Transcript Title

Healthy Indiana Plan Presentation 2009
Plan Update
Presented by MDwise
October 21, 2009
HIPP0041 (09/09)
Enrollment Funding
HIP is funded for approximately
130,000 Hoosiers
Enrollment cap of 34,000
childless adults
This category has met it’s
maximum capacity
(Applicants may still apply and
be put on a wait list)
2
Note to providers
Please do not bill or collect for POWER
account (deductible) from the HIP
member.
It is the plans responsibility to collect
payments from HIP member.
3
Preventive care
MDwise encourage 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, 19-20 year-old

Hearing Screening
Unlimited preventive services

Not subject to POWER
Account
4
Snapshot of HIP as of 9.11.09
Application ‘s
To Date: 172,708
Approved Application
47,117
Marion
And Lake County
Highest % of Population
Fully eligible
45,357
(both plans)
5
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
6
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 does not apply to HIP
7
HIP Non-Covered Services
Healthy Indiana Plan–
Excluded Services





Pregnancy services
Dental services
Vision services
Non-emergent
transportation
Chiropractic services
Please see inside folder of list
of expanded excluded HIP
services
8
Enhanced Service Plan (ESP)





HIP application contains a health screening questionnaire.
Medical conditions 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’s member eligibility period.
ACS Healthcare Solutions will process claims for ESP services
9
HIP and Pregnant Women
Pregnant women are not eligible for HIP services
 Pregnancy related services are non-covered service
 Physicians are encouraged to assist members to submit a
statement of pregnancy and report of change to the
Division of Family Resources (DFR)
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
10
HIP and Sterilization
Please note:
 State guidelines apply to an elective
sterilization.
 Coverage is available with consent
form signed and dated 30 days
prior to surgery.
 Consent form must be submitted
with claim.
11
Emergency Coverage
Additional cost sharing:
Co-pays for ER use ONLY

Parents
$3 = < 100% FPL
$6 = 100-150% FPL


*$25
or 20% of total bill= 150-200% FPL
*Childless Adults
$25 or 20% of total bill regardless of FPL
*Co-pays
will be returned if visit is deemed a true emergency using prudent layperson standard (
In-patient admissions)
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
NOTE-Providers must be enrolled in the Indiana Health Coverage
Program (IHCP) and have a active IHCP number to participate in
HIP.
MDwise plan participation will be based on delivery system acceptance.
(See quick contact sheet for participating Delivery Systems and
contact information).
13
FQHC’s and RHC’s reimbursement


All covered HIP services will be reimbursed at
the current CPT code sets.
MDwise will not recognize T1015. Services
billed using this code will be denied.
14
Eligibility
It is the responsibility of ALL
providers to check eligibility at
the time of each visit.
15
Claims Submission For HIP
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
16
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

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
P.O. Box 44123
Indianapolis, IN 46224-1423
*specialty network is open. Call Delivery System Medical Management department for services that
require prior authorization.
17
Existing AmeriChoice Claims

Call MDwise for:




Unresolved Medical claims processed by AmeriChoice,
i.e. denials, payment, authorizations issues.
To complete a provider claims dispute form.
Please attach a copy of the explanation of benefit and
any documentation that you believe my be relevant to
support the request.
The claims dispute form can be found on our website
– www.MDwise.org/providers/healthyindiana
18
HIP Prior Authorization
HIPP0041 (09/09)
Prior Authorization


HIP providers call the member’s Delivery System for
prior authorization (see quick contact sheet)
View PA requirements via website at
www.MDwise.org Healthy Indiana Plan- resources
*Until further communication, MDwise will operate as an open network for
Specialist Services Only. Please contact the appropriate HIP Delivery System
Medical Management department (see quick contact sheet) for a list of
services that require prior authorization.
20
Pharmacy Benefit
Extra pharmacy benefits (both generic and brand name
drugs (See MDwise Pharmacy Drug Formulary)
21
Plan Benefit to Members
MDwise has a number of extra programs for our members. They help our members get
healthy and stay healthy. Special MDwise programs include:
22
Plan Benefits to Members
Visit your doctor !
Visit your PMP within the first
3 months (90) days and earn
free gift:
$25.00 gift card
Complete MDwise Health
Survey with one of our
MDwise Associates
The survey must be done within
the first 20 days of becoming
fully eligible:
$25.00 gift card
23
HIP Facts
Coverage begins on the first day of the month after the monthly
contribution is cleared at the bank
MDwise HIP members can make cash payments at KeyBank
locations throughout Indiana.
Members cannot change insurers once HIP coverage begins unless:





Member becomes eligible for ESP
ESP member no longer qualified for ESP services
Member receives verifiable, irresolvable quality of care problems with
the insurer
Providers must be enrolled in the Indiana Health Coverage
Programs (IHCP) to participate in HIP
Coverage term is limited to 12 months
After the one-year term, members must be recertified to
continue in the plan for another 12 months
24
Resources
www.MDwise.org

MDwise quick contact sheet

MDwise Provider Manual (website)

MDwise member/provider service department:

Phone 1-877-822-7196
Enrollment Broker:

Maximus
State’s HIP website

www.HIP.IN.gov
Phone

1-877-GET-HIP-9

Hours: Monday-Friday 8:00am to 7:00pm; Saturdays 8:00am to 1:00pm
25
Thank You from –
26