About Benefit Plans

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About Benefit Plans

A benefit plan is a grouping of medical services or drug benefits that are provided to a defined member population, and includes processing rules specific to this grouping of services. For Medicaid Management Information System (MMIS) plans, it also includes the providers eligible to offer them. Benefit plans are associated with a particular line of business.

A benefit plan is comprised of several components:

Identifying Information - The header-level details of the benefit plan define the name, the business unit associated with it, the effective dates, the plan type, and other details. This information must be defined before the other components can be added to the plan.
MMIS plans
- Capitation or Case Management Fees - For certain managed care or primary care case management-type benefit plans, capitation or case management fees may be set up to be paid to providers on a per member per month basis instead of a fee-for-service basis. Examples The map definition component allows you to define the member populations (or cohorts) for which a certain capitation or case management fee is to be paid. The benefit plan component allows you to associate a dollar amount (the capitation or case management fee) to these member cohorts. For members enrolled in the benefit plan, who meet the criteria defined in the cohort map definition, the associated fee is billed on the system-generated capitation claim and, in turn, paid to the appropriate managed care organization or primary care case manager.
- Eligible Providers - The providers who are eligible to bill for services performed under the benefit plan are defined based on criteria such as provider type, provider specialty, etc. These provider networks are also defined with effective dates for which the association to the plan is active.
- Covered and Non-Covered Services -Services are defined as included or excluded in the benefit plan. These services can be defined using a number of different parameters, such as procedure code, provider type, or place of service. The details of these services are defined in map definitions which are then referenced when setting up the benefit plan.
- Service Authorization Rules - Some services covered by the benefit plan may require authorization before being performed. Map definitions define the details of the services and are referenced by the plan.
- Eligible Member - The member population that is eligible to be included in the benefit plan is defined based on criteria such as age, program of assistance code, special eligibility code, nursing home, and home- and community-based care indicators. The map definition component allows you to define this eligibility criteria.
- Benefit Limits, Service Limits, and Caps - Dollar and/or unit limits can be applied to various components of the benefit plan. Plan limits accumulate over the course of a fixed time period and a member's accumulation toward these limits is available on the Benefit/Service Limits Inquiry page in the Member area. High-level budget caps may also be specified. The details of the services are defined by the map definition component and used by the benefit plan.
Pharmacy plans
- Eligible Member - The member population that is eligible to be included in the benefit plan is defined based on criteria such as age, program of assistance code, special eligibility code, nursing home, and home- and community-based care indicators. The map definition component allows you to define this eligibility criteria.
- Plan information - Pharmacy information, covering default benefits, deductibles, and co-pays, Pharmacy DAW (Dispense As Written), associating the acceptable codes for the reasons to dispense a brand name drug instead of a generic, when that is normally required by a plan, is set up and maintained in OS+.

Maps

Maps are sets of logical conditions used to determine if a particular action is to be done or not. Many MMIS benefit plan components use maps to define the services or members that are included in that component. How these various maps are processed is determined by the rank you assign to each.

Rank

Rank is simply the order in which rows in a table (associated with a map definition) are evaluated by ND MMIS. You assign ranks to most components of an MMIS benefit plan on the Plan Navigator page.

Note: Pharmacy benefit plans do not use rank.

Rank is used for processing efficiency. The criteria that should be considered when defining rank to improve efficiency might include the number of claims expected to be processed for certain services covered under the benefit plan. For example, if for a given benefit plan, 90% of the claims are expected to be billed with one of five different procedure codes and the rest of the claims will be billed with one of several hundred different procedure codes, it would make sense to group the five procedure codes that come in on 90% of the claims into a single map definition, and rank this map definition first so that ND MMIS does not spend excess time and resources searching through a large map definition for every claim. The lower the number assigned to something, the earlier in the sequence it is evaluated. When assigning the sequence order, we recommend that you skip numbers to make it easier to add rows and assign new rankings. For example, assign rankings of 10, 20, and 30 instead of 1, 2, and 3.

Hierarchy

Once benefit plans have been defined, there are also separate rules for defining the hierarchy or ranking of the benefit plans. These rules are used when more than one benefit plan can be applied to the same service to a member or when a member is eligible for multiple benefit plans.

Fund Codes

Fund codes are used to determine the source of funds for the services covered by the benefit plan. Fund codes are maintained using the Claims Adjudication function of ND MMIS.

Member Enrollment

The process of linking members to benefit plans begins with the addition or update of member information to the system. Then, ND MMIS determines the benefit plan or plans for which the member is eligible. This assignment is based on matches between the member data and the benefit plan eligibility criteria defined in the MCT (Member Control Table) map for MMIS plans and the PMC (Pharmacy Member Control) map for pharmacy plans. This process also begins when eligibility criteria are updated in the system in case the new or changed information requires that members be assigned to a different plan. The MCT or PMC map is the system component that allows you to define the parameters that drive a memberto one benefit plan or another.

When the system is first installed, a decision is made as to whether members are able to choose appropriate MMIS benefit plans from a list of the ones for which they are eligible or if they are assigned plans automatically. A system parameter defines which type of enrollment is in effect.

You can view what benefit plans the member is eligible for, along with the effective dates of benefit plan eligibility, on the Eligibility Quick View page in the Member area.