FAQs for PMP Selection

FAQs for PMP Assignment

As previously announced in bulletin BT201038, the Office of Medicaid Policy and Planning (OMPP) consolidated the contracts for the managed care entities (MCEs) that manage the Hoosier Healthwise (HHW) and Healthy Indiana Plan (HIP) programs. With this consolidation, effective January 1, 2011, the scope of the MCE's role changed to include responsibility for assigning its members to primary medical providers (PMPs) within their plan. This change in responsibility for PMP assignment has elicited several recurring questions from providers. This article addresses those frequently asked questions with consistent guidance. Providers should continue to contact members' assigned MCEs for questions regarding obtaining PA and claims processing.

FAQs

Q: Who is responsible for MCE assignments and PMP assignments?

A: The Indiana Health Coverage Programs (IHCP) enrollment broker continues to be responsible for assisting members with MCE selections and making member MCE assignments. Members with questions regarding which MCE is right for them should be referred to the enrollment broker for assistance. Beginning January 1, 2011, the MCEs are responsible for assisting members with PMP selection and assigning members to PMPs. Members with questions concerning their PMPs should be referred to the MCE to which they belong. No longer will the IHCP enrollment broker or the IHCP Call Center make PMP assignments for members.

If a member does not select a PMP within the first 30 days of assignment to an MCE, he or she will be auto-assigned to a PMP by the MCE, in accordance with the auto-assignment logic described in BT201038.

Q: What should a PMP do if a member shows an MCE assignment, but no PMP assignment on Web interChange?

A: Because MCEs are now responsible for assigning members to PMPs, there may be a lag time between when the member becomes enrolled with an MCE and when the MCE makes a member's PMP assignment. Until the MCE transmits the PMP assignment, Web interChange shows "PMP not available."

PMPs seeing a member for whom Web interChange shows "PMP not available" should inform the member to contact his or her MCE and request a PMP assignment if he or she has not already done so. As long as the PMP is a participating provider under with the member's MCE, the provider can provide care to that member regardless of the "PMP not available" status in Web interChange.

Q: What happens to a PMP's panel if the PMP disenrolls from an MCE and re-enrolls with another MCE?

A: Prior to January 1, 2011, when a PMP disenrolled from one MCE and re-enrolled with another MCE, that PMP's panel automatically followed the PMP to the new MCE.

Effective January 1, 2011, however, members do not automatically follow their PMP if their PMP disenrolls from one MCE and re-enrolls with another MCE.

Under this scenario, a member has the choice to follow his or her PMP to the new MCE or remain enrolled in his or her current MCE. To follow their PMPs, members need to contact the IHCP enrollment broker and request a change in assignment to the new MCE. The enrollment broker verifies that the PMP has been disenrolled from one MCE and has re-enrolled in the new MCE, and makes the member's change regardless of open-enrollment or redetermination status. The new MCE is then responsible for assigning that member to the correct PMP.

Q: How should PMPs process full-panel add requests?

A: Because the MCEs are the only entities responsible for making member PMP assignments, MCEs are also responsible for processing full-panel add requests. Full-panel add requests do not override a member's MCE assignment.

If an MCE receives a full-panel add request from a PMP for a member who is not the MCE's member, the MCE will deny the full-panel add request with a letter to the PMP informing the PMP that if he or she wishes to have the member added to his or her panel within that MCE, the member must request an MCE change before the full-panel add can be processed. The member may request an MCE change with the IHCP enrollment broker.

Full-panel add requests that the MCEs receive for their members are processed and the member is added to the PMP's panel with that MCE. Neither the IHCP enrollment broker nor the IHCP Call Center processes full-panel add requests.

Q: How are members enrolled in the Right Choices Program (RCP) affected by the MCE contract changes?

A: MCEs remain responsible for administering the unified RCP that encourages responsible utilization of services. The MCEs' responsibilities include assigning RCP members to locked-in PMPs, hospitals, and pharmacies. In instances in which an RCP member's PMP disenrolls from one MCE and re-enrolls with another MCE, the member remains locked-in with the PMP and follows his or her PMP to the new MCE.