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HP Provider Relations October 2010 Indiana Health Coverage Programs Family Tree.

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Presentation on theme: "HP Provider Relations October 2010 Indiana Health Coverage Programs Family Tree."— Presentation transcript:

1 HP Provider Relations October 2010 Indiana Health Coverage Programs Family Tree

2 Indiana Health Coverage Programs Family Tree October Agenda –Session Objectives –Indiana Health Coverage Programs –IHCP Team –Traditional Medicaid –Care Select –Hoosier Healthwise –Healthy Indiana Plan –Enrollment Broker –The “Tree” –Resources –Questions

3 Indiana Health Coverage Programs Family Tree October 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

4 Define Indiana Health Coverage Programs

5 Indiana Health Coverage Programs Family Tree October Indiana Health Coverage Programs Traditional Medicaid Hoosier Healthwise Healthy Indiana Plan Care Select

6 6 Footer Goes Here IHCP Team

7 Indiana Health Coverage Programs Family Tree October Office of Medicaid Policy and Planning –The OMPP and CHIP Office: Determine rules and regulations (Indiana Administrative Code – IAC) Determine and approve reimbursement level Address cost containment issues Establish IHCP policies for better health outcomes

8 Indiana Health Coverage Programs Family Tree October IHCP Team Indiana Family and Social Services Administration (FSSA): –Office of Medicaid Policy and Planning (OMPP) and Children’s Health Insurance Program (CHIP) Office –Contractors: –HP – Fiscal Agent –Pharmacy Benefit Manager Affiliated Computer Services (ACS) –Care Select – Care Management Organizations: ADVANTAGE Health Solutions MDwise

9 Indiana Health Coverage Programs Family Tree October IHCP Team –Hoosier Healthwise - Managed Care Organizations: Anthem Managed Health Services (MHS) MDwise –Healthy Indiana Plan (HIP) Anthem Blue Cross Blue Shield MDwise Managed Health Services (as of January 1, 2011) Enhanced Services Plan –Enrollment Broker MAXIMUS

10 Indiana Health Coverage Programs Family Tree October IHCP Information Primary sources for information about the IHCP are found at: –FSSA Web site at –IHCP Web site at –IHCP Provider Manual –IHCP provider monthly newsletters –IHCP provider bulletins –IHCP provider banner pages –Indiana Administrative Code at Note: The IHCP reference tools apply to fee-for-service/Traditional Medicaid, not the risk-based managed care delivery system

11 11 Footer Goes Here Traditional Medicaid Fee-for-Service

12 Indiana Health Coverage Programs Family Tree October Traditional Medicaid – Fee-for-Service Traditional Medicaid - HP Claims Processing Customer Assistance Provider Education Web interChange Provider Enrollment

13 Indiana Health Coverage Programs Family Tree October Traditional Medicaid – HP –Reimbursement methodology: Fee-for-Service (FFS) –HP responsibilities include: Act as processor and payer 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

14 Indiana Health Coverage Programs Family Tree October Traditional Medicaid – HP –Traditional Medicaid includes: · 590 Program · Medical Review Team Program –The following are applicable to traditional Medicaid members: Spend-down Qualified Medicare beneficiary (QMB) Home health/hospice Long Term Care Right Choices Program Traditional Medicaid population

15 Indiana Health Coverage Programs Family Tree October ADVANTAGE Health Solutions – FFS ADVANTAGE Health Solutions - FFS Prior Authorization Traditional Medicaid Members Member Level of Care Fax: Medical Policy Audit Restricted Card Program

16 Indiana Health Coverage Programs Family Tree October ADVANTAGE Health Solutions – 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

17 Indiana Health Coverage Programs Family Tree October Fee-for-Service The FSSA administers the following functions: –Surveillance and Utilization Review (SUR) –Claims Analysis and Recovery Prepayment Review (PPR) Program Integrity (PI) –Post-Payment Audits

18 18 Footer Goes Here Care Select

19 Indiana Health Coverage Programs Family Tree October Care Select – HP Traditional Medicaid - HP Care Select Administration Fee Customer Assistance Provider Education Web interChange Certification Code Creation Claims Processing

20 Indiana Health Coverage Programs Family Tree October Care Select – HP –Claims are processed by HP –Mixed reimbursement methodology Fee for service, and Administrative fee  per member per month

21 Indiana Health Coverage Programs Family Tree October Care Select – CMOs Care Select - Care Management Organizations ADVANTAGE Health Solutions MDwise Manage PMP Panels Demographics, Scope of Practice Provide Prior Authorization for Enrolled Members Manage Right Choices Program Enroll Primary Medical Providers Provide Education to Members About Healthcare

22 Indiana Health Coverage Programs Family Tree October Care Select Care Management Organizations (CMO) –Care Management Organizations (CMOs): MDwise ADVANTAGE Health Solutions –The CMOs process all prior authorizations for members assigned to their respective organizations –Right Choices Program, primary medical provider (PMP) enrollment, and panel maintenance is administered by the CMOs –Members 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

23 23 Footer Goes Here Hoosier Healthwise Risk-Based Managed Care

24 Indiana Health Coverage Programs Family Tree October Risk-Based Managed Care Hoosier Healthwise Risk-Based Managed Care MDwise Managed Health Services Anthem 10 Delivery Systems

25 Indiana Health Coverage Programs Family Tree October Risk-Based Managed Care –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 his or her benefit package Managed Care Medicaid population

26 Indiana Health Coverage Programs Family Tree October Risk-Based Managed Care Three managed care organizations (MCOs): –MDwise or –Managed Health Services or –Anthem or Managed care organizations

27 Indiana Health Coverage Programs Family Tree October Risk-Based Managed Care Hoosier Healthwise Risk-Based Managed Care Claims Processing Provider and Member Services Panel Management Prior Authorization for Enrolled Members Provider Contracting

28 Indiana Health Coverage Programs Family Tree October Risk-Based Managed Care MCO responsibilities include: –Act as processor and payer of claims for risk-based managed care (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

29 29 Footer Goes Here Healthy Indiana Plan

30 Indiana Health Coverage Programs Family Tree October Healthy Indiana Plan MDwise Anthem Blue Cross Blue Shield Indiana Comprehensive Health Insurance Association / Affiliated Computer Services (Enhanced Services Plan) MHS (effective January 1, 2011)

31 Indiana Health Coverage Programs Family Tree October Healthy Indiana Plan –Healthy Indiana Plan (HIP) Health insurance program for uninsured Hoosier adults between ages Services became available January 1, 2008 –Eligibility Requirements: Earn between 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

32 Indiana Health Coverage Programs Family Tree October Healthy Indiana Plan –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 (2010) –Applicants will have the choice of three plan insurers beginning Enhanced Services Plan (ESP)

33 33 Footer Goes Here Enrollment Broker

34 Indiana Health Coverage Programs Family Tree October Enrollment Broker MAXIMUS Administrative Services Unbiased Member Education Aids Member Selection of MCO, CMO, and PMP

35 Indiana Health Coverage Programs Family Tree October Enrollment Broker 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

36 36 Footer Goes Here IHCP Family Tree

37 Indiana Health Coverage Programs Family Tree October IHCP Family Tree Diagram FSSA Traditional Medicaid OMPP MAXIMUS MDwise (Care Select) ADVANTAGE (Care Select) HP Advantage Healthy Indiana Plan MDwise Anthem Blue Cross Blue Shield Enhanced Services Plan (ESP) Care Select Hoosier Healthwise Risk-Based Managed Care MHS Anthem MDwise Cenpatico Behavioral Health Magellan Health Services MDwise Managed Behavioral Health Organizations MHS (effective 1/1/2011) ACS

38 Find Help Resources Available

39 Indiana Health Coverage Programs Family Tree October Resources –IHCP Web site at –FSSA Web site at –IHCP Provider Manual (Web, CD-ROM, or paper) –Customer Assistance , or (317) in the Indianapolis local area –HP Provider Written Correspondence – P.O. Box 7263 Indianapolis, IN –Provider Relations field consultant

40 Q&A


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