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Introduction:

Problem/Opportunity Description

The Care Select program is recreating the current Medicaid Select program. The Care Select program will begin 10/1/07 in the Central region of Indiana, and will be phased-in to the rest of the State by or before 7/1/09. New vendor(s) will be procured by approx. 6/1/07 for this program. Since this is a phase-in, each region will have different completion dates. Completion in each region will be determined when the identified population is enrolled in Care Select, and no longer in Medicaid Select.

The goal is for the member population is to be either in RBMC, Care Select, duals, spend-down or institutionalized.

The regions will be the regions identified in CO910 HLR.

One CMO will be selected to also perform Prior Authorization and Medical Policy suspense for the Fee for Service (FFS) population excluding the CS members which will be associated with multiple CMOs.

This is a Mod CO because this is adding new or modified functionality to the system.

Root Cause of Problem/Opportunity

This is a new Managed Care program which will transfer the Medicaid Select population, except for dual eligibles, into a new program called Care Select which will be managed by multiple vendors to ensure appropriate care.

Solution Description

The fiscal agent, enrollment broker and the Care Management Organization(s) (CMOs) will transfer data to support the assignment of the Care Select members to the CS PMPs. Claims will be processed through IndianaAIM and the CMOs will perform analysis on the data to make informed decisions on administration of the program. Additionally, the CMOs will perform Prior Authorization (PA) There will be one CMO which will be assigned FFS members (including the Medicaid Select members) and two CMOs who will coordinate care for the Care Select Population including PA.

Business Impact

The vendor(s) will need access and the ability to do data analysis on claims data, prior authorization, provider information, and IndianaAIM information. EDS will need to modify reports and identification markers to be inclusive of the Care Select program and the multiple CMO(s). EDS will also need to ensure that needed reports and information are readily accessible to the new vendor(s).

Project Requirements:

1. The system must be modified to identify the covered population for the Care Select Program.

1. The following are eligible recipients for Care Select:

1. IHCP recipients active in one of the following aid categories (formerly Medicaid Select eligible aid categories):

1. MA-A (Aged)

2. MA-B (Blind)

3. MA-D (Disabled)

1. MA-D developmentally disabled (DD) on waiver waiting list (Level of care (LOC) does not apply – this subset is not currently systematically identifiable)

2. MA-D DD on HCBS waiver

1. LOCs T, U, V, W

2. Key date for enrolling DD waiver recipients in central region is 10/1/07; members are not restricted from being assigned sooner than 10/1/07

3. MA-D other HCBS waivers:

1. Waiver AD (LOC A),

2. Waiver MF (LOCs J, X, Y, Z), Note: rolled into A/D for 7/1/06 per OMPP

3. Waiver TB (LOCs K, L),

4. Waiver AL (LOC B), Note: rolled into A/D for 1/1/07 per OMPP

5. Waiver AU (LOC P, Q),

6. Waiver SS (LOC D),

7. Waiver SE (LOC E) Terminated 1/31/07 per OMPP

4. MA-8 (Adoption Assistance)

5. MA-DI (Medworks Improved)

6. MA-DW (Medworks)

7. MA-R (Room and Board Assistance)

8. Home and Community Based Services type for non MA-D

1. Waivers AD, MF, TB, AL, AU, DD, SS, SE, MFC, AL, and SED

2. Corresponding LOCs

3. Regardless of aid category, as long as the aid category is not an exclusionary aid category

2. Hospice non-institutionalized type:

1. LOC codes 51H, 52H, 53H, 54H with no LTC

3. Recipients are eligible if under waiver types “W” or “H” for current and future waivers, as long as they’re not one of the excluded categories from requirements 1.2.1 thru 1.2.12.

4. Hoosier Healthwise RBMC-eligible recipients in a low Hoosier Healthwise PMP access county who have not been assigned in at least 30 days of becoming Hoosier Healthwise-eligible are eligible to be assigned to an available and appropriate Care Select PMP.

1. Counties identified in 2/6/07 Milliman executive summary: Clark, Elkhart, Floyd, Hendricks, Montgomery and Tippecanoe counties.

5. Hoosier Healthwise RBMC-eligible recipients in remaining counties throughout the state who have not been assigned in at least 90 days of becoming Hoosier Healthwise-eligible are eligible to be assigned to an available and appropriate Care Select PMP.

Source: H1 requirements were reviewed on 3/1/07 and 3/2/07. See HLR for other sources. E-mail from Randy indicated removal of HH potential members.

Acceptance Criteria: 1) Test and monitor potential table processing for collecting new Care Select eligibles based on the criteria in 1.1

2. The following recipients are NOT eligible for Care Select:

1. Recipients on spend-down

2. Recipients dually eligible for Medicare and Medicaid, regardless of aid category

1. Recipients with parts A and/or B.

3. QMBs-Also, SLMBs-Also, QLMBs-Only, and SLMBs-Only regardless of aid category

4. MA-12 (Breast and Cervical Cancer Treatment Services)

5. MA-G (Qualified Disabled Working Individual)

6. MA-I (Qualified individual 1)

7. MA-K (Qualified individual 2)

8. MA-O (Children < 21 in inpt psych facility)

9. MA-Q (Refugee Medical Assistance)

10. Any recipient who has an active institutional-type level of care (nursing home recipients, ICF/MRs, state operated facilities)

11. ARCH and 590 recipients

12. Undocumented aliens

13. MA-3 (Wards) and MA-4 (Foster Children) are eligible for Hoosier Healthwise but shouldn’t be excluded from Care Select if another factor makes these children ineligible for Hoosier Healthwise. There are wards/foster children in other aid categories, identified by a ward indicator.

Source: H1 requirements were reviewed on 3/1/07 and 3/2/07. See HLR for other sources. Stakeholder review w/e 5/3/07.

Acceptance Criteria: Test and monitor the bypassing or deleting of non-eligibles based on the criteria in 1.2

3. Systematically disenroll Care Select members for the following events:

1. expired IHCP eligibility

2. expired Care Select aid category eligibility (for example, member changes from MA-D to MA-U)

3. member gains Medicare Parts A and/or B

4. member becomes spend-down

5. member becomes institutionalized

6. Hoosier Healthwise-eligible member temporarily assigned to Care Select becomes assignable to a newly available PMP.

1. Reassign temporary Care Select members back to Hoosier Healthwise as soon as PMP availability is determined. May require coordination among EDS, the enrollment broker and the CMO for matching CS-assigned members as HH-assignable, before systematic disenrollment can be defined.

7. member assigned to a Care Select PMP who is disenrolling

Source: H1 requirements were reviewed on 3/1/07 and 3/2/07. See HLR for other sources.

Acceptance Criteria: Test and monitor systematic Care Select member end dating for scenarios listed in 1.3.

4. Report systematic member disenrollments to the CM vendor(s). See requirements for the 834 transactions.

Source: H1 requirements were reviewed on 3/1/07 and 3/2/07. See HLR for other sources.

Acceptance Criteria: Refer to 834 requirements

5. Modify the Eligibility Verification Systems (EVS) to report Care Select. Systems include Web interChange, automated voice response (AVR), OMNI machines, and the 270/271 HIPAA enrollment request and response transactions.

1. Identify and report active Care Select membership for date span requested

2. Report member’s Care Select PMP’s name

3. Report member’s Care Select PMP’s 24-hour PMP Service Location phone number

4. Report member’s Care Select CMO name

5. Report member’s Care Select CMO phone number for providers

6. Affiliate the member’s high-level program and benefit package in EVS as currently designed (for example, “The member is eligible for Hoosier Healthwise Package A - Standard Plan services from…”)

Source: H1 requirements were reviewed on 3/1/07 and 3/2/07. See HLR for other sources.

Acceptance Criteria: Test and monitor accurate EVS responses for Care Select member assignment information listed in 1.5.

2. The system must be modified to assign members to Care Select.

1. Convert applicable Medicaid Select members to Care Select . The program is being phased in throughout the state using managed care region designations. Phase-in members will be identified as a function of their PMP’s service location. Identification is based on the PMP’s service location in a regional phase-in county. Members assigned to those PMPs will be converted regardless if they also live in a phase-in county or not.

1. During conversion, systematically reassign active Medicaid Select members who meet Care Select eligibility criteria to a Care Select PMP using an auto-assignment type process.

1. Follow the base auto-assignment hierarchy:

1. Previous PMP

2. Previous CMO (technically won’t apply)

3. Case ID

4. Default

2. Do not be as restrictive as the 30 mile distance limit in Hoosier Healthwise. Either disregard distance logic for conversion or extend the distance limit to 45 miles

2. Maintain Medicaid Select for dual Medicare/Medicaid members and eligibles who reside in the non phase-in counties

• Duals in phase-in counties will move to FFS.

3. Maintain original Medicaid Select functionality (eligibility determination, assignment, disenrollment, reenrollment) for members who live in non phase-in counties.

4. Medicaid Select members subjected to conversion assignment but who couldn’t be assigned will revert to the potential table with a CS eligible program code, regardless if member resides in or out of the phase in region.

Source: H2 requirements were reviewed on 3/1/07 and 3/8/07. See HLR for other sources. Additions to 2.1 from 5/18/07 project status meeting.

Acceptance Criteria: Test and monitor manual Care Select assignment execution (2.3), including member location compared to phase-in region (2.1)

2. Generate member assignment letters in addition to assisting in member notifications regarding the new Care Management (CM) vendor(s) and the Care Select Program. For example, generate a member bulletin announcement to non-dual Medicaid Select members living in the Care Select phase-in counties.

1. Generate member welcome letters

1. Self-selections

2. Default auto-assignment

3. Previous relationship

2. Generate member letters when their PMP disenrolls, then reenrolls

3. Generate member letters when their PMP disenrolls but doesn’t reenroll

Source: H2 requirements were reviewed on 3/1/07 and 3/8/07. See HLR for other sources. Additions to 2.2 from 5/10/07 project status meeting.

Acceptance Criteria: Review any EDS-drafted member bulletin information referenced in 2.2 with OMPP for approval. Review and verify CS member letters for correct variable field information, letter forms, and letter language.

3. Support manual assignments, entered by the Enrollment Broker for Care Select eligibles, through a secure system mode

1. Allow for in-plan member PMP in-network assignment changes to be effective various days of the month, depending when updated by the Enrollment Broker.

2. Automatically end-date current PMP assignments affected by PMP changes concurrent to the new assignment

3. Allow assignment of new eligible members entered by the Enrollment Broker to be effective either the 1st or 15th of the month depending when updated

4. Accommodate cross-plan PMP assignment changes, effective the 1st of a month, depending when updated. For example, member wants to change PMPs from CMO1 to CMO2. Will be facilitated by a master enrollment broker for data security.

5. Accommodate cross-plan CMO eligible assignments. For example, member is pseudo assigned to CMO1 for outreach, but prefers to be assigned to a PMP in CMO2. Will be facilitated by master enrollment broker for data security.

Source: H2 requirements were reviewed on 3/1/07 and 3/8/07. See HLR for other sources. Modifications to 2.3 from 5/10/07 project status meeting.

Acceptance Criteria: Test and monitor manual Care Select assignment execution (2.3)

4. Generate HIPAA-compliant 834 benefit enrollment and maintenance transactions for Care Select members assigned to the CMOs.

1. Identify Care Select program eligibles for access by the Enrollment Broker. The Enrollment Broker currently extracts managed care eligibles via FTP and not through 834s. Continue the current process.

2. Pseudo assign eligibles to the CMOs using an auto-assignment type process that uniquely assigns each Care Select eligible to a CMO.

1. Assignment factors include Previous PMP, Previous Plan, Family participation, and neediest CMO.

3. Report Care Select eligibles to their respective CMOs for outreach and assignment to a PMP.

4. Generate systematic notifications of file transmission success/failure to CMOs and EDS

5. Generate Program Enrollment transactions 3 per month – 11th, 26th, and end of month.

1. Report assigned Care Select members to their respective CMOs for data reconciliation

2. Generate systematic notifications of file transmission success/failure to CMOs and EDS

3. Create a new report of Care Select assignees in On-Demand for OMPP and EDS.

Source: H2 requirements were reviewed on 3/1/07 and 3/8/07. See HLR for other sources. Modifications to 2.4 from 5/10/07 project status meeting

Acceptance Criteria: Care Select eligible transactions, with appropriate eligibility and assignment information, will generate to the CMO based on criteria in 2.4

5. Hoosier Healthwise and Medicaid Select auto-assignment should cross-compare Care Select assignment history for influence in previous PMP or case ID auto-assignment logic.

6. Care Select auto-assignment should cross-compare Hoosier Healthwise and Medicaid Select assignment history if relevant to the eligible they are assigning in Care Select.

Source: H2 requirements were reviewed on 3/1/07 and 3/8/07. See HLR for other sources.

Acceptance Criteria: Test and coordinate cross program auto-assignments among Hoosier Healthwise and Care Select PMP assignment histories (2.5 and 2.6)

7. Modify EDS’s phone system to include a front end announcement option to allow users to select the Care Select vendor(s).

1. Client services – provider calls (example: CMO PMP enrollment)

2. Client services - recipient calls (example: CS member grievance)

3. Create call scripts for customer service and recipient hotline.

4. Track calls for the Care Select Program by each CMO.

• Initially, track under one general call type- Care Select. May require additional call types as the program develops

Acceptance Criteria: Test and monitor Care Select related options added to the EDS phone system

8. Modify recipient subsystem windows in IndianaAIM to reflect Managed Care Entity “MCE” vs. MCO where relevant for fields that accommodate both Hoosier Healthwise and Care Select.

9. Incorporate the Care Select subprogram value where relevant in IndianaAIM’s recipient subsystem windows

Source: Internal requirements gathering

Acceptance Criteria: Test field headers and values for program changes (2.8 and 2.9)

Source: H2 reviewed at 3/8/07 meeting

2.10 Auto-assign Care Select eligibles who have not self-selected their PMP

1. Auto-assign Care Select members to a PMP. The member’s CMO and region assignment are a function of the PMP’s enrollment with the plan(s).

2. Determine Care Select auto-assignment effective dates using the following date scheme:

• Assignments generated >=11th and =26th and =1st and

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