About Indiana Medicaid

How Medicaid Benefits Indiana

Good health is important to everyone. Medicaid provides a healthcare safety net to almost one million Hoosiers who are low income, aged, disabled, blind, pregnant, or meet other eligibility requirements.

As of June 2010, there were 997,499 Medicaid members.  Of that number, 61.7 percent are children (age 0 to 18) and 38.3 percent are adults (age 19 and above).

Delivery Systems

Medicaid services are provided to members through multiple delivery systems. To be reimbursed for services, providers must enroll with the Indiana Health Coverage Programs (IHCP).

For special programs, providers must specifically request to be enrolled in (opt into) the program. This includes the following programs:

  • 590 Program
  • Medical Review Team (MRT)
  • Notification of Pregnancy (NOP)
  • Presumptive Eligibility (PE)
  • Pre-Admission Screening and Resident Review (PASRR)
  • Waiver

Enrollment in special programs can be done at the time of initial enrollment or at a later date as an update to the provider's IHCP enrollment profile.

http://provider.indianamedicaid.com/become-a-provider/enroll-as-a-provider.aspx

Traditional Medicaid

In Traditional Medicaid, sometimes called Fee-for-Service (FFS), providers are reimbursed per service. Providers bill the IHCP claims processing contractor, HP, for services rendered to members in programs subject to FFS.

Indiana Care Select

Care Select operates as a fee-for-service (FFS) delivery system with a gatekeeper approach. Each Care Select member is linked to a Care Select-enrolled primary medical provider (PMP), who provides or arranges for most of the members' medical care.

Care Select is similar to Traditional Medicaid in that services are reimbursed on an FFS basis. In addition, a $6 per-member, per-month administration fee is paid to PMPs, with the exception of rural health clinics and Federally Qualified Healthcare Centers.

PMPs in Care Select contract with care management organizations (CMOs) through an addendum to their Indiana Health Coverage Programs (IHCP) Provider Agreement. Providers should contact the CMOs with which they wish to enroll. The CMOs are responsible for enrolling PMPs into Care Select.

Member enrollment in Care Select is limited to recipients in certain aid categories who have specific disease states. PMPs may refer Medicaid patients with qualifying disease states to the enrollment broker (EB). Members have the option to "opt in" to the program once they are determined eligible (meaning they are in an appropriate aid category and have one or more qualifying disease state). Eligible Care Select members are not required to enroll if they choose not to.

Risk-Based Managed Care

The State has mandated risk-based managed care (RBMC) enrollment for eligible members. The RBMC program is called Hoosier Healthwise and offers the following benefit packages.

  • Package A - standard Plan; full coverage for children and low-income families (the package also covers Care Select).
  • Package B - pregnancy coverage only; pregnancy-related, postpartum care, family planning, pharmacy, transportation, and urgent care services for some pregnant women.
  • Package C - Children's Health Plan; preventive, primary, and acute care services for some children under 19 years old.
  • Package P - Presumptive Eligibility; presumptive eligibility for pregnant women

In RBMC, the State pays contracted managed care organizations (MCOs) a set, monthly fee for each member enrolled in the MCO's plan. This fee, called a capitation premium, covers the cost of care for services covered under the MCO program and incurred by IHCP enrollees in the MCO plan. The MCO assumes financial risk for services rendered to members in its plan.

Each MCO maintains its own provider and member services units. Each MCO pays claims, performs PA, and is responsible for subrogation activities.

All providers rendering services to Hoosier Healthwise members must enroll with the IHCP and one or more of the managed care organizations. This provision also includes out-of-state providers. Providers should contact the MCO for specific claims payment and PA policies and guidelines.

MCO members who qualify for hospice care, long-term institutional Level of Care, or waiver Level of Care are disenrolled from Hoosier Healthwise and placed in Traditional Medicaid. In addition, some Level of Care members may be eligible for the Care Select program.

Some services are excluded from RBMC and are said to be "carved out." Carved-out services are the financial responsibility of the State and are billed directly or indirectly to HP for reimbursement as FFS. Examples of carved out services include dental, pharmacy, and self-referral services.

The Healthy Indiana Plan

The Healthy Indiana Plan (HIP) is a program sponsored by the State of Indiana, that provides affordable healthcare choices to thousands of otherwise uninsured individuals throughout Indiana. HIP coverage is focused on preventive services and covers essential medical services, similar to commercial plans. The first $500 of preventive care services at no charge to member and does not require payment from each member's POWER account. There is an annual limit of $300,000 per year for services, and a lifetime maximum of $1 million.  Providers must be contracted with a HIP plan in addition to being a Medicaid (IHCP) provider to render covered services to HIP members.

The Enhanced Services Plan (ESP) is a special plan for some HIP enrollees with certain high-risk medical conditions. Applicants are screened for complex medical conditions, such as cancer, HIV/AIDS, hemophilia, transplants, and aplastic anemia. HIP enrollees who qualify are assigned to the ESP. The ESP provides all HIP benefits in addition to comprehensive disease management services.  Any Medicaid (IHCP) provider may render covered services to HIP members; ESP providers are not required to have a contract with ESP (administered through ICHIA).