Indiana Health Coverage Programs

1. Indiana Health Coverage Programs

2. Learning Objectives • Outline the basics of Medicaid and Indiana Health Coverage Programs (IHCP) • Identify and define eligibility, goals and specifics of IHCP programs • Discuss the standard elements of Medicaid and IHCP Eligibility • Examine eligibility notices, appeals and redeterminations for Medicaid and IHCP

3. What is Medicaid? • Enacted in 1965 by Title XIX of the Social Security Act • The federal government matches state spending on Medicaid • In Indiana, Medicaid is called Indiana Health Coverage Programs which is administered by the Office of Policy Planning (OMPP) and Family and Social Services Administration (FSSA) • Provides free or low-cost health insurance coverage to low-income: • Children • Pregnant women • Parents and caretakers • Blind • Disabled • Aged • Income limits are based on the Federal Poverty Level (FPL) • Offers variety of programs with varying criteria

4. Indiana’s Medicaid • The Office of Medicaid Policy and Planning (OMPP) is responsible for: • Administering Indiana Health Coverage Programs (IHCP) at the State level, including the following functions: • Medical policy development • Program and contract compliance • Contracting with MCEs • Addressing cost containment issues • Establishing IHCP policies • Program reimbursement • Program integrity, including claims analysis and recovery

5. Indiana’s Medicaid • The Department of Family Resources (DFR) is the division of FSSA responsible for processing applications and making eligibility decisions. • The County Offices of the DFR administer IHCP at the local level • Online applications for Medicaid are located on the DFR’s Benefit Portal

6. New Eligibility Groups • As of January 1, 2014, the states must cover: • Former foster children • Under age 26 • Receiving Indiana Medicaid when aged out of the system • Not subject to income limits until age 26 • Children age 6-18 • Up to 133% FPL • Pregnant Women: • Verification of pregnancy no longer required for Medicaid application • Counted as 2 people • Coverage continues 60 days postpartum

7. What are the Indiana Health Coverage Programs? • Hoosier Healthwise (HHW) • Healthy Indiana Plan (HIP) • Care Select • Traditional Medicaid • Medicaid for Employees with Disabilities (M.E.D. Works) • Home and Community-Based Service Waivers (HCBS Waivers) • Medicare Savings Program • Family Planning Services • Spend-Down—Eliminated June 1, 2014 • Breast and Cervical Cancer Programs

8. What are Federal Poverty Guidelines (FPL)? • Also known as Federal Poverty Level (FPL) • Issued each year by the Department of Health and Human Services (HHS) • Measure of pre-tax income used to determine what is considered poverty in the United States • It is also used to determine eligibility for IHCP and coverage through the federal Marketplace • Anyone living at 100% or below the FPL is considered living in poverty • In 2014, an individual with a pre-tax income of $11,670 or less is living in poverty, and so is a family of 4 with pre-tax income at or below $23,850.

9. What are Federal Poverty Guidelines (FPL)? 2014 FPL for the 48 Contiguous States and the District of Columbia

10. Hoosier Healthwise • Enrollees excluded from mandatory enrollment in Hoosier Healthwise include: • Individuals in nursing homes and other long-term care institutions • Undocumented individuals who are eligible only for emergency services (Package E) • Individuals receiving hospice or home and community-based waiver services • Individuals enrolled in Medicaid on the basis of age, blindness or disability • Wards of the court and foster children

11. Hoosier Healthwise

12. Services Available under Hoosier Healthwise Medicaid provides coverage for the following: • Medical care • Hospital care • Physician office visits • Check-ups • Well-child visits • Clinic services • Prescription drugs • Over the counter drugs • Lab & X-Rays • Mental health care • Substance abuse services • Home health care • Nursing facility services • Dental • Vision • Therapies • Hospice • Transportation • Family planning • Foot care • Chiropractors

13. Hoosier Healthwise Monthly Income Limits

14. Children’s Health Insurance Program (CHIP) • Child cannot be covered by other comprehensive health insurance • Individuals in CHIP are responsible for monthly premiums and must pay the first premium prior to coverage becoming effectuated (There is a 60-day grace period) • A child whose coverage was dropped voluntarily may not receive CHIP coverage for 90 days following the month of termination with some exceptions

15. Healthy Indiana Plan (HIP)

16. Healthy Indiana Plan (HIP) HIP provides a basic commercial benefits package. Covered services include: • Physician services • Prescriptions • Diagnostic exams • Home health services • Outpatient, inpatient hospital and hospice services • Preventive services • Family planning • Case & disease management • Mental health coverage • Vision, dental and maternity services are not currently covered by HIP

17. Healthy Indiana Plan (HIP) Enrollment • Individuals who fail to make their monthly POWER Account contribution after a 60-day grace period are disenrolled for 12 months. • If individuals fail to complete their annual redetermination, then they will be disenrolled from the program.

18. Healthy Indiana Plan (HIP) Key Dates • In September 2013, the State received authorization from CMS to continue the HIP program for one year (through December 31, 2014). • Due to problems with the roll-out of the federal marketplace, HIP eligibility was extended to those over 100% FPL (including the 5% disregard) through April 2014 to allow for transition to the Marketplace. • On May 15, 2014, Indiana Governor Mike Pence announced a plan to expand HIP from 100% to 138% of the FPL. • As of July 2014, Indiana has submitted the HIP 2.0 waiver application to CMS for approval

19. Managed Care Entities (MCEs) • MCEs provide the following services and functions to Hoosier Healthwise & HIP enrollees: • Case management and disease management • Member services helpline • Screening enrollees for special health care needs • 24-hour Nurse Call Line • Managing grievances and appeals • Provide member handbooks • Hoosier Healthwise & HIP enrollees select one of the three MCEs (Anthem, MDWise, MHS), or they are auto-assigned 14 days after enrollment

20. Managed Care Entities (MCEs) • Some factors for beneficiaries to consider when selecting an MCE include the following: • Provider network • Is the individual’s doctor available in the MCE network? • Are the locations of network providers easily accessible for the enrollee? • Are the locations convenient to the individual’s work, home or school? • Special programs & enhanced services • Is there a service or program offered by the MCE that is particularly important or attractive to the enrollee?

21. Managed Care Entities (MCEs) • Hoosier Healthwise enrollees can change MCE: • Anytime during the first 90 days with a health plan • Annually during an open enrollment period • Anytime when there is a “just cause” • Lack of access to medically necessary services covered under the MCE’s contract with State • The MCE does not, for moral or religious objections, cover the service the enrollee seeks • Lack of access to experienced providers • Poor quality of care • Enrollee needs related services performed that are not all available under the MCE network • HIP enrollees can change MCE: • In the first 60 days or until they make the first POWER Account contribution • Annually at eligibility redetermination • Anytime there is a “just cause” as outlined for Hoosier Healthwise enrollees

22. Managed Care Entities (MCEs)

23. Primary Medical Providers • Once a beneficiary is enrolled in an MCE, he or she also selects a Primary Medical Provider (PMP). • Enrollees must see their PMP for all medical care; • If specialty services are required the PMP will provide a referral. • Provider types eligible to serve as a PMP include Indiana Health Coverage Program enrolled providers with the following specialties: • Family practice • General practice • Internal medicine • Obstetrics (OB)/Gynecology (GYN ) • General pediatrics

24. Care Select will phase-out January 1, 2015 due to a new coordinated care program Care Select

25. Care Select • Individuals do not specifically apply for Care Select. • Medicaid enrollees in an eligible aid category with one of the qualifying conditions, as evidenced by claims history or their medical provider contacting the Enrollment Broker at 1-866-963-7383, have the option to participate • Care Select enrollees choose or are assigned to both a Care Management Organization (CMO) and PMP (Primary Medical Provider). • Member services contact information for the State’s two CMOs is as follows:

26. Traditional Medicaid (Fee-for-Service) The following individuals who meet income and resource requirements are eligible: • Blind, Disabled, and Aged persons • Persons in nursing homes & other long-term care institutions • Undocumented aliens who do not meet a specified qualified status; lawful permanent residents who have lived in the USA less than five years; or those whose alien status remains unverified receiving Emergency Services only • Persons receiving home and community-based waiver or hospice services • Dual eligibles (individuals receiving Medicaid & Medicare) • Persons eligible on the basis of having breast or cervical cancer • Refugees who do not qualify for another aid category • Former Independent Foster Children up to age 18, IV-E Foster Care Children, IV-E Adoption Assistance Children, and Former foster children under the age of 26 who were enrolled in Indiana Medicaid as of their 18th birthday

27. Traditional Medicaid (Fee-for-Service) • In Traditional Medicaid, beneficiaries are not enrolled in a Managed Care Entity (MCE) or Care Management Organization (CMO) and can see any Indiana Health Coverage Program enrolled provider. • All provider claims are paid fee-for-service by the State’s Fiscal Agent, Hewlett-Packard.

28. Traditional Medicaid (Fee-for-Service)

29. M.E.D. Works

30. M.E.D. Works • Enrollees are responsible for monthly premiums based on income of the applicant and spouse

31. 590 Program • Provides coverage for residents of state-owned facilities • Does not cover incarcerated individuals residing in Department of Corrections (DOC) facilities • Eligible for Package A benefits with the exception of transportation

32. Home and Community Based Waivers (HCBS)

33. Home and Community Based Waivers (HCBS) • To apply for the Aged and Disabled waiver or the Traumatic Brain Injury Waiver, individuals can go the local Area Agencies on Aging (AAA) or call 1-800-986-3505 for more information. • To apply for the Community Integration & Habilitation or Family Supports waiver, individuals can go the local Bureau of Developmental Disabilities Services (BDDS) office or call 1-800-545-7763 for more information. • There are currently waiting lists for the Family Supports waiver and the Traumatic Brain Injury waiver.

34. Behavioral and Primary Healthcare Coordination Program (BPHC) • Assists individuals with serious mental illness (SMI) who otherwise won’t qualify for Medicaid or other third party reimbursement • Individuals meet the following eligibility criteria: • Age 19+ • MRO-eligible primary mental health diagnosis (e.g. schizophrenia, bipolar disorder, major depressive disorder) • Demonstrated need related to management of behavioral and physical health and need for assistance in coordinating physical and behavioral healthcare • ANSA Level of Need 3+ • Income below 300% FPL • Single: $2,918/month • Married: $3,933/month

35. Behavioral and Primary Healthcare Coordination Program (BPHC) • Individuals may apply for the BPHC program through a Community Mental Health Center (CMHC) approved by the FSSA Division of Mental Health and Addiction (DMHA) as a BPHC provider. • A list of approved CMHCs can be found at http://www.indianamedicaid.com/ihcp/ProviderServices/ProviderSearch.aspx.

36. Medicare Savings Program • Covers low-income Medicare beneficiaries • Helps pay for out-of-pocket Medicare costs. • Individuals must be eligible for Medicare Part A

37. Family Planning Program

38. Family Planning Program Services not covered: • Abortions • Artificial insemination • IVF, fertility counseling or fertility drugs • Inpatient hospital stays • Treatment for any chronic condition Individuals must request to be considered for this program on their Indiana Application for Health Coverage if not eligible for full Medicaid benefits

39. Breast and Cervical Cancer Program (BCCP)

40. Presumptive Eligibility (PE) • Allows individuals meeting eligibility requirements access to services covered and paid for by Medicaid as they wait for their application determination for full Medicaid • Entails a simplified application process: • Applicant must know gross family income & citizenship status • Verification documents not required—applicant attests to information

41. Presumptive Eligibility (PE) • The PE period extends from the date an individual is determined presumptively eligible until… • When an Indiana Application for Health Coverage is filed: • Day on which a decision is made on that application • When an Indiana Application for Health Coverage is not filed: • Last day of the month following the month in which the PE determination was made

42. Presumptive Eligibility for Pregnant Women

43. Qualified Providers • Qualified providers (QPs) make PE determinations in accordance with Indiana eligibility policy and procedures. • QPs must meet the following criteria: • Be enrolled as an Indiana Health Coverage Program (IHCP) provider • Attend a provider training • Provide outpatient hospital, rural health clinic or clinic services • Be able to access HP Web interchange, internet, printer & fax machine • Allow PE applicants to use an office phone to facilitate the PE and Hoosier Healthwise enrollment process • May include hospitals, pediatricians, family/general practitioner, internist, medical clinic, rural health clinic among others

44. Hospital Presumptive Eligibility • All states are required to permit hospitals that meet state requirements to make PE determinations. • In Indiana, the eligibility groups or populations for which hospitals will be permitted to determine eligibility presumptively are: • Low-income infants and children • Low-income parents or caretakers • Former foster care children up to the age of 26 • Low-income pregnant women • Individuals seeking family planning services only

45. General Medicaid Eligibility and Requirements • Each Medicaid assistance category has specific eligibility requirements such as: • Age • Income • Pregnancy status • Indiana Residency • Citizenship/Immigration • Provide Social Security Number (SSN) • Provide information on other insurance coverage • File for other benefits

46. Requirement: Residency • Applicant must be resident of the state • State of residency is: • Where individual lives • Including without a fixed address OR • Has entered the state with a job commitment OR seeking employment • A homeless individual or residents of shelters in Indiana meet this requirement • There is no minimum time period for state residency to be Medicaid eligible • Individuals are permitted to be temporarily absent from the state without losing eligibility

47. Requirement: Citizenship/Immigration Status • Individual must be US citizen, a US non-citizen national or an immigrant who is in a qualified immigration status • Lawful permanent residents are eligible for full Medicaid after 5 years • Electronic data sources through the Federal Hub verify status • If not, paper documentation is required, and a “reasonable opportunity” period is granted to otherwise Medicaid eligible individuals– this period lasts 90 days from the date on the eligibility notice • Those exempt from citizenship verification process: • Individuals receiving SSI or SSDI • Individuals enrolled in Medicare • Individuals in foster care & who are assisted under Title IV-B • Individuals who are beneficiaries of foster care maintenance or adoption assistance payments under Title IV-E • Newborns born to a Medicaid enrolled mother

49. Requirement: Provide Social Security Number • Each Medicaid applicant must supply social security number (SSN) with the following exceptions: • Individual ineligible to receive SSN • Individual does not have SSN and may only be issued one for a valid non-work reasons • Individual refuses to obtain one due to well-established religious objections • Individual is only eligible for emergency services due to immigration status • Individual is a deemed newborn • Individual is receiving Refugee Cash Assistance and is eligible for Medicaid • Individual has already applied for SSN

50. Requirement: File for Other Benefits • Individuals must apply for all other benefits for which they may be eligible as a condition of eligibility unless good cause can be show for not doing so; these include: • Pensions from local, state or federal government • Retirement benefits • Disability • Social Security benefits • Veterans’ benefits • Unemployment compensation benefits • Military benefits • Railroad retirement benefits • Workers’ Compensation benefits • Health and accident insurance payments