Transcript MDwise HEDIS Efforts

HIP HIP HOORAY!
Healthy Indiana Plan
Presented by MDwise
October 19, 2010
HIPP0060 (09/10)
Purpose of today’s discussion
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HIP plan overview
Covered services
Preventive Services
Prior Authorization
HIP Tier 2 and 3 comparison
HIP update 2011
Tools and Resources
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HIP
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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
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Enrollment Funding
140000
120000
Total
Funding
100000
80000
Childless
Adult
60000
40000
Current
Enrollment
20000
•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
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HIP Enrollment
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HIP Plan overview
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Coverage is focused on preventive services
Power Account
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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.
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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 www.indianapbm.com
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
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HIP Covered Services
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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
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HIP Covered Services
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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
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Preventive care
MDwise will be encouraging members and
requests that providers encourage members to
receive appropriate age and gender preventive
services, including:
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•Unlimited preventive services
Not subject to POWER Account
Annual physical
Colonoscopy
Flu shot
Pap smear
Cholesterol testing
Mammogram
Chlamydia screening
Blood glucose screening
Tetanus-diphtheria booster
Lead testing, 19-20 year-old
Hearing Screening
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Enhanced Service Plan ESP
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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.
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HIP and Pregnant Women
Pregnant women are not eligible for HIP services
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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)
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There will be no break in coverage
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Pregnant women may re-enroll in HIP following the pregnancy
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****See attachment in folder
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Reimbursement
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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.
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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.
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(members received an updated card due to Pharmacy carve
out)
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Claims Submission For MDwise HIP
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Medical Claims
MDwise ( HIP)
P.O. Box 33049
Indianapolis, IN 46203
Electronic filing: Payor MDWIS
Behavioral Health Claims
MDwise (HIP)
P.O. Box 33049
Indianapolis, IN 46203
Electronic filing: Payor MDWIS
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Claims Dispute
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Claims dispute
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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
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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 46225
*specialty network is open. Call delivery system medical management department for services
that require prior auth.
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Prior Authorization
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HIP providers call the member’s Delivery System for prior
authorization ( see quick contact sheet)
View PA requirements via website @ www.MDwise.org
Healthy Indiana Plan/Providers/Provider Tools
*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.
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Universal PA Form
• Click here to view Universal PA form PA Form Proposal
20100708.pdf
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Pharmacy Benefit
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Pharmacy benefits (www.indianapbm.com)
Customer Service 1-800-879-0106
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2011 HIP plan updates
 MDwise, Anthem and Managed Health Services were
selected to administer the Healthy Indiana Plan for
contractual period January 2011 through December 31
2015.
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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)
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New Member Application
 Members will select Managed Care Entity on
application--not PMP
 Option to receive a copy of PMP list
 Email address will be collected
 Primary and secondary phone numbers will be added
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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.
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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).
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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.
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Disease Programs – focus for 2011
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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
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Thank You from
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