Industry Updates: FSSA Selects MCEs, Updates to PE In-Patient Coverage, and MCE Coverage for short-term Institutional stays

FSSA Selects MCEs

The Indiana Family and Social Services Administration recently announced the selection of four vendors who will administer health care services to Healthy Indiana Plan and Hoosier Healthwise members.  The four vendors are Anthem Blue Cross and Blue Shield, CareSource Indiana, MDwise Inc. and Managed Health Services of Indiana.  CareSource is a new option for members.

What you need to know:

There will be an open enrollment period later this year for Hoosier Healthwise members who would like to switch plans.  The date for the open enrollment will be announced at a later time.  Health Indiana Plan members are able to switch plans once a year during their eligibility renewal period.

FSSA made the following enhancements to the Managed Care Entity (MCE) contracts:

  • Significantly increasing the payment tied to outcomes to further incentivize the MCEs to improve the health of the populations served. The contracts do this by progressively increasing the payment amount withheld and awarded based on outcomes from 2 percent in the first year to 5 percent in year six.
  • Adding new program integrity language that requires the plans to work with the state on identifying and investigating health care providers and members suspected of fraud.
  • Including pharmacy and dental services in the contract for the Hoosier Healthwise program, aligning with the Healthy Indiana Plan and Hoosier Care Connect programs. Care is improved for members when all services are included and coordinated under one comprehensive contract.

FSSA believes these key changes with ensure Indiana Medicaid members will get better coordinated health care and customer service form their plan.

Securing final contracts with the MCEs will depend on successful negotiations between the state and the companies.  Under state law, Medicaid contracts are four years in duration, with two optional one-year extensions.

 

More information is available here: http://www.in.gov/fssa/files/HIP_HHW_Contract_Award_Press_Release_6.10.16.pdf

 

 

Updates to PE and In-Patient Coverage

IHCP released a banner on May 17, 2016 clarifying hospital in-patient coverage for presumptively eligible members.

Prior to this banner, if you did not receive a PE approval for a patient on the same date as the in-patient admit date, none of that stay would be covered under the PE benefit.  IHCP is now clarifying that some services rendered during this visit may be covered.

What you need to know:

Covered

If a hospital admission date is before the PE start date, and the in-patient service is reimbursed on a level-of-care (LOC) per diem basis, dates of service (DOS) on or after the member’s PE start date will be covered.

Some examples of LOC services are:

  • Burn cases
  • Psychiatric cases
  • Rehabilitation cases

 

Not Covered

If the hospital admission date is before the PE start date, and the in-patient service is reimbursed using the Diagnosis-Related Grouper (DRG) methodology, no portion of that member’s in-patient stay will be considered a PE-covered service.

Providers can resubmit claims meeting the policy guidelines with dates of service back to February 15, 2015.

For a printable quick reference and example, please click here.

Click here to read the full banner from IHCP.

 

 

IHCP allows MCEs to authorize short-term institutional stays

 

IHCP released a bulletin on June 30, 2016 announcing that MCEs may authorize coverage for members in need of short-term stays in institutions for mental disease (IMD).

 

What you need to know:

Members aged 21-64 enrolled in HIP, Hoosier Care Connect, and Hoosier Healthwise managed care programs can be authorized for stays in an IMD for inpatient services related to mental health, behavioral health, and substance use disorder in lieu of other settings under Indiana’s Medicaid State Plan.    If the member’s IMD stay exceeds 15 days in a calendar month and the member is awaiting placement in a state hospital, the member will be disenrolled from the MCE and enrolled in Traditional Medicaid.   For all other stays greater than 15 days in a calendar month, the member will remain enrolled with the MCE and continue to receive care.

Click here to read the full bulletin from IHCP.

 

ClaimAid is a leading provider of comprehensive eligibility and enrollment services and claims resolution for hospitals, patients, individuals and their families.  For more information about these services, please visit: https://www.claimaid.com or contact the ClaimAid Corporate Office at 800.842.4052.