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Overview

Indiana operates three managed care programs to serve the needs of its Medicaid and CHIP population:

Healthy Indiana Plan (HIP): initially established in 2008, and redesigned in 2015, brings innovative health coverage to 400,000 low-income and working adults through consumer-driven healthcare plans. HIP covers acute, primary, specialty, and behavioral health services; pharmacy benefits are excluded from the benefit package. CareSource Indiana serves as an MCO for this managed care population.  

Hoosier Healthwise: which includes Indiana’s CHIP population, serves approximately 600,000 children and pregnant women. CareSource Indiana serves as an MCO for this managed care population.

Hoosier Care Connect: which provides health coverage for nearly 90,000 aged, blind, and disabled members who are not dually eligible for Medicare. The program also covers many of Indiana’s foster children. Managed Care entities in Indiana provide intensive case management services for these vulnerable members.

The Healthy Indiana Plan (HIP), established in 2008, is a statewide, comprehensive risk-based managed care plan that enrolls adults who earn under 200 percent of the federal poverty level on a mandatory basis. HIP members have Personal Wellness and Responsibility (POWER) accounts, which are modeled after Health Savings Accounts and used to meet a $1,100 deductible on services covered by HIP. MCOs administer POWER accounts on the member’s behalf, provide coverage for up to $500 of preventive care before the deductible is met, and pay for covered services above HIP’s deductible. HIP covers acute, primary, specialty, and behavioral health services; pharmacy benefits are excluded from the benefit package.

There are four Managed Care companies supporting Indiana managed care: Anthem, MDWise, MHS, and CareSource. As of October 2019, enrollment in Indiana’s four managed care plans is as follows:

Healthy Indiana Plan (HIP): 418,933

  • Anthem: 177,893
  • CareSource: 36,021
  • MDWise: 100,586
  • MHS: 70,695
  • Unassigned to an MCO*: 33,738

Hoosier Healthwise: 601,446

  • Anthem: 219,077
  • CareSource: 51,425
  • MDWise: 189,733
  • MHS: 141,208

Hoosier Care Connect: 90,399

  • Anthem: 56,446
  • MHS: 33,953

*Unassigned includes members who are not enrolled in a managed care plan. Unassigned may include: Members in limited services paid by Fee-for-Service (such as HIP Emergency Services) and Native Americans who qualify for HIP but opt-out of managed care (i.e., services paid by Fee-for-Service.

Members with particular high-risk medical conditions enroll in HIP’s Enhanced Services Plan (ESP) option, which is paid for on a fee-for-service basis but includes disease and case management services related to the member’s qualifying health condition.

The HIP and Hoosier Healthwise programs exclude some benefits from coverage under managed care. These benefits are available under Traditional Medicaid or other waiver programs.  A member who is, or will be, receiving excluded services must be disenrolled from managed care in order to be eligible for these services.

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Eligibility

Traditional Medicaid in Indiana provides full health care coverage to individuals with low income. Eligibility is based on the member’s aid category Members in the following categories will be covered by Traditional Medicaid and their claims will be paid on a FFS basis:

  • Members eligible for home and community-based services
  • Persons in long-term care (LTC) facilities and other institutions, such as a nursing facility (NF) or an intermediate care facility for individuals with intellectual disability (ICF/IID)
  • Persons receiving hospice services in nursing facilities
  • Persons with end-stage renal disease (ESRD), including those with a waiver liability
  • Persons enrolled in the breast or cervical cancer treatment program
  • Members who are dually eligible for Medicare and Medicaid
  • Refugees who do not qualify for any other aid category
  • Wards of the State who opt out of Hoosier Care Connect
  • Current and former foster children who opt out of Hoosier Care Connect
  • Members in the 590 Program that provides coverage for certain healthcare services provided to members who are residents of state-owned facilities
  • Members receiving services via a Homes and Community-Based waiver program, including:
    • Aged and Disabled Waiver
    • Traumatic Brain Injury Waiver
    • Community Integration & Habilitation Waiver
    • Family Supports Waiver
    • Adult Mental Health Habilitation Program
    • Behavioral & Primary Healthcare Coordination Program
    • Child Mental Health Wraparound Program
  • Members in Medicaid Rehabilitation Option (MRO) services
  • Medical Review Team (MRT) services
  • Medicare Savings Programs
  • Members in Presumptive eligibility categories

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Coverage

CareSource Indiana covered services include:

  • Doctor visits
  • Chiropractic
  • Clinic services
  • Nurse midwife services
  • Pharmacy via a preferred drug list
  • Lab and X-ray services
  • Podiatry
  • Dental
  • Durable Medical Equipment (DME)
  • Home Health services
  • Behavioral Health and Addiction services
  • Rehabilitation services
  • Early Periodic Screening Diagnosis and Testing (EPSDT)
  • Family Planning services
  • Nurse practitioner services
  • Hospital care
  • Emergency services
  • Emergency transportation
  • Vision
  • Nursing Facility services
  • Orthotics/ Prosthetics
  • Hospice care
  • Physical/Occupational/Speech services

Data Considerations

CareSource Indiana began contracting with the State of Indiana in 2017.  Therefore, claims data was not available for HMS use prior to 2017. HMS receives all claims data from CareSource Indiana except for dental. 

It is important to note that since HMS receives claims data directly from CareSource Indiana, we are receiving actual claims data as opposed to encounter only data. However, providers for this claim population are not paid on a Fee-For-Service basis.  Rather payment is received directly from CareSource, which may pay more or less than the Medicaid FFS rate.

 

 

Sources

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