Hoosier Healthwise Open Enrollment

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Hoosier Healthwise Open Enrollment
2
Current Issue

• Hoosier Healthwise members may change MCOs every
  month.
• Approximately 57,120 Hoosier Healthwise members
  changed MCOs at least once between spring 2007
  and May 2008.
• Member movement between MCOs increases
  administrative costs and reduces continuity of
  care, thus limiting an MCOs ability to provide
  proper support or potential member interventions.
• During January and February 2007, there was an
  atypical volume of member movement between MCOs
  because of the exit of three Hoosier Healthwise
  MCOs and the entry of one new MCO. Therefore,
  March, April, and May 2007 were considered for
  entry into this analysis. The patterns were
  calculated starting with the first MCO during
  those three months.

3
Administrative Costs

• Member movement between MCOs increases
  administrative costs.
• Costs associated with member movement include
  mailing ID cards, handbooks, orienting new
  members, and so on.

4
Reducing Gaps in Medicaid Eligibility

• Currently, many Hoosier Healthwise members have
  gaps in coverage with an MCO because of loss of
  eligibility.
• From spring 2007 through May 2008, approximately
  135,780 Hoosier Healthwise members had gaps in
  coverage, thus losing their linkages to an MCO.
• Such breaks in eligibility may be caused by
  members not meeting the eligibility
  redetermination requirements (that is, missing
  appointment, not submitting proper paperwork).
• With open enrollment, MCOs are better able to
  track members, potentially reducing gaps in
  coverage.
• Additionally, as a separate initiative, MCOs will
  be given members redetermination dates so they
  may remind the member and serve as an additional
  resource in the process.
• Reducing gaps in Medicaid eligibility will
  further enhance continuity of care.

5
Open Enrollment Objective

• To enhance continuity of care, Hoosier Healthwise
  members will remain enrolled in their chosen MCO
  for a 12 month period so long as eligibility in
  Hoosier Healthwise is maintained
• This will enable Hoosier Healthwise MCOs to
  provide consistent medical management

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What is Open Enrollment?

• A 90-day period during which a member may change
  to another managed care organization (MCO).
• Members remain enrolled in their chosen MCOs for
  a one-year period.
• The one-year period begins on the day a member is
  enrolled, either by selection or by
  auto-assignment, with an MCO.
• For newborns, the one-year period begins on the
  date the RID is assigned.
• Members may choose another primary medical
  provider within their MCO at any time.

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What is Open Enrollment?

• Members have the opportunity to choose a new MCO
  on an annual basis during their open enrollment
  period.
• Federal requirements allow members to change to
  another MCO within the first 90 days of
  enrollment with an MCO.
• Members may change MCOs during the 12-month
  period when they have just cause.

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Just Cause

• With open enrollment, members will maintain the
  right to change MCOs when there is just cause.
• Lack of access to medically necessary services
  covered under the MCOs contract with the State.
• The MCO does not, for moral or religious
  objections, cover the service a member seeks.
• The member needs related services performed at
  the same time not all related services are
  available within the MCOs network and the
  members primary medical provider or another
  provider determines that receiving the services
  separately would subject the member to
  unnecessary risk.

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Just Cause (cont.)

• Additional just cause reasons include
• Lack of access to providers experienced in
  dealing with the members healthcare needs.
• Concerns over quality of care. Poor quality of
  care includes failure to comply with established
  standards of medical care administration and
  significant language or cultural barriers.

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Just Cause (cont.)

• The just cause process involves the following
• Member files a complaint or grievance concerning
  the MCO.
• Members must submit their complaints/grievances
  to their selected MCOs.
• MCO communicates with the member to address the
  complaint/grievance.
• If the matter remains unresolved, the member may
  contact the enrollment broker (MAXIMUS).
• The enrollment broker will make the determination
  of just cause.
• A determination of just cause is made
  approximately five days after receipt of
  documentation from the MCO.

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Member Eligibility

• Providers should continue to check a members
  eligibility prior to rendering services or
  performing prior authorization.

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Open Enrollment Time Graph
Member determined eligible
Member chooses PMP and MCO or is auto-assigned
Member maintains right to change MCOs
Eligible member remains enrolled in MCO
30 days
90 days
9 mos.
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Benefits to Providers

• Reduce disruption of treatment plans.
• Reduce administrative hassles caused by frequent
  member movement (for example, confusion regarding
  claims submission and prior authorization).
• Behavioral health providers and primary care
  providers are better able to coordinate care.

14
Improved Data Monitoring

• The State and MCOs can measure member health
  outcomes over a longer time.
• This improved data will enhance quality
  monitoring and improvement processes.

15
Continuity of Care

• Open enrollment provides opportunities for
  increased continuity of care.
• The medical home is strengthened as members
  remain aligned with providers for a longer time.
• Providers and MCOs have increased opportunities
  to collaborate to address member treatment and
  prevention needs.
• Physical and behavioral health integration
  opportunities are enhanced as both mental health
  providers and primary care physicians are better
  able to track member enrollment and coordinate
  care.

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Open Enrollment Scenarios

• Members primary medical provider (PMP)
  disenrolls from MCO A and enrolls only with MCO
  B.
• The panel members may follow the PMP to MCO B.
• PMP disenrolls from Hoosier Healthwise.
• Member may select a new PMP in his or her current
  MCO.

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Changes for Providers

• To complete a full panel add, the member must be
• Within his or her fee-for-service window, or
• Within his or her 90 day free change period
• If the PMP is within the members MCO, the full
  panel add can be processed at any time

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National Provider Indicator (NPI) Phase III

• Effective October 1, 2009, EDS will no longer
  recognize the Legacy Provider Identifier (LPI)
  for healthcare providers
• Claims reporting the LPI only will reject before
  entering system
• Atypical providers will continue to use LPI, not
  the NPI

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Web-interChange and Phase III

• Web interChange screens will no longer display
  the LPI locator for healthcare providers
• Atypical providers will see the LPI locator only
• Atypical providers rendering healthcare and
  non-healthcare services will see both the NPI and
  LPI locators
• It is recommended that healthcare providers
  remove all LPIs from their claims
• Claims reporting an LPI and an NPI will not be
  denied
• The LPI will be ignored when adjudicating claims

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Conclusion

• Questions Comments