Making PathWays Viable
Lack of Long-Term Sustainability for PathWays for Aging
The new managed care program for long-term services and supports, PathWays for Aging, which impacts more than 100,000 aged and disabled Hoosiers’ health care services is not codified in Indiana Code. As has been the case for other Medicaid programs, such as HIP, the General Assembly should dictate core components of the program if it is going to continue to operate.
Despite initial objections to the state’s intent to implement an insurance-only managed care program, the long-term care industry has worked diligently with FSSA and the Governor’s Office to launch the best possible PathWays for Aging program. Significant administrative, payment and policy challenges have been experienced and remain, but the turbulent launch has been less disruptive than many other states who have attempted similar program changes because of preemptive work by the Administration and industry stakeholders, in addition to the General Assembly who ensured claims payments last session in SEA 132. That said, sustainability and predictability are necessary for the program to successfully continue with uninterrupted services for elderly and vulnerable Hoosiers.
Making PathWays Viable
Lack of Long-Term Sustainability for PathWays for Aging
The new managed care program for long-term services and supports, PathWays for Aging, which impacts more than 100,000 aged and disabled Hoosiers’ health care services is not codified in Indiana Code. As has been the case for other Medicaid programs, such as HIP, the General Assembly should dictate core components of the program if it is going to continue to operate.
Despite initial objections to the state’s intent to implement an insurance-only managed care program, the long-term care industry has worked diligently with FSSA and the Governor’s Office to launch the best possible PathWays for Aging program. Significant administrative, payment and policy challenges have been experienced and remain, but the turbulent launch has been less disruptive than many other states who have attempted similar program changes because of preemptive work by the Administration and industry stakeholders, in addition to the General Assembly who ensured claims payments last session in SEA 132. That said, sustainability and predictability are necessary for the program to successfully continue with uninterrupted services for elderly and vulnerable Hoosiers.
Proposed Solutions and Statutory Changes
- Re-establish a centralized billing system for PathWays given chronic payment issues with managed care entities.[1]
- Set guardrails for the PathWays for Aging program and waiver to address current structural issues and improve long-term viability of service delivery, such as:
- any willing provider;
- state setting the rates,
- allowing for provider-led plans in the future; and more.
- Recognize the financial and public health value of home and community-based services, such as assisted living, within the long-term care continuum, by:
- Ending the Medicaid program’s monthly rationing of Medicaid waiver slots when slots are available and unused;
- Requiring FSSA to submit a waiver application to CMS for a standalone assisted living waiver program;
- Reinstating retroactive eligibility for assisted living services, consistent with MCE contract provisions for other PathWays participants; and
- Establishing a workgroup dedicated to improving the delivery of assisted living services in Indiana.
- Establish stronger oversight from FSSA to ensure MCE compliance and adherence to federal, state and contracting requirements, by enacting HHS OIG recommendations [2] that would:
- Establish audit requirements for claim denial rates;
- Require MCEs to report on claim types that were denied; and
- Require FSSA to implement at least annual external medical reviews of upheld MCO prior authorization denials.
- Expand the scope of the PathWays claims workgroup
- Develop policies to improve claims submission and claims processing.
- Advise the office of Medicaid policy and planning on any issues with claim submissions.
- Advise the office of Medicaid policy and planning on ways to improve PathWays.
- Support PathWays Residents
- Increase the Personal Needs Allowance to $70/month.
[1] Most pressing, current issue with PathWays with up to 22% of clean claims currently not being paid in 21 days by MCEs, let alone the high number of inappropriate MCE claim denials for “unclean” claims and other systems issues.
[2] HHS OIG: High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care
Indiana Medicaid
Indiana’s Case Mix reimbursement system is complex and frequently changing. We track and provide guidance on a range of matters from new policies, cost report changes, audits and quality programs. We also engage in policy development and expansion on Medicaid Long Term Services and Supports and Medicaid Waiver and Home and Community Based Services.