HIP HIP HOORAY! Healthy Indiana Plan Presented by MDwise October 19, 2010 HIPP0060 (09/10)

2 2 Purpose of today’s discussion  HIP plan overview  Covered services  Preventive Services  Prior Authorization  HIP Tier 2 and 3 comparison  HIP update 2011  Tools and Resources

3 HIP January 2008 The Healthy Indiana Plan was fully implemented 20,000 applications received during the first month 10,000 Hoosiers enrolled by May 2008 Today- 46,000 Hoosiers enrolled in the plan

4 4 Enrollment Funding HIP is funded for approximately 130,000 Hoosiers per year Enrollment cap of 34,000 childless adults per year This category has met it’s maximum capacity

5 5 HIP Plan overview  Coverage is focused on preventive services  Power Account Medical expenses are paid out of the Power Account first until the $1,100 has been exhausted. After POWER account dollars are exhausted, it mirrors a commercial plan coverage.  Limit of $300,000 annually and $1,000,000 lifetime.  Emergency services require a co-pay (refund to member if admitted to the hospital).  Coverage term is limited to 12 months ( member must stay current with contribution payments).  After the one-year term, members must be recertified to continue in the plan for another 12 months.

6 HIP Tier 2 and Tier 3 Healthy Indiana Plan MDwise Tier 1 MDwise Tier 2 Tier 3 -MDwise Indiana Check UP Comparison Tier 1 No member deductible Power Account contribution Preventive Services 100% covered ER co-pay required based on income Pregnancy – not covered 50% employer contribution RX Tier 2 Deductible $1,100 member out of pocket expense $25.00 Emergency Care co-payment Preventive Services 100% covered Pregnancy –not covered Member’s RID will begin with H2 50% employer contribution RX benefits Plans PBM Tier #3 $1,200 member out of pocket expense $0 Emergency Care co-payment Preventive Services 100% covered Pregnancy- not covered Member’s RID or ID number will begin withH3 50% employer contribution RX benefits Plans PBM

7 7 HIP Covered Services  Comprehensive disease management  Home health services, including case management  Urgent care center services  Preventive care services  Family planning services  Hospice services  Substance abuse services  Durable medical equipment  Lead screening services for nineteen (19) and twenty (20) year olds  Hearing aids for nineteen (19) and twenty (20) year olds

8 8 HIP Covered Services  Mental health care services  Inpatient hospital services  Skilled nursing facility services, subject to a 60-day maximum  Emergency room services, including non-emergent services provided in an emergency setting  Physician office services  Diagnostic services, including pregnancy testing  Outpatient services, including covered therapy services  * Note PE- Presumptive eligibility and NOP do not apply to HIP

9 9 Preventive care MDwise will be encouraging members and requests that providers encourage members to receive appropriate age and gender preventive services, including: Annual physical Colonoscopy Flu shot Pap smear Cholesterol testing Mammogram Chlamydia screening Blood glucose screening Tetanus-diphtheria booster Lead testing, year-old Hearing Screening Unlimited preventive services Not subject to POWER Account

10 Enhanced Service Plan ESP  HIP applicants are asked certain medical questions.  These questions include, cancer, organ transplants, HIV, AIDS, aplastic anemia, frequent blood transfusion, hemophilia, or other rare bloodstream diseases.  If answered yes, the approved applicant will be enrolled in the ESP which will allow for them to receive specialty services.  MDwise may refer to ESP during the first six months of active enrollment or at the end of a HIP member’s eligibility period.  ACS will process claims for ESP services.

11 HIP and Pregnant Women Pregnant women are not eligible for HIP services Pregnancy related services are non-covered Physicians are encouraged to assist members to submit a statement of pregnancy to the Division of Family Resources (DFR) The member’s HIP plan can also assist in the members reassignment HIP members who become pregnant are encouraged to contact the DFR to request re-assignment to Hoosier Healthwise (members are not automatically termed from HIP) There will be no break in coverage Pregnant women may re-enroll in HIP following the pregnancy ****See attachment in folder

12 Reimbursement  MDwise will reimburse the provider of service at the current Medicare rates, or 130% of Medicaid rates, if the service does not have a Medicare reimbursement rate.  180 days claims filing (90 days in 2011) NOTE-Providers must be enrolled in the Indiana Health Coverage Program (IHCP) to participate in HIP, and be contracted with MDwise HIP. MDwise plan participation will be based on delivery system acceptance. (See quick contact sheet for participating Delivery Systems and contact information). In order to see ESP members providers must be enrolled in IHCP.

13 Eligibility It is the responsibility of ALL providers to check eligibility at the time of each visit. Providers can check assigned delivery system through the MDwise web portal or through Web Interchange. (members received an updated card due to Pharmacy carve out)

14 Claims Submission For MDwise HIP Medical Claims MDwise ( HIP) P.O. Box Indianapolis, IN Electronic filing: Payor MDWIS Behavioral Health Claims MDwise (HIP) P.O. Box Indianapolis, IN Electronic filing: Payor MDWIS

15 Claims Dispute Claims dispute In and out of network- Call MDwise to inquire about claim. MDwise must respond within 30 calendar days of inquiry. Claims dispute form is available on line. Appeals – Must be in writing Provider has 60 calendar days From receiving remittance advice denial or After MDwise claims payor system fails to make determination or In-network appeals should be forward to MDwise for resolution Out-of-network appeals should be forward to MDwise Corporate at Attn: MDwise Grievance Coordinator/HIP 1200 Madison Ave. Suite 400 Indianapolis, IN *specialty network is open. Call delivery system medical management department for services that require prior auth.

16 Prior Authorization  HIP providers call the member’s Delivery System for prior authorization ( see quick contact sheet)  View PA requirements via Healthy Indiana Plan/Providers/Provider Toolswww.MDwise.org *Until further communication, MDwise will operate as an open network for Specialist Services Only. This excludes facilities. Please contact the appropriate HIP delivery system medical management department (see quick contact sheet) for a list of services that require prior authorization.

17 Universal PA Form Click here to view Universal PA form PA Form Proposal pdfPA Form Proposal pdf

18 Pharmacy Benefit Pharmacy benefits ( Customer Service

HIP plan updates  MDwise, Anthem and Managed Health Services were selected to administer the Healthy Indiana Plan for contractual period January 2011 through December

20 HIP update 2011  HIP and Hoosier Healthwise contracts are combined  Offer comprehensive package of disease management programs  Managed Care Entities ( MCEs) to complete standardized Health Risk Screening ( 70% within 90 days)  MCEs to do all PMP changes and auto assignment of members to a PMP ( this is already done by MDwise)

21 New Member Application  Members will select Managed Care Entity on application--not PMP  Option to receive a copy of PMP list  address will be collected  Primary and secondary phone numbers will be added

22 HIP membership  All members will receive a letter that indicates they will have an opportunity to change plans for a 1/1/11 effective date.  If no change is received, a HIP member will stay with their current plan.  New HIP enrollment will default to the neediest MCE.

23 Redetermination  HIP member who fails to complete redetermination results in loss of coverage for 12 months.  HIP members may select a different plan at redetermination.  Member may select a Managed Care Entity (MCE) on their applications or through Maximus (enrollment broker).

24 Member Billing  MCE’s invoices member and collects monthly payments 60 days to pay contribution/premium or termination will follow  Conditional HIP members may reapply  Fully Eligible HIP member can reapply after 12 months  Employers- HIP Members may contribute up to 50% of members contribution.

25 Disease Programs – focus for 2011  Asthma  ADHD-Attention Deficit/Hyperactivity Disorder  Diabetes  Pregnancy  CHF-Congestive Heart Failure  CAD-Coronary Artery Disease  Depression  PDD-Pervasive Developmental Disorder or Autism  COPD- Chronic Obstructive Pulmonary Disease

26 Thank You from