FAQs - MCO Procurement
Overview
The Office of Medicaid Policy and Planning (OMPP) seeks to
improve healthcare delivery to Hoosier Healthwise members. To
accomplish this task, the State implemented the following features
to the Hoosier Healthwise Program effective January 1, 2007:
- PMPs may contract with multiple MCOs. All managed care
organizations (MCOs) have the opportunity to contract primary
medical providers (PMPs), specialists, and other providers. PMPs
have the option to contract with multiple MCOs.
- The State is required by Federal regulation (42 CFR
438.52) to offer the choice of at least two MCOs in each
nonrural area. The regions are designed to include at least one
nonrural county and provide two MCOs in each region.
- The State requires MCOs to manage behavioral healthcare,
including mental health, substance abuse, and chemical dependency
services, to promote comprehensive and coordinated medical and
behavioral services for 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.
- 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.
- Electronic data sharing improves the quality of care provided
to Hoosier Healthwise members while decreasing MCO and provider
costs in the long term.
General questions
Q: When did the new Hoosier Health plans start?
A: The new Hoosier Healthwise plans began January 1, 2007. New
contracts will begin January 1, 2011.
Q: Am I required to sign up with more than one health
plan?
A: Providers have the choice to contract with more than one
health plan but are not required to do so.
Q: How does this affect my aged, blind, and disabled
Medicaid patients?
A: Care Select members in the aged, blind, and disabled
categories are not affected. To provide care to these members,
providers should enroll in Care Select. See the Care
Select page for more information.
Providers' panels and current patients
Q: Will I need to have the same panel size with all
plans?
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 maximum panel limit.
Q: Can I increase my current panel size?
A: PMPs may choose to increase their panel sizes, but it is not
a program requirement.
Q: Where do I send panel-full add requests, patient
reassignment requests, prebirth PMP selections, and requests for
member education and intervention?
A: Send requests to your MCO Provider Services Department. Send
full-panel add requests to the enrollment broker. See Contact
Information for Managed Care for contact information.
Q: Do MCO contracts involve specialist contracts as well
as PMPs? Hospitals? Ancillary?
A: Each MCO must comply with specific provider network
composition requirements to ensure adequate access to the full
spectrum of healthcare services for 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.
Q: Does this affect the "carve-out" providers?
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.
Q: Does this affect self-referral providers, such as
podiatrists, vision care, chiropractors, and so forth?
A: There are no changes for these providers. The MCOs continue
to be responsible for paying for self-referral services for their
members. The claims for these services must be sent to the
appropriate MCO for payment.
Reimbursement
Q: Does reimbursement change?
A: Reimbursement arrangements are determined contractually
between the MCO and the provider.
Q: Do I have to receive capitation payment?
A: How you will be reimbursed is part of your negotiation with
the MCO.
Q: Are other physicians in my group practice eligible for
reimbursement?
A: Yes. All IHCP providers are eligible to receive reimbursement
subject to MCO referral and prior authorization requirements.
Q: If I choose not to contract with an MCO, does the State
reimburse me for medical record duplication expenses for my
patients that are transferred to another doctor?
A: Federal regulation 42 CFR 447.15 requires that
providers participating in Medicaid accept the State's
reimbursement as payment in full (except that providers may charge
for deductibles, co-insurance, and copayments). 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 copying or transferring medical records.
Q: How much am I paid if I don't contract with an MCO but
provide services to an MCO member?
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 MCOs have a different agreement with the
provider. Out-of-network services, except for emergency services,
require prior authorization from the MCO.
Claims
Q: How does working with Hoosier Healthwise affect my time
limit for filing claims?
A: Noncontracted providers have one year to file the claims with
the MCO unless they have another arrangement. Contracted providers
have 180 days or fewer for claims that do not involved third-party
payers. This may be part of your negotiations with the MCO.
Q: Can I continue to submit my claims on paper or
electronically?
A: Yes, contact the MCOs for more information on how to submit
claims. MCOs may have different claims submission procedures and
software options.
Q: What if I disagree with how an MCO handled my
claim?
A: Providers must send MCO claim disputes to the member's MCO
(Anthem, Managed Health Services (MHS), or MDwise). 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.
Medicaid disability
Q: What if I have a patient who may qualify for Medicaid
disability?
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 healthcare provider or other
third party.
Auto-assignment
Q: If I sign up with two health plans, how are my members
be assigned?
A: If you change MCOs or add an MCO, your members stay with you
and are assigned to the MCO with the lowest number of enrolled
members. If you do not change or add MCO affiliations, your members
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 the MCO with the lowest number
of enrolled members in closest proximity order.
Q: How does this affect the number of members
auto-assigned to me?
A: There is little effect on the number of members auto-assigned
to your practice.
Service provision/authorization
Q: Do I have to send my patients to different
hospitals?
A: This depends on the MCO in which you are enrolled, and if it
has open or closed networks. Some MCOs allow their providers to use
only the hospitals with which they are contracted, while others
allow the provider to decide on the hospital. MCOs require prior
authorization for inpatient admissions.
Q: What is the eligibility verification process?
A: 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.
Q: Do my patients use the Hoosier Health Card?
A: Yes. They may also have an additional card issued by the MCO
that identifies them as a member of the MCO's plan.
Q: Do I prescribe the same prescription drugs?
A: Maybe. You need to become familiar with your MCOs
formulary.
Q: Can I participate in the Vaccines for Children (VFC)
program?
A: Yes.