Presentation on theme: "Special Populations and Review February 6, 2015. Need More HIP Resources? Visit www.IN.HIP.govwww.IN.HIP.gov AND www.indianapca.org/?page=OEHIP2HUB."— Presentation transcript:
Special Populations and Review February 6, 2015
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Learning Objectives Discuss HIP 2.0 eligibility for special populations like: a. Pregnant women b. Native Americans c.Medically frail individuals d.Low-income Parents and Caretakers e.Low-income 19- and 20-year- olds
MEDICALLY FRAIL SPECIAL POPULATION:
Medically Frail Who is considered medically frail? Individuals with certain serious physical, mental and behavioral health conditions Required to have access to standard Medicaid benefits Includes individuals with: Disabling mental disorders (including serious mental illness) Chronic substance use disorders Serious and complex medical conditions A physical, intellectual or developmental disability that significantly impairs the ability to perform one or more activities of daily living Activities of daily living include bathing, dressing, eating, etc. A disability determination from the Social Security Administration
Medically Frail What coverage does a medically frail individual receive? Medically frail individuals receive HIP State Plan benefits No visit limit for home health Coverage for Temporomandibular Joint Disorders (TMJ) Chiropractic services Bariatric surgery Requires authorization for physical, speech and occupational therapies—but unlimited No limit for skilled nursing facility Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds Pregnant women receive access to all pregnancy-additional benefits on HIP Plus or HIP Basic plan and full State Plan benefits
Medically Frail How is an individual determined medically frail? The IAHC uses answers from the Health Coverage Questionnaire (HCQ, State Form 55641) to make a preliminary determination for medically frail status o The enrollee’s MCE makes the final determination for medically frail status by reviewing the member’s: Responses on HCQ Initial health screen or health assessment Present of historical medical claims data Any other information relevant to their health condition
Medically Frail Can an individual lose their medically frail status? If an MCE cannot confirm on-going medically frail status, it will remove the designation If a member reports themselves as medically frail to their MCE and findings show they do not meet definition of medically frail, then the individual will receive notification of finding and appeal rights If member disagrees with the MCE’s medically frail appeal decision, he or she may appeal to the State
Medically Frail Verification Individual identified as potentially medically frail Managed care entity (MCE) must verify status within 60 days* If medically frail status not verified, member no longer eligible for State Plan benefits Member transferred to HIP Basic or HIP Plus Annually MCE confirms qualification for medically frail status State verifies MCE medically frail status determinations *Verification time frame is 60 days in 2015 and 30 days in all following years
LOW-INCOME PARENTS, CARETAKERS AND 19- AND 20-YEAR-OLDS SPECIAL POPULATION:
Who is considered a low-income parent or caretaker? Individuals below 19% FPL: Who is considered a low-income 19- or 20-year-old? A child age 19 or 20 who lives in the home of a parent or caretaker relative and meets the income requirements above o A parent includes biological, adopted or step-parent Low-Income Parent or Caretaker and year-olds Family SizeMonthly Income Amount 1$152 2$247 3$310 4$373 5$435 6$498 7$561 Each additional$63
Low-Income Parent or Caretaker and year-olds What coverage does a low-income parent/caretaker or year-old individual receive? These individuals will receive HIP State Plan benefits No visit limit for home health Coverage for Temporomandibular Joint Disorders (TMJ) Chiropractic services Bariatric surgery Requires authorization for physical, speech and occupational therapies—but unlimited No limit for skilled nursing facility Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds Pregnant women receive access to all pregnancy-additional benefits on HIP Plus or HIP Basic plan and full State Plan benefits
TRANSITIONAL MEDICAL ASSISTANCE SPECIAL POPULATION:
Transitional Medical Assistance (TMA) What is Transitional Medical Assistance (TMA)? Medicaid program that offers continued coverage of benefits for certain low-income parents and caretakers who would otherwise lose Medicaid coverage due to increased earnings Available up to 185% FPL (during 2 nd 6 months) How long is an individual eligible for TMA? 6-12 months Quarterly reporting required to maintain TMA
Transitional Medical Assistance (TMA) Individuals with TMA coverage before February 2015 will not transition to HIP 2.0 Individuals newly eligible for TMA will receive HIP State Plan Plus or HIP State Plan Basic benefits Regardless of income, individuals receiving Transitional Medical Assistance (TMA) may not be dis-enrolled from the program for at least 6 months o May receive TMA up to 12 months if individual complies with required quarterly reporting For TMA members with income over ~138% FPL: o May not be dis-enrolled in the first 6 months o May be eligible for a second 6-month benefit period if: Comply with required reporting Income under 185% FPL
PREGNANT WOMEN SPECIAL POPULATION:
Pregnancy Determination 24 HIP member learns she is pregnant; reports to DFR within 10 days of knowing HIP member tells MCE she is pregnant within 10 days of knowing MCE reviews and confirms claim data indicating pregnancy
HIP Coverage for Pregnant Women Woman becomes pregnant while enrolled in HIP Woman is pregnant at application or renewal No cost-sharing during pregnancy/post-partum period OPTION: May request to move to HIP Maternity (MAGP) No cost-sharing during pregnancy/post- partum period May have coverage gap when reentering HIP after pregnancy if end of pregnancy not reported on time RECOMMEND: Report end of pregnancy promptly to guarantee continued HIP coverage without a gap
HIP Maternity (MAGP) Coverage Receive HIP Maternity ID card to use when accessing services Coverage does not have a POWER account or any copayments Prevent a coverage gap: Pregnant women should promptly notify DFR of pregnancy end date (within 10 days) To maintain coverage in HIP after pregnancy, pay POWER account contribution as soon as possible after pregnancy ends
Pregnancy Benefits Pregnant women receive benefits only available to pregnant women, regardless of selected HIP plan o Exempt from cost sharing o Additional benefits continue for a 2 month (60-day) post- partum period Additional Benefits Include: Vision Dental Non-emergency transportation Chiropractic
Pregnancy Question Can pregnant women above ~138% FPL still get coverage from an Indiana Health Coverage Program (IHCP)? Yes, women between ~138% FPL and under ~208% can still get coverage through MAGP (Medicaid pregnancy category). These individuals will receive Hoosier Healthwise Package A benefits.
NATIVE AMERICANS SPECIAL POPULATION:
Native Americans By federal rule, Native Americans are exempt from cost sharing o Receive HIP Plus o Do not have POWER account contributions or emergency room copayments o May opt out of HIP Plus and into fee-for-service coverage as of April 1, 2015 May be eligible for HIP State Plan benefit option if also: o Medically frail, o Low-income Parent/Caretaker, o Low-income year olds Native American status subject to verification with DFR. Acceptable forms of verification include: tribal card, tribal letter, previous use of Indian Health Services, etc.
QUICK REVIEW OF HIP 2.0
Indiana Application for Health Coverage (IAHC) Completing the application online is the easiest and fastest methodonline Electronic sources are used to verify income, citizenship, alien status and other eligibility factors Faxing documents might speed up the application process – Write the name and Social Security Number on each item you fax or mail FAX MAIL FSSA Document Center PO Box 1810 Marion, Indiana 46952
HIP Plus For Hoosiers with incomes up to 138% FPL Required POWER account contributions (2% member income) No other required cost- sharing (copayments)* Offers vision, dental, and more comprehensive prescription drug benefit Covers maternity services with no cost-sharing Power account jointly funded by member and the State of Indiana Initial plan selection for all enrollees * Exception: using ER for routine care
HIP Basic Basic plan for Hoosiers ≤100% FPL No required POWER account contributions Requires copayments for all services Reduced benefit package and more limited prescription drug benefit Covers maternity services with no cost-sharing POWER account is completely state- funded Fall back option for members
HIP Basic ServiceHIP Basic Copay Amounts ≤100% FPL Outpatient Services$4 Inpatient Services$75 Preferred Drugs$4 Non-preferred Drugs$8 Non-emergency ED visitUp to $25 Copayments for HIP Basic members
HIP State Plan Available for qualifying individuals Keep HIP Plus or HIP Basic cost- sharing Some additional benefits, including transportation, dental and vision Qualifying individuals include: Low-income (<19% FPL) Parents and Caretakers Low-income (<19% FPL) 19 & 20 year olds Medically Frail Transitional Medical Assistance (TMA)
HIP (Employer Benefit) Link For people with access to “unaffordable” insurance through an employer Employer must sign-up and contribute 50% of member’s premium Members make PACs and receive defined contribution from the state Enrollment in HIP Link is optional Coming Soon!
Gateway to Work As part of enrollment in the Healthy Indiana Plan, if the member is not a full time student or work more than 20 hours per week he or she may be referred to Indiana’s Gateway to Work program. Gateway to Work provides members with general information on the state’s job search and training programs that could help connect them to potential employers. While participating in the Gateway to Work could help members find employment opportunities, failure to do so will not affect their HIP eligibility.
POWER Account Like an HSA, members use first $2,500 to pay for services o Members receive monthly statement o Preventive services will not be used against $2,500 POWER account Employers & not-for-profits may assist with contributions o Employers and not-for-profits may pay up to 100% of member POWER account contribution (PAC) o Payments made directly to member’s selected managed care entity Spouses split the monthly PAC amount
Non-payment Penalties Members remain enrolled in HIP Plus as long as they make PACs and are otherwise eligible Members ≤100% FPL Moved from HIP Plus to HIP Basic Copays for all services Members ≥100% FPL Disenrolled from HIP Plus Locked-out of HIP for 6 months Penalties for members not making PAC contribution:
Reporting Changes Members must report the following changes in within 10 days of when the change occurs: o Moving to a new address or change mailing addresses o Family income or family size changes o Losing a job, change jobs or get a new job. o Becoming pregnant, delivering baby or when pregnancy ends o Becoming insured under other health insurance (Private or Medicare) o Members should call or fax information to the FSSA Document Center at , mail to FSSA Document Center, PO Box 1810, Marion, IN or submit onlineonline Changes must also be reported to MCE
Managed Care Health coverage is provided by one of the three managed care entities (MCE) Dental coverage is through DentaQuest Vision coverage is through Vision Service Plan (VSP)
Dental PlanCoverage HIP Plus Oral exams every six months and emergency oral exams Dental x-rays (Complete set once every three years and Bite-wing x- rays once every 12 months) Teeth cleaning once every six months Minor restorative services like fillings Major restorative services like crowns HIP Basic (age 19 or 20) or HPE Oral exams every six months Emergency oral exams Dental x-rays (Complete set once every three years and Bite-wing x- rays once every 12 months) Teeth cleaning once every six months HIP State Plan Basic HIP State Plan Plus All Pregnancy Plans Oral exams every six months and emergency oral exams Dental x-rays Complete set once every three years Bite-wing x-rays once every 12 months Teeth cleaning once every six months Minor restorative services such as fillings Dentures and denture repairs Extractions
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