Iowa Health and Wellness Plan Healthy Behaviors Frequently Asked Questions (FAQ)

Transcription

1 Iowa Health and Wellness Plan Healthy Behaviors Frequently Asked Questions (FAQ) The Iowa PCA is working with Iowa Medicaid Enterprise (IME) to respond to questions and issues related to implementation of the Iowa Health and Wellness Plan Healthy Behaviors Program. The information contained in this document will change and be added to as additional information becomes available, and is based on staff s current understanding of the program. Program Overview Information IME has developed and disseminated several informational documents about the Healthy Behaviors program, including the following: o Iowa Health Link Site Launched: A new website for members and the general public specific to the Iowa Health and Wellness Plan has been launched. Visit iahealthlink.gov for the latest member information on the plan and the Healthy Behaviors Program. Designed to match the new branding campaign for the Iowa Health and Wellness Plan, the site can be accessed on its own, or through the new Department of Human Services site. On iahealthlink.gov, you ll find: Plan and benefit information Healthy Behaviors information News and announcements Member materials Stakeholder and provider toolkits o White Paper Available on HRA and Healthy Behavior Rewards click here o Iowa Health and Wellness Plan Healthy Behaviors Toolkit for Providers click here o Informational Letter 1387: Healthy Behaviors under the Iowa Wellness Plan and Marketplace Choice Plan click here o Informational Letter 1388: Provider Access to the AssessMyHealth Health Risk Assessment (HRA) and Value Index Score (VIS) Online Dashboard click here o Healthy Behaviors Mailing to Wellness Plan Members click here o Healthy Behaviors Mailing to the Marketplace Choice Plan Members click here o Informational Letter 1415: Claim Submission for the Health Risk Assessment (HRA) click here o Informational Letter 1425: Healthy Behaviors Wellness Exam click here o October 2014 Healthy Behaviors Mailing to Wellness Plan Patients Needing to Complete Both Behaviors click here o October 2014 Healthy Behaviors Mailing to Wellness Plan Patients Needing to Complete the HRA click here o October 2014 Healthy Behaviors Mailing to Wellness Plan Patients Needing to Complete the Wellness Exam click here o These same October 2014 mailings will be sent to Marketplace Choice Plan patients later in October

2 Patient Populations Needing to Complete the Healthy Behaviors to Avoid Cost-Sharing Q: Which patient populations need to complete the Healthy Behaviors in order to avoid costsharing for their insurance in future years of the Iowa Health and Wellness Plan (IHWP) program? A: All Marketplace Choice Plan (CoOportunity Health and Coventry) patients and Wellness Plan patients (general Wellness Plan and Meridian HMO) patients must complete the Healthy Behaviors to avoid cost-sharing. Wellness Plan patients who are in the FFS portion of the program (no PCP assignment) also must complete the Healthy Behaviors. Patients who formally had CoOportunity Health through the MCP and who are moving into the Wellness Plan FFS portion of the program beginning December 2014 will still have to complete the Healthy Behaviors. IHWP patients determined to be medically exempt are not subject to cost-sharing if they do not complete the Healthy Behaviors, but are encouraged to complete them. Q: If a person has Private Insurance as primary and IWP as secondary, then will these members have to complete the Healthy Behaviors? If so, how will Medicaid know the wellness exam is complete if this is billed under the Private Insurance? A: Yes, these individuals would need to complete the Healthy Behaviors in order to waive the contributions. As with all other situations when the member has other insurance, the claims should be submitted to both the primary insurance and to Medicaid. Even if Medicaid does not end up paying on the claim (service fully covered by primary insurance), we will have record and be able to count the wellness exam. Provider Enrollment Q: What is the best method for enrolling providers to use the Health Risk Assessment (HRA) AssessMyHealth tool whether individually or as a practice or care team? A: Providers can decide how to register to use the HRA, but clinic level registration is likely preferable. It may be easier for multi-site FQHCs to sign each site up separately so the clinic can pursue the follow up with the patient more efficiently. IME s systems recognize FQHCs based on the TINs associated with each FQHC and not by individual providers. Q: How does the information flow if a FQHC signs up as a center versus having individual staff members sign up? A: The results of the HRA will be ed to the special address provided as part of the HRA registration process once an assigned member completes the HRA. Once a FQHC or site has signed up to use the HRA, they will receive a five-digit code they can share with patients. Information about how to register to use the HRA can be found in the toolkit referenced above. Here is some additional information about the provider enrollment process from IME: For the HRA, if you register at the organization level, your PDF summaries of all patients that complete the HRA with your code, will be stored in a single in box in the Treo Dashboard tool. You would then have to sort through those completed HRAs and distribute them down to the correct clinics and docs. Some organizations are rolling this out at the location level, so it is easier to do that distribution. You can still have a staff that has access to all clinic location in boxes by going that route. In the process of completing the HRA, the patient (and possibly, the staff member helping the patient) has the opportunity to manually enter the provider name in a 2

3 field. That will help with the distribution process, however not ideal. Since you re working with FQHCs, your credentialing information with IME is only at the clinic level, but for other practices, they would have the option to roll down one level farther to the doc. However administratively, that is a lot of codes to manage for clinic staff in working with patients. We are working with Treo to improve the HRA to administer at the clinic level while still allowing a better method to associate to individual docs (other than manually) when they are credentialed that way with IME. Timing for Meeting the Healthy Behaviors Q: If a patient has already had their physical since January do they need to have another physical? A: If the patient was enrolled into the IHWP and had a wellness exam sometime between January 1, 2014 and the current time, it will count as a completed Healthy Behavior. Q: What do we do if a patient had a Wellness Exam before they came into the IHWP, but in the current calendar year? A: The preventive exam must be performed during their eligibility year for it to count towards the member s Healthy Behaviors. IME also indicated they had received a few questions related to if the new exam could be billed, which it can if the individual switched from one Medicaid coverage group to the other, or if new to the program in general. Q: Can we retro code for wellness exams performed before the updated CPT codes were distributed? We have patients that did receive a wellness exam while covered under IHWP; however, the providers did code appropriately or the updated codes were not distributed yet. A: Those claims would need to go through the standard claims adjustment process to be corrected and reimbursed properly for the wellness exams. Q: So the eligibility year and our reporting year is not the same? How does the six months of enrollment in the program weigh into this? A: The eligibility year will be based on the member s effective date. Approximately 43,000 members were effective 1/1/14 (with retro coverage added in, IME had more than 78,000 members eligible for coverage January 1 between the Iowa Wellness Plan and the Iowa Marketplace Choice Plan. Some might not have been assigned or shown up as patients until Feb- March due to the retroactive status); however, IME cannot hold a member enrolling in July to the expectation of completing behaviors others have had a full 12 months to address. IME is looking to capture the members that were eligible for the full calendar year by 12/31/14 (officially IME has to give the member 12 full months to complete the activities), but all members must complete their healthy behaviors during their first twelve months of eligibility. The six-month component is based on the member being attributed to the provider s distinct panel for a period of six months or longer to count in the denominator for performance incentives. Q: Do all Health Risk Assessments need to be completed by 12/31/2014 or if they became eligible in March 2014 would it need to be completed by 02/28/2015 to avoid paying a premium? A: The healthy behavior requirements are based on the patient's date of enrollment into the IHWP so each patient has a full 12 months to complete both requirements to avoid paying a 3

4 premium. FQHCs should place priority on the IowaCare members who were auto-enrolled into the IHWP plan beginning 1/1/2014 if possible. Q: Can someone from IME share information about how the Healthy Behaviors program affects the IowaCare patients that were auto-enrolled into the program? A: Individuals enrolled in Medicaid programs must go through a renewal process every 12 months. Because IowaCare was ending, individuals were automatically extended coverage through December 2013, and did not go through the process as usual. Further, individuals were administratively transferred to the Iowa Health and Wellness Plan and did not go through the full application process for coverage that began on January 1, Because of these circumstances, all former IowaCare members will begin the renewal process. Renewals will be staggered from June - November The staggering will be a relatively even split each month. The renewal process will "re-set" the individuals renewal clock. If the former IowaCare member renews Iowa Health and Wellness Plan coverage in July 2014, the next renewal will be July Individuals who were NOT former IowaCare members and enrolled in the Iowa Health and Wellness Plan at any other point are not included in this renewal. Their renewal will come 12 months after the initial application (example: enrolled January 2014, renewal will be January 2015). This mid-year renewal only impacts former IowaCare members who were administratively transferred to the Iowa Health and Wellness Plan. Because of this special renewal process, the effective date and renewal date for these patients will always be slightly off. Regardless, all former IowaCare members have 12 months to complete Healthy Behaviors, just like everyone else. The renewal here is not directly aligned with Healthy Behaviors as IME bases Healthy Behaviors on 12 full months of coverage. o Renewal Process: 1. The Department of Human Services mails the member a renewal form to be completed. 2. Member must complete form by the due date pre-populated on the first page of the renewal form. 3. Member should return the form in the postage-paid envelope included with the renewal form. If the envelope is lost, the form can be returned to their local DHS Income Maintenance office. Information on the local office should also be pre-populated on the first page. o What Providers Can Do: Encourage members to open and read any mail they receive from DHS. Complete the form as soon as it is received and return it to DHS. This will help ensure continued coverage, if the member remains eligible. Direct questions to the DHS office or, if comfortable, assist member in completing the form. The form contains similar information as the health care coverage application. If assisting or advising, help member make sure the form is returned. Q: Will Healthy Behaviors completed while a patient is presumptively eligible count under the IHWP? A: Yes, the Healthy Behavior completed while presumptively eligible will count. 4

5 Patient Communications Q: Did IME send out mailings to Meridian patients or was this just Marketplace Choice and IWP patients? A: Yes. All members received the first mailing about the Healthy Behaviors programs. Members will continue to receive mailings throughout the summer and fall with more specific information and details. Links to the sample mailings are included in the overview section above. Q: In the sample mailing to Wellness Plan about the HRA on page two, some patients do not have a code and are told to use a generic code. We assume this is only for patients not assigned to a PCP. Can providers use this generic code with patients who have forgotten their assigned code and what are the implications for doing so related to patients receiving credit for completing the HRA and information sharing for providers? A: Patients need to use a valid code to have the completion of the HRA count toward their meeting the Healthy Behaviors. The process is more streamlined for the provider to receive the results if the patient uses their assigned provider s code, but they can use the generic code. IME is working on improving their ability to get the HRA results to the patient s assigned provider if they use the generic code. Options if the member uses the generic code include the following: o Member receives copy of summary results in the mail if done over phone. o Member can print results if done on own with generic code. o Member can call IME Member Services and request a copy of the summary be mailed to them if generic code was used. o Member can call IME Member Services and request a copy of the summary be faxed to the provider s office (must give provider s fax #), if generic code was used. Administering the Health Risk Assessment (HRA) Q: Can IME open member services up to allow patients to call in and complete the HRA over the phone? A: Yes. Members can call the IME Member Services Phone Number at (Open 8-5, M-F) to complete the AsssessMyHealth HRA over the phone. When a member calls to complete the HRA over the phone, we first encourage them to speak to their provider, and have been since launching the HRA this spring. The purpose of this is to help better streamline the HRA results to the provider. If the member still wants to complete the HRA while on the call, the process immediately begins. This script began when the first mailing was sent in May. Since the mailing came from the IME, we received many of the questions. We do want to encourage members to speak to their provider, get the correct access code, etc., which is why the conversation includes the mention of the provider. But again, we've been doing this all along; it's not a new approach. Members are still more than welcome to complete the survey over the phone; it's just a talking point in the conversation. Q: Is there a way for patients to complete the HRA on paper? Can IME makes copies available to providers? A: The AssessMyHealth HRA is not available in paper; however, patients can print off the results of the HRA to give to their provider. Additionally, if a member calls IME s Member Services to complete the HRA over the phone, IME will mail the results of the HRA to the assigned provider. 5

6 Q: Will the patient be able to identify the provider by name and member services will fill in the number the assigned so provider gets information back? A: IME is working to connect the patient to the assigned provider and share the results of the HRA to that provider. Q: Can IME provide the phone numbers for patients to call to complete the various HRAs? A: To complete the Assess My Health HRA over the phone, members should call Iowa Medicaid Member Services at , 8am-5pm, M-F. For questions and other information about the health plan HRAs, members should contact the health plans directly. CoOportunity Health Member Services can be reached at Coventry Health Care Member Services can be reached at Meridian Health Plan Member Services can be reached at Q: What ways can a patient complete the various HRAs? A: The Assess My Health HRA can be completed online or via phone. The Coventry HRA is only available to patients online. Q: Are providers allowed to do the HRA as they assist a patient with a DHS application? Or does the client have to be approved for the IHWP before the HRA can be completed? A: To complete the HRA and receive credit, the member must enter a member ID at the end. Upon application, the member ID would not yet be available, making it difficult to accurately track the completion of the HRA. Q: Is IME able to make printed copies of the AssessMyHealth HRA educational materials that are provided to patients based on the HRA results available to patients? A: We're not able to provide the printed materials right now, since they are specific to the patient. Q: I called Member Services a couple times and stated I was an IMC and Meridian member and would like to complete the HRA via phone because I do not have a computer. The member services worker reported that I could, but would have to use the general code. I told her I was a PHC patient and want my provider to see my survey results. She stated she can "try" entering the PHC code, but was unsure if the system would take it. I would like to confirm with IME that we can have our provider code used instead of the general code when patients call into Member Services. A: Member Services cannot use alternative codes at this time. Due to potential HIPPA concerns should an incorrect code be used, only the Member Services code can be used over the phone. Results can be printed and mailed to the member, or faxed to the provider with the member's consent. Various Health Risk Assessments Available Q: Will the completion of the Assess My Health HRA count for all of the populations (IWP, MCP CoOp, MCP Coventry, Meridian) or do patients have to use the tool provided by the various payors? A: Yes. IME is encouraging members to use the tool provided by the different payors, but completing the Assess My Health tool would still count as meeting the Healthy Behaviors 6

7 requirement. The same goes if a member completes the CoOp, Coventry or Meridian HRA. If one of those is completed, the requirement is met and the member is not required to also complete Assess My Health Q: If a patient completes one of the other payors HRAs, will this count toward the patient meeting one of their required healthy behaviors for IME s purposes? A: Yes, see response above. Incentives Q: What are the incentives available to providers for each payor? We know that the $25 payments to providers are only available if the Assess My Health tool is used and only available once the HRA results have been incorporated into the patient s care plan. A: From the member perspective, the main incentive is the waiver of premiums in the next year of enrollment. CoOportunity Health has chosen to also provide all members (not just Marketplace Choice Plan members) with an additional incentive of $100 Visa gift card. From the provider perspective, the $25 is available for Wellness Plan providers who incorporate the HRA results (Assess My Health HRA only) into the member s care plan. Wellness Plan providers can also receive a $10 per member annual bonus for those members who have the wellness exam completed. This bonus is available if more than 50% of the provider s assigned members complete the exam. IME wants to make sure it is clear that the $25 can only be billed for Wellness Plan patients using the AssessMyHealth HRA tool. Any billing related to the Marketplace Choice Plan members goes through the qualified health plans, so the $25 is available to patients of the Wellness Plan population being served by Medicaid providers, who directly bill Iowa Medicaid. Coventry has not made any provider or patient incentives available. See the provider toolkit referenced above for more information. Q: Is there a timeframe requirement as far as when the provider needs to meet with the patient once the online HRA has been completed? A: IME has not set a deadline for incorporating the results of the HRA into the patient's care plan; however, providers are not able to bill IME for the $25 provider incentive until this has been accomplished. The $25 incentive is only available for patients using the AssessYourHealth HRA, which is the tool IME has rolled out and is tied to the Treo Solutions system. Sarah- Both of your answers are correct. The individual has 12 months to complete Healthy Behaviors. The IME also has not set a timeline for incorporation of the Assess My Health HRA, however, it must be done prior to being billed, as your stated Q: Do providers need to do both completion and follow up to get the $25? Only the follow up? A: The $25 incentive available to providers is for incorporating the results of the HRA into the patient s care plan so providers do not have to assist patients in completing the HRA; however, they may do so. Non-clinicians can assist in incorporating the HRA results into the care plan and providers can follow their current processes for signing off on patient charts. Q: How does a provider prove they incorporated the results of the HRA into the care plan? A: The results need to be included and maintained as part of the patient s medical record. IME is working to finalize the code that FQHCs and RHCs will need to use to bill for the $25 incentive. 7

8 Q: Can someone explain the timeline for patients to complete the Healthy Behaviors compared to how providers are measured on their assigned patients meeting the Healthy Behaviors? A: From the member perspective, they have 12 months from their enrollment date to complete the two Healthy Behaviors. From the Practice Manager (for Wellness Exams) and ACO (for both Healthy Behaviors) perspectives, the measurement year is the calendar year so we have until December 31, 2014, to support 50% of the assigned members in completing the Healthy Behaviors. This is where the enrollment of at least six months comes into play for denominator purposes. Q: Does the PCP have to be the staff person signing off on the HRA results being incorporated into the care plan if the PCP has assigned a health educator or social worker, etc. to do this work? A: Yes. Q: Can you provide an update and/or guidance on how the FQHCs should be using and submitting the HRA code when they submit a claim to IME for incorporating the results of the HRA into a patient's care plan? We are hearing that this is not yet working so wanted to provide guidance to the centers to hold off on sending claims in until IME is able to process them. A: We'll provide additional details in an informational letter that will be issued soon (aiming for within the next week). Q: When will the results about whether providers and/or ACOs met the Healthy Behaviors performance incentives? A: IME will allow a three-month claims run out through March 2015 and will then work to provide results to providers and ACOs during April Q: If a health center is using only certain providers to see patients for wellness exams (instead of trying to get each patient in with their regular PCP), how might this adversely impact their Value Index Score for the continuity of care domain? A: There should be no adverse impact to a health center Value Index Score. Billing occurs at the health center level and not the individual provider level, and patients who receive their wellness exam at their assigned health center will not negatively impact the Value Index Score. Q: How is the 50% completion rate for the Healthy Behaviors activities calculated for the ACO incentive payment purposes? A: The 50% completion rate is calculated by determining the number of patients who have been assigned to a health center and have been enrolled in the Iowa Wellness Plan for six months or more and who have completed both of the Healthy Behaviors activities. Information Sharing Q: How will providers know if a patient has already completed a wellness exam or HRA? A: IME is working to make this data available to providers via a monthly report, but this is not yet available. A member could call the IME Member Services line and find out if they have completed the Healthy Behaviors and then report this back to the provider. Q: Where are the results housed? 8

9 A: The HRA results are housed within the Treo Solutions system. Providers must sign up for an account with Treo to access their patients HRA results. The Treo data is imported into the IME systems for tracking and reporting purposes. For information about getting signed up for an account, please refer to the instructions in the toolkit mentioned in the overview section above. Q: How does a provider access the results of the HRA for their assigned patients? A: See the above response. Also, providers are able to access the HRA results within the they will receive once one of their assigned patients completes the HRA (assuming they use the provider s code). Q: Can IME identify a process to allow organizations to get access to all of their empanelled members wellness exam and HRA information so providers can act on the results (i.e., if patient does on own, via member services, or at another organization)? Does it include the effective date of coverage for the patient? A: IME has made a Healthy Behaviors completion report available to the Wellness Plan ACOs in the state, but not to individual Wellness Plan Practice Managers. This report does not include the effective date of coverage, but does indicate how many months patients have been enrolled in the program. Q: Will IME make aggregate results in their entirety available to providers? There are a number of private questions that reflect patient satisfaction and understand need for confidentiality, but providers want to know what issues members are experiencing so they can improve their practices and respond to concerns quickly instead of waiting for months for the information, or never getting it at all. A: IME is in the early phases of discussing making this data available to providers. More information will be made available to providers once IME has determined a plan. Q: Is there a way for providers to know in ELVS if a patient is at-risk for being dropped from the IHWP programs in 2015? A: IME is not able to produce this information currently as this report would require data from two different systems, IMPA and their MMIS system. Any loss of eligibility would happen at the end of the month, effective the first of the next month. Providers must continue to confirm eligibility at time of service. Members will receive at least 10 days (if not more) notice of loss of eligibility. Upcoming loss of eligibility is not something that can be incorporated into ELVS. Q: Is IME able to make the effective date of coverage available on the ELVS system? A: IME is looking into this method, and options with the patient listing, related to Healthy Behaviors. Q: Can IME share information with providers about which HRA a patient completed as part of the monthly completion report IME is building? This distinction in the report (i.e., not simply having a column HRA done--yes or no, but the type of HRA completed) could help alleviate confusion among providers in general and specifically related to billing IME for the $25 incentive for incorporating the results of the AssessMyHealth HRA into the patient's care plan. How will IME know which provider they should send the MCP patient information to since there seems to be less structure to the PCP assignment in this program compared to the Meridian HMO for the Wellness Plan and the IME PCCM Wellness Plan? 9

10 A: IME will look into what is possible. Given the timeframe, IME had only planned to indicate whether or not the member had completed the behavior, not the source. But, they understand the potential need to have the information. Q: How will Meridian, the CoOp, and Coventry be reporting to IME about their patients that have completed the HRA? Will these results be made available to providers in late summer like what IME is working to make available for the IWP population? A: The other HRA completion data will be incorporated into the IME s system of record for Healthy Behaviors. The other plans will submit the completion to the IME on a regular basis. This completion information would be incorporated into the patient listing/completion report. Q: I received a call from a patient who got a letter stating they need to complete the Wellness Exam, but it was completed 07/15/14. Who is the contact for this issue? A: IME recommends starting with Provider Services. They will be able to verify with the provider if there is a claim in the system for the member, on the date of service. We use the claims data to populate those mailings, so if we don't have anything in the system, then we assumed the exam hasn't been completed. The claim could have recently appeared though, and in that case, the member would be set. This may continue to pop up every now and then as we send the mailings. Again, we're using claims data and HRA completion reports, so if there is a lag in claim submission, or the HRA didn't have member identifying information, we don't know the activity has been completed. Q: Some patients may have completed their HRA prior to July 28 th and we cannot view the results as our Treo account was not set up. How do we get that result so we can do the Care Management Plan? A: IME Member Services can be contacted by calling (Open 8-5, M-F). Q: For patients who do not identify us as their PCP with our assigned code, how do we obtain their HRA results? A: If patients use the generic code, the assigned PCP may not receive the results, but the patient can call IME Member Services at (Open 8-5, M-F) and request the results be shared with the PCP. Other Issues Q: Has IME decided which Healthy Behaviors will be required activities for 2015? A: Completion of the HRA as well as a wellness exam will remain required Healthy Behaviors activities for IME is still determining if additional activities will also be required. Q: Is IME interested in provider feedback on the usefulness of the HRA? A: Yes, IME is interested in feedback. Please send provider feedback to Sarah Dixon, Iowa PCA (sdixongale@iowapca.org). 10