February 16 Overview Webinar
On February 16, 2015, FSSA hosted a leadership update on the implementation of the new Healthy Indiana Plan – HIP 2.0. The meeting, held live at the Indiana Government Center and statewide via webcast, included a comprehensive overview of the program before a question and answer session. The resources below are from this event.
Questions and answers from February 16 Healthy Indiana Plan overview
Additional questions should be submitted to HIP2.firstname.lastname@example.org
Q: With regard to the medically fragile, will they be using the Office of Medicaid Policy and Planning (OMPP) medical policy manual? And how will the state perform quality assurance review across plans to ensure consistency of the prior authorization (PA) decisions?
A: We have had prior authorization requirements in the Healthy Indiana Plan and in our other Medicaid programs. We do monitor the performance of our health plans in administering prior authorization standards. We have external quality review of PA processes regularly where we ensure that they are adhering to the proper standards around utilization management. That will continue. The plans will have their own prior authorization requirements, and there are variations between the plans and how they approve services.
Q: Will the HIP plans include Medicaid Rehabilitation Option (MRO)? And how will we be notified? Will it be based on level of need like it is now?
A: MRO is a service available within HIP State Plan benefits. Individuals who are pregnant or medically frail will have access to that benefit package, and it will be based on level of need. Individuals can also be eligible for the program through our 1915(i) program. MRO continues to be carved out, and there will be no changes for individuals currently eligible who may not be in HIP. HIP State Plan Basic members will be assessed a copayment for accessing MRO services.
Q: Is a navigator required to complete the HIP 2.0 application?
A: No, a Navigator is not required. The application can be completed by the applying individual online, and the individual can also walk into any Division of Family Resources office to receive help in completing the application.
NOTE: Individuals who assist Hoosiers with application for and enrollment in the federal Marketplace (www.healthcare.gov) and/or Indiana Health Coverage Programs (such as Medicaid, CHIP or HIP 2.0) are required under Indiana Code 27-19 to be certified as state navigators, and organizations that employ individuals to perform one or all of these functions must be registered as an application organization (AO) under IC 27-19. Certification procedures are posted online at http://www.in.gov/idoi/2823.htm.
Q: If a member does not pay their POWER account contribution until the 10th of the month but incurs expenses on the 2nd, will those services be paid.
A: We do go back and pay for services for the month in which the first POWER account contribution is paid and in any month in which a POWER account is made (if the individual has met all eligibility requirements for that month.)
Q: Will there be any funding provided to community non-profits to assist them with HIP education and enrollment?
A: At this time, funding for enrollment outreach will be dedicated at the state level for the state’s public education campaign.
Q: What options are available for those individuals who are over 64 but not eligible for Medicare?
A: Those over 64 and eligible for the low-income group continue in HIP 2.0 if they are not eligible for Medicare. Those over 64 and not eligible the low-income group are not eligible for the Healthy Indiana Plan, regardless of their Medicare eligibility, since the federally defined eligibility category covered under the Healthy Indiana Plan excludes those age 65 and older. These individuals may qualify for Medicaid the basis of age if they meet the Aged, Blind and Disabled income and resource requirements.
Q: Is HIP going to waive in the future the five year wait for lawful immigrants?
A: There is not a waiver of this requirement. (NOTE: The five year waiting period applies for immigrants that have the status of lawful permanent resident (LPR). Other “qualified” aliens and certain U.S. military service members and veterans are not subject to the five year waiting period.)
Q: We have had patients come into the hospital with a card showing “Anthem HIP Plus plan,” but on the card it states they have an $8.00 copay for emergency services – not non-emergent and that it increases for each visit. According to the HIP information, those in the State Plus plan shouldn't have any copays. We have seen a few patients now that have this information on their cards. Why would they have a copay listed on their card if the only exception is the $25 copay for non-emergent care?
A: “State Plan” refers to the benefit package. If you see “State Plan Plus,” it means the member has State Plan benefits but they are making their monthly contribution. They do not have copays except for inappropriate use of the ER. Those copays cannot be made out of the POWER account. The copay is $8 for first visit and $25 for subsequent visits. The member’s health plan will let you know the amount of copayment for each member. NOTES: Members may have their copayment waived by calling their plan’s nurse hotline prior to visiting the emergency room if the nurse recommends they go to the emergency room. ER copayments are not applicable to Native Americans, pregnant women and those that have met the 5 percent cost sharing in that quarter.
Q: In the CMS Terms and Conditions document there is no specification that contributions from third parties are limited to employers or not-for-profits. So, is it ok if a for-profit makes the contributions for the individual?
A: There is no exclusion for for-profit entities. The special terms and conditions do talk about providers being mindful of potential inducement issues.
Q: If the member pays their PAC at locations, is this at no cost to them.
A: Individuals should contact their health plans for more information about how to make payment at any of the locations available to them.
Q: Will women who are pregnant at time of application be awarded any retro coverage like they were under Hoosier Healthwise.
A: Yes. Eligibility for the three months prior to the date of application will be evaluated for each applicant. However, the individual must meet all of the eligibility requirements for the applicable category. There is no retroactive coverage in any of the HIP 2.0 categories but an individual may qualify for another category, such as Family Planning Services for Women and Men, in the retroactive months. If the pregnant women was not pregnant in the retroactive months or did not meet the eligibility requirements in those months, retroactive coverage cannot be awarded.
Q: If someone is currently in the marketplace and needs to transition to HIP due to income level, will be they be receiving letters?
A: Yes we have sent letters to individuals we are aware of who have coverage and need to enroll in HIP (for more information, click here) We continue to work with the federal marketplace to identify any other members as there are ongoing enrollments with the federal marketplace. More letters will be sent as additional members are identified.
Q: Will the Gateway to Work program become mandatory in the future?
A: It is an optional program and will remain optional.
Q: Could a non-profit pay the POWER account contribution of a homeless person?
A: For any individual to participate in the HIP Plus program, they need to make their required POWER account contribution of at least $1 per month. If they do not make that contribution they are still eligible for HIP Basic as long as they are below the federal poverty level. So they would still have access to the essential health benefits. A non-profit may make contributions on behalf of the individual (Up to 100 percent of the entire member contribution amount.)
Q: If a consumer is now pregnant and meets the income level to be eligible for HIP but already has insurance with her employer. Can the consumer leave her employer insurance to get HIP?
A: Yes, this person could keep her employer insurance and still qualify for the Healthy Indiana Plan. If the member feels like the HIP benefit is more appropriate for her, it is her choice if she would prefer to apply for HIP. If found eligible, the member would be enrolled in HIP Maternity.
Q: If a consumer has State Plan Basic, will he or she owe a separate copay for each service rendered in a day? For example, if a patient saw their PMP, received lab services, and had an x-ray would the charges total $12?
A: Yes. A consumer could owe $12 for those services. They will be charged a copay for every service rendered throughout the day. This is one reason why we encourage members to participate in the Plus program because it ends up being a better value for the consumer.
Q: Can HIP 2.0 be a secondary to a private insurance plan, like Tricare?
A: Yes. And Medicaid programs are always the payer of last resort.
Q: A HIP-eligible citizen's only household income is from spouse whose immigration status was denied renewal, if they report this income, will the citizen's spouse run risk of immigration interrogation.
A: DFR will need to verify income and where it came from, regardless if the income is being reported for tax purposes by the client or the employer, but DFR does not report “undocumented” aliens.
Q: Can pregnant women use HIP Maternity as supplement to their private insurance?
A: Yes, and HIP benefits or Medicaid benefits are always the benefits of last resort.
Q: If pregnant women are sick not due to condition and their Ob/Gyn does not treat them for anything not related to pregnancy is there any issue with them seeing a previous family practice doctor?
A: The member should contact their health plan to ensure the provider she wishes to see is in-network and possibly receive a referral to another primary care provider if not.
Q: Could you explain why a new hospital presumptive eligibility (HPE) HIP application would be denied for the reason "HIP conditional status, not eligible for HPE?” The person states they have not applied for HIP previously.
A: An individual can apply for HPE. That should not be impacted by the status of their application. They can call the enrollment broker at 1-877-GET-HIP-9 or DFR at 800-403-0864 to work through their individual situation and eligibility status. Individuals that are conditionally eligible are eligible for HIP and can start HIP coverage by paying their POWER account contribution. Since they have verified HIP eligibility pending a POWER account contribution, they are not eligible for HPE.
Q: As a Federally Qualified Health Center, we cannot turn away a patient. If they cannot make the copay at the time of visit, what is the alternative to collecting? Or is it written off as goodwill?
A: It is up to the individual provider organization. Medicaid requires that an individual cannot be turned away if they cannot pay. It is between the provider and the individual how payment is worked out at a later time.
Q: If preauthorization has been received for a dental service and between the time that the preauthorization (PA) was received for the service and between the time the PA was received and the patient comes in for a service he/she does not pay a POWER account contribution, where does that leave the provider?
A: We are honoring any PA that was done previously. Individuals who are converting to HIP and had dental benefits previously will be on the HIP State Plan and have dental benefits. They will have copayments until they make their POWER account contribution.
Q: What are the specific outpatient services subject to a copayment in mental health, or what services are not subject to the $4 copayment? Also, is the $75 inpatient copayment a per-stay, or per-day copayment?
A: All outpatient services are subject to a copay except for preventive services, which would include family planning services and maternity services. Dental cleanings are also preventive services. The $75 inpatient copayment is per-stay.
Q: The chronic substance abuse patient has never been considered medically frail in the past. Therefore, how can we be assured the HIP application won't be denied before the medically frail assessment has been determined?
A: There are two different processes to determine eligibility and medically frail status. When we get the application, it is used to determined financial eligibility for the program. The medically frail determination process is separate. Once they are determined eligible, if they indicate they have a condition that would qualify them as medically frail, then they are referred to the health plan to validate that condition.
Q: If a client’s Marketplace eligibility notice states the consumer may be eligible for HIP, can we also still go to the HIP website and sign them up? Is this recommended? Or will this cause their application to be denied due to duplication?
A: We encourage individuals to follow the instructions set forth in the notices they receive. These instructions can also be found on our website here. A potential HIP member could also apply with the state while still covered by the exchange. We recommend an individual NOT cancel his or her marketplace coverage until being enrolled in HIP.
Q: If you already have HIP, will you be automatically enrolled in 2.0?
A: Yes, and this was effective February 1, 2015.
Q: When is the Provider Profile page of the Medicaid InterChange website going to be updated to allow Community Mental Health Centers to be HPE providers? We note this has been made available for FQHCs, but not for CMHCs yet?
A: At this time, hospital presumptive eligibility is only available through certified hospitals. We are working on a timeframe for presumptive eligibility to be available through FQHCs, CMHC, local health departments and rural health centers.
Q: If HIP is still not providing retroactive coverage for pregnant women, will the woman have the option to transfer to the Pregnancy traditional Medicaid to cover the dates prior to application?
A: If a woman is pregnant at the time of application, she would enroll in HIP Maternity. She would be considered for retroactive coverage but will need to meet all of the eligibility requirements in the retroactive months.
Q: If someone previously purchased insurance on the federal exchange, but is now considered eligible for HIP 2.0, when does previous coverage end and new coverage start? How is notification made to the individual? When is the POWER account contribution to be made?
A: If an individual is currently receiving coverage through the marketplace we encourage them to apply or take action now. If found eligible they will be notified in writing and should discontinue marketplace coverage after becoming enrolled in HIP.
Q: For reimbursement purposes at an FQHC, are the HIP plans going to pay the same enhanced rate just as Medicaid? Will the billing codes remain the same?
A: Yes, they will remain the same. The health plans are required to pay the prevailing Medicaid rate to the FQHCs.
Q: Will the Operations Policy and Procedure Manual be updated soon to outline the new rules and regulations?
A: Yes, we are working on that now.
Q: Will emergency services Medicaid still be an option for non-citizens and will it still provide retroactive coverage if so?
A: Immigrants who meet all of the eligibility requirements for HIP but are not U.S. citizens or are not “qualified” aliens can only be eligible for “emergency services only” coverage. These individuals are covered under the applicable HIP category but their coverage is limited to “emergency services only,” and since there is no retroactive coverage under the HIP categories, these immigrants will not be given retroactive “emergency services only” coverage. Coverage for “emergency services only” would begin in the month DFR makes the eligibility determination.
Q: Are non-licensed behavioral health clinicians covered for all HIP plans?
A: We do not allow for unlicensed practitioners in our program. All Medicaid providers in Medicaid or the Healthy Indiana Plan have to be enrolled as an enrolled provider in the Indiana Medicaid program and we ask for credentialing info in that provider enrollment packet, and licensure is one of the credentials we have as a requirement for participation.
Q: What form of proof will be needed to prove a case of domestic violence so they don't have a POWER account contribution?
A: This really applies to the lockout, not the POWER account contribution. If a member with an income above the federal poverty level missed a POWER account contribution and was disenrolled and wanted to appeal that, they could submit proof that they were a resident of a domestic violence shelter, a police report or a doctor’s validation, they would be exempt from the lockout, but not from making POWER account contributions. (NOTE: Other documentation that proves domestic violence will be accepted by the DFR on a case-by-case basis.)
Q: Are HIP 2.0 members eligible for home health care?
A: Yes, home health care is a covered benefit.
Q: Will Medicaid Rehabilitation Option (MRO) be subject to the copayment under HIP Basic.
A: Yes, in the HIP State Plan Basic, MRO is subject to the copayment. The member can avoid copayments by making POWER account contributions to participate in HIP State Plan Plus.
Q: Do employers face a potential fine (like in the marketplace) if an employee enrolls in HIP 2.0?
A: They do not face any penalties.
Q: Will the Managed Care Entities recognize a member's current authorized representative?
A: No, the Managed Care Entities (health plans) do not receive information about authorized representatives. (NOTE: the authorized representative for Medicaid eligibility is not provided by the state to the MCEs. However, the MCEs may have a process in place for having a member authorize someone else to be given information from the MCE.
Q: How are you handling applications from someone who is also applying for disability coverage but would like to enroll in HIP while the medical review team determines disability?
A: Eligibility for HIP and disability can be processed concurrently. A member may enroll in HIP while completing their disability determination. Only one application is required to be filed. If an individual is indicated as “disabled” on the application that will be the category that DFR will pursue. If not found disabled, the individual will then be looked at for other categories, including HIP 2.0. If the disabled individual wants to be considered for both categories at the same time, the individual will need to indicate that to the DFR, preferable during the interview which is required for Medicaid for the Disabled.
Q: Do dental and vision providers have to contract with an MCE in order to accept someone with HIP?
A: Yes, vision and dental benefits are provided through the health plan contracts so the provider must be contracted with the member’s health plan as well as with Indiana Health Coverage Programs.
Q: If a not-for-profit contributes for a homeless person, would the homeless person have to declare that as income on a tax return?
A: No (NOTE: Member POWER account contributions made by a non-profit to the MCE is not considered as income to the member and would not be counted as such in the eligibility determination.)
Q: We are still seeing Family Planning coming back as a verified plan. Can you confirm this plan effectively stopped on 1/31/15? And, if so, should we be registering those patients as self-pay?
A: Family Planning is a very limited benefit plan. Individuals can enroll in this if they don’t qualify for any other category. Now with the advent of the HIP program, individuals with incomes under 138 percent of the federal poverty level no longer qualify for the family planning benefit because they now qualify for the HIP program. The Family Planning category will still exist for individuals that meet the criteria and are not HIP eligible.
Q: Since MRO services are carved out of HIP 2.0 how will HP know that a member isn't making contributions and apply copay?
A: A provider can look up a member’s eligibility in the validation system and it will indicate the benefit level and program of the member. When they see “HIP State Plan PLUS” it will indicate no copayment is due and “HIP State Plan BASIC” indicates a copayment is required.
Q: How do clients choose Basic vs. Plus plans?
A: All clients start with the opportunity to enroll in the HIP Plus program. If they make a POWER account contribution within 60 days, they can start in the HIP Plus program. If they don’t make that contribution and they’re above 100 percent FPL, they won’t have any benefits. That’s the only option available to them. Individuals that are below 100 FPL, if they do not make a contribution then they will default into the HIP Basic program.
Q: If clients were put into the HIP Basic plan can they change plans?
A: Yes, but they can only get back in the HIP Plus program at their annual redetermination, or if they have a POWER account rollover, that will also give them another opportunity to enroll in HIP Plus.
Q: So as before with the Healthy Indiana Plan there are no out-of-network benefits. Is this correct?
A: There are some accommodations made for emergency services.
Q: Can hospital inpatient services be reimbursed under the HPE number or do we have to wait until the HIP application is approved?
A: Services can be reimbursed during the presumptive eligibility period.
Q: Do any of the HIP 2.0 programs cover long-term care?
A: Long-term care is covered on the HIP State Plan. There are skilled nursing facility benefit s on all HIP plans, but if someone needs residential long-term care, they need to look into transitioning to the benefits on the Medicaid State Plan or in the Medicaid for the Disabled/Blind category.
Q: Please clarify use of licensed eligible, master’s level therapists providing Medicaid services?
A: Licensed clinical social workers and licensed mental health counselors can provide services to members in accordance with Medicaid guidelines for mental health services. However, those services must be supervised and billed under a psychiatrist or HSPP in accordance with Indiana Administrative Code.
Q: If I make $2,800 a month and I have three dependents, I don’t qualify according to the online calculator but I have exception. Do I still qualify for HIP?
A: The calculator only considers family income and size. It is meant only as an overview tool. The only way to know if an individual qualifies is if they apply and complete all required verifications. (NOTE: In this particular scenario with a monthly income of $2800 and family size of four, this person would qualify under 2014 FPL standards).
Q: Is it correct that a lockout has to be triggered by failure to make POWER account contribution?
A: Yes, for individuals with incomes above 100% FPL fi they are not medically frail and do not make a POWER account contribution within 60 days they are subject to a lockout. This is also true if they fail to return redetermination paperwork. Exemptions such as residing in a domestic violence shelter or a state-declared disaster area apply.
Q: What about self-referral services? What is considered self-referral in HIP 2.0 and can't members seek out this care whether provider is in or out of network so long as an IHCP provider? Vision, Dental, Family Planning were considered some of these "self-referral" services.
A: The following are self-referral services for HIP 2.0. Some services are limited to self-referral only for in-network providers and not all services are available to every HIP member.
- Emergency services
- Urgent care services (subject to network requirements)
- Diabetes self-management services (in-network)
- Family planning
- Psychiatric services
- Behavioral health services (in-network)
- Podiatric services
- Eye care services, except surgical services (Plus and State Plan only)
- Chiropractic services (State Plan and pregnant women only)
Q: If a consumer above 100 percent of the Federal Poverty Level was requested to submit documentation but fails to return it before the first PAC is due, will this individual be subject to a lock-out period?
A: Individuals are not subject to a lockout period for failure to pay a first POWER account contribution. It’s only when they are enrolled, failure to pay a subsequent PAC makes them subject to lockout.
Q: Which tax exemptions does the FSSA consider when determining income: student loan interest, mortgage interest, child support?
A: (Note: We are interpreting “exemptions” to mean deductions from earned and unearned income. Below is a list of allowable deductions from the Indiana Health Coverage Program Policy Manual.)
a) Educator expenses
b) Certain business expenses of reservists, performing artists, and fee-basis government officials
c) Health savings account deduction
d) Moving expenses
e) Deductible part of self-employment tax.
f) Self-employed SEP, SIMPLE and qualified plans
g) Self-employed health insurance deduction
h) Penalty on early withdrawal of savings
i) Alimony paid by recipient’s SSN
j) IRA deduction
k) Student loan interest deduction
l) Tuition and fees
m) Domestic production activities deduction