Qualified Provider (QP) Hospital Presumptive Eligibility (HPE) Metrics

In the last quarter of 2016, letters were distributed by the state of Indiana FSSA to all acute care and psychiatric hospitals contracted as Qualified Providers (QPs) with the Medicaid Presumptive Eligibility (PE) program. These letters served as a “first warning” of non-compliance with state metrics and included details regarding program requirements.

What you need to know:

At this time, FSSA has stated they intend to distribute notifications related to the Q4 2016 performance targets by the end of February. While we have yet to confirm future expectations regarding these metrics, we have been diligently working to ensure our clients are prepared to respond to any requests for corrective action plans. Below is a description of the current metrics.

Metric A: 95% of Approved Hospital Presumptive Eligibility applications submitted.
“Ninety-five percent (95%) of presumptively eligible individuals from a qualified hospital shall complete and submit an application before the end of the presumptive eligibility period.”
Metric C: 95% of the full applications submitted from Metric A must result in an approved application.
“Ninety-five percent (95%) of the applicants who complete and submit an application shall be determined eligible for a Medicaid program.”

If we have not already been in contact with your organization, please contact J Hopkins directly. J Hopkins: jhopkins@claimaid.com 800.842.4052 x 126. When requests for corrective action plans are received, we are prepared to detail these best practices and compliance suggestions as they apply to your specific organization. These standards have come through the rulemaking process and a direct link to the final rule and administrative code is located here.

CareSource is new MCE Option
FSSA has added a fourth Managed Care Entity (MCE) as an option for HHW and HIP members. Effective January 1, 2017, the MCE options are now Anthem, CareSource, MDwise, and MHS.

What you need to know:

  • CareSource is the new MCE being offered and they began serving HHW members January 1, 2017 and HIP members on February 1, 2017. Members may choose CareSource as their MCE at time of application or at the annual re-determination period.
  • Providers who would like to participate in the HHW and HIP MCE networks must be enrolled with the Indiana Health Coverage Programs (IHCP) and contracted with one or more of the MCEs.
  • Providers should contact the MCEs directly for contracting instructions.

  • Beginning on January 1, 2017, MCE networks for HHW include dental and pharmacy services.
  • There are updated Health Plan Summary charts for HIP and HHW programs which reflect all four MCE options.

For more information, please read the IHCP bulletin here.

IHCP is in the third week of implementing CoreMMIS and the Provider Healthcare Portal. The FSSA and Hewlett Packard Enterprise (HPE) have made progress in stabilizing the new system but are aware some performance issues still exist.

What you need to know:

MDwise and Hoosier Care Connect
IHCP recently announced that beginning April 1, 2017, MDwise will no longer be a managed care health plan option for Hoosier Care Connect members. Hoosier Care Connect members currently enrolled with MDwise have already started receiving notices from the Office of Medicaid Policy and Planning informing them of this change.
What you need to know:

Members will need to select another managed care entity (MCE) – either Anthem or Managed Health Services (MHS) – for their Hoosier Care Connect benefits.
Providers currently serving Hoosier Care Connect members enrolled with MDwise should direct those members to the Hoosier Care Connect Helpline at 1-866-963-7383 for health plan information. Providers may want to make their patients aware of their participation in one or both of the MCE networks from which the members must choose.

More details and instructions can be found in this recent IHCP bulletin.