Population Health Programs

Members having difficulties managing health conditions or treatments outside the definition of complex.  May have unmet social needs.  Providers invited to care conferences to discuss member.

MHS’ First Years of Life (FYOL) program provides care management support to infants from birth through 24 months and their caregivers. The program focuses on promoting well‑child visits, immunizations, and early identification of developmental and social needs. Care Managers work with families to provide education on infant safety, developmental milestones, and preventive care, while also connecting members to community resources and addressing social determinants of health. This program supports coordination between families and providers to promote healthy growth and development during the critical early years of life.

The Indiana Pregnancy Promise Program (IPPP) is a state led program that provides enhanced, integrated care management for pregnant and postpartum Medicaid members with current or prior substance use disorder. The program supports members from pregnancy through up to 12 months postpartum, focusing on coordination of medical, behavioral health, and substance use treatment services. Through collaboration with providers and community partners, IPPP aims to reduce barriers to care, improve engagement in treatment and recovery services, and promote positive maternal and infant health outcomes.

My Health Pays® is an incentive program that encourages members to make healthy choices. MHS members can earn rewards on a My Health Pays® Visa® Prepaid Card for getting regular checkups and exams. Members can use My Health Pays® rewards to help pay for everyday items at Walmart, utilities, transportation, telecommunications (cell phone bill), childcare services, education and rent.

The Managed Health Services (MHS) Smoking Cessation Program supports members in reducing and eliminating tobacco use through coordination of evidence-based services and benefits. The program integrates care management, provider collaboration, and external resources to promote successful tobacco cessation and improved health outcomes.

MHS facilitates access to the Indiana Tobacco Quitline, a structured telephone-based counseling program that provides individualized coaching and support for members ready to quit. In addition, MHS covers nicotine replacement therapies and pharmacologic aids, supporting providers in initiating and reinforcing cessation treatment plans. Care management teams support member engagement, reinforce provider recommendations, and address barriers to quitting, including behavioral, social, and access-related needs

Care Management is a comprehensive, member-centered program designed to assess, plan, coordinate, and monitor care for our MHS members with complex or high-risk needs for both our adult and pediatric members. The program supports integration across physical health, behavioral health, and social determinants of health to ensure members receive appropriate, timely, and effective services.
Care managers collaborate with providers to develop individualized care plans, address barriers to care, and promote adherence to treatment recommendations. This includes facilitating care transitions, coordinating services across settings, and supporting member engagement in ongoing care.

The goal of Care Management is to improve health outcomes and reduce avoidable utilization.

This is a signature program for MHS.  High-risk pregnant members are provided culturally appropriate support, advocacy, education, and resources throughout pregnancy, birth, and up to one year postpartum through the use of Doulas and Maternal Community Health Workers.  Members are encouraged to engage in preventative maternal outpatient healthcare for conditions that don’t require emergency inpatient care.  SDOH needs, face to face visits, and custom made care plans are utilized in this program.        

Learn more about Doula and Me (PDF)

The Managed Health Services (MHS) Lead Disease Management Program provides comprehensive disease management services for members identified with lead exposure, including both case and care management support to ensure timely and appropriate care.The program focuses on coordinating services and addressing gaps in care through:

Referral and coordination for lead screening and confirmatory testing
Ongoing monitoring of blood lead levels
Member and caregiver education
Follow-up to support adherence to recommended care and treatment
Identification and closure of care gaps

MHS also supports providers by sharing relevant lead level information for assigned members to promote continuity of care and informed clinical decision-making.
The program operates in alignment with the State of Indiana Lead Guidelines. In addition, MHS partners with MEDTOX to provide providers with no-cost lead screening toolkits, which include testing supplies, laboratory services, and reporting at no charge.

Members at high risk for pregnancy complications are enrolled in Special Deliveries. These members are assigned to a nurse with high-risk OB experience who follows the members throughout their pregnancies to support their treatment plans and monitor members for potential signs of complication through home visits.

Learn more about Special Deliveries (PDF)

The Managed Health Services (MHS) Sickle Cell Case Management Program provides specialized, member-centered support through a dedicated Registered Nurse Case Manager (RN CM). The program follows standard Case Management practices, including assessment, care planning, and coordination of services, with a focus on managing disease complexity and reducing avoidable utilization.
MHS emphasizes strong provider collaboration, including direct communication and the use of video conferencing to support engagement with both members and providers.
Key program outcomes include improved care coordination, increased provider engagement, and reductions in avoidable emergency department utilization and inpatient admissions through proactive management and timely intervention.

Assists members with chronic conditions (including neuro disorders, developmental disorders (i.e., autism), blood diseases, and muscular skeletal disorders.  A multidisciplinary team from MHS will be able to assist the member and the member’s family in obtaining the services they need to achieve optimal quality of life. The main goals of the unit are: A) To reduce/eliminate barriers to care, education, and social activities. B) To reduce/eliminate fragmentation of services and complications relating to co-morbidity frequently seen in special needs children. C) To increase a member’s ability to perform activities of daily living. D) Connect members and their families with community-based resources and support Improve members’ quality of life.

Learn more about Special Needs (PDF)

ED Diversion supports appropriate use of emergency services by guiding members to the right level of care. The program promotes use of primary care providers and other resources when emergency care is not needed.

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program provides preventive healthcare services to support early screening, diagnosis, and treatment, promoting the health and development of infants, children, and adolescents.

MHS wants members to stay healthy while having fun. Healthy Celebrations are special events held at the doctor’s office. It’s a time for members to get important checkups. MHS and the doctor’s office choose a day for members to schedule appointments. During the event, there are games, giveaways, goody bags with snacks, and more. It is more than just a checkup; it is a celebration. These events help members who need health screenings and exams. MHS or the doctor’s office will contact members who can join to schedule an appointment. 

MHS offers the Start Smart for Your Baby program to support pregnant members through early engagement, care coordination, and the distribution of educational materials. The program encourages timely prenatal care and provides guidance on healthy behaviors during pregnancy to support improved outcomes. Members are screened for risk factors and encouraged to enroll in OB Care Management.

Assists members who have overuse of narcotics and ED usage.  Members are assigned one PCP and one pharmacy to allow members to make right choices.