Presentation on theme: "Introduction to Indiana Health Coverage Programs"— Presentation transcript:
1 Introduction to Indiana Health Coverage Programs HP Provider RelationsMay 2012
2 Agenda What is Medicaid? Administration of Indiana Medicaid Indiana Health Coverage Programs (IHCP)Traditional MedicaidCare SelectHoosier HealthwiseChildren’s Health Insurance Program (CHIP)590 ProgramHealthy Indiana Plan (HIP)ReferencesQuestions
3 Objectives Provide a general overview of the Medicaid Program Discuss the general responsibilities of the State agencies and State contractors in regard to the administration of the IHCPDescribe the major highlights of the IHCP including Traditional Medicaid, Care Select, Hoosier Healthwise, CHIP, 590 Program, and HIP
5 What Is Medicaid?Medicaid is a federal and state funded program, enacted in 1965 under Title XIX of the Social Security Act, which pays for the medical care of people who meet specific categorical nonfinancial, income, and resource requirements.Medicaid is an entitlement program, which means that any person who meets his or her state’s Medicaid eligibility criteria has a federal right to Medicaid coverage in that state.The state cannot limit enrollment in the program or establish a waiting list.
6 Who Pays for Medicaid?The federal government matches state spending on Medicaid.Federal law outlines minimum requirements that all states’ Medicaid programs must fulfill.However, states have broad authority to define eligibility, benefits, provider payments, and other aspects of their programs.
7 Mandatory GroupsFederal law requires that states cover certain “mandatory” groups of people who meet the state’s eligibility requirements to receive any federal matching funds.HP Confidential25 March 2017
8 Mandatory Benefits Physician services Hospital services (inpatient and outpatient)Laboratory and X-ray servicesEarly and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for individuals younger than 21 years oldFederally qualified health center (FQHC) and rural health clinic (RHC) servicesFamily planning services and suppliesPediatric and family nurse practitioner servicesNurse midwife servicesNursing facility services for individuals 21 years old and olderHome health care for individuals eligible for nursing facility servicesNecessary transportation services
9 Optional BenefitsFederal law also permits states to cover many services designated as “optional” services, such as the following:Prescription drugsHospice servicesClinic servicesDurable medical equipmentVision services and eyeglassesRehabilitation and other therapiesCase managementCare furnished by other licensed practitionersTransportation (above benefit limitations)Nursing facility services for individuals younger than 21 years oldDental services and denturesIntermediate care facility for the mentally retarded (ICF/MR) servicesHome and Community-Based Services (HCBS) Waiver ProgramsInpatient psychiatric services for individuals younger than 21 years oldRespiratory care services for ventilator-dependent individualsPersonal care services
10 Indiana Medicaid Indiana Health Coverage Programs In the state of Indiana, Medicaid services are offered to eligible Indiana residents through the IHCP.The IHCP is administered by the Office of Medicaid Policy and Planning (OMPP), which is under the Indiana Family and Social Services Administration (FSSA).The IHCP covers all the mandatory services and most of the optional services established by the federal government.
11 Indiana Medicaid Indiana Health Coverage Programs IHCP Traditional MedicaidCare SelectHoosier HealthwiseCHIP Package C590 ProgramHIPIndiana MedicaidIndiana Health Coverage Programs
12 IHCP Payment Delivery System Providers are reimbursed for services rendered to members enrolled in IHCP based on the program in which the member is enrolled.The IHCP reimburses enrolled providers using the following three payment delivery systems:Fee-for-service (FFS)Care SelectRisk-based managed care (RBMC)
13 IHCP Payment Delivery System Fee for ServiceThe FFS delivery system reimburses providers on a per-service basis.Providers bill services rendered to IHCP members directly to Hewlett-Packard (HP), the IHCP fiscal agent.
14 IHCP Payment Delivery System Care SelectCare Select is similar to Traditional Medicaid in that payments for care are made on an FFS basis.In addition, a per-member, per-month administration fee is paid to primary medical providers (PMPs).Care Select operates as an FFS delivery system with a gatekeeper approach.Claims are submitted to HP for processing.
15 IHCP Payment Delivery System Risk-based Managed CareIn the RBMC delivery system, the State pays each managed care entity (MCE) a monthly capitation fee based on the member’s category of service.This capitation fee covers the costs of care for most of the covered services incurred by Hoosier Healthwise members enrolled in the MCE network.Claims are processed and paid by the MCE in which the member is enrolled.Exception: Claims for carved-out services, including but not limited to pharmacy and dental services, are processed by HP and paid on an FFS basis.Providers should contact the MCE for specific claim payment and prior authorization (PA) policies and guidelines.
18 Family and Social Services Administration The FSSA is the State agency responsible for social service and financial assistance programs.The FSSA includes the following five major service divisions:OMPPDFRDADDRSDMHA
19 Office of Medicaid Policy and Planning The OMPP is responsible for the following:Administering the IHCP at the State level, including the following functions:Medical policy developmentProgram and contract complianceContracting with MCEsAddressing cost containment issuesEstablishing IHCP policiesProgram reimbursementProgram integrity, including claims analysis and recovery
20 Division of Family Resources The DFR, formerly known as the Division of Family and Children, is the division of FSSA responsible for processing applications and making eligibility decisions.The County Offices of the Division of Family Resources administer the IHCP at the local level.
21 Division of AgingThe DA is the division of FSSA that operates the following programs:Two of the HCBS Waiver ProgramsAged and Disabled (A&D) WaiverTraumatic Brain Injury WaiverResidential Care Assistance ProgramNursing home Pre-Admission Screening Resident Review programLocal Area Agency on AgingHandles the initial requests for waiver servicesConducts nursing home pre-admission screenings
22 Indiana Medicaid State Contractors Involved in theAdministration of theIndiana HealthCoverage Programs(Indiana Medicaid)
23 State Contractor HP Enterprise Services Serves as the State fiscal agent and as a liaison between the provider and member communities and the IHCPManages the processing of claims (FFS)Processes a variety of financial transactions, including claim payments, voids, refunds, and accounts receivableProcesses provider enrollment applications and updates existing provider recordsProvides training to the provider community through on-site visits, conferences, and workshopsProvides member and provider customer assistance
24 State Contractor Traditional Medicaid or Care Select (FFS): ADVANTAGE Health SolutionsSMTraditional Medicaid or Care Select (FFS):Processes PA requestsReviews claims that suspend for medical policy auditsAdministers the Right Choices Program (RCP) for Traditional Medicaid and Care Select members
25 ADVANTAGE Health Solutions Right Choices ProgramThe RCP is designed to safeguard against the unnecessary or inappropriate use of Medicaid services.RCP case managers provide intensive member education, care coordination, and utilization management for members enrolled in the RCP.The member remains eligible to receive all medically necessary, covered services allowed by the IHCP when one of the following occurs:The service is rendered by one of the providers to whom the member is locked-in or restricted.The service is rendered by a specialist who has received a valid, written referral from the primary lock-in physician.
26 Right Choices ProgramEffective January 1, 2010, any IHCP member participating in the IHCP (including HIP) may be placed in the RCP.The RCP is administered by the health plan in which the member is enrolled.ProgramAdministered ByContact InformationTraditional MedicaidADVANTAGE Health SolutionsCare SelectMDwiseHoosier HealthwiseManaged Health Services (MHS)Anthem, Option 3HIPMHS
27 State Contractor Serves as the pharmacy benefit manager Xerox Responsible for the Drug Rebate ProgramProcesses pharmacy-related PA requests
28 State Contractor Myers and Stauffer LC Myers and Stauffer is responsible for the following:Setting rates that affect claim pricing on certain types of claims (for instance, capital cost for inpatient claims)Setting flat fee rates for per diem servicesAuditing IHCP claim processing activities
29 State Contractor Managed Care Entities Entities authorized by the state of Indiana to operate a prepaid health care delivery plan (such as an HMO) on a capitated basisThese entities arrange, administer, and process claims for the delivery of health care services to members who are enrolled in the Hoosier Healthwise Program.Administer the RCP for their members
30 State Contractor Care Management Organizations Provide a myriad of health services for members who are enrolled in Care SelectProcess PA requestsReview claims that suspend for medical policy auditsAdminister the RCP
31 State Contractor MAXIMUS Administrative Services Serves as an enrollment broker for the following:Care SelectHoosier HealthwiseHIPPresumptive Eligibility for Pregnant WomenProvides choice counseling for eligible members to assist them with choosing a health plan that best meets their needs
33 Traditional MedicaidIHCP members enrolled in Traditional Medicaid are not assigned a PMP and do not need to enroll in any MCE to receive health-related servicesServices rendered to members enrolled in Traditional Medicaid are paid on an FFS basis
34 Traditional Medicaid Spend-down Spend-down is a provision that allows a person whose income is more than the standard to receive assistance with medical bills under Medicaid.Spend-down works like an insurance deductible. Once the monthly spend-down amount is satisfied, Medicaid will pay for all other covered services for that month.The spend-down amount is determined by the DFR and is based on the member’s income and medical expenses.The member must pay the spend-down amount deducted from claims directly to the provider.
35 Traditional Medicaid Dually Eligible for Medicare and Medicaid Dually eligible members are individuals who are entitled to Medicare Part A and/or Part B and are eligible for Medicaid benefits.A Medicare beneficiary who is aged, blind, or disabled according to Medicaid’s standards and who meets the Medicaid income and resource eligibility rules can qualify for Traditional Medicaid.
36 Traditional Medicaid Dually Eligible for Medicare and Medicaid A Medicare beneficiary who does not qualify for Medicaid following the established guidelines, may still qualify for Medicaid under one of the following categories designed for Medicare beneficiaries:Qualified Medicare Beneficiary (QMB)-OnlyQMB-AlsoQMB-Also with spend-downAn individual must meet the following eligibility criteria to receive assistance with Medicare-related costs under the QMB program:Be entitled to Medicare Part ABe 65 years old or older or be younger than 65 years old and entitled to Medicare
37 Only Medicare Benefits Traditional MedicaidQualified Medicare Beneficiary-Only CoverageMedicaid benefits are limited to payment of the member’s Medicare premiums, deductibles, and coinsurance for Medicare-covered services only.The member is only eligible for the premiums, deductibles and coinsurance for Medicare-covered services.Services not covered by Medicare are also not covered by Medicaid.Only Medicare Benefits
38 Full Medicaid Benefits Traditional MedicaidQualified Medicare Beneficiary-Also CoverageMedicaid benefits include payment of the member’s Medicare premiums, deductibles, and coinsurance for Medicare-covered services.In addition, the member receives full Medicaid covered services (benefits).For QMB-Also with spend-down, the member receives full Medicaid covered services (benefits) after the monthly spend- down liability is met.Full Medicaid Benefits
39 Traditional Medicaid Long Term Care Long-term care (LTC) services are available to IHCP members who meet the threshold of nursing care needs required for admission to or continued stay in an IHCP-certified nursing facility.The goal of the LTC program is to provide services in a setting other than an acute care wing of a hospital, enabling individuals whose functional capacities are chronically impaired to be maintained at their maximum level of health and well-being.
40 Traditional MedicaidLong Term Care – Patient LiabilityPatient liability is the monetary amount that a Medicaid resident must contribute toward his or her monthly care in a facility.The amount of patient liability is determined by the local county office of the DFR.The patient liability is deducted from LTC claims.
41 Traditional Medicaid Hospice The Hospice program provides services to IHCP members who are terminally ill.Hospice requires level of care (LOC) determination and a diagnosis of a terminal illness.A hospice provider must be Medicare- certified as a hospice provider prior to enrollment in the IHCP as a Medicaid provider.
42 Traditional Medicaid Waiver Programs Medicaid also offers additional nonmedical home and community- based services under waiver programs.Waivers are designed as an alternative to institutionalization.To qualify for waiver services, a person must first meet the LOC to receive services in an institution (hospital, nursing home, or ICF/MR) but choose to receive services in the community.
43 Traditional Medicaid Package E: Emergency Services Only Package E provides coverage of serious medical emergencies for undocumented immigrants and certain visitors to the United States who meet all other categorical and financial requirements.These members are only eligible for the following:Labor and delivery until the mother is stableMedical emergenciesA maximum of four-days supply of pharmacy servicesNonemergency services may be billed to the member if a signed waiver was obtained prior to rendering services
45 Care SelectCare Select is similar to Traditional Medicaid in that payments for care are made on an FFS basis.However, members are assigned to a PMP.An additional per-member, per- month administration fee is paid to PMPs.
46 Care SelectAs of October 1, 2010, Care Select changed from a care management program that covered an extensive group of aid categories to a disease management program with a focus on members with certain chronic conditionsTo participate in Care Select, members must meet the aid category criteria and have at least one of the health conditions covered by the program.Members can opt out of Care Select at any time and enroll in Traditional Medicaid instead.
47 Aid Categories Covered by Care Select AgedCare Select Aid CategoriesBlindAgedDisabledWard of the StateFoster CareChildren/Adoptive ServicesChildren/Adoptive ServicesCare Select Aid CategoriesFoster CareWard of the State
48 Health Conditions Covered by Care Select A member must also have one of the following conditions to be eligible for Care Select:AsthmaDiabetesCongestive heart failureHypertensive heart diseaseHypertensive heart and kidney diseaseRheumatic heart illnessSevere mental illnessSerious emotional disturbanceDepression
49 Care Select Selecting a Health Plan and a Primary Medical Provider Members select a health plan, also called a care management organization (CMO), to coordinate their health care services.MAXIMUS (an enrollment broker contracted by the State) can assist members in making a CMO selection.The CMO will assign a PMP.The PMP is responsible for the following:Providing or coordinating the member's careProviding most primary and preventive services and reviewing necessary specialty care and hospital admissions
51 Hoosier Healthwise (Risk-based Managed Care Programs) The Hoosier Healthwise Program provides coverage for health care services rendered to the following aid category groups:ChildrenPregnant womenLow-income familiesThe specific eligibility aid category determines the benefit package.
52 Hoosier Healthwise Risk-based Managed Care Hoosier Healthwise follows an RBMC payment delivery system.As mentioned previously, in the RBMC delivery system, the State pays each MCE a monthly capitation fee based on the member’s category of service.
53 Hoosier HealthwiseSelecting a Health Plan and a Primary Medical Providerwithin 30 days of their initial enrollment in Hoosier Healthwise, members select a health planMAXIMUS (an enrollment broker contracted by the State) can assist members in selecting a health plan.After members enroll in a health plan, the health plan assists them in selecting a PMP.PMPs provide or authorize most primary and preventive care services.
54 Hoosier Healthwise Managed Care Entities MCEs arrange, administer, and pay (process claims) for the delivery of health care services to members who are enrolled in the Hoosier Healthwise Program.Each MCE is responsible for the following:Maintaining its own provider and member services unitsPaying claims for noncarved-out servicesProviding PA
55 Hoosier Healthwise Children’s Health Insurance Program CHIP, the State’s program created under Title XXI of the Social Security Act, provides health care coverage for children from birth through 18 years old using a buy-in option.Under CHIP, also known as Package C, the income limit is 250 percent of the federal poverty guidelines.Coverage is provided only to children who are ineligible for all other categories of the Hoosier Healthwise Program.
56 Hoosier HealthwiseChildren’s Health Insurance Program – Cost-sharing RequirementsUnlike the other Hoosier Healthwise programs, CHIP has cost- sharing requirements.A child determined eligible for Package C is made conditionally eligible pending a premium payment.The child’s family must pay a monthly premium.Only after the premium is paid is actual eligibility information transferred to IndianaAIM.Enrollment continues as long as premium payments are received and the child continues to meet all eligibility requirements.Enrollment is terminated for nonpayment of premiums after a 60-day grace period.
57 Early and Periodic Screening, Diagnosis, and Treatment
58 Early and Periodic Screening, Diagnosis, and Treatment The EPSDT program, referred to as HealthWatch in Indiana, is a federally mandated preventive health care program designed to improve the overall health of eligible infants, children, and adolescents.The primary goal of the HealthWatch/EPSDT program is to ensure that all children in the IHCP receive age-appropriate, comprehensive, preventive services.
60 590 ProgramThe 590 Program is designed for residents of State-owned facilities under the direction of the FSSA, Division of Mental Health and Addiction, and Indiana State Department of Health.The 590 Program does not include incarcerated individuals.Members enrolled in the 590 Program are eligible for the full array of benefits covered by the IHCP (with the exception of transportation services).However, members do not receive a Hoosier Health Card.
61 590 ProgramAll services provided on-site at the 590 Program facility are the financial responsibility of the facility.The 590 Program facility and all providers performing services must be enrolled in the 590 Program.Services provided to members enrolled in the 590 Program are reimbursed per claim, following an FFS payment delivery system.Billing for services includes the following:$150 or less Billed to the 590 Program facilityOver $150 Billed to HPOver $500 Services require PA
63 Healthy Indiana PlanHIP provides health insurance for uninsured adult Hoosiers between years old whose household income is between 22 and 200 percent of the federal poverty level, who are not eligible for Medicaid.Eligible participants must be uninsured for at least six months and cannot be eligible for employer- sponsored health insurance.HIP is not an entitlement program; funding is limited.Pregnant women are not eligible for HIP services.Prescription drugs are limited to seven or nine fills per month; only four brands are allowed.
65 Indiana Health Coverage Programs FSSAOMPPMDwiseMHSAnthemHoosier HealthwiseRisk-Based Managed CareMAXIMUSHP590 ProgramHealthy Indiana PlanAnthem Blue CrossBlue ShieldEnhanced Services Plan (ESP)CenpaticoBehavioral HealthManaged Behavioral Health OrganizationsFSSA = Family & Social Services AdministrationOMPP = Office of Medicaid Policy and PlanningMAXIMUS = Enrollment BrokerTraditional MedicaidMDwise (Care Select)Care SelectADVANTAGE (Care Select)
67 References ADVANTAGE Health Solutions advantageplan.com Categories of Assistance (Indiana Client Eligibility System Program Policy Manual) in.gov/fssa/files/1600.pdfAnthem anthem.comCare Select provider.indianamedicaid.com/about-indiana-medicaid/member-programs/care- select.aspx indianamedicaid.com/ihcp/BULLETINS/BT pdf in.gov/fssa/ompp/2546.htm
68 References CHIP in.gov/fssa/ompp/2545.htm HealthWatch/EPSDT Provider Manual provider.indianamedicaid.com/ihcp/manuals/epsdt_healthwatch.pdfFSSA/OMPP Glossary of Terms in.gov/fssa/ompp/3328.htmHIP in.gov/fssa/hip indianamedicaid.com/ihcp/Bulletins/BT pdf
70 ReferencesIHCP Glossary provider.indianamedicaid.com/general-provider-services/ihcp- glossary.aspxMHS mhsindiana.comMDwise mdwise.orgMyers and Stauffer in.mslc.com
71 ReferencesIHCP Provider Manual provider.indianamedicaid.com/general-provider-services/manuals.aspxTitle 405 Office of the Secretary of Family and Social Services Medicaid Covered Services and Limitations Rule in the Indiana Administrative Code (IAC) at 405 IAC 5 state.in.us/legislative/iac/title405.htmlMedicaid Waivers in.gov/fssa/ompp/2549.htm