October 2009 Presented by EDS Provider Field Consultants Indiana Health Coverage Programs Family Tree

IHCP FAMILY TREE 2/ October 2009 Agenda Session Objectives Indiana Health Coverage Programs IHCP Team Traditional Medicaid Care Select Hoosier Healthwise Healthy Indiana Plan Enrollment Broker Resources The “Tree” Questions

IHCP FAMILY TREE 3/ October 2009 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

Indiana Health Coverage Programs

IHCP FAMILY TREE 5/ October 2009 Indiana Health Coverage Programs Traditional Medicaid Hoosier Healthwise Healthy Indiana Plan Care Select

IHCP FAMILY TREE 6/ October 2009 IHCP Team

IHCP FAMILY TREE 7/ October 2009 IHCP Team Indiana Family and Social Services Administration (IFSSA): –Office of Medicaid Policy and Planning (OMPP) and Children’s Health Insurance Program (CHIP) Office –Contractors: EDS Affiliated Computer Services (ACS) –Care Select – Care Management Organizations: ADVANTAGE Health Solutions MDwise

IHCP FAMILY TREE 8/ October 2009 IHCP Team –Hoosier Healthwise - Managed Care Organizations: Anthem Managed Health Services (MHS) MDwise –Healthy Indiana Plan (HIP) –Anthem Blue Cross Blue Shield –MDwise –Enrollment Broker: MAXIMUS

IHCP FAMILY TREE 9/ October 2009 The OMPP and CHIP Office: Determine rules and regulations (IAC) Determine and approve reimbursement level Address cost containment issues Establish IHCP policies for better health outcomes Office of Medicaid Policy and Planning

Traditional Medicaid Fee-For-Service (FFS)

IHCP FAMILY TREE 11/ October 2009 IHCP Information Primary sources for information about the IHCP are found at: FSSA Web site at IHCP Web site at IHCP Provider Manual IHCP provider monthly newsletters IHCP provider bulletins IHCP provider banner pages Indiana Administrative Code at Note: The IHCP reference tools apply to fee- for-service/Traditional Medicaid, not the risk- based managed care delivery system

IHCP FAMILY TREE 12/ October 2009 Traditional Medicaid - EDS Claims Processing Customer Assistance Provider Education Web interChange Traditional Medicaid – EDS Provider Enrollment

IHCP FAMILY TREE 13/ October 2009 Traditional Medicaid – EDS Reimbursement methodology: Fee-For-Service (FFS) EDS responsibilities include: –Act as processor and payor 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

IHCP FAMILY TREE 14/ October 2009 Traditional Medicaid – EDS Traditional Medicaid includes the 590 Program The following are applicable to traditional Medicaid members: –Spend-down –Qualified Medicare beneficiary (QMB) –Home health / hospice –Long Term Care –Restricted Card Program Traditional Medicaid Population

IHCP FAMILY TREE 15/ October 2009 Traditional Medicaid Surveillance and Utilization Review Member Hotline (Fraud and Abuse) Audit Traditional Medicaid

IHCP FAMILY TREE 16/ October 2009 ADVANTAGE Health Solutions - FFS Prior Authorization Traditional Medicaid Members Member Level of Care Fax: Managed Care Disenrollment ADVANTAGE Health Solutions – FFS

IHCP FAMILY TREE 17/ October 2009 ADVANTAGE – 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

IHCP FAMILY TREE 18/ October 2009 Audit Responsibilities include: Surveillance and Utilization Review (SUR) –Prepayment Review (PPR) –Program Integrity (PI) Claims Analysis and Recovery Member Hotline Post-Payment Audits

Care Select

IHCP FAMILY TREE 20/ October 2009 Traditional Medicaid - EDS Care Select Claims Processing Customer Assistance Provider Education Web interChange Certification Code Creation Care Select – EDS

IHCP FAMILY TREE 21/ October 2009 Care Select Care Management Organizations (CMOs): –MDwise –ADVANTAGE Health Solutions Prior authorization, restricted card, primary medical provider (PMP) enrollment, and panel maintenance is administered by the CMOs Claims are processed by EDS Mixed reimbursement methodology –Fee for service, and –Administrative fee $15 per member per month

IHCP FAMILY TREE 22/ October 2009 Care Select – CMOs Care Select - Care Management Organizations ADVANTAGE Health Solutions MDwise Manage PMP Panels Demographics, Scope of Practice Provide Prior Authorization for Enrolled Members Manage Restricted Card Program Enroll Primary Medical Providers

IHCP FAMILY TREE 23/ October 2009 Care Select The CMOs will process all prior authorizations for members assigned to their respective organizations Members will 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

Hoosier Healthwise Risk- Based Managed Care

IHCP FAMILY TREE 25/ October 2009 Risk-Based Managed Care Hoosier Healthwise Risk-Based Managed Care MDwise Managed Health Services Anthem 10 Delivery Systems

IHCP FAMILY TREE 26/ October 2009 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 their benefit package Managed Care Medicaid Population Risk-Based Managed Care

IHCP FAMILY TREE 27/ October 2009 Three managed care organizations (MCOs): MDwise – or Managed Health Services – or Anthem – or Managed Care Organizations Risk-Based Managed Care

IHCP FAMILY TREE 28/ October 2009 Hoosier Healthwise Risk-Based Managed Care Claims Processing Provider and Member Services Panel Management Prior Authorization for Enrolled Members Provider Contracting Risk-Based Managed Care

IHCP FAMILY TREE 29/ October 2009 MCO responsibilities include: Act as processor and payor of claims for 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 Risk-Based Managed Care

Healthy Indiana Plan

IHCP FAMILY TREE 31/ October 2009 Healthy Indiana Plan MDwise Anthem Blue Cross Blue Shield Indiana Comprehensive Health Insurance Association / Affiliated Computer Services (Enhanced Service Plan) Healthy Indiana Plan

IHCP FAMILY TREE 32/ October 2009 Healthy Indiana Plan (HIP) –Health insurance program for uninsured Hoosier adults between ages –Services became available January 1, 2008 Eligibility Requirements: –Earn between 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 Healthy Indiana Plan

IHCP FAMILY TREE 33/ October 2009 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 Enhanced Services Plan (ESP) Healthy Indiana Plan

IHCP FAMILY TREE 34/ October 2009 Enrollment Broker

IHCP FAMILY TREE 35/ October 2009 Enrollment Broker MAXIMUS Administrative Services Unbiased Member Education Aids Member Selection of MCO, CMO, and PMP

IHCP FAMILY TREE 36/ October 2009 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 Enrollment Broker

IHCP FAMILY TREE 37/ October 2009 Resources IHCP Web site at FSSA Web site at IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance – , or –(317) in the Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant

IHCP FAMILY TREE 38/ October 2009 IHCP Family Tree Diagram FSSA Traditional Medicaid OMPP Hoosier Healthwise Risk-Based Managed Care MDwise MHS Anthem MAXIMUS MDwise (Care Select) ADVANTAGE (Care Select) EDS 590 Program Audit Healthy Indiana Plan MDwise Anthem Blue Cross Blue Shield Enhanced Services Plan (ESP) Care Select

IHCP FAMILY TREE 39/ October 2009 Questions

October 2009 EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2009 Hewlett-Packard Development Company, LP. Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W374 Indianapolis, IN EDS, an HP Company 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204