IHCP Quarterly Update
Reimbursement Update, HPE Adult Aid Category,
HIP 2.0
HP Provider Relations/March 2015
Agenda
• Indiana Health Coverage Programs
(IHCP) Rate Changes
• HPE Adult – New Aid Category
• New Healthy Indiana Plan
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IHCP 1st Quarter Update
March 2015
IHCP Rate Changes
Rate Changes
• As part of the HIP 2.0 implementation, the Indiana
Health Coverage Programs (IHCP) announced a
general increase in reimbursement rates for
providers billing physician services paid on a feefor-service basis
• Effective for dates of service (DOS) on or after
February 1, 2015, rates for most physician services
were adjusted, in aggregate, to 75% of the 2014
Medicare Physician Fee Schedule
• rate changes will apply to nonphysician
practitioners rates that are based on the
physician fee schedule
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IHCP 1st Quarter Update
March 2015
Rate Changes
Consultations
As communicated in BT201504, effective for dates of service on or after
February 1, 2015, consultation codes are no longer covered by the IHCP. These
include CPT®1 codes 99241-99245 and 99251-99255.
Although these codes are non-covered, other Evaluation and Management
(E/M) codes remain covered services, including but not limited to:
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•
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•
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99201-99205 for new patient office and other outpatient visits
99211-99215 for established patient office and other outpatient
99221-99223 for initial hospital care
99231-99233 for subsequent hospital care visits.
CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association
IHCP 1st Quarter Update
March 2015
Rate Calculation
Rate Calculation
For most services, the IHCP is using the
following data to calculate revised rates:
• 2014 Medicare Physician Fee Schedule
Relative Value Units (RVUs)
• 2014 Medicare Indiana Geographic Practice
Cost Indexes (GPCIs)
– 2014 Medicare Practice Expense GPCI – 0.922
– 2014 Medicare Work GPCI – 1.000
– 2014 Malpractice Expense GPCI – 0.615
• 75% of the 2014 Medicare Conversion Factor
of 35.8228
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IHCP 1st Quarter Update
March 2015
Note….
• While rates for physician services
increased in aggregate, providers
should note that rates for some
services may remain the same or
decrease as a result of this update
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IHCP 1st Quarter Update
March 2015
Exceptions
Exceptions
Exceptions to the rate-setting methodology:
• Nondelivery maternity services and prenatal services will
increase, in aggregate, to 100% of the 2014 Medicare rate
• Reimbursement methodology for maternity delivery
services is as follows:
– The rates for Current Procedural Terminology (CPT®1)
codes 59612 and 59620 increased to 100% of the 2014
Medicare rate
– The rates for CPT codes 59409 and 59514 are now a
blended rate of the two services; both services will
reimburse $818.87
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CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association
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IHCP 1st Quarter Update
March 2015
Exceptions
• Behavioral health services increased, in aggregate, to 80% of the 2014 Medicare rate
• Anesthesia services increased to approximately 75% of the 2014 Medicare rate
Please note that IHCP reimbursement continues to reflect age and physical status
units where applicable
• Consultation codes are no longer covered by the IHCP effective for DOS on or after
February 1, 2015
– Includes CPT codes 99241-99245 and 99251-99255
• Rates for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) visits will
increase to $87 for established patients (now $62) and $100 for new patients (now $75)
– The rate will be applied based on the reported diagnosis (V20.2) as it is today
• All other reimbursement methodologies and medical policies remain unchanged
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IHCP 1st Quarter Update
March 2015
HPE Adult – New Aid Category
HPE Adult – New Aid Category
• Effective February 15, 2015, the IHCP added a new aid
category – HPE Adult
• What are the differences in HPE Adult vs other
Hospital Presumptive Eligibility (HPE) categories?
– HPE Adult members have HIP Basic plan coverage
– HPE Adult members have cost-sharing obligations
– HPE Adult members are served under the managed care
delivery system and must be enrolled with an IHCPcontracted managed care entity (MCE)
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IHCP 1st Quarter Update
March 2015
Eligibility
Eligibility
Qualifications
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•
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Be a U.S. citizen or a qualified noncitizen
Be an Indiana resident
Not be currently incarcerated
Not be a current IHCP member
Not have Medicare coverage
Be a nondisabled adult ages 19 – 64
Have a family income of approximately 138%
(includes a 5% income disregard) of the federal
poverty level (FPL) or less for the applicable
household size
IHCP 1st Quarter Update
March 2015
Eligibility
Services covered by HPE Adult HIP
Basic:
• Ambulatory patient services
• Hospitalization
• Emergency services
• Mental health and substance abuse
• Prescription drugs
• Rehabilitative services
• Laboratory services
• Preventive care
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IHCP 1st Quarter Update
Services not covered by HPE Adult HIP
Basic:
• Dental services
• Vision services
• Bariatric surgery
• Treatment for temporomandibular joint
(TMJ) disorder
March 2015
HPE Application Process
HPE Application Process
• If the individual is deemed eligible for the HPE Adult – HIP Basic aid
category, the HPE application will generate a pop-up box to enter the
member’s MCE selection
– If a selection is not made, the member will be auto-assigned to an MCE
• As with other HPE aid categories, members are only allowed one HPE
eligibility period per rolling 12 months
• QPs are held to the same requirements and standards that apply to other
HPE aid categories
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IHCP 1st Quarter Update
March 2015
Copayments
Copayments
• A $4 copayment will apply to the following
services:
– Rehabilitative and habilitative services and
devices
– Ambulatory services
– Laboratory services
– Office and other outpatient services
– Preferred drugs
• Inpatient services = $75 per stay
• Nonpreferred drugs = $8
• Nonemergency Emergency Department (ED)
visits = $8 first visit; $25 all subsequent visits
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IHCP 1st Quarter Update
March 2015
Reimbursement
Reimbursement
• Services rendered to individuals covered under the HPE Adult aid category will be
reimbursed through the risk-based managed care (RBMC) delivery system by the MCE
with which the member is enrolled
• The member’s MCE assignment is identified when verifying IHCP eligibility
• During the HPE period, providers are required to submit claims for HPE Adults to the
appropriate MCE using the member’s HPE identification (ID) number, which will always
begin with “600”
Note: Presumptive eligibility qualified providers will be expanded to include federally qualified health
centers (FQHCs), rural health clinics (RHCs), community mental health centers (CMHCs),
county health departments, and free-standing psychiatric hospitals. Effective date: TBD
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IHCP 1st Quarter Update
March 2015
Helpful Tools
Helpful Tools
• IHCP website at indianamedicaid.com
• IHCP Provider Manual
• Electronic Solutions Service Desk
− 1-877-877-5182 (toll-free)
− [email protected]
• Customer Assistance
− 1-800-577-1278 (toll-free)
− Provider Relations field consultant
− provider.indianamedicaid.com/contact-us/providerrelations-field-consultants.aspx
• Written Correspondence
− HP Provider Written Correspondence
P. O. Box 7263
Indianapolis, IN 46207-7263
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IHCP 1st Quarter Update
March 2015
Q&A