Tribal Health Improvement Program (T-HIP) Manual
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Updated 06/26/2024
Complete Tribal Health Improvement (T-HIP) Manual
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
Update Log
Publication History
This publication supersedes any and all previous DPHHS Indian Health Service/Tribal 638 handbooks. Published by the Montana Department of Public Health & Human Services, April 2006.
Updated October 2017, April 2022, and June 2024
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Update Log
06/26/2024
Full review and changes to entire manual.
04/12/2022
- Removed Nurse First Advice Line references.
- Updated Index to Search Options.
10/20/2017
First edition of the Montana Medicaid Tribal Health Improvement Program Manual.
End of Update Log Chapter
Table of Contents
Update Log
Key Contacts
Introduction
Manual Organization
Manual Maintenance
Rule References
Overview
Eligible Providers
Eligible Members
Program Requirements
T-HIP Provider Responsibilities
Reporting Requirements
Monthly Reporting
Six-Month Survey
T-HIP Eligible Member Opt-Out
Billing Procedures
Remittance Advice and Adjustments
How Payment is Calculated
Definitions
Forms
Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS IHS/Tribal 638/UIO Program
(406) 444-1292
(406) 444-1861 Fax
Indian Health Service/Tribal 638/Urban Indian Organization Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Tribal Health Improvement Program (T-HIP) services. Other essential information for providers is contained in the separate General Information for Providers Manual, available on the IHS page of the Provider Information website. Providers are responsible both manuals.
A table of contents and an index allow you to quickly find answers to most questions. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.
Manual Maintenance
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the Home page of the provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found om this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Rule References
Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. See the Contact Us page on the Provider Information website.
Overview
The Tribal Health Improvement Program (T-HIP) is a partnership between the Tribal, State and Federal governments to address factors that contribute to health disparities in the American Indian population eligible for Medicaid and residing on a reservation. It is a health promotion and disease prevention program. Federally recognized tribes in Montana, who meet all the provider requirements, are the only eligible entities to participate in and administer the Tribal Health Improvement Program (T-HIP).
T-HIP is a three-tier Primary Care Case Management entity (PCCMe) program. All three T-HIP Tiers focus on high-risk, high-cost members identified by the Department. The case management services provided under T-HIP, which meet the 42 CFR 438.2 definition of locating, coordinating, and monitoring primary health care services, seek to improve the health of members who have chronic illnesses or are at risk of developing serious health conditions through intensive care coordination of individual members. The T-HIP PCCMes also provide the following as defined in 42 CFR 438.2 in addition to primary care case management services:
- Provision of intensive telephonic case management.
- Provision of face-to-face case management.
- Development of enrollee Wellness Plans.
- Provision of enrollee outreach and education activities.
- Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers.
A major focus in the T-HIP, is to enhance the communication and coordination link between the member and the primary care provider. T-HIP functions are designed to help members:
- Maximize the benefits of their medical and other support systems.
- Improve knowledge of their disease and self-management skills.
- Remove barriers to achieving better health.
End of Introduction Chapter
Eligible Providers
For T-HIP, Tribes must employ or contract for:
- A supervising Medical Director, who is either a physician or advanced practice registered nurse (APRN) and;
- A Care Coordinator who is a registered nurse, licensed practical nurse, social worker, health educator or paraprofessional.
- Tribes must employ or contract with adequate personnel to provide enough Care Coordinators to allow an average caseload of no more than 150 attributed members.
End of Eligible Providers Chapter
Eligible Members
Eligible Members are those who meet the following criteria:- Enrolled in Medicaid;
- An American Indian/Alaska Native;
- Indian Health Service (IHS) eligible;
- Lives within the exterior reservation boundaries; and
- Has not opted-out of T-HIP.
End of Eligible Members Chapter
Program Requirements
Federally recognized tribes may choose to operate this program for their Native American members within the exterior boundaries of their reservation. To participate as a Tribal Health Improvement Program Provider, the Tribe must:
- Be Federally recognized.
- Have a 638 agreement (contract/compact) with Indian Health Services (IHS) that contains a scope of service for the Tribal Health Improvement Program services.
- Provide proof of the 698 agreement to the State.
- Execute a Task Order with the State.
- Maintain oversight and responsibility for operating the T-HIP service.
- Maintain a dedicated telephone number for T-HIP or include T-HIP as a specific selection option on the health center phone system.
- Provide and maintain Information Technology (including computers) to fully participate in the program.
- Comply with Federal Regulations, Administrative Rules of Montana, and T-HIP Provider Manual, inclusive of any updates that occur during the term of the Task Order.
- Ensure all Care Coordination staff complete chronic care certification and recertification courses.
- Maintain verification of compliance with this requirement.
- New T-HIP providers have 210 days from the start of the program to have a chronic care management certification completed for Care Coordinators.
- Ensure care coordination staff members participate in trainings offered by the Department.
- Maintain sufficient staff to meet requirements of the Task Order with a maximum caseload of no more than 150 members per Care Coordinator. Programs retain the authority to establish different case load amounts for complex cases and staff internally as they see fit as long as the caseload maximum is met.
- Maintain data collection requirements for this program monthly and bi-yearly.
- Provide services within the entire reservation service area.
- Meet all information requirements in 42 CFR 438.10. The tribe must be able to provide examples of written communications and materials to the Department upon request. Per 42 CFR 438.3(d)(3), the T-HIP will not, not on the basis of health status or need for health care services, discriminate against individuals eligible to enroll and the T-HIP will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, or disability.
End of Program Requirements Chapter
T-HIP Provider Responsibilities
Care Coordination functions for all tiers will be provided as indicated below:
- Development of an individualized Wellness Plan to address the member’s high-risk and/or high-cost health needs in coordination with the member.
- Self-management education for members related to their condition(s) both individually and/or in a group setting.
- Telephone calls and in-person visits to check on member progress and status.
- Pre-admission and post-discharge care coordination for out-of-state hospital admissions.
- Educate members on the value of recommended preventive/screening and medical services. Remind and assist members if needed, to schedule these services and visits.
- Assistance with and referrals to local resources such as social services, housing and other life problems that could prevent members from seeking care for medical conditions.
- Educate members on how to access the Medicaid Member Guide online and/or how to obtain a current up-to-date, Medicaid Member Guide.
- Conduct member outreach:
- Within one (1) week of member identification by the Department, send introductory written notification T-HIP's will use the Welcome Letter template as it includes the minimum required information for the introductory notification. The T-HIP's may insert their own language, colors, logos, or add additional information;
- Within two (2) weeks of initial notification, follow up with a phone call to T-HIP member;
- At least once per quarter, meet with active members face-to-face. Face-to-face means the Care Coordinator meets the member in their home, place of choosing or utilizes active real-time audio/visual technology. If the member refuses to meet, the Care Coordinator must document that they attempted to meet face-to-face; and
- Annually and as updated, send a copy of the member's Wellness Plan to the primary care physician (PCP).
- Provide outreach to the following members on a monthly basis:
- A minimum of 10% of the total eligible members with highest risk score as identified by the Department's predictable modeling software;
- An at-risk member identified through a Provider Referral Form who meets the member eligibility for T-HIP;
- An at-risk member, prior authorized for out-of-state hospital stays and services, to provide post-hospital care and discharge follow-up and other enhanced care coordination services.
- Have 40% or more of the Tier 1 required 10% of eligible members as active.
- Have 100% completion of Wellness Plans for active members.
- Demonstrate accurate on-time monthly reporting.
- Have 25% completion of six (6) month surveys for active members.
- Submit a Tier Request Form to the Department, confirming that staffing requirements will be met.
T-HIP Tier 3 functions include the care coordination requirements indicated above to a minimum of 40% of high-risk/high-cost members identified by the Department. To be eligible for Tier 3, a T-HIP must demonstrate adherence to the requirements of Tier 2 as well as:
- Have 50% or more of the Tier 2 required 25% of eligible members as active.
- Have 100% completion of Wellness Plans for active members.
- Demonstrate accurate on-time monthly reporting.
- Have 25% completion of six (6) month surveys for active members.
Upon approval of a Tier Request Form, an amendment to the current T-HIP Task Order will be executed, documenting when the Tribe will begin to provide the approved Tier care coordination functions.
A T-HIP must maintain the requirements to continue at the approved tier.
Member Communication
T-HIP’s are required to provide information to members in a manner that is easily understood and is accessible by all members. This may include members who require the use of oral interpretation, auxiliary aids, or language assistance.
If a member is in need of telephones with louder volume, telephones with captions, or hands-free devices, call the Montana Telecommunications Access Program (MTAP). They can be reached at 1-800-833-8503.
The Montana Relay service can help if a member, who may be deaf or heard of hearing, would like direct call relay services. To make a TTY call:
- Dial 7-1-1
- You will be asked for the number you want to call, do not forget to include the area code.
- A Communications Assistant will relay the words between both parties.
Also included on the MTAP website is information on Blind and Low Vision Services and a list of qualified sign language interpreters. Blind and Low Vision Services (mt.gov)
T-HIP’s are required to provide care coordination information available in the prevalent non-English language in the service area. For those who may need assistance in a language that is not a native tribal language, this link provides information on language access assistance. Welcome to LEP.gov
End of T-HIP Provider Responsibilities Chapter
Reporting Requirements
The T-HIP must comply with the following reporting requirements:
- Collect and report data using a department approved format, T-HIP Monthly Reporting Measures Form and T-HIP Six-Month Reporting Measures, until such time that a new department system is available.
- Use Department approved data collection system and software when it becomes available. The Tribe and Department acknowledge that it may be necessary to adjust the reporting measures based on system capabilities.
- Assign the T-HIP member a status based on the following chart. Update the member status after each contact.
- Report T-HIP monthly data elements using the T-HIP Monthly Reporting Measures Form for the required percentage of members. Report is due by the 10th of the following month.
- Report T-HIP six-month survey data elements using the T-HIP Six-Month Reporting Measures Form for active members. Report is due by the 10th of each January and the 10th of each July.
- Evaluate and review the T-HIP annually using the Annual Review Form as sent from the Department.
- Report disenrollment requested by the enrollee, the T-HIP, and deceased members using an Opt-Out Form.
| Status | Requirement |
|---|---|
| New to T-HIP |
|
| Active |
|
| Pending |
|
|
Cannot Contact |
|
| Do Not Contact |
|
T-HIP programs must keep appropriate records in the event of an audit. Record keeping standards can be found in ARM 37.85.414. Records should reflect care coordination services provided as outlined in this manual to individual members. Records may also include Wellness Plans, Chronic Care Certifications, Sign-in Sheets, Outreach and Education Write-ups, Expenditure Reports, etc.
End of Reporting Requirements Chapter
T-HIP Eligible Member Opt-Out
- A member has the right to opt-out of the T-HIP at any time for any reason.
- An Opt-Out Form is linked in the Forms section for the Tribal Health Improvement Program.
- The provider must explain to the member that the member may remain in the program in pending status and encourage this as an option.
- If the member does not want to participate in either active or pending status, the provider shall give a copy of the Opt-Out Form to the member.
- The member must sign the Opt-Out Form and turn the form into the Tribe or Department. If the member turns the form into the Tribe, the Tribe must send the form to the Department.
- Upon opt-out, the provider will no longer receive the T-HIP PMPM fee for the member.
- An eligible member, who previously chose to opt-out, may choose to participate in T-HIP at any time by filling out the Opt-In Form.
The T-HIP may request disenrollment of a member by submitting an Opt-Out Form to the Department noting the reasons for the requested disenrollment. The provider may not request disenrollment because of:
- a change in the member's health status;
- the member's utilization of medical services; or
- the member's diminished mental capacity, uncooperative or disruptive behavior resulting from his or her special needs, except when the member's continued enrollment in the T-HIP seriously impairs the provider's ability to furnish services to either the member or other members.
End of T-HIP Eligible Member Opt-Out Chapter
Billing Procedures
The T-HIP is different from other services Montana Medicaid pays for in that providers are not required to bill for T-HIP functions provided. The T-HIP will receive a per-member-per-month (PMPM) fee that is automatically generated by the Department and paid to the T-HIP monthly.
End of Billing Procedures Chapter
Remittance Advice and Adjustments
End of Remittance Advice and Adjustments Chapter
How Payment is Calculated
T-HIP providers receive a per-member-per-month (PMPM) fee for each eligible Medicaid member who lives within the exterior reservation boundaries. The PMPM fee is based on a three-tiered system and payments at each level are inclusive. Payment will not be prorated for a partial month on service provision.
Tier 1:
- $75.00 PMPM
- Operate the Tribal Health Improvement Program as described in the Task Order and this manual.
Tier 2:
- $150.00 PMPM
- Operate the Tribal Health Improvement Program as described in the Task Order and this manual.
Tier 3:
- $213.96 PMPM
- Operate the Tribal Health Improvement Program as described in the Task Order and this manual.
The T-HIP PMPM fee is not paid for members who have voluntarily disenrolled (opted-out) of T-HIP.
A tribal provider may provide and be reimbursed for both T-HIP and other Medicaid covered services that they meet the qualifications for. (Example: Tribe provides both dialysis and T-HIP services.) However, to the extent those services are described in the T-HIP contract and/or attachments, non-PCCM medical services must have separate Medicaid State Plan or waiver authority, and FFS reimbursement cannot be included in the T-HIP PMPM.
End of How Payment is Calculated Chapter
Definitions
Care Coordinator means a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker, Health Educator or Paraprofessional who specializes in and provides care coordination services in T-HIP. Care Coordinators work under the direct supervision of a medical director, who is employed by or under contract with the Tribe.
Enhanced Care Coordination (ECC) is the array of allowable PCCMe services and functions, provided by the T-HIP Care Coordinator. These services include guiding members through healthcare options, coordinating and implementing Wellness Plans, advocating on the member’s behalf, and providing community resource information. A major focus of enhanced care coordination is to improve the communication and coordination link between the member and the primary care provider.
T-HIP Medical Director is either a Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), or an Advanced Practice Registered Nurse (APRN) employed by or under contract with the Tribe.
T-HIP Provider means a health program operated by a federally recognized tribe, who meets the provider requirements, has a 638 agreement with Indian Health Service (through compact or contract) that contains a scope of service for the Tribal Health Improvement Program, and a signed Task Order with the State.
Member or Eligible Member means a person who meets all of the following requirements:
- Enrolled in Medicaid
- American Indian/Alaska Native
- Indian Health Service (IHS) eligible
- Lives within the exterior reservation boundaries
- Has not opted out of T-HIP
Paraprofessional means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional. This individual must have a minimum of an associate degree in behavioral sciences or a related field with two years of closely related work experience. Qualifying experience may be substituted, year for year, for education.
Per Member Per Month (PMPM) means the comprehensive monthly payment methodology that DPHHS utilizes to pay for all T-HIP services for an eligible member. The PMPM reimbursement is only for the T-HIP program activities that are allowable under the 42 CFR 438.2 definitions of PCCM and PCCMe functions. Other Medicaid covered services can be billed and paid separately, however, to the extent those services are described in the T-HIP contract and/or attachments, non-PCCM medical services must have separate Medicaid State Plan or waiver authority, and fee-for-service (FFS) reimbursement cannot be included in the T-HIP PMPM. The PMPM rate is a set amount of money: Tier 1, 2, and 3 each have different PMPM rates. A tribal provider does not bill the Department for ECC on an individual basis when a service is provided; the Department will identify eligible members and initiate payment. PMPM payments are made on behalf of all eligible members, regardless of whether a particular eligible member received T-HIP services that month.
Tier 1 is the building block for the Tribal Health Improvement Program. In order to participate, a Tribe must implement Tier 1 and serve the top 10% of eligible members identified by the Department as high-cost or high-risk. Tier 1 services must be supervised by a T-HIP Medical Director.
Tier 2 is the expansion of care coordination to the top 25% of eligible members identified by the Department as high-cost or high-risk. To participate in Tier 2, the Tribe must demonstrate adherence to the programmatic requirements of Tier 1. The same requirements outlined in Tier 1 apply to Tier 2.
Tier 3 is the expansion of care coordination to the top 40% of eligible members identified by the Department as high-cost or high-risk. To participate in Tier 3, the Tribe must demonstrate adherence to the programmatic requirements of Tier 2. The same requirements outlined in Tier 1 and Tier 2 apply to Tier 3.
Service Area means the area within the exterior boundaries of the reservation.
End of Definitions Chapter
Forms
The forms listed below are available on the Forms tab of the Tribal 638 page.
• T-HIP Tier Request Form
• T-HIP Provider Referral Form
• T-HIP Opt Out Form
• T-HIP Opt-In Form
• Office of Inspector General Alert
• Welcome Letter
End of Forms Chapter
Search Options
This manual contains search functions in lieu of an index.
This edition has three search options.
- Search the whole manual. Open the Complete Manual tab. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
- Search by chapter. Open any chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
- Site search. Search the manual and other documents related to a particular search term on the Site Specific Search page.
End of Search Options Chapter
End of T-HIP Manual
Update Log
Publication History
This publication supersedes any and all previous DPHHS Indian Health Service/Tribal 638 handbooks. Published by the Montana Department of Public Health & Human Services, April 2006.
Updated October 2017, April 2022, and June 2024
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Update Log
06/26/2024
Full review and changes to entire manual.
04/12/2022
- Removed Nurse First Advice Line references.
- Updated Index to Search Options.
10/20/2017
First edition of the Montana Medicaid Tribal Health Improvement Program Manual.
End of Update Log Chapter
Table of Contents
Update Log
Key Contacts
Introduction
Manual Organization
Manual Maintenance
Rule References
Overview
Eligible Providers
Eligible Members
Program Requirements
T-HIP Provider Responsibilities
Reporting Requirements
Monthly Reporting
Six-Month Survey
T-HIP Eligible Member Opt-Out
Billing Procedures
Remittance Advice and Adjustments
How Payment is Calculated
Definitions
Forms
Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS IHS/Tribal 638/UIO Program
(406) 444-1292
(406) 444-1861 Fax
Indian Health Service/Tribal 638/Urban Indian Organization Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Tribal Health Improvement Program (T-HIP) services. Other essential information for providers is contained in the separate General Information for Providers Manual, available on the IHS page of the Provider Information website. Providers are responsible both manuals.
A table of contents and an index allow you to quickly find answers to most questions. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.
Manual Maintenance
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the Home page of the provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found om this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Rule References
Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. See the Contact Us page on the Provider Information website.
Overview
The Tribal Health Improvement Program (T-HIP) is a partnership between the Tribal, State and Federal governments to address factors that contribute to health disparities in the American Indian population eligible for Medicaid and residing on a reservation. It is a health promotion and disease prevention program. Federally recognized tribes in Montana, who meet all the provider requirements, are the only eligible entities to participate in and administer the Tribal Health Improvement Program (T-HIP).
T-HIP is a three-tier Primary Care Case Management entity (PCCMe) program. All three T-HIP Tiers focus on high-risk, high-cost members identified by the Department. The case management services provided under T-HIP, which meet the 42 CFR 438.2 definition of locating, coordinating, and monitoring primary health care services, seek to improve the health of members who have chronic illnesses or are at risk of developing serious health conditions through intensive care coordination of individual members. The T-HIP PCCMes also provide the following as defined in 42 CFR 438.2 in addition to primary care case management services:
- Provision of intensive telephonic case management.
- Provision of face-to-face case management.
- Development of enrollee Wellness Plans.
- Provision of enrollee outreach and education activities.
- Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers.
A major focus in the T-HIP, is to enhance the communication and coordination link between the member and the primary care provider. T-HIP functions are designed to help members:
- Maximize the benefits of their medical and other support systems.
- Improve knowledge of their disease and self-management skills.
- Remove barriers to achieving better health.
End of Introduction Chapter
Eligible Providers
For T-HIP, Tribes must employ or contract for:
- A supervising Medical Director, who is either a physician or advanced practice registered nurse (APRN) and;
- A Care Coordinator who is a registered nurse, licensed practical nurse, social worker, health educator or paraprofessional.
- Tribes must employ or contract with adequate personnel to provide enough Care Coordinators to allow an average caseload of no more than 150 attributed members.
End of Eligible Providers Chapter
Eligible Members
Eligible Members are those who meet the following criteria:
- Enrolled in Medicaid;
- An American Indian/Alaska Native;
- Indian Health Service (IHS) eligible;
- Lives within the exterior reservation boundaries; and
- Has not opted-out of T-HIP.
End of Eligible Members Chapter
Program Requirements
Federally recognized tribes may choose to operate this program for their Native American members within the exterior boundaries of their reservation. To participate as a Tribal Health Improvement Program Provider, the Tribe must:
- Be Federally recognized.
- Have a 638 agreement (contract/compact) with Indian Health Services (IHS) that contains a scope of service for the Tribal Health Improvement Program services.
- Provide proof of the 698 agreement to the State.
- Execute a Task Order with the State.
- Maintain oversight and responsibility for operating the T-HIP service.
- Maintain a dedicated telephone number for T-HIP or include T-HIP as a specific selection option on the health center phone system.
- Provide and maintain Information Technology (including computers) to fully participate in the program.
- Comply with Federal Regulations, Administrative Rules of Montana, and T-HIP Provider Manual, inclusive of any updates that occur during the term of the Task Order.
- Ensure all Care Coordination staff complete chronic care certification and recertification courses.
- Maintain verification of compliance with this requirement.
- New T-HIP providers have 210 days from the start of the program to have a chronic care management certification completed for Care Coordinators.
- Ensure care coordination staff members participate in trainings offered by the Department.
- Maintain sufficient staff to meet requirements of the Task Order with a maximum caseload of no more than 150 members per Care Coordinator. Programs retain the authority to establish different case load amounts for complex cases and staff internally as they see fit as long as the caseload maximum is met.
- Maintain data collection requirements for this program monthly and bi-yearly.
- Provide services within the entire reservation service area.
- Meet all information requirements in 42 CFR 438.10. The tribe must be able to provide examples of written communications and materials to the Department upon request. Per 42 CFR 438.3(d)(3), the T-HIP will not, not on the basis of health status or need for health care services, discriminate against individuals eligible to enroll and the T-HIP will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, or disability.
End of Program Requirements Chapter
T-HIP Provider Responsibilities
Care Coordination functions for all tiers will be provided as indicated below:
- Development of an individualized Wellness Plan to address the member’s high-risk and/or high-cost health needs in coordination with the member.
- Self-management education for members related to their condition(s) both individually and/or in a group setting.
- Telephone calls and in-person visits to check on member progress and status.
- Pre-admission and post-discharge care coordination for out-of-state hospital admissions.
- Educate members on the value of recommended preventive/screening and medical services. Remind and assist members if needed, to schedule these services and visits.
- Assistance with and referrals to local resources such as social services, housing and other life problems that could prevent members from seeking care for medical conditions.
- Educate members on how to access the Medicaid Member Guide online and/or how to obtain a current up-to-date, Medicaid Member Guide.
- Conduct member outreach:
- Within one (1) week of member identification by the Department, send introductory written notification T-HIP's will use the Welcome Letter template as it includes the minimum required information for the introductory notification. The T-HIP's may insert their own language, colors, logos, or add additional information;
- Within two (2) weeks of initial notification, follow up with a phone call to T-HIP member;
- At least once per quarter, meet with active members face-to-face. Face-to-face means the Care Coordinator meets the member in their home, place of choosing or utilizes active real-time audio/visual technology. If the member refuses to meet, the Care Coordinator must document that they attempted to meet face-to-face; and
- Annually and as updated, send a copy of the member's Wellness Plan to the primary care physician (PCP).
- Provide outreach to the following members on a monthly basis:
- A minimum of 10% of the total eligible members with highest risk score as identified by the Department's predictable modeling software;
- An at-risk member identified through a Provider Referral Form who meets the member eligibility for T-HIP;
- An at-risk member, prior authorized for out-of-state hospital stays and services, to provide post-hospital care and discharge follow-up and other enhanced care coordination services.
T-HIP Tier 2 functions include the care coordination requirements indicated above to a minimum of 25% of high-risk/high-cost members identified by the Department. To be eligible for Tier 2, a T-HIP must demonstrate adherence to the requirements of Tier 1 as well as:
- Have 40% or more of the Tier 1 required 10% of eligible members as active.
- Have 100% completion of Wellness Plans for active members.
- Demonstrate accurate on-time monthly reporting.
- Have 25% completion of six (6) month surveys for active members.
- Submit a Tier Request Form to the Department, confirming that staffing requirements will be met.
T-HIP Tier 3 functions include the care coordination requirements indicated above to a minimum of 40% of high-risk/high-cost members identified by the Department. To be eligible for Tier 3, a T-HIP must demonstrate adherence to the requirements of Tier 2 as well as:
- Have 50% or more of the Tier 2 required 25% of eligible members as active.
- Have 100% completion of Wellness Plans for active members.
- Demonstrate accurate on-time monthly reporting.
- Have 25% completion of six (6) month surveys for active members.
Upon approval of a Tier Request Form, an amendment to the current T-HIP Task Order will be executed, documenting when the Tribe will begin to provide the approved Tier care coordination functions.
A T-HIP must maintain the requirements to continue at the approved tier.
Member Communication
T-HIP’s are required to provide information to members in a manner that is easily understood and is accessible by all members. This may include members who require the use of oral interpretation, auxiliary aids, or language assistance.
If a member is in need of telephones with louder volume, telephones with captions, or hands-free devices, call the Montana Telecommunications Access Program (MTAP). They can be reached at 1-800-833-8503.
The Montana Relay service can help if a member, who may be deaf or heard of hearing, would like direct call relay services. To make a TTY call:
- Dial 7-1-1
- You will be asked for the number you want to call, do not forget to include the area code.
- A Communications Assistant will relay the words between both parties.
Also included on the MTAP website is information on Blind and Low Vision Services and a list of qualified sign language interpreters. Blind and Low Vision Services (mt.gov)
T-HIP’s are required to provide care coordination information available in the prevalent non-English language in the service area. For those who may need assistance in a language that is not a native tribal language, this link provides information on language access assistance. Welcome to LEP.gov
End of T-HIP Provider Responsibilities Chapter
Reporting Requirements
The T-HIP must comply with the following reporting requirements:
- Collect and report data using a department approved format, T-HIP Monthly Reporting Measures Form and T-HIP Six-Month Reporting Measures, until such time that a new department system is available.
- Use Department approved data collection system and software when it becomes available. The Tribe and Department acknowledge that it may be necessary to adjust the reporting measures based on system capabilities.
- Assign the T-HIP member a status based on the following chart. Update the member status after each contact.
- Report T-HIP monthly data elements using the T-HIP Monthly Reporting Measures Form for the required percentage of members. Report is due by the 10th of the following month.
- Report T-HIP six-month survey data elements using the T-HIP Six-Month Reporting Measures Form for active members. Report is due by the 10th of each January and the 10th of each July.
- Evaluate and review the T-HIP annually using the Annual Review Form as sent from the Department.
- Report disenrollment requested by the enrollee, the T-HIP, and deceased members using an Opt-Out Form.
| Status | Requirement |
|---|---|
| New to T-HIP |
|
| Active |
|
| Pending |
|
|
Cannot Contact |
|
| Do Not Contact |
|
T-HIP programs must keep appropriate records in the event of an audit. Record keeping standards can be found in ARM 37.85.414. Records should reflect care coordination services provided as outlined in this manual to individual members. Records may also include Wellness Plans, Chronic Care Certifications, Sign-in Sheets, Outreach and Education Write-ups, Expenditure Reports, etc.
End of Reporting Requirements Chapter
T-HIP Eligible Member Opt-Out
- A member has the right to opt-out of the T-HIP at any time for any reason.
- An Opt-Out Form is linked in the Forms section for the Tribal Health Improvement Program.
- The provider must explain to the member that the member may remain in the program in pending status and encourage this as an option.
- If the member does not want to participate in either active or pending status, the provider shall give a copy of the Opt-Out Form to the member.
- The member must sign the Opt-Out Form and turn the form into the Tribe or Department. If the member turns the form into the Tribe, the Tribe must send the form to the Department.
- Upon opt-out, the provider will no longer receive the T-HIP PMPM fee for the member.
- An eligible member, who previously chose to opt-out, may choose to participate in T-HIP at any time by filling out the Opt-In Form.
The T-HIP may request disenrollment of a member by submitting an Opt-Out Form to the Department noting the reasons for the requested disenrollment. The provider may not request disenrollment because of:
- a change in the member's health status;
- the member's utilization of medical services; or
- the member's diminished mental capacity, uncooperative or disruptive behavior resulting from his or her special needs, except when the member's continued enrollment in the T-HIP seriously impairs the provider's ability to furnish services to either the member or other members.
End of T-HIP Eligible Member Opt-Out Chapter
Billing Procedures
The T-HIP is different from other services Montana Medicaid pays for in that providers are not required to bill for T-HIP functions provided. The T-HIP will receive a per-member-per-month (PMPM) fee that is automatically generated by the Department and paid to the T-HIP monthly.
End of Billing Procedures Chapter
Remittance Advice and Adjustments
End of Remittance Advice and Adjustments Chapter
How Payment is Calculated
T-HIP providers receive a per-member-per-month (PMPM) fee for each eligible Medicaid member who lives within the exterior reservation boundaries. The PMPM fee is based on a three-tiered system and payments at each level are inclusive. Payment will not be prorated for a partial month on service provision.
Tier 1:
- $75.00 PMPM
- Operate the Tribal Health Improvement Program as described in the Task Order and this manual.
Tier 2:
- $150.00 PMPM
- Operate the Tribal Health Improvement Program as described in the Task Order and this manual.
Tier 3:
- $213.96 PMPM
- Operate the Tribal Health Improvement Program as described in the Task Order and this manual.
The T-HIP PMPM fee is not paid for members who have voluntarily disenrolled (opted-out) of T-HIP.
A tribal provider may provide and be reimbursed for both T-HIP and other Medicaid covered services that they meet the qualifications for. (Example: Tribe provides both dialysis and T-HIP services.) However, to the extent those services are described in the T-HIP contract and/or attachments, non-PCCM medical services must have separate Medicaid State Plan or waiver authority, and FFS reimbursement cannot be included in the T-HIP PMPM.
End of How Payment is Calculated Chapter
Definitions
Care Coordinator means a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker, Health Educator or Paraprofessional who specializes in and provides care coordination services in T-HIP. Care Coordinators work under the direct supervision of a medical director, who is employed by or under contract with the Tribe.
Enhanced Care Coordination (ECC) is the array of allowable PCCMe services and functions, provided by the T-HIP Care Coordinator. These services include guiding members through healthcare options, coordinating and implementing Wellness Plans, advocating on the member’s behalf, and providing community resource information. A major focus of enhanced care coordination is to improve the communication and coordination link between the member and the primary care provider.
T-HIP Medical Director is either a Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), or an Advanced Practice Registered Nurse (APRN) employed by or under contract with the Tribe.
T-HIP Provider means a health program operated by a federally recognized tribe, who meets the provider requirements, has a 638 agreement with Indian Health Service (through compact or contract) that contains a scope of service for the Tribal Health Improvement Program, and a signed Task Order with the State.
Member or Eligible Member means a person who meets all of the following requirements:
- Enrolled in Medicaid
- American Indian/Alaska Native
- Indian Health Service (IHS) eligible
- Lives within the exterior reservation boundaries
- Has not opted out of T-HIP
Paraprofessional means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional. This individual must have a minimum of an associate degree in behavioral sciences or a related field with two years of closely related work experience. Qualifying experience may be substituted, year for year, for education.
Per Member Per Month (PMPM) means the comprehensive monthly payment methodology that DPHHS utilizes to pay for all T-HIP services for an eligible member. The PMPM reimbursement is only for the T-HIP program activities that are allowable under the 42 CFR 438.2 definitions of PCCM and PCCMe functions. Other Medicaid covered services can be billed and paid separately, however, to the extent those services are described in the T-HIP contract and/or attachments, non-PCCM medical services must have separate Medicaid State Plan or waiver authority, and fee-for-service (FFS) reimbursement cannot be included in the T-HIP PMPM. The PMPM rate is a set amount of money: Tier 1, 2, and 3 each have different PMPM rates. A tribal provider does not bill the Department for ECC on an individual basis when a service is provided; the Department will identify eligible members and initiate payment. PMPM payments are made on behalf of all eligible members, regardless of whether a particular eligible member received T-HIP services that month.
Tier 1 is the building block for the Tribal Health Improvement Program. In order to participate, a Tribe must implement Tier 1 and serve the top 10% of eligible members identified by the Department as high-cost or high-risk. Tier 1 services must be supervised by a T-HIP Medical Director.
Tier 2 is the expansion of care coordination to the top 25% of eligible members identified by the Department as high-cost or high-risk. To participate in Tier 2, the Tribe must demonstrate adherence to the programmatic requirements of Tier 1. The same requirements outlined in Tier 1 apply to Tier 2.
Tier 3 is the expansion of care coordination to the top 40% of eligible members identified by the Department as high-cost or high-risk. To participate in Tier 3, the Tribe must demonstrate adherence to the programmatic requirements of Tier 2. The same requirements outlined in Tier 1 and Tier 2 apply to Tier 3.
Service Area means the area within the exterior boundaries of the reservation.
End of Definitions Chapter
Forms
The forms listed below are available on the Forms tab of the Tribal 638 page.
• T-HIP Tier Request Form
• T-HIP Provider Referral Form
• T-HIP Opt Out Form
• T-HIP Opt-In Form
• Office of Inspector General Alert
• Welcome Letter
End of Forms Chapter
Search Options
This manual contains search functions in lieu of an index.
This edition has three search options.
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