August 27, 2024 9:00AM – Medicaid Oversight Committee Meeting

Key Topics

• Pathways for Aging Program Implementation:
  • • The Indiana Pathways for Aging program, which started on July 1, is a managed long-term services and supports (MLTSS) program. It integrates Medicaid and Medicare benefits, targeting elderly populations, particularly dual-eligible individuals. Three health plans—Anthem, Humana, and UnitedHealthcare—were selected to provide managed care under this program.
    • Several discussions revolved around managed care entities’ outreach, member enrollment, plan changes, and issues with ID card distribution.
• Managed Care Entity Oversight:
  • The state is monitoring the Pathways program closely, with a year-long post-implementation oversight process. Frequent secret shopper calls and reports from managed care entities ensure quality services, particularly regarding service authorization, claims processing, and provider network adequacy.
  • An emphasis was placed on ensuring robust compliance measures for managed care contracts and improving issue resolution, with daily stand-up calls involving all three managed care entities.
• Waiver Programs and Medicaid Slot Capacity:
  • The aged and disabled waiver is split into two programs: the Pathways Waiver (for those 60 and older) and the Health and Wellness Waiver (for those under 60). There is a significant focus on managing the waiver’s slot capacity and addressing a waiting list of over 9,000 people.
  • The growing cost of care for Medicaid patients was discussed, including the significant budgetary implications. For example, aged and disabled waiver expenditures doubled to $2.23 billion in FY24, driven by increased enrollment and service utilization.
• Cost Containment Strategies:
  • Various cost containment strategies were discussed, such as limiting waiver slots, stopping 2% Medicaid rate indexing, and monitoring the financial impacts of program changes. These strategies aim to manage the increasing Medicaid budget effectively.
  • The state is focusing on ensuring the waiver processes are aligned with CMS-approved terms to maintain the financial health of the Medicaid system.

Committee Actions and Votes

• No specific vote outcomes were directly highlighted in the provided transcript sections. However, key decisions such as the approval of the Pathways program and associated oversight measures were implicitly supported.

Additional Notes

• Indiana Medicaid is working closely with the Center for Medicare & Medicaid Services (CMS) to maintain compliance, including monitoring waiver programs, managed care plans, and financial reporting.
• There are challenges in forecasting Medicaid expenditures, and efforts are being made to enhance data transparency and reduce lag time in Medicaid expenditure reporting.
• The committee acknowledged the difficulties faced by Medicaid members in assisted living and nursing facilities, especially those awaiting waiver slots, and efforts are underway to bridge financial support gaps.
• Doubling of Medicaid Expenditures: In FY24, the aged and disabled waiver expenditures more than doubled from $1.07 billion to $2.23 billion due to increased enrollment and service utilization.
• Transition to Structured Family Caregiving: a transition was completed for families relying on paid caregiving services by legally responsible individuals, moving many to structured family caregiving to ensure better service quality and fiscal responsibility.

       Morning, and the chair seats of quorum will call the meeting to order. Doctor BARRETt unfortunately cannot make it this morning, so I’m his substitute and so I’ll be conducting the meeting. I’d like to start, please, by having the members at the table here introduce themselves. Cora, if you’d start, please just go around, please. Cora Steinmatz, director of the Office of Medicaid Policy and Planning Jason Barrett Legislative Services Agency Senator Travis Holdman Senate District 19 Northeast Indiana Senator Ed Carboneau Senate District five, Northwest Indiana Chris de Ricci Senate Majority fiscal analyst Jeff Thompson House, District 28 Ben Tooley House Republican, fiscal analyst representative, House Slager, portions of Lake County Greg reporter House District 96, Indianapolis Eric Gonzalez House Democrat, fiscal analyst Hope Tribbles Senate Democrat, fiscal analyst David Nysgotsky State Senate, district ten, South Bend and portions of St. Joseph Johnny. Chris Johnston Office of Management and Budget thank you. We have a presentation by FSSA, and the way it kind of works, it’s kind of a natural, breaks four or five times there, if I recall that we stop and we’ll have questions, that they’ll present a while, ask questions and continue on. So core, if you want to do the presentation, please. Thank you. Thank you, Mister chairman, members of the committee, thanks for bearing with me as I got set up here. Cora Steinmetz, director of the Office of Medicaid Policy and Planning and I’m joined today by the FSSA chief financial officer, Paul Bolling. We appreciate the opportunity to be here with you today. As Chairman Thompson said, there are a number of topics, and we’ve tried to follow the agenda closely throughout these different presentations, noting that there are some areas of potential overlap. So we’ll just try to call that out as we go, but otherwise, we appreciate the opportunity to share important updates with you about the Medicaid program. The first topic today is an update on the implementation for the Indiana Pathways for Aging program. The pathways program, as you know, launched July 1, so we are just nearly two months into the program. Pathways is a managed long term services and supports program in our managed care programs. This becomes the fourth managed care program for the Indiana Office of Medicaid Policy and Planning. MLTSS programs allow for Medicaid to integrate long term services and supports, such as nursing facility services and home and community based services, such as waiver services, into a single form of health coverage. The integrated approach that we’ve taken with MLTSS is helpful for our aging population that’s targeted in the pathways program, over 80% of whom are eligible for both Medicare and Medicaid referred to as our dually eligible population. We know the complexities of our health system can be challenging to navigate for anyone, especially our aging population. We’re able to see improved outcomes for our members to the extent we can coordinate their benefits between Medicare and Medicaid, as is one of the goals of this program. Through a competitive procurement process, three health plans were selected. To serve as the pathways managed care entities. Those are anthem, humana and UnitedHealthcare. Anthem and UnitedHealthcare were existing Indiana managed care entities in other programs, and Humana is new to our Indiana Medicaid system. A quick note of a question we frequently receive is around MCE plan changes pathways plan enrollment for these three plans began in February and March of this year. Prospective pathway members who had not selected a plan as of May 1 were auto assigned to one of these three mces. Our pathways members still retain the ability to make a change, however, to their assigned health plan through the end of September. You can see from the slide a variety of other criteria that would allow for plan changes throughout the year, including upon a pathways member’s annual redetermination date for Medicaid. Pathways members or their authorized representatives can contact the enrollment broker with information listed here, their phone number eight seven pathway four to make that plan change. This is also the number for individuals to contact if they don’t know who their MCE is for the pathways program or they don’t know if they are enrolled in the pathways program. The MCE’s mailed member id cards and are continuing outreach to all plan members, but if we did not have the most up to date address information for that particular member, they may not have received that. This slide details the eligible population for the pathways program. These are Indiana Medicaid. Indiana residents who are eligible for Medicaid on the basis of age, blindness, or disability and who are ages 60 and up. As I mentioned, many of these individuals are also eligible for Medicare and receive benefits that program as well. The pathways program may include individuals who are residing in a nursing facility or who receive waiver services. Individuals who are 60 and older and were on the former aged and disabled waiver, which we’ll speak about later, were enrolled in the pathways program. Managed care and the partnership with our health plans brings an ability to better manage both qualified quality care for our members and the rate of growth in our program expenditures. This is important because while the pathways population accounts for 7% of total Medicaid enrollment, these individuals expenditures account for a projected 15% of our state fiscal year 25 Indiana Medicaid budget. This slide appears several times in our deck because it is the most common question we receive right now around the pathways program, and that is the intersection between the pathways waiver and the pathways program at large. Before July 1, the aged and disabled waiver provided waiver services for approximately 42,000 individuals of all ages. As of July 1, that waiver became two separate waivers shown here in the orange and teal green color. Individuals under 60 became health and wellness waiver members, which was a new waiver, and individuals 60 and older were enrolled in the pathways waiver in order to integrate with the broader pathways plan. As discussed, waiver services are different than healthcare services, and these include services that help people remain in their homes and communities, such as modifications to their homes or vehicles or home delivered meals. 90,000 individuals receive their healthcare coverage through the pathways program but are not enrolled in the pathways waiver. Put another way, all 120,000 pathways members receive their Medicaid health coverage through the Pathways program for services like hospital pharmacy, physician Behavioral health services, just like our hip members receive their health coverage through the Healthy Indiana plan. Additionally, roughly 30,000 of those 120,000 pathways members also receive home and community based waiver services in addition to their healthcare services. We’ll share additional information about this shortly when we discuss waiver slots, but thought this context was important as we continue our discussion about pathways implementation, you may be familiar with our robust readiness review process that was launched. This was a year long dedicated process to ensure that the three managed care entities and the state were prepared to go live with the program on July 1 through the success of that readiness review. We were able to catch issues before the July 1 go live and feel that this process is important enough to extend this readiness like approach to a year long post implementation monitoring period. In addition to the typical managed care oversight and quality activity, we take some of the best indicators about how things are going in these 1st 60 days of the pathways program are through our secret shopper calls by which we monitor the call lines with both our three managed care entities as well as our member support services MSS vendor which we’ll speak more about. Both the MCEs and the member support services vendor are subject to robust reporting requirements to the state. This slide details the member support services overview. This is an independent vendor with the state that is separate from the MCES and from the state. The MSS operates similar to an ombudsman, but is unique and separate from the long term care ombudsman that we have in the state. MSS adds another layer of oversight and support for our pathways members. MSS provides members and their authorized representatives with education, advocacy and support to navigate and also resolve issues they may experience while enrolled in the pathways for aging program. This includes assisting members who are experiencing challenges accessing care, who have a dispute with their managed care entity and need education on the formal grievance and appeals process, and supporting navigating issues with managed care entities to ensure that the member voice is upheld. In all of our person centered planning and quality work, MSS resolution involves an escalation process with the MCEs directly when issues are received by that independent entity. Most escalations are resolved within two to three days currently, and MSS follows up directly with all members. When an urgent issue is flagged that is a matter of health or safety, those issues are directly escalated to the state immediately. Both MSS and MCEs have regular touch points with the Office of Medicaid Policy and planning and again have required reporting. We’ve listed a few of the top call reasons that we’ve seen in these 1st 45 to 60 days, which are inquiries about who is my care service coordinator, requests for how to access transportation or medical supplies, and inquiries about how to receive their pharmacy benefits under the Pathways program. Listed here is the member support services phone number and email address, and there’s also a website where members can find more information. As I mentioned, we are continuing our readiness like approach with this one year robust oversight process, which will then come into our typical managed care oversight processes. We’ve taken a three prong approach here for oversight and auditing of our managed care plans for this first year post. Go live. This is broken down into three distinct areas, go live reporting, in which weekly reports to monitor a variety of topics and MCE processes, including claims processing, call center management, member health assessments, our non emergency medical transportation work, and prior authorization for services that require PA, such as home health. These reports are submitted on a weekly basis and reviewed by executive level staff, including myself. On site and desk review audits are also conducted. We have established an annual plan, inclusive inclusive of on site visits to the managed care entity’s office, location, and desk reviews. This includes again shadowing the call centers, shadowing the care and service coordinator staff, and performing reviews of it systems. Finally, our third prong is continued MCE interaction and oversight. We continue to have daily stand up calls post go live with all three managed care entities to quickly address and resolve issues that have been brought to the state’s attention. This means ongoing, frequent touch points on various topics, an organized process for tracking issues brought to OMPP, and a dedicated process for follow up. We also have a number of avenues where we continue to work with stakeholders such as provider associations, member advocates, et cetera to solicit feedback to share with the managed care entities and request action. As mentioned, the call center helpline data has been an important finger on the pulse of how the pathways program is going. Managed care entities have specific performance metrics that they must meet around the time in which it takes the managed care entity to answer the calls and the number of calls that are abandoned. We also are monitoring what the most common call reasons are. To track systemic issues. As of now, the most common member call data into the managed care entities includes questions about eligibility, receiving a new id card, finding a provider, questions about the MCE’s network or covered services for the pathways program. You can see that our three mces are well within the metric for the percent of calls answered live within 30 seconds. Similarly, we are closely monitoring the issues that providers are reporting to the managed care entities or inquiries that are coming to them. These inquiries, of course, are smaller in number, but also increasing in complexity as they deal sometimes with claims inquiries or status authorization issues for services that require prior authorization, questions about a member’s service plan for those waiver members benefits and coverage information, as well as member verification of eligibility. As mentioned, at the state level, we have a robust issue resolution process. Individual provider issues are an area that we constantly review, and resolution for our state team, as well as the MCU provider relations directors is of the utmost importance. Individual provider issues, as a first step, should be directed to the provider relations team at each of the three managed care entities. However, we also have direct escalation to the state for provider issues where there are challenges with the managed care entities or the resolution that they’re performing. To date, we have logged over 400 issues through our escalated issue resolution process and have closed well over 300 of these issues issues. Again, our daily stand up calls with the pathways directors is an important way that we’re continuing to monitor status of these issues. If we have provider associations who are looking to escalate issues with us, the most important thing that we share with them is the importance of specific details around what the issue is. It’s most challenging for us to track down anecdotal or generic information if providers are experiencing issue and can provide the MCE or the state with direct claims examples or member level data. That’s the fastest way that we can find the root cause issue and address quickly. An area where we have invested significant time and resources is in monitoring the provider claims space. We’ve been very direct with our managed care entity partners that the two most important aspects of our pathways go live is one, ensuring members receive services, and then two, that providers know how to properly submit claims and be reimbursed for providing those services. An integral part of this claims monitoring has been the claims workgroup that was the output of legislation last session. Through this claims workgroup, each of the primary provider associations involved in the pathways plan have designated representatives that participate in our weekly and now biweekly claims workgroup that includes the state from both an IT technology standpoint and Medicaid leadership, as well as each of the managed care entity pathways directors and claims representatives from the managed care entities to troubleshoot issues that exist on claims submission and payment. Prior to go live, we conducted a robust claims testing process that was also required under that legislation that triggered eligibility for the emergency financial assistance program. I’ll speak about later. This claims workgroup has also worked to solidify a single billing format for pathways claims across the three managed care entities, and we’ve received direct provider feedback about the areas where providers may need more training or education, either from the plans or the state, about how to submit these claims and be paid in a timely manner. This claims work group has also bubbled to the surface claims issues that existed at the time of go live. As a result of the issues that a handful of issues that the claims work groups shared with the state and with the MCEs, FSSA directed the managed care entities to reconfigure their systems or otherwise have flexibility in the way that providers can submit claims to resolve cash flow issues that might exist for providers. As a result, denials for our claims have gone down significantly. I’ll share some more data on the next slide, particularly our institutional claims, which are nursing facility claims, as well as other provider types. Those have decreased significant denials have decreased significantly in the last month. For those, there is still additional work to do on our professional claims. Submission training for providers because our home health and HCBs or home and community based services waiver provider denial rate is still not where we would like to see it be, and so we have been pushing the plans and advocating at the state level as well with training and education opportunities for providers. It’s notable that not all denials are inappropriate denials. We continue to see some common claims issues for providers with certain submissions, including submitting duplicate claims, submitting claims for services that are not covered under the pathways program and were not previously covered under Medicaid fee for service, as well as when providers submit claims without the provider id registered with the Office of Medicaid Policy and Planning. This is a snapshot of a week’s worth of claims data under the Pathways program for each of the three mces. Again, institutional primarily represents nursing facility claims and professional claims are primarily our waiver or home health providers. You can see that the percentages of paid claims, they’re about the middle of the chart, are these have increased significantly, again, especially for our institutional claims. As mentioned, we’d like to see our home health and HCBS claims claim percentages increase, so we’re working with providers to ensure that they have the proper understanding of what an appropriate claim submission looks like for the three mces. The bottom three rows of this particular chart also show timeliness of claims paid if claims are not paid within the required timeliness under the managed care entity scope of work, the MCE must pay that claim with interest. You can see that the vast majority of claims are being adjudicated within the timeliness window. As mentioned, for providers who participated in the claims testing window in advance of go live, they have the opportunity to apply, if needed, for temporary emergency financial assistance under the pathways program. It’s important to note that this is not a grant, this is a reconciliation against future claims that may be submitted and operates as a six month advance on historical claims payments. Again, a provider had to participate in claims testing to be eligible for the TFAP program, which we had over 2500 Medicaid providers do with our three mces. This program operates through January 31 of next year, and we are continuing to actively review and issue approvals or denials to the number of emergency financial assistance applications we have received to date. I’d like to also note that even if a provider applies for emergency financial assistance and is not eligible because they did not participate in claims testing, or they don’t meet the statutory criteria that constitutes a financial emergency, we’re directing the MCE to perform specific outreach on a one on one basis to that provider to help them navigate whatever claims issues they are experiencing. Finally, just a reminder that there is a plethora of information on our pathways website, pathways dot in dot gov comma, with many faqs, and we continue to update that information as we receive additional inquiries now that we are into the go live period. With that, I’m happy to answer any questions. Thank you. Any questions at this point? Yes, go ahead please, Mister Johnson. Thank you Mister chairman. Cora on Slide Ten, where we talked about the oversight, the on site and desk review audits, is that a dedicated group within FSSA or is that contracted out? Thanks for that question. It is a dedicated group within FSSA. We also have contractors who support this work in a variety of capacities, but we have a dedicated FSSA employed team in the Office of Medicaid policy and planning that their sole responsibility is compliance, meaning the MCEs complying with our managed care contracts and the scope of works. So they are the ones that are going out on site to the managed care entities, performing those on site reviews. They’re the ones receiving those weekly and or monthly reports, reviewing those in detail, asking questions, issuing corrective action plans if needed, if managed care entities are not complying with the requirements of the contract. Thank you representative Slager. Thank you Mister chairman. Just to help me out, when would we have dual eligibility between Medicaid and Medicare? Why wouldn’t Medicare take over if that were the case? Great question. Thank you for that. So our dual eligible population are primarily those individuals who qualify for Medicare, which would be 65 and older. So it’s not our entire pathways population that is eligible. Under federal law, Medicare is the primary payer and Medicaid is the secondary payer, meaning that Medicare does cover those services and pay for the services that are Medicare covered services first, and then the remainder of the claim or those services that aren’t covered by Medicare are then picked up by Medicaid. For example, nursing facilities or nursing facility services are primarily covered under Medicaid, not Medicare. Hospital services, however, are primarily covered under an individual’s part A or part B Medicare plan, and Medicaid only picks up the remainder of that amount. Thank you. Further questions seeing none. Continue please then, thank you. Okay, great. Turning now to the implementation of additional Medicaid waiver slots, this agenda item focused on pathways, but for the purposes of this discussion, we’re going to discuss pathways and health and wellness. So again, just a quick reminder on this slide that we discussed previously. Before July 1, the aged and disabled waiver covered all ages. We now have broken those two waivers into age based criteria in order to facilitate that integration with the pathways program for those waiver members who are aged 60 and up. Waiver slot capacity was announced in January as one of the cost containment strategies coming out of the December 2023 Medicaid forecast. We’ll speak in greater detail about cost containment strategies as a whole at a later agenda item. But throughout those cost containment strategy development, we worked to ensure that strategies we were deploying and proposing targeted the specific areas of unanticipated expense. The aged and disabled waiver in state expenditures for the aged and disabled waiver in state fiscal year 23 were just over $1.07 billion. For state fiscal year 24. This more than doubled and the aged and disabled waiver expenditures for this particular fiscal year, state fiscal year 24, were $2.23 billion. We also saw enrollment grow at an unprecedented pace on the aged and disabled waiver. As of July 1, 2022, there were 32,000 enrollees on the a and D waiver. By July 1 23, this had grown to 39,000 and we now have over 42,000 individuals enrolled in the two waiver programs. In April 24, FSSA also announced that we had reached the slot capacity for state fiscal year 24 and would be implementing a waitlist again. At that time, the waiver was the aged and disabled waiver. We also announced again that on July 1, 2024, the new waiver year would begin, which would be state fiscal year 25 and additional slots would open for which we would invite individuals to be added to what was now two new waivers, the pathways waiver and the health and wellness waiver. As of July 1, we have been inviting individuals onto the two waivers at a rate that is consistent with our prior year’s monthly enrollment onto the waivers. This translates to about 800 individuals for the pathways waiver per month and 125 individuals per month for our health and wellness waiver. The next I’ll turn to the next slide, which hopefully helps paint this picture a little more clearly. The first half of this chart, or the top half of this chart is for our pathways waiver. Again, 800 individuals each month are invited off of the waiting list onto the pathways waiver. Currently, as of last week, there were 9247 individuals on the pathways waiver waiting list. It’s important to note that this number changes on an ongoing basis as individuals are added to the waiting list. Our total number of cms approved slots for the pathways waiver is just under 40,000. That’s for this state fiscal year 2025, the waiver years aligned to the state fiscal year. This means that as based on current pathways enrollment, we have 8237. Slots available again as of last week for the pathways waiver. Similarly, on our health and wellness waiver, there are 120 individuals invited each month onto the health and wellness waiver. Currently, there are 4431 individuals on that waiting list and 16,127 total approved slots. This means there are 3507 slots available. Again, these numbers fluctuate. The invitation process again, is based on our historic enrollment onto the waiver because of the complexity of processing individuals onto the waiver. Unlike typical Medicaid for our non waiver members, there are additional assessments that must be performed of these individuals. In addition to qualifying from a financial eligibility standpoint, waiver members must also meet what is called nursing facility level of care, which means that they need assistance with activities of daily living such as eating, bathing, dressing, such that they may require nursing facility care. When an individual is invited from the wait list onto the waiver, the individual must have their financial eligibility determination performed, as well as this nursing facility level of care process completed. Last week, we launched the waiting list dashboard to help paint the picture for individuals of where we are in our wait list invitation work to give them an idea of when they may receive an invitation from the waitlist onto the waiver. Another complexity, which creates challenges in pinpointing for an individual exactly when they will become invite or when they will be invited onto the waiver, are the priority categories in the CMS federally approved waiver. We have certain priority categories for individuals, which means that they go to the front of the waiver waiting list. These include individuals who are leaving a hospital or being discharged from a hospital or being discharged from a nursing facility. Because it is difficult or impossible to predict the number of individuals in a given month on Medicaid who meet this priority category were unable to state exactly what month someone will receive their invitation. Because that waiting list number fluctuates as priority category members are added to the waitlist, and I apologize it’s very small on the screen, but within our dashboard, we’ve provided information about the number of priority category individuals who were added to the waiver invitation list for a given month. Additionally, you’ll see that our numbers are just over 800 and just over 125 for each of the months of July and August for which we’ve performed this wait list invitation. That’s because FSSA is working very hard to ensure that if an individual declines the waiver invitation, we move to the next individual in the waitlist so that we are still translating into that same number of enrolled individuals per month. In the first month, we had approximately 56 individuals who had either moved out of state or declined the waitlist. I’m sorry, the waiver invitation once it was received. So we added 56 additional invitations into that month’s set of invites. We understand that this is a challenging situation for many individuals who are waiting for waiver slots. Additional supports are available through the area agencies on aging, such as the choice program for individuals where there may be choice dollars available. Additionally, two one one is prepared to help individuals find supports in their community of other community resources that may be available. We’ve had positive discussions with our assisted living association partners who also have experienced challenges due to individuals who may be in the assisted living facilities and are spending down resources waiting for that waiver slot to become available. And we’re looking at additional supports that may help bridge that gap for individuals who had been admitted into an assisted living facility before the time of the waitlist announcement. With that, I’m happy to answer any questions. Thank you. Yes, Senator Holman. Thank you, Mister chairman. Cora, let’s suppose we have an individual that’s in skilled care or intermediate care in a nursing facility. They are spending down their assets and they have spent down their assets and they don’t get on the wait. They’re not moved up on the wait list for some reason. Do they stay, practically speaking, do they stay in that facility for 1234 months, and then Medicaid goes back and picks up that tab with an effective date of when the spin down occurred? How is that handled and what guarantees do you have to the facility that they’re going to be made whole in those situations? Thank you. Thank you for that question. Senator Holmande, within the skilled, the skilled nursing facilities operate slightly differently than the assisted living facilities because nursing facility services are required benefit under the Medicaid program. Those individuals, when they are in a nursing facility and they are on the Medicaid program, come out as a priority category and are able to go directly onto the waiver. The assisted living facility is where we see more challenges in this regard because that is a waiver only service, and so an individual must be on the waiver to have it reimbursed by Medicaid. So in that particular regard, that’s where we’re working with the assisted living facilities to see one. What process improvements can we put into place to help work through the wait list more quickly and to what financial support might be available through ARPA dollars that we still have to help bridge that gap for individuals who may be in the assisted living facility spending down and have now spent down, but are not able to get onto the waiver if they have spent down to a point where they qualify for Medicaid at full Medicaid, and not just waiver Medicaid because those have different income levels. There are other Medicaid supports available for them, such as home health benefits and the like. It’s really these individuals that we know have experienced challenges who might be over income for traditional Medicaid and need that special waiver budget to qualify and are waiting for this invitation in order to get onto the waiver and qualify for Medicaid in those circumstances. We’re working closely with the assisted Living Provider association to find some temporary financial resources for that particular instance, because to your other question, I believe there is no retroactive waiver payments. So an individual or a provider providing services to a waiver member is only eligible for Medicaid reimbursement from the date of enrollment forward. So if I could get a physician to order that patient to intermediate or skilled care, that would be the resolution to the funding problem, would it not, for the patient, for the individuals funding issues. So if the individual meets the nursing facility level of care and goes to a nursing facility location, then that individual will be covered if they meet the financial eligibility criteria for Medicaid. That is an option for them in those circumstances. I’m not sure that I answered or understood your question. No, I think you did. It just, it concerns me that we would have physicians who, because the family can’t afford the assisted living, that the physician just says, go ahead and send them to the nursing home for intermediate care because that’ll automatically boot them into the system then to be covered by Medicaid, which is, I think, could be a gap that we need to be careful of that doesn’t get filled erroneously. Appreciate that. Representative Porter, thank you very much for your presentation. I have a couple of questions here. Could you please reiterate the explanation what has happened to necessitate the creation of the wait list? Could you reiterate that for me again, please? Because before we didn’t have a wait list, now we do. Could you, I just, for the record, I just want to reiterate that. Oh, yes. Thanks. Representative Porter. The waitlist while the limit on slots. I’ll say that first we announced in our number of cost containment strategies that we put forward as a result of the December 2023 forecast. One of those strategies was the decision to not increase slightly slots beyond our current slot capacity. The number of slots we had on the waiver in state fiscal year 24, we determined we would cap enrollment on that particular waitlist, or, I’m sorry, on that particular waiver, and then for the next year, we would moderate growth on that waiver by increasing only up to 55,000 slots total across the two. So it was a cost containment strategy that we deployed as a result of the December 2023 forecast. Okay, so american rescue plan dollars, do we still have those dollars? Where are those dollars? And what have we done with those? What is the intent of american rescue plan dollars and how much we have? Because I know the dollars are still out there. Right. We could provide the exact number of the dollars that are unobligated of our american rescue plan dollars through the home and community. I’m speaking specifically to the home and community based spend plan enhanced federal match dollars that we’ve used to fund a number of things, including direct support, workforce initiatives and the like. That particular pool of dollars is what we’re looking to use to assist those individuals who are in the assisted living facilities and are in that spin down situation. So that is, I don’t have the particular dollar amount for you right now, but we could definitely follow up with how much of that remains in line that if you will, could you give it, provide that information to the chairman so this chairman can disseminate it out to us so we can make sure we get that at times they don’t get to us. But okay. Another question I have in regards to keeping individuals out of restricted settings. It appears that the goals of pathways diversion to the front end. So I’m concerned about the restrictive settings. That appears to be one of the paramount goals of, I guess, pathways waiver. So when we talk about the pathway waivers, my question, my concern is the non priority population that includes those assisted living who could be potentially diverted from the nursing home placement to a secure waiver slot. So could you enlighten that for me? I’m sorry, I’m not sure I entirely understand the question. This is about the priority category. That’s correct. Okay, thank you. So within the federally approved waiver, states can determine priority categories for their waivers and or if they have a waitlist to determine the priority category of individuals who receive invitations off of that waitlist. So we, as we developed this particular waiver, had a couple different priority categories. One of those is the nursing facility priority category in order to help expedite individuals out of those institutional based settings into home and community based settings, realizing that they need waiver services to wrap around and help them in that transitional support time. Thank you, Britney Slager. Yes, thank you, mister chairman. Thank you, Cora. I just want to make sure that I understand some of the mechanics as it relates to a year from now. In other words, you indicate the plan years started July 1 for each individual that’s brought in. Does their plan year then begin whenever they’re brought in so that next year they’re not necessarily on a waitlist, so that this will smooth out a year from now. Thanks for that question. Representative Slager. Yes. Once an individual is on the waiver, they are no longer subject to a waiting list. The current waiver enrollment, as long as that individual continues to meet the criteria, both the level of care or physical need that they have, plus the financial eligibility, they remain on the waiver and are not subject to going back onto the waiting list. That waiver slot, in fact, can only be held by one individual for the entirety of the waiver year. Senator Niskoski. Thanks, mister chair. I’m just trying to take this all in and understand it better, too. And I’m trying to figure out for, let’s say, individuals that may have spent down their assets and they would, they were all ready to go onto this waiver. Let’s take an assisted living facility. You did state that you’re going to try to seek out additional resources because there may be, if it’s assisted living facility that they are, that assisted living facility has a number of patients like that. So what happens when an assisted living facility where someone had already been present, you know, they can’t afford, if you can’t go retroactive in payment, just seeking out additional assistance. This is not a situation of let’s hope it’s going to work out. So what happens if that individual was qualified. They paid down their assets, and now the family is beginning to have to draw down their assets to keep that. What’s the solution there? Because everything would have been in place for that individual to go forward, but now they fall in this gap. And that’s my greatest concern, too. What happens to some of these members in the gap that we later on found out were really hurt or damaged, whether it’s financially or they say there’s no need that will not be met. I mean, you can understand where there’s going to be great consternation on this, what is going to happen to help those individuals or those families or those care facilities that, you know, if it’s not retroactive. Thank you, Senator. Really two prong approach on this one, again, as we mentioned, is the use of some temporary funding to be able to help those individuals who, again, were perhaps in the assisted living facility spending down their assets at the time that FSSA announced the wait list and had relied on the ability to hopefully translate that into a waiver slot or waiver enrollment. So that temporary funding, working with the assisted living facility, we’ve identified the source of the funds for that and are just finalizing sort of process and application format and that type of thing for that particular funding pool. The other piece that can assist in this is ensuring that we’re processing the waiver applications and working through what is a very complex process, as you can see, as quickly as possible. And that includes working closely with our area agency on aging partners with the providers who might be providing services to these waiver members, the waiver member themselves and their family or caregivers or authorized representatives who are helping them through their financial eligibility determination. So we’re convening a workgroup that is really based off of our pathways claims advisory workgroup because that was so successful to look for operational efficiencies to decrease the time it takes to translate an individual’s waiver waitlist invitation into enrollment so that they can quickly be, as quickly as possible be enrolled in the waiver, and Medicaid can begin paying those waiver claims. And that’s part of my concern, too. I mean, this new program was very well planned out. It’s been incorporated. It started July 1. So if it’s found that the proper resources are not there to adequately address adding people faster to this wait list, I mean, is there going to be additional resources sought for others to help that wait list period time go down? I mean, I guess we’d like to have some form of guarantee that, you know, it’s not going to just be, well, this is just how long it’s going to take. Because if people are getting hurt in this process, that’s the number one thing we should be concerned about. And it’s really a. Thank you for that. It’s really twofold. It’s both on the administrative side of the processing and then it’s also on the Medicaid assistance funding side of is there funding for the number of slots that would need to be increased? So certainly hear that and we’ll talk a little bit about our fork, our improved forecasting processes, where we hope to have data available for policymakers to engage in those discussions. And I would just. I’m sorry, I’m just one more follow up. I guess I’d like to understand why is it that some will be prioritized and they need to be? I mean, I think it’s essential. Why is it that there can’t be some form of idea where they fall on this wait list? I mean, why should everyone just be seemingly random? I mean, that really throws people into, they just have no knowledge and that creates fear for these people. Certainly appreciate that. With the launch of this new dashboard, we hope to give individuals a better idea of how quickly we’re working through the waitlist. And then based on when they came on to the waitlist and the number of individuals that we’ve invited off, as well as the transparency around the number of priority categories that or priority categorized individuals that have been invited, we hope to continue to be able to give people a better idea of where they are on the waiver waiting list so that they have an idea their families can plan, because we certainly appreciate that that’s a challenging situation to be in. Representative Porter. Thank you, Mister Chairman. Just one more quick question, because you mentioned a word that tricked my mind, tipped my mind in regards to the budget. So as we continue to look at building the budget for this upcoming year, my question is, if the state, if we demonstrate that we can address the needs and increase the slots, do you think. CMS will allow us to do that here in the state of Indiana because I think, you know, are we going to be capped at those slots or will we increase the slots to take care of the needs of hoosiers? So that’s my question because I think that if we can demonstrate that we have more dollars or CMS or whatever, give us more dollars that we can continue to increase those slot numbers. Will you, can those discussions move forward in regards to that? That’s my question. Yes, I believe so. Historically, we. The way that this. I’ll just speak to how this waiver has operated historically, which is that however many slots we needed, we brought forward that request to CMS and it was always approved. Okay. Keep looking at Senator Mitchell. Okay. So I guess I need to talk to him about that. Thank you. Other questions? You know, I have one and I couldn’t process quick enough. Back at the start of this section, you talked about the numbers and the growth. To me, it was just, and I couldn’t get it all in my brain. Could you repeat that, please? Excuse me. I think I was referring to the reason why so many of the cost containment strategies, including the waitlist or the slot capacity, focused on the aged and disabled waiver, which is now these two new waivers, is because that’s really where we saw the unanticipated growth from the forecast. So for state fiscal year 23, expenditures on the waiver were 1.07 billion, and it more than doubled the next year. In state fiscal year 24 to 2.23 billion. That’s on the expenditure side. We also saw growth not to the same amount in enrollment. So as of July 1 22, enrollment was 32,000. Enrollment today is roughly 42,000 across those two waivers. So in two years, you had 10,000 more. Okay, thank you. Other questions, Senator Holman, and follow up. And follow up to the chairman’s question. Why? Why has there been that much growth? Has there been some study done to find out the reasons for that increase at all? So thank you, Senator Holman. There’s a couple drivers of the expenditure increase, which I’ll focus on first. One is a rate increase. There was a fairly significant home and community based services rate increase that went into effect on July 1, 2023. So that drove a decent piece of the growth that we saw in that particular waiver. Additionally, utilization really grew. We’ll talk a little bit about the attendant care and legally responsible individuals and the increases we saw in the attendant care service that is incorporated in those numbers that I shared. And then enrollment, that is a little bit more subjective in why we think the enrollment grew. Certainly more people became aware of the availability of this waiver during the pandemic period, people were more likely to want to remain in their homes. And so I think we saw increased growth in that regard as far as the enrollment piece. So the enrollment plus the utilization increases plus the rate increases contributed to the overall doubling over that time period of expenditures. Thank you for the questions, Senator. Go ahead. Place Charbonneau. Yep. Thank you, mister Chairman. What are the percentages of the three reasons you gave? What how much was because of the rate increases? I’m not sure that I know that off the top of my head, Senator Charbonneau, but we could look at that. It is a little bit complex to pull apart the three multipliers of that equation, but we could certainly take a look and see how, even if it was rough math around how much we thought it grew in terms of rates versus enrollment, certainly utilization for attendant care, specifically. Utilization was the number one driver of the increases in expenditures. Thank you. Thank you. Further questions, can you please. Then I will move somewhat quickly through this section. Although happy to answer any questions, this is with regards to the monitoring of our managed care programs as well as our waiver programs. So, a quick snap snapshot of our Indiana Medicaid programs. This chart, which you may have seen before. Our four managed care programs and the dark green represents that population which remains in Medicaid under fee for service, meaning that there is no managed care partner or program for those individuals. The population is defined on this slide as well as the total enrollment as of August for these five different sections of our Medicaid population. If there is a managed care entity involved, that also is noted on this slide. You can see that with the launch of pathways, we now have six different managed care plans. As we’ve added humana, the plans are competitively procured on the traditional state contracting cycles. As far as Indiana, we’re about in the middle of the pack as far as the number of managed care entities we work with. Some state Medicaid agencies work with as many as 20 different managed care plans. Some have only one or two. This information on this slide is similar to what we discussed when we talked about the pathways oversight. So with our healthy Indiana plan, who’s your health wise program? Who’s your care connect? And of course, the pathways for Aging program, we have extensive contract oversight and compliance programming. As I’ve discussed, this has been a priority of FSSA for a number of years, and other states have sought to model Indiana’s approach to managed care oversight and ensuring the quality of our health plans, particularly in the areas of readiness review systems and processes. The CMS, which is our federal partner managed care group, is also extensively involved in plan oversight. The capitation rates that are set for our plans for each of these programs, as well as our state managed care contracts, are reviewed and approved by CMS again before a program go live. Even if a plan has already been involved in that particular program in Indiana, that plan must complete that robust year long readiness review, and OMP vigorously monitors the oversight or monitors the compliance with those requirements. We’ve talked a little bit about the reports that are submitted to OMPP, both on a monthly and quarterly basis. Those are reviewed by executive level staff. We look for trends and there are hundreds of service level agreements that we have incorporated into each of those hundreds of pages of managed care contracts that are available on the transparency portal website. We also have monthly onsite meetings. We frequently are in conversation with each of the MCE plan presidents across all of our programs and are asking for constant guidance around their quality measures and finding information about how we can better serve Medicaid members. The box on the right includes information again about those specific areas we’ve targeted for our pathways implementation as far as monitoring and oversight tracking member issues, the MCE provider training that we are requiring this is particularly important for our pathways population, especially those that may be receiving home and community based services to ensure that we have quality. Those individuals know how to escalate issues to their managed care entity if they’re experiencing challenges. We’ve talked a bit about the readiness review, so again, that’s a systematic, large scale review and we’re looking at all aspects of the managed care entity operations. We approve the key staff that work on our programs in Indiana. We review all policies and procedures, notices that they send to members, marketing materials. We review provider networks to ensure that there’s network adequacy and we have a number of safeguards to ensure that the MCEs are prepared to help translate that access into making sure our members can receive services and that they understand the population that we’re serving. In Indiana Medicaid examples of the readiness review topics include provider contracting, the covered benefits, and again, claims processing. Turning to oversight of our hcbs waivers, we have five home and community based services waivers in Indiana Medicaid. Now, we’ve talked quite a bit about the ones on the left, the pathways waiver, and the health and wellness waiver. This slide also depicts which of the waivers are in managed care, which is only our pathways waiver, and that the remaining four hcbs waivers are overseen by our division of disability and rehabilitative services. One objective that we have by having the health and wellness waiver be under the auspices of the DDRH. IR’s is to ensure uniformity to the extent possible across the waivers and make sure that we’re aligning smoothly about how each of the waivers operate and how individuals access services on the waivers. Again, this slide shows the population that is covered or eligible under that particular waiver and the current rough enrollment of those particular waivers. Our waivers are overseen also by the Centers for Medicare Medicaid Services CMS. By calling it a waiver, it simply refers to the fact that we, the state, have sought a waiver of a federal law that would either restrict or require certain things to happen within our Medicaid program. So in the case of our HCBS waivers, we’re frequently waiving the statewideness requirements and allowing a dedicated portion of our population to receive a specific set of services, in this case, the HCBS waiver services. Our waivers are subject to a public comment period. Additionally, Indiana state law requires that new waivers or waiver changes, as well as state plan amendment, go before state budget committee for review. The state must also operate the waivers in accordance with CMS approved terms and conditions, which operate as the contract between the federal government and the state. In order to receive the federal funding for those particular waivers, we frequently meet with CMS to talk about waiver operations. We are required to do extensive reporting on waiver from all things from expenditures to enrollment to how the waiver operates and how the state oversees and administers that waiver. The waivers are also an important aspect, an important tool that we were looking at in terms of our enhanced financial oversight structures, which we’ll share about, as well as reporting to ensure that we have a strong understanding of what’s happening in our waivers, what the trends are looking like to pinpoint issues or necessary policy changes. Happy to answer any questions on this section. Thank you, Representative Slager. Yes, thank you, mister chairman. Cora, could we go back to the first slide of this section where you review the Indiana Medicaid programs? Is there any overlap between the participants in these programs? Generally, no. There’s some very, I’ll say, technical or wonky eligibility requirements around. Sometimes an individual starts in fee for service before they’re assigned a managed care program or certain populations will shift based on eligibility. But generally, no. Generally they are unique population cohorts. So just doing some quick math, we’re looking at about 2 million Hoosiers in one program or another. That’s correct. I think just shy of 2,000,001. Last question on this on the healthy Indiana plan. Can you explain for me under population, including expansion population, can you explain what the expansion is about certainly the expansion population are the individuals that, through the healthy Indiana plan, have a higher income level requirement through Medicaid expansion under the Affordable Care act that in 2015, Indiana adopted expansion in the state and used the healthy Indiana plan as the vehicle by which we covered that expansion population. Do you have just a rough idea of what percentage of the hip is the expansion? We could definitely follow up with that. I think I have an idea in my head, but I hesitate to say it. I’m just trying to get, you know, is it half, is it a third, that kind of a thing? I think it’s less than half. Okay, thank you. Because in this hip population also includes our hip maternity population, low income, parent caretaker population, our medically frail population. And so those individuals fall outside of the federal definition of expansion. Okay, thanks. Thank you. Is any porter? Thank you, mister chairman. Going back to slide 27, Cory, you talked about the website. We tried to find information off the website. They provided us with specific information and in regards to your trans. To the portal and the contracts, and we couldn’t find it. It was very, very difficult. So is there someone within your team that we can go to to get that information? Because we look for a while to get the contracts in regards to those three entities. Sure. That is no problem. We’d be happy with the follow up information to share a set of links to each of the managed care contracts that are out there. I know it can be challenging to search and find the specific valid contract. Right. So who’s going to help us navigate that? You have a assigned staff person that would do that for us? We do have assigned staff, but I’m happy to follow up directly through packaging, whatever follow up information. In addition to the other question around ARPA funding, we could share that if the chairman is okay with that in one. Okay, thank you. Thank you very much, senor Noskoski. Thank you, mister chair. I’m going to probably go back to the very beginning of our presentation today, but my question I think really takes in every bit of what we’re talking about. I mean, I remember it was mentioned about doing secret shopper calls, are just trying to find just what the response was. Is there any plan to potentially go into some of these care facilities and randomly maybe speak with some of the employees that are willing to speak or some of the, some of the patients that are in there to see just exactly how their needs are being met prior and now after? I mean, the bottom line is, are we still going to be giving the proper and adequate quick care to these, to these individuals? Thank you for that question. Yes, we are planning to. And it is required that in fact, a third party will be taking direct survey information from members. There’s a number of tools out there and surveys to ensure that Medicaid members can directly express to us through the state their experience with the pathways program. And we will also be required to federally report that information. So we’ll definitely be including that as part of our oversight and quality monitoring work. What’s the timeframe where that will begin? That’s a great question. I’m not sure I know exactly off the top of my head, but I know that we have already started informal member surveys, and I think some of the more formal work happens at the six month and also year implementation mark. Further questions? Can you help me out with regard to how does Indiana compare on these waivers to our neighboring states or nationwide? Are we typical? Are we, where do we sit, so to speak? Thank you for that question. I’ll just answer maybe broadly, and you can let me know if that helps. I would say that many states have hcbs waivers, 1915 C waivers, which are what this particular hcbs waivers are. In fact, I’m not sure if it’s all states, but if it’s not, it’s nearly all that have supports for, particularly individuals with disabilities, as well as the aging population that they serve through waivers, or they serve these individuals via other contract vehicles within their Medicaid program. And I think it is not unique to Indiana that this population, the expenditures are higher than other areas of our Medicaid population, such as our expansion population, or in our Hoosier health wise program, the per member cost is the lowest. So that’s the population of our children who tend to be the healthiest, children who don’t, those children who don’t otherwise qualify for a waiver or have a disability. And so I think we’re not unique in that regard. We’re also not unique in the area of having a waitlist for our waivers. I think there’s, by last count, somewhere like 34 states that have waiver wait lists for these types of services because it is an expensive investment that the state is making. And I think that’s reflected by the fact that there are wait lists. I will also say that we are not unique in working to transition our mltss or launch mltss, meaning that using managed care as a vehicle to help also with our aging waiver, ensure that we have appropriate resources for our members and that service utilization is at the appropriate level and sort of moderate some of the expenditure growth. Thank you. Any further questions? Continue, please. Then. Okay. At this point, I’m going to turn it over to Paul to speak a little bit about our monthly financial reporting and the transparency around Medicaid expenditures. All right, thanks, Cora. In order to provide some more transparency around our Medicaid expenditures, starting around eight months ago, we started to develop more detailed Medicaid financial reporting to provide more transparency to data on our overall Medicaid programs. We took on this robust process to be able to develop and create Medicaid monthly financials that we could post monthly and make available. That data to the public. The overall objective of creating financial reporting is to improve our monitoring of various Medicaid data elements such as enrollment, expenditures, and utilization, and the comparison of this data to forecasted projections. The more robust reporting ensures that we can be more responsive to unanticipated trends and timely notifying key decision makers to see if changes need to be addressed from these items. With the creation of these monthly financial reports, we have created a review process to ensure that the right individuals are reviewing this data on a monthly basis to help us identify any trends or risk as early as possible so that they may be addressed. The process starts each month by we create the monthly financials. These monthly financials are then shared with our subject matter experts across the agencies. The subject matter experts are then able to review and provide any feedback or trends or potential risks that they may note. This feedback is then shared with the reporting workgroup and steering committee to validate this information and determine if any additional research or discussions need to occur based on these comments. Before posting our monthly financials, we do collaborate with the state budget agency on the development of our commentary that accompanies our financials posted to our website. As part of the Medicaid financial reports, we wanted to be able to provide more detailed information on a monthly basis in three main areas, expenditures to include both current month and year to date expenditure amounts and the comparison of these to what we had forecasted for that particular month and year. This allows us to be able to more closely monitor some of the primary cost drivers such as utilization provider rates and benefits. We also provide an enrollment report that includes data on the number of individuals enrolled in that current month and an average year to date enrollment, and comparing these to our forecasted amounts. Lastly, we provide a funding report that provides information around the source of funding that are utilized to cover our Medicaid expenditures. This can include federal funding, state general fund assessment fees, intergovernmental transfers, and a wide variety of different funding sources. As I mentioned previously, these reports are prepared monthly and are posted on our FSSA dedicated website with a narrative to provide additional comments around the information that is being presented. We’ve been posting these reports for the last four months back to the February of 2024, and we will continue to post these monthly as we move forward. Thank you. Questions Representative Porter thank you Mister chair. In regards to number 32, slide 32, I think our over the last few months, our caucus has been really asking about what was the disconnect in 2023 in December of the forecast that we did not hit the mark in regards to the forecast of this situation, the monthly Medicaid financial reporting is good going forward, but we still particularly, I still want to know what happened, what items were not incorporated in regards to the drastic increase of what happened a few months ago. Yeah. And I think what we’re saying through our monthly financial and this reporting structure is we’re setting up a reporting structure and review process so that we can identify certain trends and risks that we may have not been able to catch in the past. From that standpoint, this gives us data on a monthly basis that we’re able to review, see what trends look like, if we’re seeing certain trends, that we’re able to react to those and bring those to the right people so those discussions can happen, so we can catch things before they get to a certain point. So I think this is why we’re developing these financial reports, so that we did, can address those items. I understand that and I commend you for moving forward with that. But what happened 23rd December 23, what things occurred that precipitated that gap, that disconnected. Yeah. And part of this also as we talk about our Medicaid forecast process and in our next section, kind of address what we’re doing with the Medicaid forecast also from that standpoint, again, because that. Specifically to the Medicaid forecast. And I think that’s directly representative to your question. Like what part of the Medicaid forecast process, you know, that we weren’t able to see or maybe address that ahead of time? Further questions? Yes, go ahead, please. Maybe not so much a question, but just an elaboration on, on Paul’s response. And also, I want to thank the secretary, Cora and Paul for putting in this effort on these monthly reports. It’s a lot of work to put all of this together, and there’s a lot of different influences that affect these monthly reports. As you all know, we prepare monthly revenue reports and add a commentary to that. When you think about the expenditure side, other than k through twelve tuition support, there’s no other expense that impacts the general fund like Medicaid. And unlike k through twelve, it’s a large number, but it’s pretty stable. We know what the rates are going to be. We know what ADM is, what the enrollment is. We have roughly a million to a million .1 kids in k through twelve. This is an issue where I guess maybe I might be leading a little bit to where Paul’s going. In the next section is you have the confluence of the economy, enrollment, utilization, and rates that all come together that impact this and the earlier. You can see the trends, just like we see the trends on the revenue side, where the executive branch and the budget agency can take actions based on where revenue is going. We need to be able to do the same thing here with Medicaid, and that’s what this monthly reporting is trying to do. Thank you, Mister Johnson. Great points back. Earlier, it was mentioned that we have about 2 million total in the program currently. Prior to Covid, how many did we have? I believe it was between like 1.41.5. So in four years, we’re looking at a 30% to 35% increase in utilization. Thank you. Other questions? I get ready for the next section. Please go ahead. All right, we wanted to take just a couple minutes to provide an update on where we are in regards to meeting the requirements under Indiana code 1215 to make data accessible to LSA. Currently, LSA does have access to our system to view our Medicaid data. We have met with LSA multiple times over the summer to ensure that they are getting the data that is needed to generate the fiscal impacts that are prepared to propose legislation to do this. We have done several different things. One, we have appointed a dedicated resource in our data team that LSA can work directly with. We have made sure the LSA is aware of the data they have access to. And then we also to ensure that the Medicaid members phi information is properly protected, we will continue to meet with them on a regular basis or as needed as they wish, to make sure that we can make sure that they’re getting the data that is needed. Thank you. Any questions? Can you please then? Thank you. This section is perhaps maybe responsive in some ways to representative Porter’s question around how did the deviation occur between the April 23 forecast and the December 2023 forecast? So at the time of the December 2023 forecast, we shared that there were a couple, several controls that we were going to immediately put into place to ensure that there was nothing this wide variation to the extent that we could prevent it in future forecasts. So a handful of these items are listed here on this slide. We’ll talk in a little bit greater detail in a few slides about the policies and controls around ensuring that prospective policy changes are well understood before they’re implemented. So policy staff, be it in Medicaid or in a different division that uses Medicaid dollars, making sure that they have a robust understanding of the fiscal and operational impact of things that may change. Such as new types of coverage or telehealth utilization, or we’ll go through some specific examples of that. So the first area is really making sure we understand policy changes on a prospective basis. Paul shared then what we’re doing on sort of a monitoring basis with the Medicaid monthly financials. So then using that prospective policy information to then look back at our month over month expense, expenses and enrollment and funding trends, and seeing if that’s matching what we anticipated it would from both a budget standpoint and the most recent forecast standpoint. Additionally, we talked about reducing the lag in data. The April 2023 forecast was based on January data through January 2023. With the upcoming forecast, we hope to reduce and shorten the time between the most recent experience that is being used in the forecast to what we then are presenting in our December 2023 forecast. If we have as close to possible of real time data, which is challenging because claims are paid in arrears through the Medicaid program, but the more we can shrink that gap in data lag, the more accurate we’re going to be able to forecast what we think expenditures and enrollment utilization looks like going forward, and then finally having processes where we can identify emerging risk. We have a very hard working and intelligent staff throughout FSSA who operates these programs, and making sure that they are working with their fiscal colleagues to share what they think might be happening from a programmatic standpoint as well as other economic factors or what’s happening with healthcare at large. Senator. Thank you, Mister chairman. Cora, this is good data. If something gets out of whack, what can you do? The steering committee? Yeah, I mean, I think part of the structure, Senator, thanks for the question. Part of the structure, and I’ll go over here next, is kind of the structure we built. So as we’re identifying specific things in the financial reporting, what the steps we’re taking, who we’re trying to elevate those two, so then the conversations can be had about, you know, if there’s things that we’re addressing, how can we address them? If there’s anything that we’re able to do at this time, or what those next steps would. What are your options? What would your options be if one of these things we see that is getting out of control? It really depends on what it is, I would say. So there are certain services. This is where we get into a lot of discussion about mandatory versus optional services. So if it’s a mandatory service and the individual is appropriate, and I, we have enrollment where it is. If utilization is really growing. We have limited abilities to really control those costs, except certain utilization tools, prior authorization for certain services, et cetera. So we can make changes like that, really trying to balance access and quality of services with the sustainability of the program and the costs. If these are mandatory services or something that we’re required to provide, we have limited ability to really control that as much as if it is something where that’s within our authority to take action to steer towards a lower cost of care setting or steer towards a lower cost service or control utilization or rates. I take that. To me, we don’t have many options. There are certainly areas where we can exercise different authorities to try to really contain costs. And the three big sort of categories of how cost controls in Medicaid are structured are really what’s the eligibility and enrollment criteria, what is the set of services that are covered, and what sorts of areas do you have control over how those services are utilized and to what number and extent? And then what are you paying for those services or what are the rates? So there’s different tools in each of those categories. Okay, thank you. Further questions. Just thinking here, you talked about utilization and it’s more like 35% to 40% increase in utilization over the past four years. If that had been 15% to 20%. And I’m just running rough numbers. Just really ballpark numbers. We wouldn’t be worried about this today. If we had 15% to 20% growth, we’d handle that fine. It was the 35% to 40% in place of 15% to 20% growth and utilization probably caused this. It’s just kind of off the back, the napkin kind of calculation. Go ahead, please. Chairman Thompson, I think my definite. I should have defined my terminology at the outset. Are you referring to enrollment or the number of individuals? Just total numbers. Right. To go from 1.4 million, 1.5 to 2 million. I mean, that is substantial in four years. And if it just had been half that, I think we can probably make the fair statement that we wouldn’t have this issue today. Thank you, senator. Go ahead, please. Representative, please. Yes, thank you. Just to follow up on that point, I just want to confirm we’re done with the wind down operation. That’s correct. So enrollment, I will say, peaked at around 2.2 million, and we were now through the twelve month unwind period. Further questions? Thank you. Go ahead, please. So, as part of our new Medicaid forecasting process, we did set up a governance structure to define the responsibilities and increase transparency in our Medicaid programs. In this slide here shows a graph of the structure. Starting from the bottom. We have created two new groups, the financial reporting group and the policy Change Review group. Both these groups were formed after the December 2023 forecast. The reporting group was established for the creation of the ongoing Medicaid financial reports and are responsible for the maintenance of these reports, review monthly financial data, and provide feedback on expected or unexpected trends. The policy Change review group was established to ensure all Medicaid policies go through a review process to ensure we have fully looked at the potential impact of these changes. Cora will touch on a little more detail in the next slide on this, particularly the policy change review group. Output from these two teams is routed through a steering committee before final decisions are made. This group will also be responsible for collaborating with the governor’s office, state budget and legislative fiscal staff to gain their input. Thank you. Questions? I believe. Is that everything or is there one more presentation? We have a couple more topics. Go ahead. Okay. Go ahead. Yeah, sure. The policy change review process. We’ll just go over this very briefly. This is that prospective programmatic policy review group that we talked about. So as new legislation is passed that requires Medicaid coverage for an item, or if someone externally submits a policy consideration request for a new service to be covered or for a new provider type to offer a service, it goes through this policy change review process so that we ensure we have an understanding of the fiscal and utilization impact and can incorporate that into the forecast as necessary. So currently, we are in the process of developing our updated December 2024 Medicaid forecast through a new, improved process, with the main objectives being a more detailed review of the assumptions and trends in the forecast, reduce the lag time in data and identify merging risk. One of the main areas we are changing is the process is the thorough review of the assumptions that are being built into the forecast. A thorough review is currently underway by our program fiscal staff and our actuarial vendor are on the underlying assumptions to be built into our forecast, along with any new federal requirements and approved legislative changes that will inform future forecasts. Our once initial assumptions are reviewed and completed by our program staff, these will be validated by the two workgroups that I discussed earlier, the reporting workgroup and the policy Change Review group. This feedback from these groups will be utilized by the actuarial vendor when creating our updated forecast amount. Since we are starting this process much earlier than normal in our normal process, we will also be refreshing our data before the forecast is finalized, which allows us to utilize the most current. Current data available. Thank you. Questions? Can you please the next agenda item we were asked to discuss is an update on the cost containment strategies. Again, at the time of the December 2023 forecast, the agency committed to implementing a series of cost containment solutions to mitigate the impact of the unexpected forecasted increase need, particularly in the state appropriation, and to try to address future cost growth at the current rate. For each of the strategies, FSSA evaluated all aspects of the proposed solutions from impact to members and providers, the feasibility to operate or to implement operationally, and the potential fiscal impact. Again, we targeted this to the areas of the unanticipated increase and wanted to work towards improved compliance with the federal waivers. The majority of our cost containment strategies are completed or have already been implemented and are ongoing. Our final topic today will be an update around the transition for paid caregiving for legally responsible individuals and the move from attendant care to structured family caregiving. We also took steps to improve enforcement of our waiver service thresholds and to ensure that the way that waiver services were being utilized was in compliance with those federal definitions and met the limits outlined in the waiver. We also adjusted the continuity of care requirements under our pathways transition to allow existing service plans for pathways members to be changed if there was utilization that did not meet the individual’s level of need. We ended retroactive compliance, or, I’m sorry, retroactive coverage of waiver services when Medicaid eligibility was still pending. That was to also ensure compliance with federal law. We’ve discussed here today the work that we undertook around maintaining the current level of slots and then increasing the slots to 55,000 for this year. In for the pathways in health and wellness waivers combined and implementing the waitlists, we paused the 2% Medicaid rate indexing that was planned for this biennium under the Medicaid rate matrix, and our final item that we will implement on July 1, 2025 is a new pediatric eligibility tool for the waiver level of care assessment. Acknowledging that pediatric waiver members have different assessments needed to see what sorts of assistance they need with those activities of daily living. We’ve discussed again. We’ll share more on LRI next. Thank you. Questions? Can you please. I’m sorry. Okay. Okay. Go ahead, please then. Thank you. Our final topic is with regard to the transition from attendant care to structured family caregiving for our paid family caregivers. As of July 1, FSSA, in partnership with care managers at the area agencies on aging and the independent case managers companies have transitioned individuals who were providing paid caregiving through the waiver from a legally responsible individual, which is defined as a parent of a minor child or a spouse. So this was one of the strategies that was announced in January. In March, we began the collection of data from the care managers about the individuals who would need to be making this transition, with a specific focus on the pediatric population. We began family newsletters and webinars to ensure that families were supported and understood what the transition may mean for them, and we conducted service plan updates with families, again in collaboration with their care managers. By June, we had finalized the service plans for those who had a legally responsible individual providing attendant care. As of June 15 and on July 1, the transition was completed. Although we are continuing family engagement and stakeholder discussions, the reason for this particular cost containment strategy I spoke of the growth of the expenditures on the a and d waiver as a whole. Expenditures for attendant care on that waiver totaled $1.4 billion. Last state this, I’m sorry, last state fiscal year. State fiscal year 24, which had tripled since state fiscal year 23, when that expenditure amount was 557 million. The impact, as I mentioned, was driven primarily by increases in utilization, particularly for members who were receiving 60 or more hours of attendant care per week. As a reminder, the state reimburses Medicaid providers who employ the caregivers and pay a per diem or hourly rate. This final. Slide shows for the pediatric population, the output of the transition. You can see that 70% of individuals who were receiving attendant care from a legally responsible individual moved to the service of structured family caregiving. That’s the blue color on the first pie chart. We further break out the different tiers of the structured family caregiving. There are three separate tiers based on need that have increasing rates as you move up from tier one to tier two to tier three. And you can see that 90% of the pediatric LRI transition population who chose structured family caregiving moved into structured family caregiving. Tier 322 percent of the pediatric population that had previously received LRI provided attendant care, selected a non legally responsible individual as their attendant care giver and remained in the service of attendant care. 5% of those individuals moved to a service such as home health aid, provided service, or another type of service. And then a small category fell into other, which were primarily individuals who moved out of state or were no longer on the waiver. With that, I’m happy to answer any questions. Thank you, Representative Porter. Thank you, mister Chairman. Cora, you mentioned $1.4 billion. What was that again? That’s. Thank you, Representative Porter. That’s the attendant care number for state fiscal year 24. Is that all state dollars or state and federal dollars? That state and federal dollars, it would be a two third, one third match. So that would be how much from the state? 40 million. You can do the math. I can’t do it. 400 and change. 400,000. 400 million. 400 million some change, yeah. Okay. Yes. All right. So 400 million some change versus 1.4 billion. Okay, so we dissect. When you look at the disaggregate those dollars, there’s a lot of fellow dollars going in. I just wanted to make that clarification, mister chairman. Also, you’re moving from the tender care, the structured care. What has been the impact on those families and the quality of life for those said families out there, for Hoosier families, that you looking at this cost containment scenario, have you heard from those, from those, our residents to talk about their life and their lifestyle changes or what they have to do if they are still in the home taking care of the children or whomever? Or do they have to now go seek other ways to make ends meet because they don’t want to put them in a facility or anything like that? And I understand that from that perspective, personally putting someone loved one in the facility and their quality of life and their life expectancy does depreciate what’s going to some of those facilities. Thank you for that question. I hesitate to make a blanket statement. We do have a family stakeholder group that is continuing to meet with our division of Disability Rehabilitative Services leadership as well as FSSA leadership to hear from the families about how the transition is going. And so I think we are continuing to take that input and make sure that there are robust supports for those families who had to participate in the transition. Yeah. And I do remember that conversation happening at the end. Thank you, mister chairman. End of session. I think there was ten or twelve requests, and of that, with that stakeholder group, maybe three or four were addressed at that point. I don’t know where they are right now, but I’m very concerned in regards to those individuals that make those requests. And even though they’re, they’re at the table doesn’t mean necessarily they are being heard and the outcomes are coming in concert with each group. I still think that they may be somewhat been looked over as part of this cost containment situation. Appreciate that feedback, and I think that’s just an area we’re committed to continuing to hear from those individuals and their families and make sure that they have a voice in the discussion. And I know that our Bureau of Disability Services team, our beads team, is very passionate about making sure we’re supporting these individuals to the best of our ability. Further questions? Yes, senator. So do you have a way to track those individuals that are in long term care that transfer their assets and shield their assets to become eligible for decade? I. Not that I’m aware of. I would probably want to confirm that with my eligibility team though, before I said absolutely not. Okay. Further questions. Senator? Thank you, Mister Chairman Cora, this has been fantastic information and I particularly like the fact that you’re going to be gathering or paying attention to data to help drive decisions in the future. But most of what we’ve talked about seems to be pretty reactive to what has already happened. And you may be all tied up, understandably, in getting the reactive stuff taken care of. But as we move forward, are you beginning to look at how we, what are the things that we can do? Should do? And maybe the question goes to us along with you about what we do in the future to, to avoid. Not only avoid, but kind of take a leadership role in moving forward. I don’t know if I made sense with that question. I know what I want to ask, but I don’t think it came out right. Thank you, Senator Charbonneau. I think I understand where you’re going. I think this is one of the things that we are most looking forward to with the improved forecasting processes that Paul spoke of, because it’s really going to give us a picture of what we think state fiscal year 26 27 beyond is going to look like to help inform the policy decisions of what we will be able to do from more strategic standpoint with the Medicaid program as a whole. I think also the input from other states is especially helpful because the challenges that we are experiencing are not unique to Indiana. As the federal match that was an enhanced FMAP during the COVID period and for that year beyond goes back to, has gone back now to its normal rate. A lot of states are discussing how do we ensure sustainability for our program. So I think we can really leverage partners in other Medicaid agencies across the country to help inform that as well. Thank you Senator Sakoski. Thank you Mister chair. Corey. So I would imagine in tracking certain things, we do have the availability now for those that are going through the transition that were providing the legally responsible individuals to go into the structured family care. I mean the main thing is so if they need structured family care, we need to determine for those that really have the greatest critical needs. Do we know the numbers that are out there that are being provided with home family assistance right now and that we could look to transition to them in the same setting where it could be a structured family caregiving, where they are professionals? I mean, the whole thing is that those caring for their loved ones should. I think that pertain a little bit to representative Porter’s question earlier. We should not disrupt their quality of life when they really don’t have quality of life to begin with, but their loved ones are able to still oversee to the extent that it, now that’s professionals. I mean, can we track how many individuals are out there? We should be able to have those numbers, shouldn’t we? Within the. Thanks, Senator Nyskotsky. Within the Medicaid program, we certainly have the claims data to show how many individuals are receiving structured family caregiving, how many individuals are receiving attendant care in their homes and then the other supports, the other Medicaid services, be it waiver services or Medicaid state plan services such as home health, that that individual is receiving. I’m not sure if I entirely answered your question, maybe a little bit. It’s just trying to determine on, if we find out that we are, let’s say it becomes where we’re grossly underestimating the care that we are going to provide to some of those that had a different form of care, that we’re being able to address those needs. I just want to make sure. That we have a way to help those families in a similar manner that they had been providing for their loved one. Thank you for that. The transition from attendant care to structured family caregiving provides an avenue for them to continue providing that care. The real change is the hourly reimbursement to the provider under attendant care versus the per diem structure for structured family caregiving. And I think I understand that too. So then it does come down to those that maybe, maybe should have been able to go straight from when they should have been going on Medicaid and now being filled within a gap that it was nothing wrong that they did. So we need to be able to look at that and if there’s a method to prioritize some of them, that sort certainly would make sense. Thank you for that. Thank you. Further question, everything. Porter. Thank you, mister Chairman, just to, thank you, Senator Ngoski, for your comments. And Miss Corr, also because it’s about economics from this perspective of going from one to another, from tender care to structure care is a harsh impact, economic impact on those families. The least of these from my perspective, and equality of life. I have a one pager of testimony or information that I would like to pass out to the committee of those parents and families that have been part of the attended care and now have moved to structured care and the impact that has caused the stress and profound negative impact on those said families. And I just want to put that on the record for us to understand, because unless you live it, you don’t understand it. And we think we’re inoculated against it and we’re really not as a state. So with that, Mister chairman, I appreciate you allowing me to pass this information out as a way of giving more information which is pertinent to this new model that’s been implemented by FSSA. Thank you. Further questions? Seeing none. Thank you. Thank you very much. I know we do have a hard stop, and I know at least in ways moons have a practice of no more than three minutes of testimony. I know we have one person signed up I would welcome, but I would like to limit to three minutes because we do have a hard stop because we have another meeting afternoon. And the person that has signed up is Kendra Duff, if she wants to speak. You’re welcome to thank for up to three minutes. Thank you. So I actually am the person that gathered this information yesterday from our families. I’m a parent myself. I have two medically complex microphone. Thank you. I’m a parent myself. I actually have two medically complex kiddos myself. So I am directly impacted from this change, from going to attendant care to structured family care. This just kind of gives you some. A little bit of information on what the families are struggling with, both financially, both medically. It’s not. It’s deeper. Like, we talk about pathways, and that’s all I’ve heard is pathways and pathways and pathways. We haven’t talked about our medically complex pediatric children and the health and wellness waiver. The focus seems to be on the pathways. So I ask that as we’re looking at this, to don’t forget about those 59 and under and the impact that this is having on that, not the individuals and the families. A lot of these families are struggling to get the care that these kiddos need to get them to appointments, to get them to therapies, just because they don’t have that financial means to be able to do that anymore. The challenge lies on even if you have nursing, there was somebody else that was supposed to be here today, but her nurse had Covid, so she’s now staying home to care for her child. There’s so many unknowns and unexpecteds that we don’t know as families ourselves, let alone everybody out there who may not have a complex child. So as we’re talking about this, don’t forget about our pediatric, very medically complex families. We don’t know. There’s already been many of our children who have passed away since we began this fight in January, Christina was down at the state house in. February, right before her child’s birthday, third birthday, fourth birthday, she passed away. Hawk flune did a video with his mom about the impact that this has had on our families. He has since passed away. So time is of the essence. So as we’re talking about this, many of our families, many of our children don’t have that time. So if we can just remember that and think about that, and there’s nobody better to be with our children during those curricula moments than the families themselves. And to be able to do that in a stress free set of mind where their focus can be on their children, not how they’re going to pay groceries, not how they’re going to get to the doctor’s appointments. Thank you. Any questions for the lady? Thank you for your words. Anyone else? I do ask, if you do testify, we’d have you sign up after you testify. You can go ahead. And if anybody would like to also speak, I would welcome that. Anything else from members of committee? Any other comments? Senator Scotsky? Yes, thanks, mister. Just a comment. So we are forming, we’re listening, we’re providing all these new means. So I guess this committee is tasked with oversight, oversight, transparency, how to determine or where these things will not occur. Again, with all the essence of speed. I’m just curious, what is the thoughts? How often will this committee be meeting? Because with the new implementation of everything we’re doing right here, we want to make sure that that is going to go forward and it will become efficient as possible, as quickly as possible. I would like to answer, but actually Doctor Barrett is the chairman, of him being the chair, I hate to comment for him. And so I guess he’ll set that, I would assume sometime later in the fall, but I’m not sure on that. Yeah, so I just wanted to put it on the record, just so I know our responsibility here is of the highest order. Thank you. Thank you. Any other comments or questions? Again, thank you for the presentation. Thank you for the public being here. And with that, we stand adjourned. 

• Cora Steinmatz – Director of the Office of Medicaid Policy and Planning
• Jason Barrett – Legislative Services Agency
• Senator Travis Holdman – Senate District 19, Northeast Indiana
• Senator Ed Carboneau – Senate District 5, Northwest Indiana
• Chris de Ricci – Senate Majority Fiscal Analyst
• Jeff Thompson – House District 28
• Ben Tooley – House Republican Fiscal Analyst
• Representative Slager – House Portions of Lake County
• Greg Porter – House District 96, Indianapolis
• Eric Gonzalez – House Democrat Fiscal Analyst
• Hope Tribbles – Senate Democrat Fiscal Analyst
• David Nysgotsky – State Senate District 10, South Bend
• Chris Johnston – Office of Management and Budget
• Paul Bolling – Chief Financial Officer, FSSA