Indiana Care Select Overview

1. Mitchell E. Daniels, Jr., Governor State of Indiana Indiana Family and Social Services Administration Anne W. Murphy, Secretary; Pat Casanova, Medicaid Director Indiana Care SelectOverview

2. Today’s Agenda • Program Goals & Overview • Member Enrollment Process • Primary Medical Provider (PMP) Overview • Certification Code Policy • Right Choices Program Referral Process • Care Management Overview • Member Support Services • Care Coordination Conferences • HEDIS • On-line CM Portals • Question & Answer

3. Program Goals • To more effectively tailor benefits to its members • To improve the quality of care and health outcomes of its members • To control the growth of health care costs • To provide a more holistic approach to member’s health needs

4. Program Overview • Care Coordination • Individualize services for its members • Assist its members in gaining access to needed medical, social, educational and other services • Disease Management • Population-based • Target specific diseases • Utilization Management • Appropriate use of facilities, services and pharmacy

5. Program Overview • Care Select Care Management Organizations (CMOs) • ADVANTAGE Health Solutions, Inc.sm • MDwise, Inc. • Care Select Members • Members that are Aged, Blind or Disabled • Wards of the Court and Foster Children • Home & Community-Based Waiver participants • Members who receive Adoption Assistance • M.E.D. Works participants • Will NOT include members in institutional settings, spend down, or dual-eligibles (Medicare/Medicaid)

6. Care Select Member Enrollment Process Member letter sent Does Member have a PMP? Yes Member enrolled in PMP’s CMO Member auto-assigned to CMO and PMP No Yes No Did member choose a PMP and CMO? Enrollment Broker (MAXIMUS) begins to call members to answer questions and help enroll * If Primary Medical Provider (PMP) is in both plans, member will choose a plan or be auto-assigned to a plan.

7. The Primary Medical Provider (PMP) • What is a PMP and why is having one so important? • Linked to each Care Select member as the member’s medical home • Connects primary and specialty health care • Provides referrals to specialists via telephone or in writing • Works with member and care manager to improve the health of the member • Who can be a PMP? • Primary care physicians • i.e. family practice, general practice, internist, pediatrician, and OB/GYN • Specialists

8. The Primary Medical Provider (PMP) • How does a PMP enroll? • PMPs in Care Select may contract with one or both CMOs. • Why are there two CMOs? • IHCP wants to give both members and providers a choice. • How does this affect a member’s choice between CMOs? • The member is enrolled in the CMO with which his or her PMP is contracted. • Members with no prior PMP linkage will receive a letter and call from the enrollment broker to assist in choosing a PMP. • Members can change PMPs by contacting their CMO or Maximus. • Those who do not choose a PMP get auto-assigned to one.

9. 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

10. Certification Code Policy Policy Description Statement: • 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:

11. Certification Code Policy Exceptions • PMP change is still pending after a previously auto-assigned 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 (i.e. wards and foster children) who are in need of treatment (i.e. EPSDT) within the first sixty (60) days of enrollment • Auto-assigned 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

12. Right Choices Referral Processformerly known as Restricted Card Program • ADVANTAGE Health Solutions identifies and monitors individuals in both ADVANTAGE Care Select and the Traditional or fee-for-service Medicaid Program • MDwise Care Select identifies and monitors individuals in the MDwise Care Select Program • This includes members who have shown a pattern of potential mis - utilization or over - utilization of services The RCP is: • Not a loss of benefits • Not a reduction in benefits • Not 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

13. Right Choices Referral Process The RCP identifies members appropriate for assignment and subsequent “lock-in” to: • one Primary Care Physician (PCP) • one pharmacy and • one hospital The RCP Program applies to both members in Traditional Medicaid and Indiana Care Select • 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

14. Right Choices 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

15. Right Choices 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.

16. When a Referral is Not Necessary: 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 Referral Process

17. Right Choices 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

18. 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: 1-866-440-2449 or 317-829-8189 Option 1 Fax: 1-877-822-7187 or 317-822-7517 Right Choices Referral Process CMO Right Choices Contact Information

19. Care Management Overview PHILOSOPHY • Member-centered care management focus • Strong partnerships with community providers to coordinate behavioral, developmental and medical services • Utilize assessments and risk stratification tools to determine needs at the member/provider level • Excel in communication with members, their families and their caregivers

20. Step 4. Measure Results Step 1. Assess Member Needs Step 3. Coordinate Care Step 2. Design Care Plan Care Management Overview

21. Step 4. Measure Results Step 1. Assess Member Needs Step 3. Coordinate Care Step 2. Design Care Plan Step 1: Assess Member Needs • Identify high risk members through medical claims history/risk stratification • Identify and reach out to member’s family or facility case manager • Share existing assessments/care plans to avoid duplicative assessment questions or interventions • Conduct initial interview with member or caregiver • Assign care management Level 1-4 • Identify the need for more comprehensive medical, behavioral, psychosocial, and/or functional assessments • Identify immediate needs and implement immediate interventions if needed • Members are reassessed and care plans updated as needed (at least annually)

22. Stratification Once the assessments are complete, the member is stratified into one of four need groups • Level one – minimum provided to all Care Select members • Level two – all level one services plus more support/guidance • Level three – all level one and two services plus high level support as determined by risk issues related to health • Level four – all level one, two and three services plus support related to require most services and often face crisis situations Note: all Care Select members who are pregnant or are seriously mentally ill are automatically placed into Level two and members can be re-stratified at anytime depending on condition and need

23. Step 4. Measure Results Step 1. Assess Member Needs Step 3. Coordinate Care Step 2. Design Care Plan Step 2: Design Care Plan • Involve member, caregivers and providers in developing the member’s Care Select Care Plan: • Establishing care plan goals that are evidence-based and outcome-oriented • Taking responsibility for achieving care plan goals • Integrate goals/interventions across a member’s other care plans • Primary Care • Family Teaming • Medicaid waiver program • Individualized Education Plan (IEP) • CMHC/behavioral health treatment plan • Prioritize goals/interventions recognizing the member’s priorities

24. Step 4. Measure Results Step 1. Assess Member Needs Step 3. Coordinate Care Step 2. Design Care Plan Step 3: Coordinate Care • Share individualized care plan with: • Member/Caregiver • PMP • Waiver/CMHC Case Managers • Involve members, caregivers, Care Managers, Care Partners, Care Advocates, Family Case Managers, and providers in active dialogue about barriers, goals and progress • Web-based care plans • Care conferences • Ongoing dialogue • Facilitate communication with health care providers, i.e. physicians, community organizations, waiver programs, school-based services, and the Division of Child Services

25. Step 4. Measure Results Step 1. Assess Member Needs Step 3. Coordinate Care Step 2. Design Care Plan Step 3: Coordinate Care (cont.) • Connect member/caregiver with needed services • Advocate for member by • Removing barriers to care • Providing education about conditions, access to care, member rights and responsibilities • Facilitate member/caregiver independence through teaching and reinforcing self-management skills • Utilize the member’s comprehensive assessment and care plan to provide context and support for PA requests

26. Step 4. Measure Results Step 1. Assess Member Needs Step 3. Coordinate Care Step 2. Design Care Plan Step 4: Measure Results • Member level outcomes • Achievement of care plan goals • Annual health needs assessment • Program level outcomes • Member and provider satisfaction • Evidence-based practice • Improvement in quality of life metrics • Reduction in inpatient/ER admissions • Complaints, grievances/appeals

27. Member Support Services The CMO care management teams are engaged in the provider community in order to create a well rounded approach to providing member support, care plan development and improved treatment outcomes. The CMOs currently partner with several providers to achieve these goals: • Community Mental Health Centers (CMHCs) – incorporate behavioral health treatment plans into the member’s overall plan or care AND assist the CMHC in accessing physical health services (i.e. primary care and dental services) for their Care Select population • Developmentally Disabled (DD) Waiver Providers – incorporate the member’s plan of care developed by the Waiver case manager as well as non DD Waiver provider training materials to educate PMPs on best practices for working with the DD population AND assist the DD Waiver provider in accessing physical health services (i.e. primary care, dental, and behavioral) for their Care Select population

28. Member Support Services • Hospitals – obtaining notification from hospitals that they are about to discharge a Care Select member allows the care manager to work to ensure the member has access to needed post – inpatient services that reduce the chance of another inpatient admit • Dental – informing our members on the importance of getting dental care and reminding those, by mail, if they have not seen the dentist within the calendar year • Social Services – supporting members with social crisis (i.e. eviction, utilities disconnection) and connecting pregnant members with pregnancy related services (i.e. WIC, parenting classes, etc..)

29. Care Coordination Conferences The CMOs will coordinate with its Care Select PMPs to perform care coordination conferences to review a member’s plan of care and the progress with that plan of care. Care Coordination Conference: • is a covered benefit for Indiana Care Select Program members assigned PMP • can occur up to twice per member per rolling calendar year • will be scheduled on a semi annual basis • can be held in person at the PMP’s office or via phone conference • is a billable service (not applicable to FQHC/RHC providers)

30. Care Coordination Conference Care Coordination Conference Purpose: • open communication and coordination between all healthcare providers • to provide a forum for PMPs to interact directly with our care management teams • discuss the care plans of your patients and collaboratively decide how we can effectively facilitate the management of your patients “We realize that our members often require complex medical care from a variety of sources, which often extend beyond the confines of your office. Our goal in care management is to coordinate the efforts of the healthcare team with other participating government, social and community agencies working together on behalf of the patient.” – Indiana Care Select Program CMO Care Management Departments

31. Care Coordination Conference How to Schedule/Plan for the Care Coordination Conference : ADVANTAGE Care Select Program • Will notify each contracted PMP by mail, when it is time to schedule the conference • Mailing will include “How to schedule and complete your Biannual Case Conference” form where the PMP will: • Select date and time • Review a panel listing of your members • Identify additional concerns • Note any additional information • Fax, Email, or direct mail the panel back to ADVANTAGE prior to scheduled date of conference • each conference will last no longer than 60 minutes and can be conducted via phone or an on site visit by request (pending availability)

32. Care Coordination Conference How to Schedule/Plan for the Care Coordination Conference: MDwise Care Select Program • Will notify each MDwise PMP by mail or phone, when it is time to schedule the conference • Mailing will include a member checklist form and member’s care plan where the PMP will (Please note: Providers can sign up for CareConnect and access each member’s plan of care there rather than receiving a mailed care plan): • Review the member’s care plan • Identify additional concerns on the checklist • Note any additional information on the checklist • Fax, Email, or direct mail the member checklist form back to MDwise prior to scheduled date of conference • Each conference will last no longer than 60 minutes and can be conducted via phone or an on site visit by request (pending availability)

33. Care Coordination Conference How to Bill for Care Coordination Conferences • PMPs, or their designated nurse practitioner (NP) or physician assistant (PA) who works for the PMP or PMP’s employer such as a group or clinic are eligible to receive reimbursement from Indiana Health Coverage Programs (IHCP) for their participation in the care coordination conferences • Both the CMO and the PMP will be responsible for checking eligibility on the date of the care coordination conference • Submit claims for members discussed during the care coordination conferences to EDS as with all other covered Care Select services

34. Care Coordination Conference How to Bill for Care Coordination Conferences (continued) • No prior authorization is required for care coordination conferences • Care coordination conferences are carved out of the Third Party Liability requirements for Care Select so providers do not need to submit claims for these services to the member’s private insurance company prior to submitting them to EDS for reimbursement • Submit claims on a CMS – 1500 claim form using the CMS – 1500 paper claim format found in Chapter 8, Section 4 of the IHCP Provider Manual. Providers may also submit these claims electronically using their proprietary software or using EDS’s web interChange

35. Care Coordination Conference How to Bill for Care Coordination Conferences (continued) • The primary diagnosis providers should use when billing for care coordination conferences is either the member’s last known diagnosis related to the member’s disease state or V70.9 • All PMPs, or NPs must be linked to the billing group • The CMO and provider will identify via the CMO’s bi-annual Care Coordination Conference Checklist, potential members to be reviewed and discussed during the conference. If neither the PMP nor the CMO have issues resulting in a discussion of the member’s plan of care, the provider cannot bill for a care coordination conference for that member

36. Care Coordination Conference How to Bill for Care Coordination Conferences (continued) • The Bi-annual Care Conferences Checklist verifies the PMP’s review regarding the plan of care. Providers are required to keep a copy of the Bi-annual Care Conferences Checklist for auditing and documentation purposes • PMPs are limited to billing up to two care coordination conferences per member per rolling calendar year • The service code to be used to identify billing for care coordination conferences for each Care Select member is 99211 SC – “Office or other outpatient visit for the evaluation and management of an established patient.” Note: Please refer to both IHCP Bulletins BT200723 & BT200804 for further details

37. Care Coordination Conference How to Bill for Care Coordination Conferences (cont.) • If the PMP’s NP is in the same group or clinic as the PMP who performs the care coordination conference with the member’s CMO care manager, the NP’s IHCP provider number is appended to 99211 SC. If the NP is not enrolled in the IHCP, providers must append modifier SA • Services for NPs not linked to the PMP’s clinic or group will be denied because that practitioner does not participate in the same group or clinic as the member’s PMP and it will be assumed that those practitioners have no practical experience with that member and are not in a position to discuss that member’s plan of care

38. Care Coordination Conference How to Bill for Care Coordination Conferences (cont.) • PAs cannot enroll in the IHCP, but can participate in the care coordination conference and be reimbursed. The care coordination service code 99211 SC must be billed along modifier HN or HO (use the modifier that corresponds to the PA’s education level) • The PMP or the PMP’s NP or PA will be reimbursed by the IHCP at a rate of $40 per member per conference. PMPs, or their NP/PA who refuse to participate or do not attend a scheduled care coordination conference cannot bill the IHCP for that conference

39. Healthcare Effectiveness Data and Information Set (HEDIS) • The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). • Set of standardized performance measures based on evidenced-based best practice • HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks. • The Indiana Care Select CMO’s both use HEDIS or HEDIS-like measures to assess the quality outcomes for Indiana Care Select members.

40. HEDIS Performance Metrics Acute Inpatient Mental Illness 7 Day Follow-up (ages 6+) Planned Activity Increasing the Rate of Follow-Up after Hospitalization for Mental Illness Scope and Population • Members 6 years of age and older as of the date of discharge. • Discharged alive from an acute inpatient setting with a principal mental health diagnosis. • Eligible population is based on discharges (not members). • Includes all discharges for members who have more than one discharge on or between Jan 1 and Dec 31 of measurement year.

41. HEDIS Performance Metrics Acute Inpatient Mental Illness 7 Day Follow-up (ages 6+) RATIONALE • Over 40% of our Indiana Care Select members have a Behavioral Health Diagnosis. Selecting this particular HEDIS measure allows us to improve the health and continuity of care for a large portion of our population. • Monitoring and positively affecting this HEDIS measurement allows us the opportunity to potentially decrease high cost services by replacing them with community interventions.

42. HEDIS Performance Metrics Care Select Initiatives to Increase the Rate of Follow-Up after Hospitalization for Mental Illness • Our Care Management staff has been trained and has implemented new daily communication program between the Prior Authorization department and the Care Management Department to identify members who fit criteria. • Coordinating with providers and members to ensure that follow up care is being provided in a timely fashion. • Working in collaboration with the Office of Medicaid Policy and Planning and all of the Indiana Health Coverage Programs to increase the performance for this HEDIS metric.

43. HEDIS Performance Metrics Adolescent Well-Care Visit (ages 12-21) Planned Activity Increasing the Rate of Adolescent Well-Care Visits Scope and Population Members 12-21 who had at least one comprehensive well-care visit with a PMP or OB/GYN practitioner during the measurement year and have been continuously enrolled with no more than a 45 day gap in coverage.

44. HEDIS Performance Metrics Adolescent Well-Care Visit (ages 12-21) Rationale • The Indiana Care Select Program has received a large influx of members in this age group due to assignment of Ward and Foster children. • Establish a medical home-trust, coordination of care, outreach • Evaluate physical health, emotional health, growth and development • Allow for early diagnosis and treatment of chronic conditions, diseases • Identify and provide guidance about risky behaviors

45. HEDIS Performance Metrics Care Select Initiatives to Increase Rate of Adolescent Well Child Exams • Member Incentive to schedule and complete their Well Child exam • Provider Incentive to ensure all assigned members are receiving their Well Child exam • Initiative to increase transportation access to ensure all members are able to get their appointments

46. HEDIS Performance Metrics Breast Cancer Screening (ages 40-69) Planned Activity Increase rate of Breast Cancer Screenings Scope and Population Women ages 40 – 69 years of age who have had a mammogram to screen for breast cancer and continuously enrolled with no more than a 45 day gap in coverage

47. HEDIS Performance Metrics Breast Cancer Screening (ages 52-69) Rationale • Early diagnosis of breast cancer allows for less invasive treatment and is associated with better outcomes. • Breast Cancer Screenings have shown to reduce breast cancer mortality rates. • One in 8 women in the US will be diagnosed with breast cancer in their lifetime. • In an effort to improve the overall health of our Indiana Care Select members, we will target this preventative care measure to improve timely intervention in order to enhance treatment options.

48. HEDIS Performance Metrics Care Select Initiatives to Increase rate of Breast Cancer Screenings • Member Incentive to schedule and complete their Breast Cancer Screening • Provider Incentive to ensure their assigned members are completing their Breast Cancer Screenings • Educational mailings on the importance of women’s preventative health • Just-in-time education and assistance with appointments (during health screening and assessment, mailings, inbound calls for other reasons).

49. HEDIS Performance Metrics Cervical Cancer Screening (ages 21-64) Planned Activity Increase rate of Cervical Cancer Screenings Scope and Population Women ages 21-64 continuously enrolled with no more than a 45 day gap in coverage who received one or more Pap tests to screen for cervical cancer.

50. HEDIS Performance Metrics Cervical Cancer Screening (ages 21-64) Rationale • Early diagnosis of cervical cancer allows for highly effective treatment and cure. • Easiest form of female cancer to prevent with regular screening tests and follow-up • Control Studies have found that the risk of developing invasive cervical cancer is three to ten times greater in women who have not been screened • Screenings can detect early changes in the body that may lead to cervical cancer