1. Introduction to Indiana Health Coverage Programs
HP Provider Relations
May 2012

2. Agenda What is Medicaid? Administration of Indiana Medicaid
Indiana Health Coverage Programs (IHCP)
Traditional Medicaid
Care Select
Hoosier Healthwise
Children’s Health Insurance Program (CHIP)
590 Program
Healthy Indiana Plan (HIP)
References
Questions

3. Objectives Provide a general overview of the Medicaid Program
Discuss the general responsibilities of the State agencies and State contractors in regard to the administration of the IHCP
Describe the major highlights of the IHCP including Traditional Medicaid, Care Select, Hoosier Healthwise, CHIP, 590 Program, and HIP

4. Learn
What is Medicaid?

5. What Is Medicaid?
Medicaid is a federal and state funded program, enacted in 1965 under Title XIX of the Social Security Act, which pays for the medical care of people who meet specific categorical nonfinancial, income, and resource requirements.
Medicaid is an entitlement program, which means that any person who meets his or her state’s Medicaid eligibility criteria has a federal right to Medicaid coverage in that state.
The state cannot limit enrollment in the program or establish a waiting list.

6. Who Pays for Medicaid?
The federal government matches state spending on Medicaid.
Federal law outlines minimum requirements that all states’ Medicaid programs must fulfill.
However, states have broad authority to define eligibility, benefits, provider payments, and other aspects of their programs.

7. Mandatory Groups
Federal law requires that states cover certain “mandatory” groups of people who meet the state’s eligibility requirements to receive any federal matching funds.
HP Confidential
25 March 2017

8. Mandatory Benefits Physician services
Hospital services (inpatient and outpatient)
Laboratory and X-ray services
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for individuals younger than 21 years old
Federally qualified health center (FQHC) and rural health clinic (RHC) services
Family planning services and supplies
Pediatric and family nurse practitioner services
Nurse midwife services
Nursing facility services for individuals 21 years old and older
Home health care for individuals eligible for nursing facility services
Necessary transportation services

9. Optional Benefits
Federal law also permits states to cover many services designated as “optional” services, such as the following:
Prescription drugs
Hospice services
Clinic services
Durable medical equipment
Vision services and eyeglasses
Rehabilitation and other therapies
Case management
Care furnished by other licensed practitioners
Transportation (above benefit limitations)
Nursing facility services for individuals younger than 21 years old
Dental services and dentures
Intermediate care facility for the mentally retarded (ICF/MR) services
Home and Community-Based Services (HCBS) Waiver Programs
Inpatient psychiatric services for individuals younger than 21 years old
Respiratory care services for ventilator-dependent individuals
Personal care services

10. Indiana Medicaid Indiana Health Coverage Programs
In the state of Indiana, Medicaid services are offered to eligible Indiana residents through the IHCP.
The IHCP is administered by the Office of Medicaid Policy and Planning (OMPP), which is under the Indiana Family and Social Services Administration (FSSA).
The IHCP covers all the mandatory services and most of the optional services established by the federal government.

11. Indiana Medicaid Indiana Health Coverage Programs IHCP
Traditional Medicaid
Care Select
Hoosier Healthwise
CHIP Package C
590 Program
HIP
Indiana Medicaid
Indiana Health Coverage Programs

12. IHCP Payment Delivery System
Providers are reimbursed for services rendered to members enrolled in IHCP based on the program in which the member is enrolled.
The IHCP reimburses enrolled providers using the following three payment delivery systems:
Fee-for-service (FFS)
Care Select
Risk-based managed care (RBMC)

13. IHCP Payment Delivery System
Fee for Service
The FFS delivery system reimburses providers on a per-service basis.
Providers bill services rendered to IHCP members directly to Hewlett-Packard (HP), the IHCP fiscal agent.

14. IHCP Payment Delivery System
Care Select
Care Select is similar to Traditional Medicaid in that payments for care are made on an FFS basis.
In addition, a per-member, per-month administration fee is paid to primary medical providers (PMPs).
Care Select operates as an FFS delivery system with a gatekeeper approach.
Claims are submitted to HP for processing.

15. IHCP Payment Delivery System
Risk-based Managed Care
In the RBMC delivery system, the State pays each managed care entity (MCE) a monthly capitation fee based on the member’s category of service.
This capitation fee covers the costs of care for most of the covered services incurred by Hoosier Healthwise members enrolled in the MCE network.
Claims are processed and paid by the MCE in which the member is enrolled.
Exception: Claims for carved-out services, including but not limited to pharmacy and dental services, are processed by HP and paid on an FFS basis.
Providers should contact the MCE for specific claim payment and prior authorization (PA) policies and guidelines.

16. Describe
Administration of Indiana Medicaid

17. Indiana Medicaid Administration
Division of
Family
Resources (
DFR )
OMPP
Indiana
State
Department
of Health
(ISDH)
Mental
Health
&
Addictions
DMHA
Disability
and
Rehabilitative
Services
DDRS
Aging DA

18. Family and Social Services Administration
The FSSA is the State agency responsible for social service and financial assistance programs.
The FSSA includes the following five major service divisions:
OMPP
DFR DA
DDRS
DMHA

19. Office of Medicaid Policy and Planning
The OMPP is responsible for the following:
Administering the IHCP at the State level, including the following functions:
Medical policy development
Program and contract compliance
Contracting with MCEs
Addressing cost containment issues
Establishing IHCP policies
Program reimbursement
Program integrity, including claims analysis and recovery

20. Division of Family Resources
The DFR, formerly known as the Division of Family and Children, is the division of FSSA responsible for processing applications and making eligibility decisions.
The County Offices of the Division of Family Resources administer the IHCP at the local level.

21. Division of Aging
The DA is the division of FSSA that operates the following programs:
Two of the HCBS Waiver Programs
Aged and Disabled (A&D) Waiver
Traumatic Brain Injury Waiver
Residential Care Assistance Program
Nursing home Pre-Admission Screening Resident Review program
Local Area Agency on Aging
Handles the initial requests for waiver services
Conducts nursing home pre-admission screenings

22. Indiana Medicaid State Contractors
Involved in the
Administration of the
Indiana Health
Coverage Programs (
Indiana Medicaid )

23. State Contractor HP Enterprise Services
Serves as the State fiscal agent and as a liaison between the provider and member communities and the IHCP
Manages the processing of claims (FFS)
Processes a variety of financial transactions, including claim payments, voids, refunds, and accounts receivable
Processes provider enrollment applications and updates existing provider records
Provides training to the provider community through on-site visits, conferences, and workshops
Provides member and provider customer assistance

24. State Contractor Traditional Medicaid or Care Select (FFS):
ADVANTAGE Health SolutionsSM
Traditional Medicaid or Care Select (FFS):
Processes PA requests
Reviews claims that suspend for medical policy audits
Administers the Right Choices Program (RCP) for Traditional Medicaid and Care Select members

25. ADVANTAGE Health Solutions
Right Choices Program
The RCP is designed to safeguard against the unnecessary or inappropriate use of Medicaid services.
RCP case managers provide intensive member education, care coordination, and utilization management for members enrolled in the RCP.
The member remains eligible to receive all medically necessary, covered services allowed by the IHCP when one of the following occurs:
The service is rendered by one of the providers to whom the member is locked-in or restricted.
The service is rendered by a specialist who has received a valid, written referral from the primary lock-in physician.

26. Right Choices Program
Effective January 1, 2010, any IHCP member participating in the IHCP (including HIP) may be placed in the RCP.
The RCP is administered by the health plan in which the member is enrolled.
Program
Administered By
Contact Information
Traditional Medicaid
ADVANTAGE Health Solutions
Care Select
MDwise
Hoosier Healthwise
Managed Health Services (MHS)
Anthem
, Option 3
HIP
MHS

27. State Contractor Serves as the pharmacy benefit manager Xerox
Responsible for the Drug Rebate Program
Processes pharmacy-related PA requests

28. State Contractor Myers and Stauffer LC
Myers and Stauffer is responsible for the following:
Setting rates that affect claim pricing on certain types of claims (for instance, capital cost for inpatient claims)
Setting flat fee rates for per diem services
Auditing IHCP claim processing activities

29. State Contractor Managed Care Entities
Entities authorized by the state of Indiana to operate a prepaid health care delivery plan (such as an HMO) on a capitated basis
These entities arrange, administer, and process claims for the delivery of health care services to members who are enrolled in the Hoosier Healthwise Program.
Administer the RCP for their members

30. State Contractor Care Management Organizations
Provide a myriad of health services for members who are enrolled in Care Select
Process PA requests
Review claims that suspend for medical policy audits
Administer the RCP

31. State Contractor MAXIMUS Administrative Services
Serves as an enrollment broker for the following:
Care Select
Hoosier Healthwise
HIP
Presumptive Eligibility for Pregnant Women
Provides choice counseling for eligible members to assist them with choosing a health plan that best meets their needs

32. Explain
Traditional Medicaid

33. Traditional Medicaid
IHCP members enrolled in Traditional Medicaid are not assigned a PMP and do not need to enroll in any MCE to receive health-related services
Services rendered to members enrolled in Traditional Medicaid are paid on an FFS basis

34. Traditional Medicaid Spend-down
Spend-down is a provision that allows a person whose income is more than the standard to receive assistance with medical bills under Medicaid.
Spend-down works like an insurance deductible. Once the monthly spend-down amount is satisfied, Medicaid will pay for all other covered services for that month.
The spend-down amount is determined by the DFR and is based on the member’s income and medical expenses.
The member must pay the spend-down amount deducted from claims directly to the provider.

35. Traditional Medicaid Dually Eligible for Medicare and Medicaid
Dually eligible members are individuals who are entitled to Medicare Part A and/or Part B and are eligible for Medicaid benefits.
A Medicare beneficiary who is aged, blind, or disabled according to Medicaid’s standards and who meets the Medicaid income and resource eligibility rules can qualify for Traditional Medicaid.

36. Traditional Medicaid Dually Eligible for Medicare and Medicaid
A Medicare beneficiary who does not qualify for Medicaid following the established guidelines, may still qualify for Medicaid under one of the following categories designed for Medicare beneficiaries:
Qualified Medicare Beneficiary (QMB)-Only
QMB-Also
QMB-Also with spend-down
An individual must meet the following eligibility criteria to receive assistance with Medicare-related costs under the QMB program:
Be entitled to Medicare Part A
Be 65 years old or older or be younger than 65 years old and entitled to Medicare

37. Only Medicare Benefits
Traditional Medicaid
Qualified Medicare Beneficiary-Only Coverage
Medicaid benefits are limited to payment of the member’s Medicare premiums, deductibles, and coinsurance for Medicare-covered services only.
The member is only eligible for the premiums, deductibles and coinsurance for Medicare-covered services.
Services not covered by Medicare are also not covered by Medicaid.
Only Medicare Benefits

38. Full Medicaid Benefits
Traditional Medicaid
Qualified Medicare Beneficiary-Also Coverage
Medicaid benefits include payment of the member’s Medicare premiums, deductibles, and coinsurance for Medicare-covered services.
In addition, the member receives full Medicaid covered services (benefits).
For QMB-Also with spend-down, the member receives full Medicaid covered services (benefits) after the monthly spend- down liability is met.
Full Medicaid Benefits

39. Traditional Medicaid Long Term Care
Long-term care (LTC) services are available to IHCP members who meet the threshold of nursing care needs required for admission to or continued stay in an IHCP-certified nursing facility.
The goal of the LTC program is to provide services in a setting other than an acute care wing of a hospital, enabling individuals whose functional capacities are chronically impaired to be maintained at their maximum level of health and well-being.

40. Traditional Medicaid
Long Term Care – Patient Liability
Patient liability is the monetary amount that a Medicaid resident must contribute toward his or her monthly care in a facility.
The amount of patient liability is determined by the local county office of the DFR.
The patient liability is deducted from LTC claims.

41. Traditional Medicaid Hospice
The Hospice program provides services to IHCP members who are terminally ill.
Hospice requires level of care (LOC) determination and a diagnosis of a terminal illness.
A hospice provider must be Medicare- certified as a hospice provider prior to enrollment in the IHCP as a Medicaid provider.

42. Traditional Medicaid Waiver Programs
Medicaid also offers additional nonmedical home and community- based services under waiver programs.
Waivers are designed as an alternative to institutionalization.
To qualify for waiver services, a person must first meet the LOC to receive services in an institution (hospital, nursing home, or ICF/MR) but choose to receive services in the community.

43. Traditional Medicaid Package E: Emergency Services Only
Package E provides coverage of serious medical emergencies for undocumented immigrants and certain visitors to the United States who meet all other categorical and financial requirements.
These members are only eligible for the following:
Labor and delivery until the mother is stable
Medical emergencies
A maximum of four-days supply of pharmacy services
Nonemergency services may be billed to the member if a signed waiver was obtained prior to rendering services

44. Define
Care Select

45. Care Select
Care Select is similar to Traditional Medicaid in that payments for care are made on an FFS basis.
However, members are assigned to a PMP.
An additional per-member, per- month administration fee is paid to PMPs.

46. Care Select
As of October 1, 2010, Care Select changed from a care management program that covered an extensive group of aid categories to a disease management program with a focus on members with certain chronic conditions
To participate in Care Select, members must meet the aid category criteria and have at least one of the health conditions covered by the program.
Members can opt out of Care Select at any time and enroll in Traditional Medicaid instead.

47. Aid Categories Covered by Care Select
Aged
Care Select Aid Categories
Blind
Aged
Disabled
Ward of the State
Foster Care
Children/Adoptive Services
Children/Adoptive Services
Care Select Aid Categories
Foster Care
Ward of the State

48. Health Conditions Covered by Care Select
A member must also have one of the following conditions to be eligible for Care Select:
Asthma
Diabetes
Congestive heart failure
Hypertensive heart disease
Hypertensive heart and kidney disease
Rheumatic heart illness
Severe mental illness
Serious emotional disturbance
Depression

49. Care Select Selecting a Health Plan and a Primary Medical Provider
Members select a health plan, also called a care management organization (CMO), to coordinate their health care services.
MAXIMUS (an enrollment broker contracted by the State) can assist members in making a CMO selection.
The CMO will assign a PMP.
The PMP is responsible for the following:
Providing or coordinating the member's care
Providing most primary and preventive services and reviewing necessary specialty care and hospital admissions

50. Discuss
Hoosier Healthwise

51. Hoosier Healthwise (Risk-based Managed Care Programs)
The Hoosier Healthwise Program provides coverage for health care services rendered to the following aid category groups:
Children
Pregnant women
Low-income families
The specific eligibility aid category determines the benefit package.

52. Hoosier Healthwise Risk-based Managed Care
Hoosier Healthwise follows an RBMC payment delivery system.
As mentioned previously, in the RBMC delivery system, the State pays each MCE a monthly capitation fee based on the member’s category of service.

53. Hoosier Healthwise
Selecting a Health Plan and a Primary Medical Provider
within 30 days of their initial enrollment in Hoosier Healthwise, members select a health plan
MAXIMUS (an enrollment broker contracted by the State) can assist members in selecting a health plan.
After members enroll in a health plan, the health plan assists them in selecting a PMP.
PMPs provide or authorize most primary and preventive care services.

54. Hoosier Healthwise Managed Care Entities
MCEs arrange, administer, and pay (process claims) for the delivery of health care services to members who are enrolled in the Hoosier Healthwise Program.
Each MCE is responsible for the following:
Maintaining its own provider and member services units
Paying claims for noncarved-out services
Providing PA

55. Hoosier Healthwise Children’s Health Insurance Program
CHIP, the State’s program created under Title XXI of the Social Security Act, provides health care coverage for children from birth through 18 years old using a buy-in option.
Under CHIP, also known as Package C, the income limit is 250 percent of the federal poverty guidelines.
Coverage is provided only to children who are ineligible for all other categories of the Hoosier Healthwise Program.

56. Hoosier Healthwise
Children’s Health Insurance Program – Cost-sharing Requirements
Unlike the other Hoosier Healthwise programs, CHIP has cost- sharing requirements.
A child determined eligible for Package C is made conditionally eligible pending a premium payment.
The child’s family must pay a monthly premium.
Only after the premium is paid is actual eligibility information transferred to IndianaAIM.
Enrollment continues as long as premium payments are received and the child continues to meet all eligibility requirements.
Enrollment is terminated for nonpayment of premiums after a 60-day grace period.

57. Early and Periodic Screening, Diagnosis, and Treatment

58. Early and Periodic Screening, Diagnosis, and Treatment
The EPSDT program, referred to as HealthWatch in Indiana, is a federally mandated preventive health care program designed to improve the overall health of eligible infants, children, and adolescents.
The primary goal of the HealthWatch/EPSDT program is to ensure that all children in the IHCP receive age-appropriate, comprehensive, preventive services.

59. Describe
590 Program

60. 590 Program
The 590 Program is designed for residents of State-owned facilities under the direction of the FSSA, Division of Mental Health and Addiction, and Indiana State Department of Health.
The 590 Program does not include incarcerated individuals.
Members enrolled in the 590 Program are eligible for the full array of benefits covered by the IHCP (with the exception of transportation services).
However, members do not receive a Hoosier Health Card.

61. 590 Program
All services provided on-site at the 590 Program facility are the financial responsibility of the facility.
The 590 Program facility and all providers performing services must be enrolled in the 590 Program.
Services provided to members enrolled in the 590 Program are reimbursed per claim, following an FFS payment delivery system.
Billing for services includes the following:
$150 or less  Billed to the 590 Program facility
Over $150  Billed to HP
Over $500  Services require PA

62. Inform
Healthy Indiana Plan

63. Healthy Indiana Plan
HIP provides health insurance for uninsured adult Hoosiers between years old whose household income is between 22 and 200 percent of the federal poverty level, who are not eligible for Medicaid.
Eligible participants must be uninsured for at least six months and cannot be eligible for employer- sponsored health insurance.
HIP is not an entitlement program; funding is limited.
Pregnant women are not eligible for HIP services.
Prescription drugs are limited to seven or nine fills per month; only four brands are allowed.

64. View
The Indiana Health Coverage Programs Tree

65. Indiana Health Coverage Programs
FSSA
OMPP
MDwise
MHS
Anthem
Hoosier Healthwise
Risk-Based Managed Care
MAXIMUS HP
590 Program
Healthy Indiana Plan
Anthem Blue Cross
Blue Shield
Enhanced Services Plan (ESP)
Cenpatico
Behavioral Health
Managed Behavioral Health Organizations
FSSA = Family & Social Services Administration
OMPP = Office of Medicaid Policy and Planning
MAXIMUS = Enrollment Broker
Traditional Medicaid
MDwise (Care Select)
Care Select
ADVANTAGE (Care Select)

66. Find Help
References

67. References ADVANTAGE Health Solutions advantageplan.com
Categories of Assistance (Indiana Client Eligibility System Program Policy Manual) in.gov/fssa/files/1600.pdf
Anthem anthem.com
Care Select provider.indianamedicaid.com/about-indiana-medicaid/member-programs/care- select.aspx indianamedicaid.com/ihcp/BULLETINS/BT pdf in.gov/fssa/ompp/2546.htm

68. References CHIP in.gov/fssa/ompp/2545.htm
HealthWatch/EPSDT Provider Manual provider.indianamedicaid.com/ihcp/manuals/epsdt_healthwatch.pdf
FSSA/OMPP Glossary of Terms in.gov/fssa/ompp/3328.htm
HIP in.gov/fssa/hip indianamedicaid.com/ihcp/Bulletins/BT pdf

69. References
590 Program Provider Manual provider.indianamedicaid.com/ihcp/manuals/590_program_provider_ manual.pdf
Hoosier Healthwise in.gov/fssa/ompp/2544.htm
Hospice Provider Manual provider.indianamedicaid.com/ihcp/manuals/hospice_benefit_ manual.pdf
IHCP indianamedicaid.com/ihcp/index.asp

70. References
IHCP Glossary provider.indianamedicaid.com/general-provider-services/ihcp- glossary.aspx
MHS mhsindiana.com
MDwise mdwise.org
Myers and Stauffer in.mslc.com

71. References
IHCP Provider Manual provider.indianamedicaid.com/general-provider-services/manuals.aspx
Title 405 Office of the Secretary of Family and Social Services Medicaid Covered Services and Limitations Rule in the Indiana Administrative Code (IAC) at 405 IAC 5 state.in.us/legislative/iac/title405.html
Medicaid Waivers in.gov/fssa/ompp/2549.htm

72. Q & A