11/1/2016. Molina Healthcare of Michigan. Prior Authorizations. Third Party Payer Day Julie Hurst. Director, Provider Contracting and Services

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Alan Summers
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Third Party Payer Day Julie Hurst 1 Director, Provider Contracting and Services November 11, 2016 Molina Healthcare of Michigan 2000 2006 Awarded Medicaid contract as licensed HMO and begin serving

products on Marketplace Exchange with focus on low income population.

1 Third Party Payer Day Julie Hurst 1 Director, Provider Contracting and Services November 11, 2016 Molina Healthcare of Michigan Awarded Medicaid contract as licensed HMO and begin serving 22,000 members in 34 counties Molina Healthcare of Michigan Awarded contract from Centers for Medicare & Medicaid Services to serve Medicare population 2014 Began offering individual coverage products on Marketplace Exchange with focus on low income population Awarded contract for MI Health Link program (Duals Demonstration program serving beneficiaries with Medicare and Medicaid) 2016 Awarded new Medicaid contract with expansion of service area to all 68 counties of the lower peninsula MHM Snapshot Membership: 399K Employees: 771 Statewide MHM Offices: 3 Provider Network PCP/Specialists: 30K Hospitals: 106 Ancillary 2Services: 7k Prior Authorizations 1

Prior Authorization/Pre-Service Review Guide is located at http://www.molinahealthcare.com/members/mi/en-us/pages/home.

authorization Located with the Prior Authorization Guide *Reminder: Referrals not needed to in-network providers.

2 Prior Authorization/Pre-Service Review Guide is located at CLICK - I m a Health Care Professional CLICK Forms Molina PA Code Matrix Provides list of code sets that require prior authorization Located with the Prior Authorization Guide *Reminder: Referrals not needed to in-network providers. PAs not required for procedures performed in the office setting 4 4 Select Line of Business here Click on Forms 5 5 For Medicaid and Marketplace 6 6 2

3 For Medicare Scroll until you get to Michigan 7 7 Inpatient Authorizations Notification within 24 hours or next business day of admission Provide clinical information supporting admission using evidence based medical necessity criteria It is important that documentation is submitted that supports the request Peer to peer is available We will review and provide a decision within 24 hours of receipt of the clinical information 8 8 Redeterminations 3

4 Redetermination Process WHAT IS A REDETERMINATION? Defined by the Michigan Department of Health and Human Services (MDHHS) Annual review an individual s eligibility for continued Medicaid coverage Thorough review of all eligibility factors HOW CAN YOU HELP YOUR PATIENTS? Remind patients to call MDHHS to ensure their income verification is complete Educate them on the redetermination process Identify assigned members in Redetermination on the Provider Portal Visit the Molina website for more information 10 Healthy Michigan Plan Healthy Michigan Plan Second waiver of Healthy Michigan Section 1115 Demonstration was approved in 2015 Beginning on April 1, 2018 Income requirement of 100% of the FPL and not medically frail Choice of coverage through Healthy Michigan Plan (HMP) or A Qualified Health Plan (QHP) offered on the Marketplace After April 1, 2018 beneficiaries must meet a healthy behavior requirement

5 Healthy Michigan Plan What does this mean to your office? Anyone currently on HMP with an income above 100% of the FPL that is not frail must meet a healthy behavior requirement Healthy behaviors are identified through the Health Risk Assessment (HRA) If the HRA is not complete the HMP Plan recipient will lose their Medicaid coverage and be required to obtain coverage through the Marketplace Exchange Your Provider Service Representative can provide you with a list of Molina HMP members assigned to your office that have not yet completed an HRA Identify impacted members on the Molina Provider Portal Healthy Michigan Plan Incentive Annually, Molina will reimburse the member s assigned Primary Care Physician (PCP) a $25 incentive for completing the Michigan Medicaid Healthy Michigan Plan (HMP) Health Risk Assessment (HRA) form. $25 Providers will receive $25 for each HRA completed and submitted for newly enrolled members and their annual reenrollment. Additional $25* *Paid quarterly Complete HRA within 150 days of enrollment in HMP Provider submits a clean claim reflecting member s PCP visit occurred within 150 days of HMP enrollment with Molina; and Provider submitted a completed HRA to Molina The Healthy Michigan Plan, Health Risk Assessment form can be found on our website at: Provider Information 5

6 Provider Information Provider directory regulatory bodies, including Medicare, Medicaid and NCQA, require health plans to communicate at least quarterly with providers and hospitals to ensure the accuracy of the provider directory information. Providers must review the following information Name, gender and specialty Hospital and Medical group affiliation Board Certification Products the provider participates in, e.g.; Medicaid, Medicare If accepting new patients (PCP only) Languages spoken (by provider and staff) Office location and phone number Office hours Provider website address Accessibility for people with disabilities Provider Information Please review your information in our online directory today. If you find updates that need to be made to online provider information, please complete and submit a Provider Change Form. Provider Change Forms can be found on our website. Data accuracy is essential for easy and correctness of member assignment and claims payment. Please provide a minimum of 60 days notice for all provider information changes Thank you! 6

MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES NOTICE OF PROPOSED POLICY

MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES NOTICE OF PROPOSED POLICY Public Act 280 of 1939, as amended, and consultation guidelines for Medicaid policy provide an opportunity to review proposed