Mitchell E. Daniels, Jr., Governor State of Indiana

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

2. 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

3. Indiana Care Select Program Change in Scope 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.

4. Indiana Care Select ProgramChange in Scope • 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

5. Indiana Care Select ProgramChange in Scope • 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)

6. Indiana Care Select ProgramChange in Scope • 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)

7. Indiana Care Select Program Change in Scope 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

8. Care Select Member Opt-out Process Overview Member letter sent in August Member staying in Care Select Member no longer in Care Select Member new to Care Select 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. Call Maximus Opt-Out Pick PMP & CMO May call Maximus if they have ?s. OR

9. Indiana Care Select Program Change in Scope 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

10. Indiana Care Select ProgramChange in Scope 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

11. 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

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

19. Certification Code Policy 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

20. Certification Code Policy 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

21. Certification Code Policy 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

22. Right Choices Program (RCP)Referral Process • 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

23. Right Choices Program (RCP)Referral Process 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

24. Right Choices Program (RCP)Referral Process • 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 reimbursed Note:The RCP Program applies to both members in Traditional Medicaid and Indiana Care Select

25. Right Choices Program (RCP)Referral Process • 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

26. Right Choices Program (RCP)Referral Process 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

27. 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 Right Choices Program (RCP)Referral Process

28. Right Choices Program (RCP)Referral Process 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

29. ADVANTAGE ADVANTAGE Health Solutions – Traditional FFS Attn: Right Choices Program P.O. Box 40789 Indianapolis, IN 46240 1-800-784-3981 Fax: 1-800-689-2759 ADVANTAGE Health Solutions - Care Select Attn: Right Choices Program P.O. Box 40789 Indianapolis, IN 46240 1-800-784-3981 Fax: 1-800-689-2759 MDwise MDwise Care Select Attn: Care Management P.O. Box 44214 Indianapolis, Indiana 46244-0214 Phone: 1-800-356-1204 or 317-630-2831 Fax: 1-877-822-7187 or 317-822-7517 Right Choices Program (RCP)Referral Process Contact Information

30. 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

31. Step 4. Submit claim to HP Step 1. Identify care gap Step 3. Provide service to member Step 2. Notify member 2010 Care Select Quality Measures

32. 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

33. CMO Contact Information MDwise Care Select: 1-800-356-1204 ADVANTAGE Care Select: 1-800-784-3981

34. Q&A Thank you for attending!