participating Delivery Systems and contact information).

• In order to see ESP members providers must be enrolled in IHCP.

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Eligibility•It is the responsibility of ALL providers to check eligibility at the time of each visit. Providers can check assigned delivery system through the MDwise web portal or through Web Interchange.

• (members received an updated card due to Pharmacy carve out)

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Claims Submission For MDwise HIP

• Medical ClaimsMDwise ( HIP)P.O. Box 33049Indianapolis, IN 46203Electronic filing: Payor MDWIS

• Behavioral Health ClaimsMDwise (HIP)P.O. Box 33049Indianapolis, IN 46203Electronic filing: Payor MDWIS

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Claims Dispute

• Claims dispute• In and out of network- Call MDwise to inquire about claim.• MDwise must respond within 30 calendar days of inquiry. • Claims dispute form is available on line. • Appeals – Must be in writing• Provider has 60 calendar days

• From receiving remittance advice denial or• After MDwise claims payor system fails to make determination or • In-network appeals should be forward to MDwise for resolution• Out-of-network appeals should be forward to MDwise Corporate at

Attn: MDwise Grievance Coordinator/HIP1200 Madison Ave. Suite 400Indianapolis, IN 46225

*specialty network is open. Call delivery system medical management department for services that require prior auth.

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Prior Authorization

HIP providers call the member’s Delivery System for prior authorization ( see quick contact sheet)

View PA requirements via website @ www.MDwise.org Healthy Indiana Plan/Providers/Provider Tools

• *Until further communication, MDwise will operate as an open network for Specialist Services Only. This excludes facilities. Please contact the appropriate HIP delivery system medical management department (see quick contact sheet) for a list of services that require prior authorization.

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Universal PA Form

• Click here to view Universal PA form PA Form Proposal 20100708.pdf

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Pharmacy Benefit

• Pharmacy benefits (www.indianapbm.com)• Customer Service 1-800-879-0106

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2011 HIP plan updates

MDwise, Anthem and Managed Health Services were selected to administer the Healthy Indiana Plan for contractual period January 2011 through December 31 2015.

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HIP update 2011

HIP and Hoosier Healthwise contracts are combined

Offer comprehensive package of disease management programs

Managed Care Entities ( MCEs) to complete standardized Health Risk Screening ( 70% within 90 days)

MCEs to do all PMP changes and auto assignment of members to a PMP ( this is already done by MDwise)

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New Member Application

Members will select Managed Care Entity on application--not PMP

Option to receive a copy of PMP list Email address will be collected Primary and secondary phone numbers will be

added

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HIP membership

All members will receive a letter that indicates they will have an opportunity to change plans for a 1/1/11 effective date.

If no change is received, a HIP member will stay with their current plan.

New HIP enrollment will default to the neediest MCE.

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Redetermination

HIP member who fails to complete redetermination results in loss of coverage for 12 months.

HIP members may select a different plan at redetermination.

Member may select a Managed Care Entity (MCE) on their applications or through Maximus (enrollment broker).

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Member Billing

MCE’s invoices member and collects monthly payments• 60 days to pay contribution/premium or termination will

follow

Conditional HIP members may reapply Fully Eligible HIP member can reapply after 12

months Employers- HIP Members may contribute up to

50% of members contribution.

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Disease Programs – focus for 2011

Asthma ADHD-Attention Deficit/Hyperactivity Disorder Diabetes Pregnancy CHF-Congestive Heart Failure CAD-Coronary Artery Disease Depression PDD-Pervasive Developmental Disorder or Autism COPD- Chronic Obstructive Pulmonary Disease

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Thank You from