Indiana Health Coverage Programs Family Tree

1. Indiana HealthCoverage ProgramsFamily Tree HP Provider Relations October 2010

2. 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. 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 Indiana Health Coverage Programs Traditional Medicaid Hoosier Healthwise Healthy Indiana Plan Care Select

6. IHCP Team

7. 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. 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. 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. IHCP Information Primary sources for information about the IHCP are found at: • FSSA Web site at www.in.gov/fssa • IHCP Web site at www.indianamedicaid.com • IHCP Provider Manual • IHCP provider monthly newsletters • IHCP provider bulletins • IHCP provider banner pages • Indiana Administrative Code at www.in.gov/legislative/iac/title405.html Note: The IHCP reference tools apply to fee-for-service/Traditional Medicaid, not the risk-based managed care delivery system

11. Traditional Medicaid Fee-for-Service

12. Traditional Medicaid – Fee-for-Service Traditional Medicaid- HP Claims Processing Customer Assistance Provider Education Web interChange Provider Enrollment

13. 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. 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. ADVANTAGE Health Solutions – FFS ADVANTAGE Health Solutions - FFS Prior Authorization Traditional Medicaid Members Restricted Card Program Member Level of Care Medical Policy Audit Fax: 1-800-689-2759

16. 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. 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. Care Select

19. Care Select – HP Traditional Medicaid - HP Care Select Claims Processing Administration Fee CertificationCode Creation Customer Assistance Provider Education Web interChange

20. Care Select – HP • Claims are processed by HP • Mixed reimbursement methodology • Fee for service, and • Administrative fee • per member per month

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

22. 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. Hoosier HealthwiseRisk-Based Managed Care

24. Risk-Based Managed Care Hoosier Healthwise Risk-Based Managed Care MDwise www.mdwise.org 10 Delivery Systems Managed Health Services www.managedhealthservices.com Anthem www.anthem.com

25. 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. Risk-Based Managed Care Three managed care organizations (MCOs): • MDwise • 1-800-356-1204 or www.mdwise.org • Managed Health Services • 1-877-647-4848 or www.managedhealthservices.com • Anthem • 1-866-408-6132 or www.anthem.com Managed care organizations

27. Risk-Based Managed Care Hoosier Healthwise Risk-BasedManaged Care Claims Processing Provider and Member Services Panel Management Prior Authorization for Enrolled Members Provider Contracting

28. 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. Healthy Indiana Plan

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

31. Healthy Indiana Plan • Healthy Indiana Plan (HIP) • Health insurance program for uninsured Hoosier adults between ages 19-64 • Services became available January 1, 2008 • Eligibility Requirements: • Earn between 22-200 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. 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 1-1-11 Enhanced Services Plan (ESP)

33. Enrollment Broker

34. Enrollment Broker MAXIMUS Administrative Services 866-963-7383 Unbiased Member Education Aids Member Selection of MCO, CMO, and PMP

35. 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. IHCP Family Tree

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

38. Find Help Resources Available

39. Resources IHCP Web site at www.indianamedicaid.com FSSA Web site at www.in.gov/fssa IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance • 1-800-577-1278, or • (317) 655-3240 in the Indianapolis local area HP Provider Written Correspondence • P.O. Box 7263Indianapolis, IN 46207-7263 Provider Relations field consultant

40. Q&A