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