What is Medically Frail?
- Federal Title attached to our Healthy Indiana Plan
- For people who are not legally disabled or who are but failed the income or resource guidelines for Medicaid
- Given to clients with physician, mental or emotional conditions including substance abuse
- Gives access to enhanced benefits, Plus benefits if on Basic, and Medicaid Rehab Option (MRO) services
- Basically HIP members gain access to Medicaid benefits that are not included in the HIP package
- HIP Maternity clients automatically gain access to MRO services
- Protects the clients from “Lock Outs” which can occur when a person does not make power account payments
- HIP State Plan Plus members who fail to make the payments will stay on Plus but with co-pays if otherwise they would be entirely kicked off HIP (105-138% of poverty not eligible for Basic)
How it is determined?
- MCE – Managed Care Entity has panels and departments that decide if a person is medically frail based upon criteria and diagnoses of the client
- This should happen naturally within the first thirty days of the person being on a MCE with HIP – Healthy Indiana Plan (Medicaid Policy 3515.05.00)
- Done by a review of medical claims and clinical history
- Rarely does this occur that fast
How to get it done as fast as possible?
- A client should always do the Health Needs Screening or Survey for their MCE when they get approved. Their honest answers will put a beacon on the case to be reviewed.
- Since it can take some time for the people to review claims, see codes matching medically frail categories and send them for review, you can send the person directly to review as the provider.
- Each MCE has a form or forms that can be completed and sent directly to the medical review board.
- All the forms must be done by the medical professional who is treating the person (doctor, NP, therapist, counselor, etc) or the direct staff such as a nurse.
- Anthem – different forms for different health categories
CareSource – document needs to be signed by the client and then have the cover sheet competed and sent with medical records
- Phone: not specific, ask for Medically Frail team – 844-607-2829
- Fax: 937-487-0131
- Email: email@example.com
MHS – cover sheet which you send with assessment or medical records
MDWise – cover sheet which you send with assessment or medical records
- Phone: 844-293-6307
- Fax: 844-407-6455
- Email: MedFrailFax@mdwise.org
- If a person is in need of MRO services, please indicate that on the form
- If a person is taking an unusually long time after sending, a provider who completed the forms can reach out to the MCE directly to check on the case
- Clients who are legally disabled by the Social Security administration but not on Medicaid should open in State Plan
- If a client is approved while on HIP regular for SSD, the approval should be sent to the MCE for State Plan approval.
- When can you do the forms? The first day of coverage on the HIP plan.
- If a member calls and requests to be reviewed for Medically Frail Status, the MCE will send you the documents above. We are just jumping that step.
How will I know the client is approved?
- The client will receive written notification from the MCE as well as the FSSA.
- The FSSA letter will state the date the State Plan benefits will begin.
- Examples of the letters
- Opening on State Plan
- State Plan after already active
- Authorized Representatives who have ongoing responsibilities will also get the notice from the FSSA only, not the MCE
- Those benefits do not retro back to earlier dates like Medicaid does
- The Provider Portal on IndianaMedicaid.com will show the client on State Plan on and after the start date
Can you be kicked off of Medically Frail?
- You must have HIP to have the Medically Frail status. If you no longer have HIP because your received another category of insurance such as Medicaid or Medicare, became income ineligible*, or voluntary withdrawal, you will lose your Medically Frail Status.
- If you reapply, it may automatically come on with enrollment
- Clients will be reviewed annually and sent notification if their medically frail status is not reapproved for the next year. Which is why using the HIP coverage and having claims is important.
*During the Federal Public Health Emergency nobody is being terminated for being over income.