Presentation on theme: "Changing Plans, Switching MCEs, Redeterminations, Appeals and More February 5, 2015."— Presentation transcript:
Changing Plans, Switching MCEs, Redeterminations, Appeals and More February 5, 2015
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Learning Objectives I.Discuss transferring plans and changing MCEs II.Discuss the annual eligibility redetermination process III.Highlight factors of becoming ineligible and disenrollment IV.Discuss reporting changes, retroactive coverage, lockout periods and appeals
Transferring Plans: Basic to Plus A member will have the opportunity to transfer from HIP Basic to HIP Plus or HIP State Plan Basic to HIP State Plan Plus under these circumstances: a)At annual renewal b)For a member with a balance remaining in his or her POWER account at the end of the benefit period The provider network is the same for Basic and Plus
Changing MCEs Individuals can change MCEs before their first POWER Account contribution (PAC) has been made. They can also change plans: o At redetermination, but before paying PAC o For poor quality of care such as: Action, or lack of action, by the insurer which puts the life or health of the member at risk or jeopardizes the member’s ability to reach and maintain maximum function Unreasonable delay by the insurer in granting a prior authorization request Failure of the insurer to provide covered services Corrective Action levied against the insurer by OMPP Other circumstances determined by FSSA to constitute poor quality of care o Pregnant women in the Medicaid category can change MCEs at any time during pregnancy
Annual Redeterminations The applications states: “Redeterminations will be completed every 12 months. DFR will attempt to complete using available electronic data sources and will automatically continue enrollment for another 12 months if found eligible.” o If unable to verify information, consumer will receive a pre- populated reenrollment form in the mail that must be completed and returned o Form/mailer will arrive 75 days prior to coverage end date Return mailer on time and determined eligible: Continue coverage without a coverage gap Return mailer late: Late redetermination processing with possible coverage gap
Redeterminations: Medically Frail Status is redetermined at least annually If a member is determined not to be medically frail, but still eligible for HIP, the member will transfer from HIP State Plan benefits to: a)HIP Plus if he or she is currently enrolled in HIP State Plan Plus or b)HIP Basic if he or she is currently enrolled in HIP State Plan Basic The same process is used for Section 1931 Parent or caretaker relative or low income dependent
Redeterminations: Pregnant Women A member who becomes pregnant during her benefit period will remain enrolled in the plan unless: a)She chooses to transfer to the pregnant women Medicaid category (HIP Maternity); or b)She is pregnant at annual renewal, at which time she will be transferred to the pregnant women Medicaid category.
Late Redeterminations Members have until 90 days after the coverage end date to return redetermination paperwork and have it processed o If paperwork turned in late and member is eligible for HIP but not other Medicaid categories: May have a health coverage gap o If paperwork not turned in within 90 days: 6 month HIP lockout period*, starting from coverage end date Member must reapply for HIP benefits after lockout period ends, if desire benefits Member application considered for other Medicaid category eligibility, as well 9 RECOMMENDATION: To avoid lockout, all HIP 2.0 members should complete and submit redetermination paperwork on time
Becoming Ineligible During the twelve (12) month coverage period, an individual will become ineligible to participate in the plan under the following circumstances: No longer an Indiana resident Becomes eligible for Medicare Becomes eligible for another Medicaid assistance category (e.g. disability, aged, pregnancy) o Except for Section 1931 parents and caretaker relatives, low income dependents, age nineteen or twenty years old, transitional medical assistance, or pregnant women Medicaid category) The member has household income above 100% FPL and is terminated for failure to make the required POWER account contributions.
Becoming Ineligible (con’t.) The member requests in writing that coverage be terminated. The member falsifies information on the application. The member is at least sixty-five (65) years of age unless he or she is: (A) a Section 1931 parent or caretaker relative; or (B) eligible for transitional medical assistance
Disenrolling from HIP 2.0 Members leaving the program early may receive a refund for any unused POWER account contributions: Refund amount is 100% of remaining member contribution Reporting a change that makes them ineligible for HIP Refund amount will be reduced by 25% Non-payment of POWER account contribution
Reporting Changes 13 Change may impact member eligibility and/or benefits Why report changes? The Division of Family Resources (1-800-403-0864) The Division of Family Resources EXCEPTION: Report medically frail status changes to health plan Where are changes reported? HIP 2.0 member OR Member’s authorized representative Who must report changes? Family size Income Address Employment Pregnancy Insurance coverage, including Medicare What types of changes should be reported? If a member reports a change in income over HIP 2.0 eligibility limits, his/her application will be sent to the Health Insurance Marketplace
Verified Member Changes 14 Member reports changes Changes verified Some changes allow for self- attestation Identify if changes impact member eligibility Check member eligibility As needed, update member eligibility Changes in federal poverty level may result in increased or decreased POWER account contributions, change eligibility for HIP Basic, or make individual ineligible for HIP
Impact of Verified Member Changes Verified Increase in Income HIP Plus Members: May need to pay more in PAC HIP Basic Members: May no longer be eligible for HIP Basic May need to move to HIP Plus to make PAC Will be disenrolled if PAC is not received All: No longer eligible for HIP 2.0 if income is over ~138% FPL Application data will be sent to the FFM Verified Decrease in Income HIP Plus members: May not need to pay as much in PAC May be able to access HIP Basic if miss PAC Changes not Reported in Timely Manner HIP Plus members subject to benefit recovery
Retroactive Coverage HIP 2.0 does not provide coverage for: o The months before the initial POWER account contribution is (PAC) paid OR o The months prior to when an individual defaults into HIP Basic
Lockout Periods Individuals who submit a new application during their HIP lockout period will have their eligibility considered for Medicaid categories, but will not be eligible for HIP HIP Members are subject to a 6 month lockout period if: o They were HIP Plus members receiving benefits AND o Have income greater than 100% FPL and less than ~138% FPL AND o Failed to make POWER account contributions Members have 60 days after the due date to pay POWER account contribution before being locked out of the program If locked out, application data forwarded to the federal Health Insurance Marketplace – OR they fail to submit their redetermination paperwork on time 17
Appeals A pending applicant, conditionally eligible individual or plan member dissatisfied with the action of an insurer must first go through the insurer’s internal appeals process After this process, the consumer can request a hearing with the state no later than 33 days from the date of the insurer’s resolution of appeal
Appeals (con’t.) If a member requests a hearing prior to the effective date of the adverse action, plan coverage will continue without change until an administrative law judge issues a decision after the hearing – If POWER account contributions were required for that member to receive services, he or she must continue to make contributions to his or her POWER account during the appeal in order to continue coverage. If the administrative law judge sustains the action, the member is responsible for repaying the cost of any services furnished, minus any POWER account contributions made for coverage during the pendency of the appeal
Appeals (con’t.) If the action under appeal is overturned, the State or the insurer will make coverage available effective to the date the overturned action was taken. – However the individual must make any POWER account payments (unless not required to) that became due during the appeal within sixty (60) days of the insurer’s date of invoice in order to continue participating in the plan. A member will not receive continued benefits pending the outcome of an administrative hearing if: a)The action is the result of the member’s nonpayment of POWER account contributions; OR b)The member requests in writing that plan benefits not be maintained pending the administrative appeal.
Primary Medical Provider HIP enrollees must select a PMP The MCE can assist the consumer in selecting one
Pharmacy Benefits HIP Basic and HIP State Plan Basic Limited to 30-day prescription drug supply Subject to a copayment HIP Plus and HIP State Plan Plus Up to a 90-day prescription supply Mail order pharmacy benefit Medication therapy management services One drug in every US Pharmacopeia category and class is offered The same number of drugs in each category and class of the EHB benchmark plan is covered
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