1. Special Populations and Review
February 6, 2015

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3. IPHCA’s Annual Conference
When: May 3-5, 2015
Where: Indianapolis Marriot North
Join us for an exciting two-day Outreach & Enrollment track open to all interested individuals!
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5. Learning Objectives
Discuss HIP 2.0 eligibility for special populations like:
Pregnant women
Native Americans
Medically frail individuals
Low-income Parents and Caretakers
Low-income 19- and 20-year-olds

6. SPECIAL POPULATIONS

7. Special population:
Medically frail

8. Medically Frail Who is considered medically frail?
Individuals with certain serious physical, mental and behavioral health conditions
Required to have access to standard Medicaid benefits
Includes individuals with:
Disabling mental disorders (including serious mental illness)
Chronic substance use disorders
Serious and complex medical conditions
A physical, intellectual or developmental disability that significantly impairs the ability to perform one or more activities of daily living
Activities of daily living include bathing, dressing, eating, etc.
A disability determination from the Social Security Administration
HIP 2.0 is available to those determined medically frail at or below 138% FPL
So, Who is considered medically frail?
Individuals with certain serious physical, mental and behavioral health conditions
Required to have access to standard Medicaid benefits
Includes individuals with:
Disabling mental disorders (including serious mental illness)
Chronic substance use disorders
Serious and complex medical conditions
A physical, intellectual or developmental disability that significantly impairs the ability to perform one or more activities of daily living
Activities of daily living include bathing, dressing, eating, etc.
A disability determination from the Social Security Administration

9. Medically Frail
What coverage does a medically frail individual receive?
Medically frail individuals receive HIP State Plan benefits
No visit limit for home health
Coverage for Temporomandibular Joint Disorders (TMJ)
Chiropractic services
Bariatric surgery
Requires authorization for physical, speech and occupational therapies—but unlimited
No limit for skilled nursing facility
Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds
Pregnant women receive access to all pregnancy-additional benefits on HIP Plus or HIP Basic plan and full State Plan benefits
What coverage does a medically frail individual receive?
Medically frail individuals receive HIP State Plan benefits
No visit limit for home health
Coverage for Temporomandibular Joint Disorders (TMJ)
Chiropractic services
Bariatric surgery
Requires authorization for physical, speech and occupational therapies—but unlimited
No limit for skilled nursing facility
Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds
Pregnant women receive access to all pregnancy-only benefits on HIP Plus or HIP Basic plan and full State Plan benefits

10. Medically Frail How is an individual determined medically frail?
The IAHC uses answers from the Health Coverage Questionnaire (HCQ, State Form 55641) to make a preliminary determination for medically frail status
The enrollee’s MCE makes the final determination for medically frail status by reviewing the member’s:
Responses on HCQ
Initial health screen or health assessment
Present of historical medical claims data
Any other information relevant to their health condition
How is an individual determined medically frail?
The IAHC uses answers from the Health Coverage Questionnaire (HCQ, State Form 55641) to make a preliminary determination for medically frail status
The enrollee’s MCE makes the final determination for medically frail status by reviewing the member’s:
Responses on HCQ
Initial health screen or health assessment
Present of historical medical claims data
Any other information relevant to their health condition

11. Medically Frail Can an individual lose their medically frail status?
If an MCE cannot confirm on-going medically frail status, it will remove the designation
If a member reports themselves as medically frail to their MCE and findings show they do not meet definition of medically frail, then the individual will receive notification of finding and appeal rights
If member disagrees with the MCE’s medically frail appeal decision, he or she may appeal to the State
Can an individual lose their medically frail status?
If an MCE cannot confirm on-going medically frail status, it will remove the designation
If a member reports themselves as medically frail to their MCE and findings show they do not meet definition of medically frail, then the individual will receive notification of finding and appeal rights
If member disagrees with the MCE’s medically frail appeal decision, he or she may appeal to the State

12. Medically Frail Verification
Individual identified as potentially medically frail
Managed care entity (MCE) must verify status within 60 days*
If medically frail status not verified, member no longer eligible for State Plan benefits
 Member transferred to HIP Basic or HIP Plus
Annually
MCE confirms qualification for medically frail status
 State verifies MCE medically frail status determinations
The steps for medically frail verification
First the individual is identified as potentially medically frail
The managed care entity then has 60 days to verify this determination
If the MCE does not find the applicant to be medically frial, the member would no longer be eligible for state plan benefits, be eligible for HIP benefits if they meet the income requirements and would be transferred to HIP Basic or HIP Plus
Annually the MCE will confirm qualification for medically frail status and the state will verify the MCE medically frail status determinations
*Verification time frame is 60 days in 2015 and 30 days in all following years

13. Low-income parents, caretakers and 19- and 20-year-olds
Special population:
Low-income parents, caretakers and 19- and 20-year-olds

14. Low-Income Parent or Caretaker and 19-20-year-olds
Who is considered a low-income parent or caretaker?
Individuals below 19% FPL:
Who is considered a low-income 19- or 20-year-old?
A child age 19 or 20 who lives in the home of a parent or caretaker relative and meets the income requirements above
A parent includes biological, adopted or step-parent
Family Size
Monthly Income Amount 1
$152 2
$247 3
$310 4
$373 5
$435 6
$498 7
$561
Each additional
$63
Who is considered a low-income parent or caretaker?
Individuals below 19% FPL:
That would mean a family size of 1 with monthly income at or below $152 and a family of four at or below the monthly income of $373
Who is considered a low-income 19- or 20-year-old?
A child age 19 or 20 who lives in the home of a parent or caretaker relative and meets the income requirements above
A parent includes biological, adopted or step-parent

15. Low-Income Parent or Caretaker and 19-20-year-olds
What coverage does a low-income parent/caretaker or year-old individual receive?
These individuals will receive HIP State Plan benefits
No visit limit for home health
Coverage for Temporomandibular Joint Disorders (TMJ)
Chiropractic services
Bariatric surgery
Requires authorization for physical, speech and occupational therapies—but unlimited
No limit for skilled nursing facility
Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds
Pregnant women receive access to all pregnancy-additional benefits on HIP Plus or HIP Basic plan and full State Plan benefits
What coverage does a low-income parent/caretaker or year-old individual receive?
These individuals will receive HIP State Plan benefits
No visit limit for home health
Coverage for Temporomandibular Joint Disorders (TMJ)
Chiropractic services
Bariatric surgery
Requires authorization for physical, speech and occupational therapies—but unlimited
No limit for skilled nursing facility
Early periodic screening diagnosis and testing (EPSDT) services for 19 & 20 year olds
Pregnant women receive access to all pregnancy-only benefits on HIP Plus or HIP Basic plan and full State Plan benefits

16. TRANSITIONAL MEDICAL ASSISTANCE
Special population:
TRANSITIONAL MEDICAL ASSISTANCE

17. Transitional Medical Assistance (TMA)
What is Transitional Medical Assistance (TMA)?
Medicaid program that offers continued coverage of benefits for certain low-income parents and caretakers who would otherwise lose Medicaid coverage due to increased earnings
Available up to 185% FPL (during 2nd 6 months)
How long is an individual eligible for TMA?
6-12 months
Quarterly reporting required to maintain TMA
What is Transitional Medical Assistance (TMA)?
Medicaid program that offers continued coverage of benefits for certain low-income parents and caretakers who would otherwise lose Medicaid coverage due to increased earnings
If low income parent/caretaker in HIP 2.0 has increase in earnings that puts them over the converted AFDC income standards (approximately 19% FPL), they will go in HIP 2.0 with TMA indicator and receive 6 months of coverage as long as they have dependent child under 18 in the home and then can get up to an additional 6 months of coverage in HIP 2.0 (TMA indicator) based on periodic reports that must be submitted at 3, 6, and 9 months.
The children will also go to TMA but in the TMA category for children.
The 185% FPL standard applies to the coverage in the second 6 month period. Individuals in TMA can have income above 185% during the first 6 months—the 6 months is guaranteed despite income amount.
Remember that those that convert to TMA are eligible for 6 months automatically and will have quarterly reporting. If a period report is not completed/returned, coverage under TMA will end but will be at least 6 months.
After the HIP 2.0 TMA ends, consumers eligibility for other categories will be determined, including the other HIP 2.0 groups/indicators.  At the end of TMA, a member under 138% would still be eligible for HIP 2.0.

18. Transitional Medical Assistance (TMA)
Individuals with TMA coverage before February 2015 will not transition to HIP 2.0
Individuals newly eligible for TMA will receive HIP State Plan Plus or HIP State Plan Basic benefits
Regardless of income, individuals receiving Transitional Medical Assistance (TMA) may not be dis-enrolled from the program for at least 6 months
May receive TMA up to 12 months if individual complies with required quarterly reporting
For TMA members with income over ~138% FPL:
May not be dis-enrolled in the first 6 months
May be eligible for a second 6-month benefit period if:
Comply with required reporting
Income under 185% FPL
(~ means approximately)
Individuals on TMA will get state plan benefits during TMA period

19. Special population:
Pregnant women

20. Pregnancy Determination
HIP member learns she is pregnant; reports to DFR within 10 days of knowing
HIP member tells MCE she is pregnant within 10 days of knowing
MCE reviews and confirms claim data indicating pregnancy

21. HIP Coverage for Pregnant Women
Woman becomes pregnant while enrolled in HIP
No cost-sharing during pregnancy/post-partum period
OPTION: May request to move to HIP Maternity (MAGP)
Woman is pregnant at application or renewal
No cost-sharing during pregnancy/post-partum period
May have coverage gap when reentering HIP after pregnancy if end of pregnancy not reported on time
1/21/15: Removed “Regular Medicaid reimbursement for claims when member moves to MAGP” – added recommendation
RECOMMEND:
Report end of pregnancy promptly to guarantee continued HIP coverage without a gap

22. HIP Maternity (MAGP) Coverage
Receive HIP Maternity ID card to use when accessing services
Coverage does not have a POWER account or any copayments
Prevent a coverage gap: Pregnant women should promptly notify DFR of pregnancy end date (within 10 days)
To maintain coverage in HIP after pregnancy, pay POWER account contribution as soon as possible after pregnancy ends

23. Additional Benefits Include: Non-emergency transportation
Pregnancy Benefits
Pregnant women receive benefits only available to pregnant women, regardless of selected HIP plan
Exempt from cost sharing
Additional benefits continue for a 2 month (60-day) post-partum period
Additional Benefits Include:
Vision
Dental
Non-emergency transportation
Chiropractic
Verify pregnancy benefits

24. Pregnancy Question
Can pregnant women above ~138% FPL still get coverage from an Indiana Health Coverage Program (IHCP)?
Yes, women between ~138% FPL and under ~208% can still get coverage through MAGP (Medicaid pregnancy category). These individuals will receive Hoosier Healthwise Package A benefits.

25. Special population:
Native Americans

26. Native American status subject to verification with DFR.
By federal rule, Native Americans are exempt from cost sharing
Receive HIP Plus
Do not have POWER account contributions or emergency room copayments
May opt out of HIP Plus and into fee-for-service coverage as of April 1, 2015
May be eligible for HIP State Plan benefit option if also:
Medically frail,
Low-income Parent/Caretaker,
Low-income year olds
According to U.S. Census Bureau in 2013, there were roughly 5.2 million American Indians and Alaska Natives living in the U.S., representing approximately 2% of the U.S. total population. The projected U.S. population of American Indians and Alaska Natives for July 1, 2060 is estimated to reach 11.2 million, constituting approximately 2.7% of the U.S. population by that date. From:
reveals that Indiana has a 0.4% population of American Indians and Alaska Natives
Native American status subject to verification with DFR.
Acceptable forms of verification include: tribal card, tribal letter, previous use of Indian Health Services, etc.

27. Quick review of hip 2.0

28. Indiana Application for Health Coverage (IAHC)
Completing the application online is the easiest and fastest method
Electronic sources are used to verify income, citizenship, alien status and other eligibility factors
Faxing documents might speed up the application process
Write the name and Social Security Number on each item you fax or mail
FAX
MAIL
FSSA Document Center
PO Box 1810
Marion, Indiana 46952

29. HIP Plus Initial plan selection for all enrollees
For Hoosiers with incomes up to 138% FPL
Required POWER account contributions (2% member income)
No other required cost-sharing (copayments)*
Offers vision, dental, and more comprehensive prescription drug benefit
Covers maternity services with no cost-sharing
Power account jointly funded by member and the State of Indiana
Initial plan selection for all enrollees
* Exception: using ER for routine care

30. HIP Basic Fall back option for members
Basic plan for Hoosiers ≤100% FPL
No required POWER account contributions
Requires copayments for all services
Reduced benefit package and more limited prescription drug benefit
Covers maternity services with no cost-sharing
POWER account is completely state-funded
Fall back option for members

31. HIP Basic Copayments for HIP Basic members Service
HIP Basic Copay Amounts ≤100% FPL
Outpatient Services $4
Inpatient Services
$75
Preferred Drugs
Non-preferred Drugs $8
Non-emergency ED visit
Up to $25
When members with income less than or equal to 100% FPL do not pay their HIP Plus monthly contribution, they are moved to HIP Basic. HIP Basic members are responsible for the following copayments for health and pharmacy services.

32. HIP State Plan Qualifying individuals include:
Available for qualifying individuals
Keep HIP Plus or HIP Basic cost-sharing
Some additional benefits, including transportation, dental and vision
Qualifying individuals include:
Low-income (<19% FPL) Parents and Caretakers
Low-income (<19% FPL) 19 & 20 year olds
Medically Frail
Transitional Medical Assistance (TMA)

33. HIP (Employer Benefit) Link
For people with access to “unaffordable” insurance through an employer
Employer must sign-up and contribute 50% of member’s premium
Members make PACs and receive defined contribution from the state
NEW EMPLOYER PLAN OPTION
Families can choose to enroll in employer-sponsored health insurance
Employer must sign up and contribute 50% of member’s premium
POWER ACCOUNT
Member makes contributions to POWER account
Defined contribution from State to allow individuals to
Pay for employer plan premiums &
Defray out-of-pocket expenses
Enrollment in HIP Link is optional
Coming Soon!

34. Gateway to Work
As part of enrollment in the Healthy Indiana Plan, if the member is not a full time student or work more than 20 hours per week he or she may be referred to Indiana’s Gateway to Work program.
Gateway to Work provides members with general information on the state’s job search and training programs that could help connect them to potential employers.
While participating in the Gateway to Work could help members find employment opportunities, failure to do so will not affect their HIP eligibility.
HIP members who are unemployed or working less than 20 hours a week will be referred to available employment, work search and job training programs that will assist them in securing new or potentially better employment.
Gateway to Work is a voluntary program. HIP members will be notified if they have been referred to the program. Eligibility for HIP coverage is not affected if a member chooses to not participate.
Those interested in participating in Gateway to Work should call and select Option 1 for the health coverage menu and then Option 6 for Gateway to Work.
Once engaged in the Gateway to Work program, members may receive case management services, participate in a structured job readiness program and receive help with their job search. Additional training, volunteer work experiences and/or education may be provided, as appropriate. Gateway to Work participants will also be invited to attend hiring events with employers.
CMS did not approve a work requirement as part of this agreement. Indiana will seek to encourage employment through a state-funded incentive program that will be administered separate from the Medicaid program. Participation in this program will not impact coverage or costs for individuals. While states may promote employment through state programs operated outside of the demonstration, this is not permitted under the Medicaid program.

35. POWER Account
Like an HSA, members use first $2,500 to pay for services
Members receive monthly statement
Preventive services will not be used against $2,500 POWER account
Employers & not-for-profits may assist with contributions
Employers and not-for-profits may pay up to 100% of member POWER account contribution (PAC)
Payments made directly to member’s selected managed care entity
Spouses split the monthly PAC amount
As an example, MDwise has a form for non-profits and employers to complete in order to pay on behalf of a consumer
Anthem gives consumers the option to pay their PAC at Walmart for 88 cents
Consumers can pay via bank drafts, online, by phone, check; MDwise offers payroll deduction

36. Non-payment Penalties
Members remain enrolled in HIP Plus as long as they make PACs and are otherwise eligible
Penalties for members not making PAC contribution:
Members ≤100% FPL
Moved from HIP Plus to HIP Basic
Copays for all services
Members ≥100% FPL
Disenrolled from HIP Plus
Locked-out of HIP for 6 months
*EXCEPTION: Individuals who are medically frail.
**EXCEPTIONS: Individuals who are 1) medically frail, 2) living in a domestic violence shelter, and/or 3) in a state-declared disaster area. If an individual locked out of HIP becomes medically frail, he/she should report the change to his/her former health plan to possibly qualify to return to HIP early.

37. Reporting Changes
Members must report the following changes in within 10 days of when the change occurs:
Moving to a new address or change mailing addresses
Family income or family size changes
Losing a job, change jobs or get a new job.
Becoming pregnant, delivering baby or when pregnancy ends
Becoming insured under other health insurance (Private or Medicare)
Members should call or fax information to the FSSA Document Center at , mail to FSSA Document Center, PO Box 1810, Marion, IN or submit online
Changes must also be reported to MCE

38. Managed Care
Health coverage is provided by one of the three managed care entities (MCE)
Dental coverage is through DentaQuest
Vision coverage is through Vision Service Plan (VSP)

39. Dental Plan Coverage HIP Plus HIP Basic (age 19 or 20) or HPE
Oral exams every six months and emergency oral exams
Dental x-rays (Complete set once every three years and Bite-wing x-rays once every 12 months)
Teeth cleaning once every six months
Minor restorative services like fillings
Major restorative services like crowns
HIP Basic (age 19 or 20) or HPE
Oral exams every six months
Emergency oral exams
Dental x-rays (Complete set once every three years and Bite-wing x-rays once every 12 months)
HIP State Plan Basic
HIP State Plan Plus
All Pregnancy Plans
Dental x-rays Complete set once every three years
Bite-wing x-rays once every 12 months
Minor restorative services such as fillings
Dentures and denture repairs
Extractions

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