• Q:  Why is the state making more changes?
• Q:  When do the new health plans start?
• Q:  When do contracts have to be signed?
• Q:  Am I required to sign up with more than one health plan?
• Q:  How does this affect my aged, blind, and disabled Medicaid patients?

• Q:  Are my patients being notified of this change?
• Q:  Will my patients automatically transfer with me?
• Q:  Will I need to have the same panel size with all plans?
• Q:  Will I have to increase my current panel size?
• Q:  Where will I send panel-full add requests, patient reassignment requests, pre-birth PMP selections, and requests for member education and intervention?
• Q:  Will the revised MCO contracts involve specialist contracts as well as PMPs? Hospitals? Ancillary?
• Q:  Does this affect the ''carve-out'' providers?
• Q:  Does this affect the self-referral providers, such as podiatrists, vision care, chiropractors, and so forth?

• Q:  Will my reimbursement change?
• Q:  Do I have to receive capitation payment?
• Q:  Will other physicians in my group practice be eligible for reimbursement?
• Q:  If I choose not to contract with a MCO, will the State reimburse me for medical record duplication expenses for my patients that are transferred to another doctor?
• Q:  How much will I get paid if I don’t contract with an MCO but provide services to an MCO member?

• Q:  How does this affect my time limit for filing claims?
• Q:  Can I continue to submit my claims on paper or electronically?
• Q:  What if I disagree with how an MCO handled my claim?

• Q:  Do I have to complete another application or contract?
• Q:  Should I begin contract discussions with an MCO now?
• Q:  What is the latest date I can sign-up with a MCO before I lose my Hoosier Healthwise patients?
• Q:  What if a MCO does not contact me? How long should I wait before I call them?
• Q:  What if I am dissatisfied with my MCO. Can I change to another one?
• Q:  What if I have a patient who may qualify for Medicaid disability?

• Q:  If I sign up with two health plans, how will my members be assigned?
• Q:  How will this affect the rate of auto-assignments to me?
• Q:  Will patients that I have previously disenrolled be assigned to me?

• Q:  Do I have to send my patients to different hospitals?
• Q:  Will the eligibility verification process be the same?
• Q:  Will my patients continue to use the Hoosier Health Card?
• Q:  Do I need to resubmit requests for prior authorization or referral requests to providers that I have previously issued?
• Q:  If a hospital has an inpatient on the transition date, does the MCO need to be contacted for a new authorization to be reimbursed?
• Q:  Can I continue to prescribe the same prescription drugs?
• Q:  Can I continue participation in the Vaccines for Children (VFC) program?

A: The Office of Medicaid Policy and Planning (OMPP) seeks to improve health care delivery to Hoosier Healthwise Program. To accomplish this task, the State is implementing the following features to the Hoosier Healthwise Program effective January 1, 2007:

1. PMPs may contract with multiple MCOs – All managed care organizations (MCOs) will have the opportunity to contract primary medical providers (PMPs), specialists, and other providers. PMPs will have the option to contract with multiple MCOs.
2. New regions – The State is required by Federal regulation (42 CFR 438.52) to offer the choice of at least two MCOs in each non-rural area. The regions are designed to include at least one non-rural county and provide two MCOs in each region.
3. Covered services – The State is requiring the MCOs to manage behavioral health care, including mental health, substance abuse, and chemical dependency services, to promote comprehensive and coordinated medical and behavioral services for the Hoosier Healthwise members. Services for Medicaid Rehabilitation Option (MRO), Psychiatric Residential Treatment Facility (PRTF), and long-term inpatient services in State-operated facilities are excluded from the behavioral health requirement.
4. Provider networks – MCOs must offer a provider network in each region that meets the State’s requirements for access, availability, and comprehensiveness. MCOs must contract with Community Mental Health Centers (CMHCs), Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs). MCOs should also affiliate with Women, Infants, and Children (WIC) clinics, school-based health clinics, homeless shelters, and other providers of service.
5. Health information technology and data sharing – Electronic data sharing will improve the quality of care provided to Hoosier Healthwise members while decreasing MCO and provider costs in the long term.

A: The new Hoosier Healthwise plans begin on January 1, 2007.

A: PMP contracts must be signed by October 30, 2006.

A: Providers have the choice to contract with more than one health plan, but are not required to do so.

A: Medicaid Select members in the Aged, Blind, and Disabled categories are not affected. To provide care to these members, providers should enroll in the Medicaid Select program.

A: Notices are being mailed to the members from September through November 2006, and will provide information about the changes for 2007.

A: In most cases, yes. If the PMP enrollment in the MCO is completed by the deadline date, your members will automatically transfer to you in the new plan. Wards of the court and foster children on your panel will be manually reassigned to you.

A: PMPs are required to have a minimum panel of 150 members with at least one MCO and panels greater than zero for all other plans. There is no longer a maximum panel limit.

A: PMPs may choose to increase their panel sizes at this time, but it is not a program requirement.

A: Send future requests to your MCO Provider Services Department. Direct full panel add requests to the enrollment broker.

A: Each MCO must comply with specific provider network composition requirements to ensure adequate access to the full spectrum of health care services for its members within its network. With closed networks, services must be rendered by MCO-contracted providers. MCOs must pay out-of-network providers at 100 percent of the Medicaid rate, unless they have an agreement with the provider.

A: Yes, the behavioral health providers, including mental health, substance abuse, and chemical dependency services are no longer considered “carved-out” and payment for these services are the responsibility of the MCO. Medicaid Rehabilitation Option (MRO), Psychiatric Residential Treatment Facility (PRTF), and long-term inpatient services in State-operated facilities are not included and still considered carved out.

A: There are no changes for these providers. The MCOs continue to be responsible to pay for self-referral services for their members. The claims for these services must be sent to the appropriate MCO for payment.

A: Reimbursement arrangements are determined contractually between the MCO and provider.

A: How you will be reimbursed is part of your negotiation with the MCO.

A: Yes. All IHCP providers are eligible to receive reimbursement subject to MCO referral and prior authorization requirements.

A: Federal regulation 42 CFR 447.15 provides that providers participating in Medicaid must accept the State’s reimbursement as payment in full (except that providers may charge for deductibles, co-insurance, and co-payments). The reimbursement for services and the monthly administration fee you receive is intended to cover those costs. You do not receive additional reimbursement from the State for any cost associated with medical record duplication. In addition, any physician receiving payments from the IHCP for rendered services may not charge an IHCP member for medical record copying or transferring.

A: MCOs must pay out-of-network providers at the lesser of the provider’s usual and customary charges or 100 percent of the Medicaid rate, unless they have a different agreement with the provider. Out-of-network services, except for emergency services, require prior authorization from the MCO.

A: Non-contracted providers have one year to file the claims with the MCO unless they have another arrangement. Contracted providers will have 180 days, or less, for claims that do not involved third party payers. This may be part of your negotiations with the MCO.

A: Yes, contact the MCOs for more information on how to submit claims. MCOs may have different claims submittal procedures and software options.

A: Providers must send MCO claim disputes to the member’s MCO (Anthem, CareSource, Harmony Health Plan, Managed Health Services (MHS), MDwise, or Molina). Medicaid rule 405 IAC 1-1.6 outlines the MCO claims dispute process for out-of-network providers. Although a provider may make verbal inquiries at any time, the rule requires the provider to send an informal, written objection to the MCO within 60 days of the provider’s receipt of claim payment or denial. If the matter is not resolved to the provider’s satisfaction within 30 days of the commencement of the informal process, the provider has 60 days to submit a formal appeal to the MCO. Contracted providers have a similar dispute process in their contracts with the MCO.

A: Yes, all current contracts expire December 31, 2006, so you must sign a new contract with a MCO. However, your enrollment in the IHCP is not affected unless you choose to make other changes.

A: Yes, you should begin negotiations as soon as possible. OMPP is requiring the MCOs to have an adequate provider network by November 1, 2006.

A: PMP contracts must be signed by October 30, 2006, two months prior to the mandatory transition date. This enables the MCOs, EDS, and AmeriChoice to process all the appropriate changes and address any outstanding issues.

A: You are encouraged to contact the MCO now, if they have not already contacted you. The earlier you begin the process, the better.

A: Yes, you may contract with another MCO. All PMP contracts expire December 31, 2006, when the current MCO/State contracts expire.

A: The member must initiate the disability determination process by contacting the caseworker at the local office of the Division of Family Resources (DFR).The request for Medicaid disability determination must come from the member or authorized representative and cannot be made by a health care provider or other third party.

A: If you change MCOs or add an MCO, your members will stay with you and be assigned to the MCO with the lowest number of enrolled members. If you do not change or add MCO affiliations, your members will also stay with you. The auto-assignment process reviews for previous PMP relationships, family relationships, and MCO relationships. If no match is found, the process compares member's geographical coordinates to PMPs in MCO with the lowest number of enrolled members in closest proximity order.

A: There will be little effect on the rate of auto-assignments to your practice. But in the transition to January 1, 2007, your payer mix may be affected.

A: Member assignment should be based on the members enrolled in your panel on the effective date of transfer to the new MCO. However, members previously assigned to you may get reassigned to you, in which case you would need to resubmit a request for reassignment.

A: This depends on the MCO in which you are enrolled, and if it has open or closed networks. Some MCOs only allow their providers to use the hospitals with which they are contracted, while others allow the provider to decide which hospital to send the patients. MCOs require prior authorization for inpatient admissions.

A: Yes. The OMPP recommends that all providers verify member eligibility each time a member presents for services, before the service is rendered. Eligibility verifications include the following options: Automated Voice Response System (AVR), OMNI, and the Web interChange Web site.

A: Yes. They may also have an additional card issued by the MCO that identifies them as a member of the MCO’s plan.

A: To promote continuity of care, existing referral requests and prior authorizations are honored for at least the first 30 days after the transition date. Beyond that time, referral requests and requests for prior authorization must be resubmitted to the MCO.

A: No, but notifying the new MCO would be appreciated for coordination and discharge planning purposes. For diagnosis-related grouping (DRG)-based reimbursement, the MCO on the date of admission is responsible for the hospital claim for the entire length of stay. However, per diem and professional services are reimbursed by the plan in effect on the date of service. The provider should contact the MCO for billing questions. Hospital transfers require authorization by the MCO in effect on the date of transfer.

A: Maybe. You will need to become familiar with your MCOs formulary.

A: Yes.