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THIP

Tribal Health Improvement Program (T-HIP) Manual

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.

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  1. Search the whole manual. Open the Complete Manual pane.  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 discussed in the manual.
  2. 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 discussed in just that chapter.
  3. Site SearchSearch the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.


 


Tribal Health Improvement Program Manual

Updated 10/20/2017

This manual was updated 10/20/2017

Complete T-HIP Manual

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

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

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

Start-Up Requirements

Eligible Providers

Eligible Members

T-HIP Provider Responsibilities

Tier 1 Activities

Tier 2 Activities

Tier 3 Activities

Reporting Requirements

T-HIP Eligible Member Opt-Out

T-HIP Eligible Member Disenrollment

Passport to Health Program

Billing Procedures

Remittance Advice and Adjustments

How Payment is Calculated

Tier 1

Tier 2

Tier 3

Definitions

Forms

Index

 

End of Table of Contents Chapter

Key Contacts

 

See the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website, http://medicaidprovider.mt.gov/, for a list of key contacts and websites.

DPHHS IHS/Tribal 638 Program

(406) 444-4540
(406) 444-1861 Fax

DPHHS IHS/Tribal 638 Program Officer
Hospital and Physician Services Bureau
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

Manuals must be kept current.

Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the home page of the provider website and under Provider Notices on the provider type 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 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.

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.  In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are applicable to T-HIP:

  • ARM 37.86.5201 - 37.86.5205 and 37.86.XX

Overview

The Tribal Health Improvement Program (T-HIP) is a historic 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.  This manual will give you an overview of the Tribal Health Improvement Program, goals of the program and a link to the forms necessary to complete the documentation required for program participation. 

T-HIP services are designed to help members:

  • maximize the benefits of their medical and other support systems; 
  • improve knowledge of their disease and self-management skills; and 
  • remove barriers to achieving better health and a better life. 

Federally recognized tribes in Montana are the only eligible entities able to participate in and administer T-HIP. T-HIP is a three tier program.  A tribe may choose which level they wish to participate.  Implementation of Tier 1 is mandatory prior to participating in Tier 2 and Tier 3. Tier 1 focuses on high-risk, high-cost members identified by the Department.  Services provided under Tier 1 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 services in Tier 1 also seek to enhance the communication and coordination link between the member and the Passport primary care provider. In addition to Tier 1 there are two other Tier choices. Tier 2 and Tier 3 address specific health focus areas that contribute to health disparities.  Activities generally focus on improving the health of a population rather than individual members.  (i.e. obesity prevention program for grade school youth.)  


End of Introduction Chapter

Start-Up Requirements

Federally recognized tribes may choose to operate this program for their Native American members within the exterior boundaries of their reservation.   To enroll as a T-HIP provider the following criteria must be met: 

  • Acquire and maintain a 638 agreement with Indian Health Service (through compact or contract) that includes the scope of the T-HIP; 
  • Provide a copy of the 638 agreement to the State; and
  • Execute a Task Order for T-HIP with DPHHS/Medicaid.

 

End of Start-Up Requirements Chapter

 

Eligible Providers:


For Tier 1, Tribes must employ or contract for:

  • 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.

For Tier 2 and Tier 3 services, Tribes must employ or contract with adequate personnel to provide the services as defined.  Staff may include people with culturally relevant and/or practical experience, health care or social service backgrounds.  These staff must be supervised by the Medical Director that is employed or contracted by the Tribe.
 

End of Eligible Providers Chapter

 

Eligible Members:

Eligible Members are those who meet the following criteria:
•    Enrolled in Medicaid and Passport to Health Program;:
•    Is an American Indian/Alaska Native;
•    Is Indian Health Service (IHS) eligible;
•    Lives within the exterior reservation boundaries; and
•    Has not opted out of T-HIP.
 

End of Eligible Members Chapter

T-HIP Provider Responsibilities:

Tier 1 Activities:

 

  • Development of an individualized treatment 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;
  • 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.

  • Provide outreach to the following members on a monthly basis:
  • A minimum of 10% of the total eligible members with the highest risk score as identified by the Department’s predictive modeling software; plus
  • No more than a maximum of 1% of total eligible members per month who meet one or more of the following criteria:
  1. An at risk member identified through a Provider Referral Form;
  2. An at risk member who has difficulty navigating and making decisions about their health care needs; or
  3. 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.
  • Conduct member outreach:
    • Within one (1) week of member identification by the Department, send introductory written notification (that includes a complete description of services available and T-HIP provider contact 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 care plan to the primary care physician (PCP).

Tier 2 Activities:

  • Continue Tier 1 activities; and
  • Identify and develop two (2) programs that address two (2) different health focus areas that contribute to health disparities. Each program must include:
  1. A description of the need;
  2. Proposed staffing, interventions and timelines;
  3.  Short and long term goals and outcomes; and
  4. Short and long term program measurements.
  • Tier 2 programs must be submitted on the Tier Request Form and be mutually agreed upon by the Tribe and Department. 
  • Tier 2 programs will be reflected in an amendment to the Task Order.

Tier 3 Activities:

  • Continue Tier 1 and Tier 2 activities and;
  • Identify and develop two (2) additional programs that address two (2) more health focus areas that contribute to health disparities.  Tier 3 requires provision of a minimum of four (4) programs.  Each program must include:
  1. A description of the need;
  2. Proposed staffing, interventions and timelines;
  3. Short and long term goals and outcomes; and 
  4. Short and long term program measurements.
  • Tier 3 programs must be submitted on the Tier Request Form and be mutually agreed upon by the Tribe and Department. 
  • Tier 3 programs will be reflected in an amendment to the Task Order.

End of T-HIP Provider Responsibilities Chapter

Reporting Requirements

The Tribe must comply with the following reporting requirements:

  • 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; 
  • Report Tier 1 monthly data elements using the Monthly Reporting Measures for active members.  Reports are due by the 10th of the following month;
  • Report Tier 1 six month survey data elements using the Six Month Reporting Measures for active members.  Reports are due by the 10th of the following month;
  • Collect and report mutually agreed upon data elements for Tier 2 and Tier 3. 
  • Assign Tier 1 member status based on the following chart.  Update member status after each contact;
     
Member Status Requirements
Status Requirement
Active
  • Member has agreed to actively participate in T-HIP and a care plan is documented or in progress. 
Pending
  • Member cannot be reached upon initial outreach attempts; 
  • Positive contact with the member is not completed after six (6) months; member is placed in pending status and sent pending letter; 
  • Member did not respond to mail or phone contact with no indication these were invalid; 
  • Despite attempts, unable to gather quality measures;
  • Notify member they can contact T-HIP provider at any time; 
  • Contact member either by letter or phone once every three (3) months. 

Cannot Contact

  • Letter sent to member and returned (wrong address or unable to deliver); 
  • Disconnected/wrong/invalid phone number or no phone; 
  • Member moved (provider must notify the Department with this information); 
  • Demographic searches from other sources attempted without success; and 
  • Member will continue to be monitored at the T-HIP Provider’s discretion for updated information and contact with T-HIP. 
     
Do Not Contact
  • Member has sent an Opt-Out Form to the Tribe or Department; 
  • Member has not filled out the Opt-Out Form, but stated they do not want contact from T-HIP;
  • Member is deceased (provider must notify the Department with this information);
  • No longer eligible for Passport;
  • No longer eligible for T-HIP.
     

 

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 in Tier 1.  Tier 2 and Tier 3 records should reflect the approved Tier Request Forms and agreed upon reporting measurements.  Records may also include sign-in sheets, program curriculum, advertisements, event 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 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.
  • The Department will notify the T-HIP provider of any members in their service area who have opted out of the program.
     

End of T-HIP Eligible Member Opt-Out Chapter

T-HIP Eligible Member Disenrollment


The T-HIP provider may request disenrollment of a member by submitting in writing to the Department 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
  • 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 Disenrollment Chapter

Passport to Health Program

 

Passport to Health is the primary care case management (PCCM) program for Montana Medicaid and HMK Plus members. The Passport to Health program provides case management related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:

  • Nurse First Advice Line
  • Team Care
  • Tribal Health Improvement Program (T-HIP)

Medicaid and HMK Plus members who are eligible for Passport must enroll in the program (about 70% of Montana Medicaid and HMK Plus members are eligible). Each member has a designated Passport provider such as a physician, midlevel practitioner, or primary care clinic.
For more information regarding Passport to Health, see the Passport to Health
manual available on the Provider Information website.
 

End of Passport to Health Program Chapter

Billing Procedures

T-HIP is different from other services Montana Medicaid pays for in that providers are not required to bill for T-HIP services provided.  Providers will receive a per member per month fee that is automatically generated by the Department and paid to the T-HIP enrolled providers monthly. 

End of Billing Procedures Chapter

Remittance Advice and Adjustments

See the General Information for Providers manual for information on remittance advices 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 Passport to Health 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. 
  • Provide Tier 1 services plus two (2) health prevention focus areas. 

Tier 3: 

  • $213.96 PMPM
  • Operate the Tribal Health Improvement Program as described in the Task Order and this manual. 
  • Provide Tier 1 services plus four (4) health prevention focus areas.  

The T-HIP PMPM fee is not paid for members who have voluntarily dis-enrolled (opted out) of T-HIP.

T-HIP funded services may not duplicate services furnished or reimbursed under another Montana Medicaid State Plan, Department or Federally funded program (for example, Medicaid State Plan targeted case management services).  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, a single encounter by T-HIP staff may not be used to fulfill the requirements for both provider types. (Example: Certified diabetes educator office visit is not both a separately billable service and a T-HIP service.)
 

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 Tier 1.  Care Coordinators work under the direct supervision of a medical director, physician, or advance practice registered nurse who is employed by or under contract with the Tribe.

Enhanced Care Coordination (ECC) is the array of services provided by the Tier 1 Care Coordinator. Services include guiding members through healthcare options, coordinating and implementing care plans, advocating on the member’s behalf, and providing community resource information.  One of the purposes of enhanced care coordination is to improve the communication and coordination link between the member and the Passport primary care provider.  Enhanced care coordination also includes utilizing quality measures to improve health outcomes.

Medical Director is defined as a Physician (an M.D. or a D.O.) or an Advance Practice Registered Nurse. 

Member or Eligible Member means a person who is enrolled in the Medicaid Passport to Health Program and who also meets the following requirements:

  1. American Indian/Alaska Native;
  2. Indian Health Service (IHS) eligible;
  3. Lives within the exterior reservation boundaries; and 
  4. 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’s 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 Medicaid utilizes to pay for all T-HIP services for an eligible member.  The PMPM reimbursement is only for T-HIP services. Other Medicaid covered services can be billed and paid separately.  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 T-HIP services 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.  

T-HIP Provider means a health program operated by a federally recognized tribe who has an approved 638 agreement with Indian Health Service (through compact or contract) and a signed Task Order with the State.

Tier 1 is the core building block for the Tribal Health Improvement Program.  In order to participate, a Tribe must implement Tier 1 and serve eligible members identified by the Department as high cost or high risk. Tier 1 services must be supervised by a Medical Director.

Tier 2 requires the implementation of Tier 1 in addition to the implementation of two (2) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members).  Tier 2 services must be supervised by a Medical Director.

Tier 3 requires the implementation of Tier 1 in addition to the implementation of four (4) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members).  Tier 3 services must be supervised by a Medical Director.

Service Area means the area within the exterior boundaries of the reservation.

 

End of Definitions Chapter

Forms

The forms listed below and others are available on the Forms page of the Montana Healthcare Programs Provider Information website. See the site index in the left menu on http://medicaidprovider.mt.gov/ .
•    T-HIP Tier Request Form 
•    T-HIP Provider Referral Form 
•    T-HIP opt-out form 

 

End of Forms Chapter

 

Index

This manual contains search functions in leiu of an index.

This edition has three search options.

  1. Search the whole manual. Open the Complete Manual pane.  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 discussed in the manual.
  2. 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 discussed in just that chapter.
  3. Site SearchSearch the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

End of Index Chapter

End of T-HIP Manual

Update Log

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

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

10/20/2017
First edition of the Montana Medicaid Tribal Health Improvement Program Manual.

 

End of Update Log Chapter

Table of Contents

Key Contacts

Key Contacts

 

See the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website, http://medicaidprovider.mt.gov/, for a list of key contacts and websites.

DPHHS IHS/Tribal 638 Program

(406) 444-4540
(406) 444-1861 Fax

IHS/Tribal Program Officer
Hospital and Physician Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

 

End of Key Contacts Chapter

Introduction

Introduction

 

Thank you for your willingness to serve members of the Tribal Health Improvement Program (T-HIP).

Manual Organization

This manual provides information specifically for Tribal Health Improvement (T-HIP) Program 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

Manuals must be kept current.

Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the home page of the provider website and under Provider Notices on the provider type 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 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.

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.  In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are applicable to T-HIP:

  • ARM 37.86.5201 - 37.86.5205 and 37.86.XX

Overview

The Tribal Health Improvement Program (T-HIP) is a historic 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.  This manual will give you an overview of the Tribal Health Improvement Program, goals of the program and a link to the forms necessary to complete the documentation required for program participation. 

T-HIP services are designed to help members:

  • maximize the benefits of their medical and other support systems; 
  • improve knowledge of their disease and self-management skills; and 
  • remove barriers to achieving better health and a better life. 

Federally recognized tribes in Montana are the only eligible entities able to participate in and administer T-HIP. T-HIP is a three tier program.  A tribe may choose which level they wish to participate.  Implementation of Tier 1 is mandatory prior to participating in Tier 2 and Tier 3. Tier 1 focuses on high-risk, high-cost members identified by the Department.  Services provided under Tier 1 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 services in Tier 1 also seek to enhance the communication and coordination link between the member and the Passport primary care provider. In addition to Tier 1 there are two other Tier choices. Tier 2 and Tier 3 address specific health focus areas that contribute to health disparities.  Activities generally focus on improving the health of a population rather than individual members.  (i.e. obesity prevention program for grade school youth.)  


End of Introduction Chapter

Start-Up Requirements

Start-Up Requirements

Federally recognized tribes may choose to operate this program for their Native American members within the exterior boundaries of their reservation.   To enroll as a T-HIP provider the following criteria must be met: 

  • Acquire and maintain a 638 agreement with Indian Health Service (through compact or contract) that includes the scope of the T-HIP; 
  • Provide a copy of the 638 agreement to the State; and
  • Execute a Task Order for T-HIP with DPHHS/Medicaid.

 

End of Start-Up Requirements Chapter

Eligible Providers

Eligible Providers:


For Tier 1, Tribes must employ or contract for:

  • 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.

For Tier 2 and Tier 3 services, Tribes must employ or contract with adequate personnel to provide the services as defined.  Staff may include people with culturally relevant and/or practical experience, health care or social service backgrounds.  These staff must be supervised by the Medical Director that is employed or contracted by the Tribe.
 

End of Eligible Providers Chapter

Eligible Members

Eligible Members:

Eligible Members are those who meet the following criteria:
•    Enrolled in Medicaid and Passport to Health Program;:
•    Is an American Indian/Alaska Native;
•    Is Indian Health Service (IHS) eligible;
•    Lives within the exterior reservation boundaries; and
•    Has not opted out of T-HIP.

End of Eligible Members Chapter

T-HIP Provider Responsibilities

T-HIP Provider Responsibilities:


Tier 1 Activities:

 

  • Development of an individualized treatment 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;
  • 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.

  • Provide outreach to the following members on a monthly basis:
  • A minimum of 10% of the total eligible members with the highest risk score as identified by the Department’s predictive modeling software; plus
  • No more than a maximum of 1% of total eligible members per month who meet one or more of the following criteria:
  1. An at risk member identified through a Provider Referral Form;
  2. An at risk member who has difficulty navigating and making decisions about their health care needs; or
  3. 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.
  • Conduct member outreach:
    • Within one (1) week of member identification by the Department, send introductory written notification (that includes a complete description of services available and T-HIP provider contact 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 care plan to the primary care physician (PCP).

Tier 2 Activities:

  • Continue Tier 1 activities; and
  • Identify and develop two (2) programs that address two (2) different health focus areas that contribute to health disparities. Each program must include:
  1. A description of the need;
  2. Proposed staffing, interventions and timelines;
  3.  Short and long term goals and outcomes; and
  4. Short and long term program measurements.
  • Tier 2 programs must be submitted on the Tier Request Form and be mutually agreed upon by the Tribe and Department. 
  • Tier 2 programs will be reflected in an amendment to the Task Order.

Tier 3 Activities:

  • Continue Tier 1 and Tier 2 activities and;
  • Identify and develop two (2) additional programs that address two (2) more health focus areas that contribute to health disparities.  Tier 3 requires provision of a minimum of four (4) programs.  Each program must include:
  1. A description of the need;
  2. Proposed staffing, interventions and timelines;
  3. Short and long term goals and outcomes; and 
  4. Short and long term program measurements.
  • Tier 3 programs must be submitted on the Tier Request Form and be mutually agreed upon by the Tribe and Department. 
  • Tier 3 programs will be reflected in an amendment to the Task Order.

 

End of T-HIP Provider Responsibilities Chapter

 

 

 

 

 

Reporting Requirements

Reporting Requirements

The Tribe must comply with the following reporting requirements:

  • 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; 
  • Report Tier 1 monthly data elements using the Monthly Reporting Measures for active members.  Reports are due by the 10th of the following month;
  • Report Tier 1 six month survey data elements using the Six Month Reporting Measures for active members.  Reports are due by the 10th of the following month;
  • Collect and report mutually agreed upon data elements for Tier 2 and Tier 3. 
  • Assign Tier 1 member status based on the following chart.  Update member status after each contact;
     
Member Status Requirements
Status Requirement
Active
  • Member has agreed to actively participate in T-HIP and a care plan is documented or in progress. 
Pending
  • Member cannot be reached upon initial outreach attempts; 
  • Positive contact with the member is not completed after six (6) months; member is placed in pending status and sent pending letter; 
  • Member did not respond to mail or phone contact with no indication these were invalid; 
  • Despite attempts, unable to gather quality measures;
  • Notify member they can contact T-HIP provider at any time; 
  • Contact member either by letter or phone once every three (3) months. 

Cannot Contact

  • Letter sent to member and returned (wrong address or unable to deliver); 
  • Disconnected/wrong/invalid phone number or no phone; 
  • Member moved (provider must notify the Department with this information); 
  • Demographic searches from other sources attempted without success; and 
  • Member will continue to be monitored at the T-HIP Provider’s discretion for updated information and contact with T-HIP. 
     
Do Not Contact
  • Member has sent an Opt-Out Form to the Tribe or Department; 
  • Member has not filled out the Opt-Out Form, but stated they do not want contact from T-HIP;
  • Member is deceased (provider must notify the Department with this information);
  • No longer eligible for Passport;
  • No longer eligible for T-HIP.
     

 

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 in Tier 1.  Tier 2 and Tier 3 records should reflect the approved Tier Request Forms and agreed upon reporting measurements.  Records may also include sign-in sheets, program curriculum, advertisements, event write ups, expenditure reports, etc.  

 

End of Reporting Requirements Chapter

T-HIP Eligible Member Opt-Out

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 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.
  • The Department will notify the T-HIP provider of any members in their service area who have opted out of the program.
     

End of T-HIP Eligible Member Opt-Out Chapter

T-HIP Eligible Member Disenrollment

T-HIP Eligible Member Disenrollment


The T-HIP provider may request disenrollment of a member by submitting in writing to the Department 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
  • 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 Disenrollment Chapter

 

 

Passport to Health Program

Passport to Health Program

 

Passport to Health is the primary care case management (PCCM) program for Montana Medicaid and HMK Plus members. The Passport to Health program provides case management related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:

  • Nurse First Advice Line
  • Team Care
  • Tribal Health Improvement Program (T-HIP)

Medicaid and HMK Plus members who are eligible for Passport must enroll in the program (about 70% of Montana Medicaid and HMK Plus members are eligible). Each member has a designated Passport provider such as a physician, midlevel practitioner, or primary care clinic.
For more information regarding Passport to Health, see the Passport to Health
manual available on the Provider Information website.
 

 

End of Passport to Health Program Chapter

Billing Procedures

Billing Procedures

T-HIP is different from other services Montana Medicaid pays for in that providers are not required to bill for T-HIP services provided.  Providers will receive a per member per month fee that is automatically generated by the Department and paid to the T-HIP enrolled providers monthly. 

End of Billing Procedures Chapter

Remittance Advice and Adjustments

Remittance Advice and Adjustments

See the General Information for Providers manual for information on remittance advices and adjustments.

 

 

End of Remittance Advice and Adjustments Chapter

How Payment is Calculated

How Payment is Calculated

 

T-HIP providers receive a per member per month (PMPM) fee for each eligible Passport to Health 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. 
  • Provide Tier 1 services plus two (2) health prevention focus areas. 

Tier 3: 

  • $213.96 PMPM
  • Operate the Tribal Health Improvement Program as described in the Task Order and this manual. 
  • Provide Tier 1 services plus four (4) health prevention focus areas.  

The T-HIP PMPM fee is not paid for members who have voluntarily dis-enrolled (opted out) of T-HIP.

T-HIP funded services may not duplicate services furnished or reimbursed under another Montana Medicaid State Plan, Department or Federally funded program (for example, Medicaid State Plan targeted case management services).  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, a single encounter by T-HIP staff may not be used to fulfill the requirements for both provider types. (Example: Certified diabetes educator office visit is not both a separately billable service and a T-HIP service.)
 

End of How Payment is Calculated Chapter

Definitions

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 Tier 1.  Care Coordinators work under the direct supervision of a medical director, physician, or advance practice registered nurse who is employed by or under contract with the Tribe.

Enhanced Care Coordination (ECC) is the array of services provided by the Tier 1 Care Coordinator. Services include guiding members through healthcare options, coordinating and implementing care plans, advocating on the member’s behalf, and providing community resource information.  One of the purposes of enhanced care coordination is to improve the communication and coordination link between the member and the Passport primary care provider.  Enhanced care coordination also includes utilizing quality measures to improve health outcomes.

Medical Director is defined as a Physician (an M.D. or a D.O.) or an Advance Practice Registered Nurse. 

Member or Eligible Member means a person who is enrolled in the Medicaid Passport to Health Program and who also meets the following requirements:

  1. American Indian/Alaska Native;
  2. Indian Health Service (IHS) eligible;
  3. Lives within the exterior reservation boundaries; and 
  4. 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’s 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 Medicaid utilizes to pay for all T-HIP services for an eligible member.  The PMPM reimbursement is only for T-HIP services. Other Medicaid covered services can be billed and paid separately.  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 T-HIP services 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.  

T-HIP Provider means a health program operated by a federally recognized tribe who has an approved 638 agreement with Indian Health Service (through compact or contract) and a signed Task Order with the State.

Tier 1 is the core building block for the Tribal Health Improvement Program.  In order to participate, a Tribe must implement Tier 1 and serve eligible members identified by the Department as high cost or high risk. Tier 1 services must be supervised by a Medical Director.

Tier 2 requires the implementation of Tier 1 in addition to the implementation of two (2) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members).  Tier 2 services must be supervised by a Medical Director.

Tier 3 requires the implementation of Tier 1 in addition to the implementation of four (4) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members).  Tier 3 services must be supervised by a Medical Director.

Service Area means the area within the exterior boundaries of the reservation.

 

End of Definitions Chapter

Forms

Forms

The forms listed below and others are available on the Forms page of the Montana Healthcare Programs Provider Information website. See the site index in the left menu on http://medicaidprovider.mt.gov/ .
•    T-HIP Tier Request Form 
•    T-HIP Provider Referral Form 
•    T-HIP opt-out form 
 

 

End of Forms Chapter

 

Index

Index

This manual contains search functions in leiu of an index.

This edition has three search options.

  1. Search the whole manual. Open the Complete Manual pane.  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 discussed in the manual.
  2. 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 discussed in just that chapter.
  3. Site SearchSearch the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

End of Index Chapter

End of T-HIP Manual