P0601(10/10) 1 Hoosier Healthwise and Healthy Indiana Plan ……… Now and Then A 2011 guide to help you understand Managed Care Medicaid

P0601(10/10) 1

Hoosier Healthwise and Healthy Indiana Plan ……… Now and Then

A 2011 guide to help you understand Managed Care

Medicaid

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General Overview

Office of Medicaid Policy and Planning released a Request for Proposals (RFP) in February 2010

Proposals were submitted in May 2010 by interested health plans

Invitations were made in June MDwise, Anthem and Managed Health Services

(MHS) were selected Currently in Readiness Review which is a

comprehensive review of all operational areas

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Highlight of New Contract

Combine Hoosier Healthwise and HIP- family friendly

Debit card for medical services (HIP) only Offer comprehensive package of disease

management programs Managed Care Entity (MCE) to complete

standardized Health Risk Screening (70% within 90 days)

MCE’s to do all PMP changes and auto assignments of new members to PMP

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Topic 2010… Currently January 2011

Claims Payment: Hoosier Healthwise (HHW) and Health Indiana Plan (HIP)

Anthem processing guidelines are:

HHW submit claims with YRH prefix and RID number

HIP submit claims with YRK prefix and unique ID number

www.anthem.com for complete processing guidelines

MDwise claims processing guidelines are:

Adjudicated by MDwise (HIP) and its delivery systems for Hoosier Healthwise: See quick contact sheet

HIP and HHW - submit claims with RID number.

Managed Health Services claims processing guidelines are:

MHS follows IHCP claims processing guidelines.

Claims Processing –Managed Health ServicesP.O. Box 3002Farmington, MO 63640-3802Claims Appeals – Managed Health Services P.O. Box 3000Farmington, MO 63640-3800

Each MCE will be responsible for claims payment;

Anthem HHW and HIP– same as it was for previous contractual period

MDwise HHW and HIP- same as it was for previous contractual period

Managed Health Services- no changes to HHW processing. HIP claims will be processed same as HHW. Member RID# to be used. Same PO box as HHW claims.

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Claims Filing Limit

Contractually set by each Managed Care Organization (MCE).

Claims filing for all Managed Care Entities (MCEs) including behavioral health will be 90 days.

Claims Reimbursement for HIP

Medicare rates or 130% of Medicaid IHCP fee schedule.

No changes for 2011.

Watch for upcoming HIP Reimbursement Manual published by OMPP.

Claims Edits Contractually set by each MCE.

Each MCE will institute the National Correct Coding Initiative (NCCI) edits for claims adjudication. This began October 1, 2010. Anthem HIP no changes necessary.

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Appeals and Grievances

Effective July, 1, 2010, denied services from Medical Management such as reduction of services – Prior Authorization.

Providers will submit an appeal for the denied services (not grievance).

Providers will be able to submit an appeal within 30 calendar days from the denial.

There are no changes in how providers submit medical claims denials. Providers will submit a dispute.

Members will file a grievance (formerly known as a complaint) and will have 30 calendar days to file.

Effective July, 1, 2010, denied services from Medical Management such as reduction of services – Prior Authorization.

Providers can submit an appeal on behalf of the member (not grievance).

Providers will be able to submit an appeal within 30 calendar days from the denial.

There are no changes in how providers submit medical claims denials. Providers will submit a dispute.

Members will file a grievance (formerly known as a complaint) and will have 30 calendar days to file.

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Online Claims Enhancements

Current online claims functions:Anthem – www.anthem.com Claims and billing information/guidelinesPrior authorization requirements & formsForms LibraryHealth EducationClaim StatusMDwise – www.mdwise.org Billing guidelinesPrior authorization forms & requirementsMember eligibility – HIP Quick contact sheet- delivery systemsManaged Health Services- www.managedhealthservices.com File claims directly (no charge)Verify member eligibility and TPL informationCheck claim statusView payment historyDownload and print EOB’sClaim auditing tool

Future online claims functions:Anthem- www.anthem.com Claims and billing information /guidelinesPrior authorization requirements & formsForms LibraryHealth EducationAvaility MDwise- www.mdwise.org Billing guidelinesPrior authorization form & requirementsMember eligibility – HIP & HHW Quick contact sheet- delivery systemsClaims and prior authorization reviewSpecial ProgramsMember and Provider incentivesManaged Health Services – www.managedhealthservices.com Care Gap AlertsCost Estimator AssistantPOWER/HIP informationElectronic attachments (EDI)Member Portal

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Prior Authorization

Each MCE develops and manages its own medical/behavioral prior authorization processes.

Anthem PA requirements forms: Can be found on our website www.anthem.com

MDwise PA requirements:MDwise is a delivery system model and the delivery system forms can be found under the provider tab for forms at www.mdwise.org

MHS PA requirements: PA requirements are listed on the MHS Quick Reference Guide. PA forms are located on www.managedhealthservices.com on the provider tab under the resources section.

OMPP has mandated a universal PA form for each of the MCE’s. This form will be used for requesting PA for services for all programs for all MCE’s.

Click here for new PA form

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Online PA Enhancements

Current online PA functions:

Anthem- PA forms and its requirements can be found on our website at www.Anthem.com. Online submission is unavailable at this time

MDwise-PA forms and its requirements can be found on our website at www.mdwise.org. Online submission not available at this time.

Managed Health Services – PA’s can be initiated online. Clinical must be either faxed or called into a Nurse for review.

Future online PA functions:

Anthem- PA forms and its requirements can be found on our website at www.Anthem.com. Online submission is unavailable at this time

MDwise- PA forms and its requirements can be found on our website at www.mdwise.org. Online submission may be available by delivery system.

Managed Health Services- Online PA requests available. Process enhancement to include attachments will be provided in 2011.Online QRG available on line as tool/guide.www.managedhealthservices.com

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Provider Enrollment

All providers must have an active IHCP provider number on file to participate with an MCE.

Anthem- Contract includes the base agreement, amendments for the specific product line and a provider maintenance form (PMF) plus credentialing as applicable.

MDwise- Along with the provider contract for the delivery system the provider is contracting, a MDwise specific supplemental cover sheet is required.

Managed Health Services – Along with the contract MHS requires a supplemental form, a contract attestation (if adding additional providers), and a completed W-9. Providers who do not wish to be contracted should complete a Non-Par form.

Each MCE will recontract with providers for a new contractual period beginning January 1, 2011. OMPP has mandated a universal enrollment form for each of the MCEs. This form will be used for contracting all lines of business (Hoosier Healthwise, HIP, and Care Select).

Embed form here to click.

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Contracting

All MCE provider contracts for HHW and HIP will terminate effective 12/31/10.

Each MCE will be responsible for re-contracting its own providers.

Anthem- Contracting conducted by Anthem’s commercial contracting team.

MDwise- Contracting will be conducted by MDwise and its delivery systems.

Manged Health Services- Contracting will be conducted by MHS.

Providers will be notified about re-contracting by each MCE by the following:

Anthem- Anthem contracting will begin 4th quarter 2010.

MDwise- MDwise contracting will start in the summer of 2010. MDwise delivery system provider relation staff will reach out to current and new providers.

Managed Health Services – MHS contracting will start in the summer of 2010. Providers will receive their new contract documents via the mail or from their Providers Relations Specialist.

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EligibilityHoosier Healthwise

Currently members can select a provider or plan.

Hoosier Healthwise – If a member does not select a provider within 30 days, one will be assigned for them and after 90 days the member will be locked into the MCE for the remainder of their enrollment period. (lock – in)Auto-assignment is currently done by Maximus.

Hoosier Healthwise – The member will select the plan MCE (Anthem, MDwise or Managed Health Services).

HHW Auto Assignment LogicMembers will be assigned:-Assign to MCE after 14 days (9 days from potential table)- Assigned within MCE to PMP within 30 days-Members assigned to previous MCE with 12 month look-back-Family member’s MCE-Hoosier Healthwise; Rotating Assignment

Exceptions to Application Choice- Open Enrollment ( <2 months)- Right Choices Program members- If a member calls the enrollment broker to request a change, that will trump application selection •If a PMP disenrolls from a MCE and goes to another MCE, member WILL NOT follow PMP Plan changes: 90 days HHW with Open Enrollment

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EligibilityHIP

HIP – The member currently selects the plan. The plan then assigns the provider. MDwise currently assigns the provider. Anthem does not currently assign a provider.

*Please note that pregnancy services are not covered for HIP members.

HIP – The member will select the MCE (Anthem, MDwise, or Managed Health Services).

HIP Auto Assignment Logic-Neediest Plan-60 days HIP plan choice, prior to 1st payment

Exceptions to Application Choice- Open Enrollment ( <2 months)- Right Choices Program members- If a member calls the enrollment broker to request a change, that will trump application selection If a PMP disenrolls from a MCE and goes to another MCE, member WILL NOT follow PMP Plan changes:


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Online Eligibility Enhancements

Current online Eligibility functions:

Anthem HIP: Eligibility can be verified via myanthem at www.anthem.com. PMPs can download members assigned to them in excel format

MDwise- Eligibility can be verified for HIP member thru provider web portal.

Managed Health Services – TPL and Eligibility information can be verified. PMPs can download eligibility lists in excel format.

Future online Eligibility functions:

Anthem HIP: Eligibility can be verified via myanthem at www.anthem.com. PMPs can download members assigned to them in excel format.

MDwise-Eligibility can be verified for HIP and HHW members thru provider web portal.

Managed Health Services -MHS Same as current - Verification, PMP assignment/eligibility listings available. Will provide online PMP selection and changes online in 2011.

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Right Choices Program (RCP)

Program is in place to safeguard against unnecessary and inappropriate use of services.Members are locked in to one PMP, one pharmacy, and one hospital.PMPs are the gatekeepers for the member’s services.Members must be referred to specialists by the PMP.A member can be in the program for up to 5 years.

There are no changes to the RCP program for the contract year 2011.

Power Account for HIP

The Power Accounts are currently managed by MDwise and Anthem.Members receive monthly statements that summarize provider and pharmacy services.

In the new contract year, each MCE (Anthem, MDwise, and Managed Health Services) will manage the member’s power account. Each member will receive monthly statements that summarize provider and pharmacy services. Providers will also be able to conduct point of service transactions for power accounts.

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BehavioralHealth

Anthem- Magellan manages HHW Behavioral Health and Anthem Behavioral Health manages HIP

MDwise- Contracting delegated to InteCare (BH). Behavioral Health Managed by MDwiseProviders must be credentialedProvider must have active IHCP number

Managed Health Services - Contracting and maintenance of the network is delegated to Cenpatico. Cenpatico manages the behavioral health network. All providers must be contracted with Cenpatico separately and go through Cenpatico’s credentialing process.

Anthem- Behavioral Health integrated with medical and managed by Anthem Behavioral Health. Contracting will begin 3rd Quarter 2010

MDwise- Contracting delegated to InteCare (BH)Behavioral Health, managed by MDwiseProvider will sign new addendum.Addendum will be sent out by email or mail.Providers will have 30 days to return form.No re-credentialing.Online enhancements to come.

Managed Health Services- Contracting and maintenance of the network is delegated to Cenpatico. Cenpatico manages the behavioral health network. All providers must be contracted with Cenpatico separately and go through Cenpatico’s credentialing process. Current contracted providers will receive a contract amendment and have any appropriate required documentation returned to Cenpatico within 45 days of receipt. Re-credentialing will not be required for existing providers.

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Pharmacy Currently managed by HP.Preferred Drug List (PDL) has the approved drugs, please refer to the below link:http://provider.indianamedicaid.com/provider-specific-information/pharmacy.aspx

* ALL lines of business

Please refer to the PDL at the below link for the most up to date approved list of drugs and changes to the formulary:

http://provider.indianamedicaid.com/provider-specific-information/pharmacy.aspx

•ALL lines of business

•HIP Tier 2 and Tier 3•The MCE HIP plans to administer PBM

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Quality

Currently OMPP has targeted performance measures for Hoosier Healthwise.

AnthemAnthem has a Quality Assessment Improvement Program which promotes best clinical practices with focus on preventative health guidelines. Anthem promotes a medical home model which highlights the goal of member focused preventative care. Methods include webinars, general and targeted education to providers and members which focus on adult/child preventative services, including High Risk OB and Childhood Obesity Initiatives.

The targeted performance measures will be changing for 2011 and each MCE will work with the provider networks to provide education and tools around the new measures and focus.

A program and targeted measures are in place for HIP.

Each MCE will discuss upcoming performance initiatives.

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Topic 2010… Currently January 2011 QualityCont.


MDwiseMDwise has a dedicated Network Improvement Program (NIP) Team and programs in place focused on Quality and the performance measures. The Well – child campaign, medical chart review, billing education, and incentive programs were a large focus for this year. (LJ will discuss tools and resources here)Currently there are no targeted performance measures for HIP..



Each MCE will discuss upcoming performance initiatives

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QualityCont.


MHS MHS provides PMPs with a quarterly listing of performance metrics, complete with a listing of members in need of services. Annual HEDIS chart audits take place during the first and second quarters. MHS also conducts semi-annual provider workshops to provide billing education. Billing updates are also communicated via the Provider Watch and web updates.

HIP-Currently there are no targeted performance measures for HIP



Each MCE will discuss upcoming performance initiatives.


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Disease Management

HRS completion within 90 days of new enrollmentAnnual Assestmetments

Member Stratification

Currently each MCE has targeted disease management programs in place for the member population for HHW and HIP.

AnthemPrograms can be found on our website www.anthem.com , which consist of: Asthma, Diabetes, Cardiovascular, Smoking Cessation, Childbirth, Preventive Care for Women & Children, & Kids Learn Healthy Habits

In the new contract year, each MCE will be responsible for implementing 10 targeted disease management programs.

AnthemPrograms can be found on the website www.Anthem.com which consists of: Condition Care of Asthma, DM, COPD, CAD, CHF. Behavioral Health will be integrated with Physical Health Care Management, programs consisting of CoDa, Maternal Depression, Bipolar Disorder, Autism, and ADHD.

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Disease ManagementCont.

HRS completion within 90 days of new enrollmentAnnual Assestmetments



MDwiseProgram information can be found on the website at www.mdwise.org which consists of asthma, diabetes, and high risk pregnancy.


MDwise- MDwise will expand our program requirements by implementing seven additional disease management programs per the above requirements.Health Risk Screening (HRS)

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Disease ManagementCont.

HRS completion within 90 days of new enrollmentAnnual Assessments



Managed Health Services Asthma, COPD, Diabetes, Pregnancy, and Lead.


Managed Health ServicesAsthma, COPD, Congestive Heart Failure, Chronic Kidney Disease, Bi-polar disease, Perinatal depression, ADHD,Autism/pervasive developmental disorder,Lead, Coronary Artery Disease, Depression, and Diabetes.

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Member updates and changes HHW: Members must be in their “ free change”

or Open Enrollment period for plan selection to be honored Members who lose eligibility <2 months will remain

locked-in Members who complete an application within 90 days

of annual enrollment period will start “ free change” period

HIP: Members may select different plan at redetermination Members may select a Managed Care Entity on their

application or through Maximus (enrollment broker)

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Current HIP and HHW Membership HHW

Members Primary Care Physician (PMP) Health Plan will not change unless: PMP contracts with a different Managed Care Entity- member follow PMP prior to

1/1/11 PMP contracts with more than one MCE-member stays with current MCE PMP leaves Hoosier Healthwise- member stays In MCE and is assigned to a

new PMP Member may follow PMP to another MCE if member is outside of his/her free

change period by filing a “just cause” request HIP

All members will receive a letter that indicates they will have an opportunity to change plans for a 1/1/2011 effective date If no changes is received, a HIP member will stay with their current plan

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Redetermination for HHW and HIP

For Hoosier Healthwise and Healthy Indiana Plan:MCE’s will outreach to members to remind

them to renew eligibilityManaged Care Entities will assist members in

gathering required documentation With HIP, failure to complete determination

results in loss of coverage for 12 months

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Thanks from your MCO… MCE’s

Questions?

Documents

P0601(10/10) 1 Hoosier Healthwise and Healthy Indiana Plan ……… Now and Then A 2011 guide to help you understand Managed Care Medicaid