Mitchell E. Daniels, Jr., Governor State of Indiana Indiana Family and Social Services Administration 2010 IHCP Annual Seminar Indiana Care Select Program

Mitchell E. Daniels, Jr., GovernorState of Indiana

Indiana Family and Social Services Administration

2010 IHCP Annual SeminarIndiana Care Select Program

Overview

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Today’s Agenda

• October 1, 2010 Change in Scope– Restructured Program Goals– CMO’s, Member Eligibility & Opt-out Process– Disease Management– HP Continued Functions– Disease Management

• Prior Authorization Process• Certification Code Policy• Right Choices Program Referral Process• 2010 Care Select Quality Measures• CMO Updates• Q&A

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Restructured Program Goals• Transition from a care management program to a disease

management program focusing on members with chronic conditions

• Re-designed to help patients with chronic illnesses lead healthier and more productive lives

• About 32,000 Medicaid members are eligible for the disease management program

• Members no longer eligible for Care Select were sent a letter in August 2010 informing them they are eligible for Traditional Medicaid and that their benefits will remain the same.

Indiana Care Select ProgramChange in Scope

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• Care Select Care Management Organizations (CMO’s)– ADVANTAGE Health Solutions, Inc.sm

– MDwise, Inc.

• Statewide Populations Served– The aged, if not eligible for Medicare;– Blind members;– Physically and/or mentally disabled members (collectively known

as “the ABD population”);– Wards of the court and foster children; or– Children on adoption assistance

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• Eligible Care Select Members (Conditions)– Asthma– Diabetes– Congestive Heart Failure– Coronary Heart Disease– Hypertension– Chronic Kidney Disease– Severe Mental Illness (SMI) and Depression– Serious Emotional Disturbance (SED)

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• Statewide Populations not eligible for the Care Select program– Dual-eligible members– The population on Home and Community Based Service (HCBS)

waivers– MED Works participants– Individuals receiving room and board assistance– Breast and Cervical Cancer Group– Individuals with QMB or SLMB only (not in combination with

another aid category)

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Member Opt-out Process• Members can opt-out if they are eligible to participate in

disease management programs that the Care Management Organizations (CMOs) provide for their chronic conditions

• Members who opt-out will be enrolled in Traditional Medicaid

• HCBS waiver members will no longer be in Care Select and continue to receive case management services through the waiver


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Member letter sent in August

Member new to Care Select

Care Select Member Opt-out Process Overview

Member needs to do nothing; Moves back to

Traditional Medicaid 10-1-10

Member needs to do

nothing. Can call Maximus to opt-out at

any time.

Member staying in Care Select

Member no longer in Care Select

Call Maximus

Opt-Out Pick PMP & CMO

OR May call Maximus if they have ?s.

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Disease Management• Members with a chronic condition will have access to

additional health education resources with the CMO• Increased compliance with disease management treatment

plans including medication compliance and appropriate preventative care visits

• Disease specific assessments and care plans• Goals: individualized & preventative care


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HP’s Continued Functions• Process claims for all services provided to Care Select

Members• Follow the IHCP Provider Manual• The member must be eligible for Medicaid – check eligibility

prior to providing services• Web InterChange administration & maintenance• Remittance advices and claims adjudication• Claims resolution• IHCP Provider Enrollment• PMP Quarterly Certification Code Distribution

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Prior Authorization

• ADVANTAGE Health Solutions, Inc.sm

– www.advantageplan.com/advcareselect– 1-800-784-3981 – Care Select PA– 1-800-269-5720 – Traditional FFS & MRO PA

• ADVANTAGE was selected to function as the Traditional Medicaid fee–for–service and MRO Transformation PA administrator

• MDwise, Inc.– www.mdwise.org– 1-866-440-2449 – Care Select PA

Note: All PA’s for prescription drugs are processed by ACS and not the CMOs

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Prior Authorization

General Information• The STATE plan requirements for Prior Authorization are the

same for both Indiana Care Select and Traditional Medicaid (FFS)

• The CMO’s PA departments use OMPP approved criteria in addition to the Indiana Administrative Code (IAC), PA guidelines, and Indiana Health Coverage Programs (IHCP) bulletins, banner pages, and newsletters when considering PA requests

• The CMO’s PA Departments review all medical, facility, or dental PA requests

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Prior Authorization

General Information• Decisions to authorize, modify, or deny a PA is based on

medical reasonableness, necessity, and other criteria outlined in 405 IAC 5-3 and reflects the current standards of practice in the provider community

• For a full detailed explanation of PA processes and procedures, please refer to Chapter 6 of the IHCP Provider Manual

• Out-of-state providers must obtain PA prior to performing services (except emergencies & CMO contracted out-of-state PMPs performing services that don’t require PA)

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Prior Authorization

PA Helpful Tips• All prior authorizations (PA) are submitted to the member’s health

plan on the date of request• Fax the Indiana Prior Review and Authorization Request form

along with supporting documents • Web InterChange allows providers to submit non-pharmacy PA

requests Note: Prior to contacting the CMO on PA status, providers should verify PA status using web interChange first

• Mail – Written requests for PA are submitted using an Indiana Prior Review and Authorization Request form along with supporting documents

• View fee schedule at www.indianamedicaid.com to see if a covered service requires PA

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Prior Authorization

PA Helpful Tips (Cont.)• New services require a new Prior Authorization request form

– Reminder: Providers may not add new services to an existing PA request as this constitutes a new PA request

• Indiana Prior Review and Authorization Request Form, System Update Form and Dental Prior Review and Authorization Request Form– These forms are available on the Forms page, under the

provider section of the IHCP Website at www.indianamedicaid.com

– View PA form completion information in Chapter Six of the IHCP Provider Manual at www.indianamedicaid.com

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Prior Authorization

PA Helpful Tips (Cont.)• PA form information left open to interpretation

– Please submit legible forms if mailing or faxing– Keep supporting documentation and PA request form

together– If faxing, please consider volume and use direct mail as an

alternative (please do not batch faxes) – Make sure PA request form is signed by appropriate

authorized provider

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Prior AuthorizationWeb Interchange

• The following provider types can submit PA requests via Web interChange:– Chiropractor– Dentist– Doctor of Medicine– Doctor of Osteopathy– Home Health Agency (authorized agent)– Hospice– Hospitals– Optometrist– Podiatrist– Psychologist endorsed as a Health Service Practitioner in Psychology

(HSPP)– Transportation providers

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Prior Authorization

Top PA Suspension/Denied Reasons• Certificate of medical necessity missing/incomplete• Home health plan of care missing/incomplete• Incomplete PA form • Missing physician orders• Clinical documentation missing• Incorrect form submitted

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• The Care Select PMP is responsible for providing and/or overseeing a member’s care during the time the member is linked to that PMP through the PMP assignment process

• The PMP agrees to provide the necessary primary and preventive health services directly to their assigned members or agrees to refer the member to another health care provider for those services undeliverable by the PMP

• Each Care Select PMP is assigned a cert code on a quarterly basis • This code, in addition to the PMP’s National Provider Identifier (NPI)

is needed to allow a specialist or another provider’s claims to be paid when appropriate

Certification Code Policy

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Policy Description Statements• While it is always preferable that the assigned PMP authorize

treatment and provide their NPI and cert code, there may be occasions when this is not possible

• Appropriate and designated CMO staff will need to provide this information to another health care provider in order to allow the Care Select member access to appropriate and timely care

• The following are specific circumstances in which designated CMO staff may release to another health care provider a member’s PMP’s cert code and NPI before or after a service has been rendered as approved by the State

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Exceptions• PMP change is still pending after a member has selected a new

PMP• Death of PMP• PMP moves out of the region without proper notification to the

program• Newly transitioned members into the program who are in need of

treatment (i.e. EPSDT) within the first sixty (60) days of enrollment• Member lives in an underserved area and is unable to select a

PMP from that area• Other urgent, emergent, or ongoing issues (i.e. dialysis or

emergent ER admission) where the member is unable to access necessary services and the assigned PMP is unwilling or unable to provide services or the appropriate referral

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• ADVANTAGE Health Solutions identifies and monitors RCP members in both ADVANTAGE Care Select and Traditional fee-for-service Medicaid Programs

• MDwise Care Select identifies and monitors RCP members in the MDwise Care Select Program

• RCP includes members who have shown a pattern of potential mis-utilization or over-utilization of services (for example)– Non-emergent use of the ER– “drug seeking” behavior– Resistance to PCP interventions

Right Choices Program (RCP)Referral Process

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The RCP is:• Not a loss of benefits• Not a reduction in benefits• Not a punitive action, but is a legal action

Note: Members are still eligible for all medically necessary IHCP services. However, those services must be ordered or authorized in writing by the member’s assigned PMP


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• The RCP identifies members appropriate for assignment and subsequent “lock-in” to:– one Primary Medical Provider (PMP)– one pharmacy and– one hospital

• The goal of “lock-in” is to ensure members receive appropriate care and prevent members from mis-utilizing services

• Specialty providers receive written authorization from the PMP

• The CMO’s add those specialists to the member’s provider list in order for the specialty provider to be reimbursedNote: The RCP Program applies to both members in Traditional Medicaid and Indiana Care Select

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• The PMP manages the member’s care and determines whether a member requires evaluation or treatment by a specialty provider – Referrals are required by the PMP for most specialty

medical providers (except self referral services)

– Referrals should be based on medical necessity and not solely on the desire of the member to see a specialist

– Emergency services for life threatening or life altering conditions are available at any hospital, but non-emergency services require a referral from the PMP

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Adding Providers to a Right Choices Member’s Lock In List

• Additional providers may be locked-in, either short-term or on an ongoing basis, if the PMP sends a written referral

• Providers may be locked-in for one specified date of service or for any defined duration of time, up to one year

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Self Referral• Behavioral health (except

prescriptions)• Chiropractic services• Dental services (except

prescriptions)• Diabetes self-management

services• Family planning services• HIV/AIDS targeted case

management

• Home health care• Hospice• Podiatric services (except

prescriptions)• Transportation • Vision care (except surgery)• Waiver services

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Referral Guidelines for the PMP• Referrals must be faxed or mailed• Referrals may be handwritten on letterhead or a prescription

pad, however, they must include the following information:– IHCP member’s name– IHCP member’s RID– First and last name and specialty of the physician to whom

the member is being referred– Primary lock-in physician’s signature (not that of a staff

member)– Date and duration of referral

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Contact Information

ADVANTAGEADVANTAGE Health Solutions –

Traditional FFSAttn: Right Choices ProgramP.O. Box 40789Indianapolis, IN 462401-800-784-3981Fax: 1-800-689-2759

ADVANTAGE Health Solutions - Care Select

Attn: Right Choices ProgramP.O. Box 40789Indianapolis, IN 462401-800-784-3981Fax: 1-800-689-2759

MDwiseMDwise Care SelectAttn: Care Management P.O. Box 44214Indianapolis, Indiana 46244-0214Phone: 1-800-356-1204 or 317-630-2831 Fax: 1-877-822-7187 or317-822-7517

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2010 Care Select Quality Measures

The office of Medicaid Policy and Planning (OMPP) requires the CMOs to report their PMP’s performance in preventative service delivery.

• Annual HEDIS recommended preventative services are based on age and/or sex of the member

• Examples of preventative services that OMPP measures the CMOs on include:– Adolescent Well child Visits– Cholesterol Screening– Diabetes Screening– ER Bounce Back

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2010 Care Select Quality Measures

Step 1.Identify care gap

Step 2.Notify member

Step 3.Provide service to

member

Step 4.Submit claim to HP

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CMO Updates

• State Mandated Preventative Services Guidelines will be made available at www.mdwise.org and www.advantageplan.com

• To date ADVANTAGE and MDwise have paid out a total of approx. $400,000 in P4P programs paid to the PMP community for providing high quality preventative care

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CMO Contact Information

MDwise Care Select:1-800-356-1204

ADVANTAGE Care Select:1-800-784-3981

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Q&A

Thank you for attending!

Documents

Mitchell E. Daniels, Jr., Governor State of Indiana Indiana Family and Social Services Administration 2010 IHCP Annual Seminar Indiana Care Select Program