october 2009 presented by eds provider field consultants indiana health coverage programs family...

October 2009

Presented by

EDS Provider Field Consultants

Indiana Health Coverage Programs Family Tree

IHCP FAMILY TREE2 / October 2009

Agenda

•Session Objectives

• Indiana Health Coverage Programs

• IHCP Team

•Traditional Medicaid

•Care Select

•Hoosier Healthwise

•Healthy Indiana Plan

•Enrollment Broker

•Resources

•The “Tree”

•Questions


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

Indiana Health Coverage Programs




Traditional Medicaid

Hoosier Healthwise

Healthy Indiana Plan

Care Select


IHCP Team


IHCP Team

• Indiana Family and Social Services Administration (IFSSA):

– Office of Medicaid Policy and Planning (OMPP) and Children’s Health Insurance Program (CHIP) Office

– Contractors:• EDS• Affiliated Computer Services (ACS)

– Care Select – Care Management Organizations:• ADVANTAGE Health Solutions• MDwise


IHCP Team

– Hoosier Healthwise - Managed Care Organizations:• Anthem• Managed Health Services (MHS) • MDwise

– Healthy Indiana Plan (HIP)

–Anthem Blue Cross Blue Shield

–MDwise

– Enrollment Broker:• MAXIMUS


The OMPP and CHIP Office:

•Determine rules and regulations (IAC)

•Determine and approve reimbursement level

•Address cost containment issues

•Establish IHCP policies for better health outcomes

Office of Medicaid Policy and Planning

Traditional Medicaid Fee-For-Service (FFS)


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/


Traditional Medicaid - EDS

Claims Processing

Customer Assistance

Provider Education

Web interChange

Traditional Medicaid – EDS

Provider Enrollment



•Reimbursement methodology: Fee-For-Service (FFS)•EDS responsibilities include:

– Act as processor and payor 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



• Traditional Medicaid includes the 590 Program

• The following are applicable to traditional Medicaid members:

– Spend-down

– Qualified Medicare beneficiary (QMB)

– Home health / hospice

– Long Term Care

– Restricted Card Program

Traditional Medicaid Population



Surveillance and Utilization Review

Member Hotline(Fraud and Abuse)

Audit



ADVANTAGE Health

Solutions - FFS

Prior Authorization

Traditional Medicaid Members

Member Level of Care

Fax: 1-800-689-2759

Managed Care Disenrollment

ADVANTAGE Health Solutions – FFS


ADVANTAGE – 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


Audit

Responsibilities include:

•Surveillance and Utilization Review (SUR)

–Prepayment Review (PPR)

–Program Integrity (PI)

•Claims Analysis and Recovery

•Member Hotline

•Post-Payment Audits

Care Select


Traditional Medicaid - EDSCare Select

Claims Processing

Customer Assistance

Provider Education

Web interChange

Certification Code Creation

Care Select – EDS


Care Select

•Care Management Organizations (CMOs):

– MDwise

– ADVANTAGE Health Solutions

•Prior authorization, restricted card, primary medical provider (PMP) enrollment, and panel maintenance is administered by the CMOs

•Claims are processed by EDS

•Mixed reimbursement methodology

– Fee for service, and

– Administrative fee

• $15 per member per month


Care Select – CMOs

Care Select - Care

Management Organizations

ADVANTAGE Health

SolutionsMDwise

Manage PMPPanels

Demographics,Scope of Practice

Provide PriorAuthorizationfor EnrolledMembers

ManageRestricted

Card Program

Enroll PrimaryMedical

Providers


Care Select

•The CMOs will process all prior authorizations for members assigned to their respective organizations

•Members will 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

Hoosier Healthwise Risk-Based Managed Care


Risk-Based Managed Care

Hoosier Healthwise Risk-Based Managed Care

MDwisewww.mdwise.org

Managed Health Serviceswww.managedhealthservices.com

Anthemwww.anthem.com

10 Delivery Systems


• 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 their benefit package

Managed Care Medicaid PopulationRisk-Based Managed Care


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 orwww.anthem.com

Managed Care OrganizationsRisk-Based Managed Care

http://www.managedhealthservices.com/


Hoosier Healthwise Risk-BasedManaged Care

Claims Processing

Provider and Member Services

Panel Management

Prior Authorization for Enrolled Members

Provider Contracting



MCO responsibilities include:

•Act as processor and payor of claims for 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




MDwise

Anthem Blue Cross Blue Shield

Indiana Comprehensive HealthInsurance Association /

Affiliated Computer Services(Enhanced Service Plan)



•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



• 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

Enhanced Services Plan (ESP)Healthy Indiana Plan


Enrollment Broker


Enrollment Broker

MAXIMUS Administrative Services866-963-7383

Unbiased Member Education

Aids Member Selection of MCO, CMO, and PMP


•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

Enrollment Broker


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

•Written Correspondence

– P.O. Box 7263Indianapolis, IN 46207-7263

•Provider Relations Field Consultant


IHCP Family Tree Diagram

FSSA


OMPP

Hoosier HealthwiseRisk-Based Managed Care

MDwise

MHS

Anthem

MAXIMUS

MDwise (Care Select)

ADVANTAGE (Care Select)

EDS

590 Program

Audit


MDwise

Anthem Blue Cross

Blue Shield

Enhanced Services Plan(ESP)

Care Select


Questions

October 2009

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Indianapolis, IN 46204

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october 2009 presented by eds provider field consultants indiana health coverage programs family...

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