Indiana Navigator Test Study Guide Solved 100%

Define IHCP - Answer Indiana Health Coverage Program: programs under Indiana Medicaid developed to address the medical needs of low income, aged, disabled, pregmant and other populations meeting the different eligibility criteria of each program. What programs fall under the Indiana Health Coverage Programs? - Answer Indiana Medicaid: Hoosier Healthwise, Childrens's Health Insurance Program, Healthy Indiana Plan, Hoosier Care Connect, Traditional Medicaid, and Home and Community Based Waiver Services (HCBS) Define FFM - Answer Federally-facilitated Marketplace: federally developed and operated insurance marketplace that makes Qualified Health Providers, Premium Tax Credits, and Cost Share Reductions available to individuals and/or employers in accordance with the Affordable Care Act (ACA). Also referred to as or an Exchange. Define Producer, Agent, Broker, Agency - Answer an individual/entity licensed by the state/Indiana Dept. of Insurance (IDOI) as a health insurance producer to sell, solicit, or negotiate insurance (products) and are therefore unable to be certified as an Indiana Navigator or Application Organization due to receiving compensation for enrolling an individual in a plan. If they want to sell on the FFM, they must be federally certified through the CMS. Define Indiana Navigator - Answer an individual certified by the state of Indiana to provide application assistance through the Federally Facilitated Marketplace (FFM: QHPs, PTCs, CSRs) and/or the Indiana Health Coverage Program (Medicaid, CHIP, HIP, HHW, Hoosier Care Connect) Define AO - Answer Application Organization: an entity that must be certified and registered with the state of Indiana to assist Hoosiers with applications on the FFM and/or for IHCPs Define CAC - Answer Certified Application Counselors: individuals (staff members or volunteers) who fulfill some of the same roles as Navigators and are certified as Indiana Navigators through the IDOI; they are not responsible for outreach and education but they do provide free information to consumers about insurance programs and they help to facilitate the enrollment in health coverage. Define Non-Navigator Assistance Personnel - Answer a role with the same certification requirements as a Navigator that complements Navigator programs in Partnership Marketplace states; not available in Indiana and other FFM Model states Define Navigator PE - Answer Navigator Precertification Education: education and training programs approved by the IDOI that must be completed by individuals as part of the initial Indiana Navigator certification application process and prior to taking the Navigator Examination. Navigator CE - Answer Navigator Continuing Education: education and training programs approved by the IDOI that must be completed by certified Indiana Navigators to satisfy their yearly two-hour Navigator CE requirement to renew their licensure. What is a Conflict of Interest Policy? - Answer A state policy that establishes what may constitute an actual or potential Conflict of Interest (Financial Interest or Conflict of Loyalty) and disclosure and other requirements surrounding such conflicts by which all Indiana Navigators and AOs must comply. What is an example of a conflict of interest and what type is it? - Answer Conflict of loyalty- an Indiana Navigator and/or an AO have a close relationship with a hospital that prefers a high payment rate plan What are the kinds of conflict of interests? - Answer Direct financial incentive, indirect financial incentive, no additional financial incentive, and conflict of loyalty. Define direct financial incentive. - Answer A conflict of interest: an individual receives compensation from a health insurance company for enrolling a consumer in a specific/stop-loss plan. Not allowed (ie agents or brokers) Define indirect financial incentive. - Answer Conflict of interest: must be disclosed to IDOI and all consumers prior to assisting with coverage that an AO or Navigator holds stock in an insurance company and may indirectly benefit if consumer purchases a plan with the assistance of a Navigator. Define no additional financial incentive. - Answer Conflict of interest that is permissible: an Indiana Navigator receives an hourly wage from an employer/AO, regardless of number of consumers helped or plans selected Define conflict of loyalty. - Answer A business or personal interest that keeps the IN Navigator or AO from acting in the best interest of the consumer that must be reported. Privacy & Security; Personal Information; Security Breach - Answer All Indiana Navigators and AOs must comply with state privacy and security agreements established, which defines what constitutes a consumer's Personal Information and a Security Breach or improper disclosure of such information. It also establishes privacy and security standards and procedures that all Indiana Navigators and AOs must follow in order to protect a consumer's personal information. How long does a Navigator have to notify a consumer and the IDOI of a security breach or an improper disclosure of personal information? - Answer A Navigator must notify the consumer within 10 days of the breach/disclosure and must notify the IDOI within 5 days. What are the reporting requirements for Indiana Navigators? - Answer Information that must be reported to the IDOI within 30 days by an Indiana Navigator (about said party) including a change in name or contact information, administrative, criminal, or other legal action after final disposition, a change in a conflict of interest status, and/or a security breach or improper disclosure of a consumer's personal information. What are the reporting requirements for Application Organizations? - Answer A change in name, Federal Employer Identification Number (FEIN), or contact information, as well as any criminal, administrative, or other legal action, a changed or new conflict of interest, an addition/removal of associated Indiana Navigators, a security breach or improper disclosure of consumer information, or a change/addition/removal of a location with more than one location What are the requirements for producers (agents and brokers) to sell on the Federally-facilitated Marketplace? - Answer Post-Affordable Care Act 2010: must have health producer license with IDOI and must complete FFM registration and training through the Centers for Medicare and Medicaid Services (CMS) What is the Department of Health and Human Services (HHS)? - Answer The United States federal government's principal health agency that develops and manages the federal Marketplace/ through the Centers for Medicare & Medicaid Services (CMS) and manages the establishment, training, certification, monitoring, and oversight of Marketplace agents, brokers, carriers, and federally-certified consumer assistants. What is the Centers for Medicare & Medicaid Services (CMS)? - Answer A federal agency within the US Department of Health and Human Services (HHS) that administers Medicare, works with state governments to administer Medicaid and the Children's Health Insurance Programs (CHIP), and oversees the federal Marketplace/ What is the Affordable Care Act (ACA)? - Answer Also known as Obamacare. A federal statute that was signed into law March 23, 2010 and later amended by the federal Health Care and Education Reconciliation Act of 2010. The law reformed healthcare and health insurance systems by establishing health insurance Marketplaces and federal consumer assistance programs (such as federal Navigators, Certified Application Counselors (CACs), and non-Navigator Assistance Personnel. The law also enacted that there are no lifetime limits on coverage and that insurance is guaranteed to be available and renewable, it subsidized coverage for low-income people, and made it illegal for companies to deny coverage or raise premiums based on preexisting conditions. It also established that Americans are required to have health coverage or will be charged extra taxes (Individual Mandate) for lack of coverage. What is the Individual Mandate tax penalty? - Answer The greater of 2.5% of annual household income; a charge for each individual in household Adult: $695, under 18: $347.50 up to a Maximum of $2,085; or the National Average Premium for a QHP Bronze Plan that would cover the household/individual(s). What website would you purchase or view a QHP? - Answer ("FFM/Exchange") What is the difference between Federal and Indiana Navigators? - Answer Indiana Navs. are certified through the Indiana Dept. of Insurance and Federal Navs. are certified through the Centers for Medicare & Medicaid Services (CMS) and receive federal grant awards. How to become a CAC in Indiana? - Answer Individuals cannot be designated as a Certified Application Counselor because the FFM only designated organizations and not individuals. CAC Organizations must also be registered as Application Organizations and certified (individual) Indiana Navigators in the state of Indiana. What are the two laws that regulate requirements for Indiana Navigator's? - Answer IC 27-19: Indiana Code Title 27, Article 19 760 IAC 4: Title 760, Article 4 of the Indiana Administrative Code Which states are Non-Navigator Personnel active in? - Answer Partnership Marketplace states (not states with the FFM Model, such as Indiana) A federally-designated consumer assistant may be which of the following? - Answer Certified Application Counselor (CAC), Federal Navigator, or a Producer (Broker and/or Agent) An individual cannot be an Indiana Navigator if: - Answer 1. They have been denied, suspended, or revoked of an insurance agent/broker license, IN Navigator Certification, or an equivalent license certification 2. They have been convicted of a disqualifying felony or crime as determined by the Commissioner of Insurance 3. They have been convicted of unfair trade practice or fraud in insurance business 4. They have an unpaid state income tax or child support obligation The Indiana Dept. of Insurance May respond to complaints against IN Navigators or AOs with: - Answer 1. A reprimand 2. A civil penalty (fine) 3. Suspension of certification 4. A temporary or permanent revocation of certification 5. A cease and desist order Who determines the punishment of a complaint against IN Navs and AOs? - Answer The Commissioner of the Indiana Dept. of Insurance- the severity of the punishment depends on the severity of the crime A complaint about an IN Nav can be made to the IDOI and will be processed within - Answer 72 hours Define the IAHC. - Answer The Indiana Application for Health Coverage: an application for an Indiana Health Coverage Program (IHCP), which may be submitted to the Division of Family Resources (DFR) online through the DFR Benefits Portal at , by phone, fax, mail, or in-person at a local DFR office. What are the two important websites for applying for health coverage, and for which programs? - Answer Federally-facilitated Marketplace (FFM) QHPs at Indiana Application for Health Coverage (IAHC) IHCPs at What is Medicaid? - Answer A federal-state program providing free or low-cost health insurance coverage to individuals meeting state eligibility criteria, which are developed within the parameters established by the federal government. What is Hoosier Healthwise (HHW)? - Answer Am Indiana Medicaid program for low-income pregnant women and children up to age 19. The program covers medical care like doctor visits, prescription medicine, mental healthcare, dental care, hospitalizations, and surgeries, at little or no cost to the member or their family. What is the FPL for HHW? - Answer Hoosier Healthwise Children: 250% FPL Pregnant Women: 208% FPL What is the Children's Health Insurance Program (CHIP)? - Answer A joint federal-state program providing health coverage to children whose income is too high to qualify for other Medicaid categories. What is the FPL for CHIP? - Answer 250% FPL What is the Healthy Indiana Plan (HIP)? - Answer Indiana's health coverage plan for Hoosiers between ages 19-64 with family income less than 138% of the Federal Poverty Level (FPL) and who are not eligible for Medicare or another Medicaid category. HIP has three options: Basic, Plus, and State Plan. What are the four HIP plan options and their FPLs? - Answer HIP: 138% FPL HIP Plus: 138% FPL HIP Basic: 100% FPL HIP State Plan Basic: 100% FPL HIP State Plan Plus: 138% FPL HIP Maternity: 138% FPL What programs fall under Medicaid and Indiana Medicaid? - Answer Hoosier Healthwise, Healthy Indiana Plan (HIP), Hoosier Care Connect, Traditional Medicaid, and the Home and Community Based Services (HCBS) waiver. What is the POWER Account? - Answer Account used to pay medical costs for HIP Plus members that covers the first $2500 of covered services and fully covers additional services. The state funds most of the $2500, but the member is responsible for an affordable monthly payment of $1, $5, $10, $15 or $20 based on income. What is a Managed Care Entity (MCE)? - Answer A general term used to describe health plans designed to control the quality and cost of healthcare delivery. In IN Medicaid, benefits are delivered in the Hoosier Healthwise, HIP, and Hoosier Connect programs through MCEs for some populations. What are the four Managed Care Entities (MCEs) that administer Hoosier Healthwise and Healthy Indiana Plan (HIP)? - Answer Anthem, CareSource, MDwise, and Managed Health Services (mhs) What specific Managed Care Entities administer Hoosier Care Connect? - Answer Anthem and Managed Health Services (mhs) Who is the covered population for Hoosier Care Connect? - Answer Individuals not eligible for Medicare and also 65+, blind, disabled, receiving Supplemental Security Income (SSI), or enrolled in M.E.D. Works What is Presumptive Eligibility (PE)? - Answer Determination by a Qualified Provider (QP) that an individual is eligible for temporary Medicaid benefits on the basis of preliminary self-declared information. During this period, the individual is able to receive treatment from the IHCP providers. Individuals must still complete a full application to determine eligibility for continued coverage. A QP guides PE members in submitting an IAHC within 30 days of a PE application approval. What is a Medical Review Team (MRT)? - Answer Who determines an applicant's eligibility for Indiana Medicaid based on a disability determination through medical records, doctor examinations, lab results, etc. and social summary. Who is fully covered in Presumptive Eligibility? - Answer Infants, children, parents/caretakers, and former foster children. Who is under limited coverage for Presumptive Eligibility? - Answer Pregnant women (no labor and delivery), family planning (covers services and supplies intended to prevent or delay pregnancy), adults (equivalent to HIP Basic), and inmates (covers inpatient hospital stays only) Who is eligible for Presumptive Eligibility? - Answer A resident/citizen of the US and Indiana who is not currently enrolled in any other IHCP or another PE plan and meets income level requirements. What are the FPL limits for Presumptive Eligibility? - Answer Infants 213% FPL Children 1-18 163% FPL Parents/Caretakers converted to AFDC limits Former Foster Care Children No FPL Requirement Pregnant Women 213% Family Planning 146% Adult 138% Can inmates be covered under Presumptive Eligibility? - Answer Yes, but only for inpatient hospital stays and they must be in a correctional facility and under contract with the FSSA. What are the Hoosier Healthwise Packages? - Answer Package A for low-income children and Package C (CHIP) for children with higher income Who does Hoosier Healthwise Package A cover? - Answer Package A covers children (newborn- age 19) with income 158% FPL Who does Hoosier Healthwise Package C cover? - Answer Package C (CHIP) cover children with income between 158% and 250% FPL, but there are monthly premiums and copays. Besides children, who does Hoosier Healthwise cover? - Answer Pregnant women up to 208% FPL, but there are monthly premiums and copays. What is HIP Plus? - Answer A Healthy Indiana Plan that offers comprehensive coverage (health, dental, vision, chiropractic) to individuals 138% FPL; consumers pay into a mostly state-funded $2500 POWER account with $1, $5, $10, $15, or $20 monthly payments determined by income but pay no copays for services. What is the only way a HIP Plus member would have a copay for a service? - Answer For inappropriate use of the ER, which results in a copay of $8. What is HIP Basic? - Answer A fall-back option Healthy Indiana Plan for individuals with up to 100% FPL that meets Minimum Essential Coverage (MEC) but is not comprehensive; individuals do not pay into a POWER account and instead have copays for dr visits, hospital stays, and prescriptions. What are the HIP Basic copay amounts? - Answer outpatient services/office visits: $4 inpatient services/hospital stays: $75 Preferred drugs: $4 Non-preferred drugs: $8 Non-emergency ER visit: $8 What is the HIP State Plan? - Answer Can be a Healthy Indiana Plan (HIP) State Plan Basic or Plus, and follow the same guidelines in terms of POWER accounts, FPL, etc. but are for individuals who qualify for extra benefits (ie transportation) on top of the completely comprehensive coverage (for both) based on condition, disorder, or disability. What is HIP Maternity? - Answer A Healthy Indiana Plan that covers pregnant women with comprehensive coverage and extra benefits (non-emergency transportation and enhanced smoking cessation services) with no cost sharing (copays or POWER account) An unborn child counts toward family size for which programs? - Answer Presumptive Eligibility and/or Hoosier Healthwise What is the HIP Gateway to Work? - Answer A requirement through HIP that requires all able-bodied HIP members work, go to school, or volunteer for at least 20 hours a week, and eligibility for HIP will be suspended if they are not working 8/12 months of the year. Who is exempt from HIP Gateway to Work? - Answer Students, pregnant women, primary caregivers of a dependent child or disabled dependent, the medically frail, someone with a certified mental illness or incapacity, someone in active substance use disorder treatment, aged 60+, the recently incarcerated, the chronically homeless, and any TANF/SNAP recipients. Define Medically Frail through HIP. - Answer someone who has a severe/debilitating physical medical condition; a serious mental health issue such as alcohol/substance abuse or major depression, schizophrenia, bipolar disorder, or PTSD; or needs assistance in the activities of daily living (eating, moving, dressing, bathing, using toilet) and/or requires 24 hour supervision, assistance, or monitoring Which plan are the medically frail enrolled in? - Answer The HIP State Plan (Basic or Plus). Cost sharing applies, but access to vision, dental, and non-emergency transportation benefits is ensured regardless of cost sharing option and they will not be locked out for not paying POWER account contributions. Are Native Americans required to pay cost sharing fees when enrolled in HIP? - Answer No, by federal rule they are exempt from cost sharing. How much is the HIP Fast Track payment and what does it do? - Answer A $10 payment that allows eligible Hoosiers to expedite the start of their coverage in the HIP Plus program by establishing coverage on the first of the month in which the payment is made. If no payment is made, the HIP Plus coverage will begin the first of the month in which the first POWER account contribution is made (members have 60 days to make either payment or they will default to the HIP Basic Plan). What is the HIP Tobacco Surcharge? - Answer HIP members who use tobacco have 12 months to quit or their PAC (payment) amount for the next year What is Hoosier Care Connect? - Answer A plan that covers individuals not eligible for Medicare and are Aged (65+), blind, disabled, receiving Supplemental Security Income (SSI) or are enrolled in M.E.D. Works. Are covered under the Managed Care Entities (MCEs) Anthem and Managed Health Services (MHS). How are individuals assigned to an MCE through Hoosier Care Connect or Healthy Indiana Plan (HIP)? - Answer Individuals select at application or are auto-assigned. PCP are then selected by individual or assigned by the MCE. What is Traditional Medicaid? - Answer Covered populations include Aged, blind, disabled (who are all dual eligible- Medicaid and Medicare coverage possible at same time but only for this group), adults, children, and refugees who do not qualify for another aid category. Former foster care children can enroll in Medicaid and are covered until what age if they were not covered as of their 18th birthday? - Answer 21 Which plans have (or could apply) 3 month retroactive coverage? - Answer Hoosier Healthwise and Medicaid (BCCP, MED Works, Aged, Blind, and Disabled) What is M.E.D. Works? - Answer Medicaid for Employees with Disabilities who are working. Ages 16-64 are covered as long as their income is 350% FPL and below, and their assets are below $2000 for singles and $3000 for married couples. They receive full benefits and Medicaid may work in conjunction as a secondary payer with employer insurance. What are some the income details of MED Works (ie, how is income counted, premiums, etc.) - Answer Income standards are based on the individual's income and does NOT consider other potential household member's (including spouse's) income when determining eligibility by FPL. If the individual's FPL is over 150%, a monthly premium based on income would cost anywhere from $48-187/mo. If they are married, the spousal income is considered when calculating a premium (but not an FPL), and payments would range from $65-254/mo. What is the Home & Community-Based Services (HCBS) Waiver? - Answer Coverage through Medicaid for individuals who meet certain Medicaid requirements and are at risk of being institutionalized due to "level of care" reasons like complex medical conditions and intellectual disabilities. This program exists to keep individuals under care in their own home and community setting. What is the eligibility criteria for HCBS Waivers? - Answer The individual has to have less income than or equal to 300% of the maximum Supplemental Security Income (SSI) federal benefit rate, which is roughly $3035/mo. (as of 2018). They also have to meet the "Level of Care-" for example, complex medical conditions and/or an intellectual disability. Must be at risk of being institutionalized in a care facility. What is the Behavioral and Primary Healthcare Coordination Program (BPHC) through the HCBS? - Answer a program consisting of the coordination of healthcare services to manage the mental health/addiction and physical healthcare needs of eligible recipients.