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Hoosier Healthwise Open EnrollmentHoosier Healthwise Open Enrollment

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Current Issue

• Hoosier Healthwise members may change MCOs every month.

• Approximately 57,120 Hoosier Healthwise members changed MCOs at least once between spring 2007 and May 2008.*

• Member movement between MCOs increases administrative costs and reduces continuity of care, thus limiting an MCO’s ability to provide proper support or potential member interventions.

*During January and February 2007, there was an atypical volume of member movement between MCOs because of the exit of three Hoosier Healthwise MCOs and the entry of one new MCO. Therefore, March, April, and May 2007 were considered for entry into this analysis. The patterns were calculated starting with the first MCO during those three months.

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Administrative CostsAdministrative Costs

• Member movement between MCOs increases administrative costs.

• Costs associated with member movement include mailing ID cards, handbooks, orienting new members, and so on.

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Reducing Gaps in Medicaid Eligibility

• Currently, many Hoosier Healthwise members have gaps in coverage with an MCO because of loss of eligibility.– From spring 2007 through May 2008, approximately 135,780

Hoosier Healthwise members had gaps in coverage, thus losing their linkages to an MCO.

• Such breaks in eligibility may be caused by members not meeting the eligibility redetermination requirements (that is, missing appointment, not submitting proper paperwork).

• With open enrollment, MCOs are better able to track members, potentially reducing gaps in coverage.

• Additionally, as a separate initiative, MCOs will be given member’s redetermination dates so they may remind the member and serve as an additional resource in the process.

• Reducing gaps in Medicaid eligibility will further enhance continuity of care.

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Open Enrollment ObjectiveOpen Enrollment Objective

• To enhance continuity of care, Hoosier Healthwise members will remain enrolled in their chosen MCO for a 12 month period so long as eligibility in Hoosier Healthwise is maintained

• This will enable Hoosier Healthwise MCOs to provide consistent medical management

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What is Open Enrollment?What is Open Enrollment?

• A 90-day period during which a member may change to another managed care organization (MCO).

• Members remain enrolled in their chosen MCOs for a one-year period.– The one-year period begins on the day a member is

enrolled, either by selection or by auto-assignment, with an MCO.

– For newborns, the one-year period begins on the date the RID is assigned.

• Members may choose another primary medical provider within their MCO at any time.

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What is Open Enrollment?What is Open Enrollment?

• Members have the opportunity to choose a new MCO on an annual basis during their open enrollment period.– Federal requirements allow members to change to another MCO

within the first 90 days of enrollment with an MCO.• Members may change MCOs during the 12-month period when they

have “just cause.”

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Just CauseJust Cause

• With open enrollment, members will maintain the right to change MCOs when there is just cause.– Lack of access to medically necessary services covered under

the MCO’s contract with the State.– The MCO does not, for moral or religious objections, cover the

service a member seeks.– The member needs related services performed at the same

time; not all related services are available within the MCO’s network; and the member’s primary medical provider or another provider determines that receiving the services separately would subject the member to unnecessary risk.

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Just CauseJust Cause (cont.)

• Additional just cause reasons include:– Lack of access to providers experienced in dealing with the

member’s healthcare needs.– Concerns over quality of care. Poor quality of care includes

failure to comply with established standards of medical care administration and significant language or cultural barriers.

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Just CauseJust Cause (cont.)

• The just cause process involves the following:– Member files a complaint or grievance concerning the MCO.

• Members must submit their complaints/grievances to their selected MCOs.

– MCO communicates with the member to address the complaint/grievance.

– If the matter remains unresolved, the member may contact the enrollment broker (MAXIMUS).

– The enrollment broker will make the determination of just cause.

– A determination of just cause is made approximately five days after receipt of documentation from the MCO.

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Member Eligibility

• Providers should continue to check a member’s eligibility prior to rendering services or performing prior authorization.

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Open Enrollment Time GraphOpen Enrollment Time Graph

Member determined

eligible

30 days

Member chooses

PMP and MCO or is

auto-assigned

90 days

Member maintains right to change MCOs

9 mos.

Eligible member remains

enrolled in MCO

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Benefits to ProvidersBenefits to Providers

• Reduce disruption of treatment plans.• Reduce administrative hassles caused by frequent

member movement (for example, confusion regarding claims submission and prior authorization).

• Behavioral health providers and primary care providers are better able to coordinate care.

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Improved Data & MonitoringImproved Data & Monitoring

• The State and MCOs can measure member health outcomes over a longer time.

• This improved data will enhance quality monitoring and improvement processes.

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Continuity of CareContinuity of Care

• Open enrollment provides opportunities for increased continuity of care.

• The medical home is strengthened as members remain aligned with providers for a longer time.

• Providers and MCOs have increased opportunities to collaborate to address member treatment and prevention needs.

• Physical and behavioral health integration opportunities are enhanced as both mental health providers and primary care physicians are better able to track member enrollment and coordinate care.

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Open Enrollment Scenarios

• Member’s primary medical provider (PMP) disenrolls from MCO ‘A’ and enrolls only with MCO ‘B.’– The panel members may follow the PMP to MCO ‘B.’

• PMP disenrolls from Hoosier Healthwise.– Member may select a new PMP in his or her current MCO.

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Changes for Providers

• To complete a full panel add, the member must be:– Within his or her fee-for-service window, or– Within his or her 90 day free change period

• If the PMP is within the member’s MCO, the full panel add can be processed at any time

DY574_261023_brNational Provider Indicator (NPI)

Phase III

• Effective October 1, 2009, EDS will no longer recognize the Legacy Provider Identifier (LPI) for healthcare providers— Claims reporting the LPI only will reject before

entering system

• Atypical providers will continue to use LPI, not the NPI

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Web-interChange and Phase III

• Web interChange screens will no longer display the LPI locator for healthcare providers

• Atypical providers will see the LPI locator only• Atypical providers rendering healthcare and non-

healthcare services will see both the NPI and LPI locators

• It is recommended that healthcare providers remove all LPIs from their claims— Claims reporting an LPI and an NPI will not be

denied— The LPI will be ignored when adjudicating claims

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Conclusion

Questions & Comments