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FAQs Regarding PMP Assignment

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•  FAQs Regarding PMP Assignment 

FAQs regarding PMP Assignment

As announced in 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, answered here. Providers should continue to contact members' assigned MCEs for questions regarding 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. As of 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 is the IHCP enrollment broker or the IHCP Call Center making 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 is 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 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: Before 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.

As of 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/hold panel add requests?

A: Mangaged care entities (MCEs) are responsible for accepting all full panel/hold panel add (FPA/HPA) requests. FPA/HPA requests can only override a member's MCE assignment during the member's MCE open enrollment period.

Once a primary medical provider (PMP) agrees to request a full panel/hold panel add (FPA/HPA) for a member, the PMP and member (or parent/guardian of the member) must sign the request form (located on the MCE websites). If you are a PMP who works with multiple MCEs, please note the form's disclaimer directing the member to the IHCP enrollment broker to discuss the member's MCE options. Once the form is completed, it should be faxed to the relevant MCE.

If an MCE receives an FPA/HPA request from a PMP for a member who is assigned to a different MCE, and the member is not within his or her open enrollment period, the receiving MCE denies the FPA/HPA request with a letter to the PMP. The denial letter informs the PMP that if he or she wishes to have the member added to the PMP's panel within that MCE, the member must request an MCE change before the FPA/HPA can be processed. The member should be directed to the IHCP enrollment broker to understand how to change MCEs during the open enrollment period or to pursue a change for "just cause."

If an MCE receives an FPA/HPA request for one of its current members, the FPA/HPA is processed and the member is added to the PMP's panel. If an MCE receives an FPA/HPA for a member assigned to a different MCE, but within the member's open enrollment period, the FPA/HPA is processed, the member is assigned to the receiving MCE and added to the PMP's panel.

Neither the IHCP enrollment broker nor the IHCP Call Center directly accepts FPA/HPA 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. If 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.