Medicaid Today Medicaid 101 and Utilizing Online Resources Indiana Health Coverage Programs DXC Technology October 2017
Session Objective Definitions The Indiana Health Coverage Programs (IHCP) Overview of indianamedicaid.com Helpful Tools Q&A 2
3 Definitions
Definitions Aid Category The category under which a person qualifies for the Indiana Health Coverage Programs. The aid category is determined by the Division of Family Resources (DFR) using specified criteria. Benefit Package The package of services that are covered for an IHCP member. The package is determined by various factors including the aid category. Fee-for-Service (FFS) A delivery system that reimburses providers on a per-service basis, using a standard fee schedule. indianamedicaid.com IHCP website dedicated to providing information for both members and providers. It includes provider reference modules and manuals, Bulletins and Banner pages, forms, and other valuable resources. 4
Definitions Presumptive Eligibility (PE) Process whereby Qualified Providers (QPs) can make temporary eligibility determinations for individuals which provides coverage while their full Indiana Application for Health Coverage is being reviewed by the DFR. Right Choices Program (RCP) The RCP identifies Indiana Health Coverage Programs (IHCP) members who use services more extensively than their peers. Members identified with high utilization are assigned (or locked in) to one primary medical provider (PMP), one hospital (for non emergent visits), and one pharmacy. Note: The PMP can determine a need for a specialist to be added to the members profile through communication with the appropriate RCP administration. Risk-Based Managed Care (RBMC) A managed care delivery system model in which contracted managed care entities (MCEs) are paid a capitated monthly premium for each Indiana Health Coverage Programs (IHCP) member enrolled with the MCEs. The MCE assumes financial risk for services rendered to its members. 5
Definitions Traditional Medicaid Program Provides coverage for healthcare services rendered to members in various eligibility groups including persons in long-term care facilities, receiving waiver or hospice services, wards of the state, foster children and others. Provider Healthcare Portal A free interactive web application that allows IHCP providers to access member eligibility information, check claim status, submit claims electronically, submit prior authorization (PA) requests, review/download weekly Remittance Advance (RA) statements and more. Revalidation Federal regulations require all providers participating in the IHCP to revalidate their enrollment at least every five years. Durable medical equipment (DME) providers and pharmacy providers with DME or home medical equipment (HME) specialties revalidate every three years. Revalidation of an enrollment requires submission of a new IHCP provider packet or use of the Revalidation option in the Portal. Recertification Certain provider types are required to recertify by updating expiring license, insurance information, and certifications (as applicable) with the IHCP. Providers that are required to recertify must submit the appropriate updates via the Provider Maintenance page of the Portal or using the IHCP Provider Enrollment Recertification of Licenses and Certifications Form. 6
Definitions Pharmacy Benefit Manager (PBM) OptumRx provides fee-for-service pharmacy claim processing, prior authorizations, and member and provider services, as well as drug rebate services, pharmacy rate setting and pharmacy related claim audit functions. Managed care entities are responsible for providing PBM services for members enrolled in their health plans. Dental Benefits Manager (DBM) Dental claims provided to members enrolled in a managed care program, such as the Healthy Indiana Plan (HIP), Hoosier Care Connect, or Hoosier Healthwise, are submitted to and processed by the managed care entity (MCE) dental benefits manager in which the member is enrolled. Each DBM may establish and communicate its own criteria for claim submission and processing, prior authorization requests, eligibility and customer service inquiries. Anthem (HIP, Hoosier Care Connect & Hoosier Healthwise) DentaQuest CareSource (HIP, Hoosier Care Connect & Hoosier Healthwise) CareSource MDwise (HIP & Hoosier Healthwise) DentaQuest MHS (HIP, Hoosier Care Connect & Hoosier Healthwise) Envolve 7
Definitions Managed Care Entity The State has mandated a managed care delivery system for members enrolled in the Healthy Indiana Plan (HIP), Hoosier Care Connect, or Hoosier Healthwise. Under the managed care system, members are enrolled with a managed care entity (MCE), which is responsible for the members healthcare services. Each MCE maintains its own provider network, provider services unit, and member services unit. 8
The Indiana Health Coverage Programs (IHCP) 9
The Indiana Health Coverage Programs (IHCP) The IHCP is the umbrella of health plans administered by the Indiana Family and Social Services Administration (FSSA): Jointly funded by the federal and state government Provides health coverage for Hoosiers who meet specific financial and nonfinancial requirements Payer of last resort The FSSA has categorized benefits into programs/plans such as: Traditional Medicaid Hoosier Healthwise Hoosier Care Connect Healthy Indiana Plan (HIP) Waiver Programs Family Planning Medicaid Rehabilitation Option (MRO) Hoosier Rx 10
Stakeholders FSSA OMPP DXC Technology CMCS Risk-Based Managed Care Myers & Stauffer OptumRx HIP HHW HCC Anthem j j j MHS j j j Caresource j j MDwise j j *Not all IHCP programs/contractors are listed 11
IHCP Delivery Systems Fee-for-Service (FFS) vs. Managed Care FFS Members are not required to have a primary medical provider (PMP) Members must seek care from an enrolled IHCP provider of their choice Providers are reimbursed on a per service basis, using a standard fee schedule Providers must submit all FFS claims, except pharmacy, directly to DXC for payment consideration Managed Care Members must have a primary medical provider (PMP) Members are required to seek most care from only providers within their MCE network, Providers are reimbursed by the member s MCE Providers submit all claims directly to the member s MCE Some specialty services are billed through a subcontractor 12
DXC Technology Provider Enrollment Customer Service and Provider Relations Manage the processing of FFS claims Process a variety of financial transactions, including claim payments, voids, refunds, and accounts receivables Provider education through conferences, workshops, webinars and one-on-one assistance via on-site visits Communication with the provider community via Provider Bulletins, weekly Provider Banner Pages, website updates, news alerts, and provider Reference materials News alerts Provider Association liason 13
Cooperative Managed Care Services (CMCS) FFS Prior Authorization Administrator Processes prior authorization (PA) requests for FFS (non-pharmacy) claims, which includes: PA requests may be approved, denied, modified or suspended Process PA system updates Reviews FFS claims that suspend for medical review Administers Right Choices Program (RCP) for Traditional Medicaid members 14
Anthem, CareSource, Mdwise, and MHS Managed Care Entities for HIP, Hoosier Care Connect & Hoosier Healthwise) Four managed care entities (MCEs) Anthem, CareSource, MDwise, and MHS administer Healthy Indiana Plan (HIP) and Hoosier Healthwise; two MCEs, Anthem and MHS, administer Hoosier Care Connect Require most member services to be furnished only by innetwork/contracted providers MCE providers must be enrolled with the IHCP before enrolling with an MCE Provide member services, provider services, care coordination, and care management Process claims and provide reimbursement directly to the provider for covered services rendered to its members RCP Administrator for members enrolled with the MCE Process PA for benefits covered by the MCE 15
Myers and Stauffer (M&S) Responsible for: Establishing rates for IHCP services, including capital costs for inpatient claims Auditing IHCP claims processing activities Calculating supplemental payments for FFS providers 16
Optum RX Pharmacy Benefit Manager (PBM) for FFS programs Processes pharmacy claims Responsible for the Drug Rebate Services Processes pharmacy-related prior authorization requests 17
Overview of indianamedicaid.com 18
Overview of indianamedicaid.com Welcome to the IHCP website http://www.indianamedicaid.com/ 19
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Overview of indianamedicaid.com 1. Fulton, Jasper, Lake, LaPorte, Marshall, Newton, Porter, Pulaski, Starke and St. Joseph 2. Adams, Allen, Blackford, Dekalb, Elkhart, Huntington, Jay, Kosciusko, LaGrange, Noble, Steuben, Wabash, Wells and Whitley 3. Benton, Boone, Carroll, Cass, Clinton, Delaware, Fountain, Grant, Hamilton, Howard, Madison, Miami, Montgomery, Tippecanoe, Tipton, Warren and White 4. Bartholomew, Dearborn, Decatur, Fayette, Franklin, Hancock, Henry, Jackson, Jefferson, Jennings, Ohio, Randolph, Ripley, Rush, Scott, Shelby, Switzerland, Union, Washington, Wayne 5. Marion 6. Brown, Clay, Daviess, Greene, Hendricks, Johnson, Knox, Lawrence, Martin, Monroe, Morgan, Owen, Parke, Putnam, Sullivan, Vermillion, Vigo 7. Clark, Crawford, Dubois, Floyd, Gibson, Harrison, Orange, Perry, Pike, Posey, Spencer, Vanderburgh, Warrick 24
Overview of indianamedicaid.com Territory Number Consultant Name Telephone Number 1 Jean Downs (317) 488-5071 2 Shari Galbreath (317) 488-5080 3 Janet Shields-Cruz (317) 488-5363 4 Tami Foster (317) 488-5309 5 Crystal Woodson (317) 488-5324 6 Virginia Hudson (317) 488-5186 7 Ken Guth (317) 488-5153 25
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Helpful Tools IHCP website at indianamedicaid.com IHCP Provider Reference Modules Medical Policy Manual Customer Assistance available 8am-6pm EST Monday Friday 1-800-457-4584 IHCP Provider Relations Field Consultants See the Provider Relations Field Consultants page at indianamedicaid.com Secure Correspondence via the Provider Healthcare Portal Written Correspondence DXC Technology Provider Written Correspondence P.O. Box 7263 Indianapolis, In 46207-7263 35
36 Questions Following this session please review your schedule for the next session you are registered to attend