Committee provides updates on Medicaid programs for aging, maternal health

An estimated 130,000 Hoosiers over the age of 60 using Medicaid will receive notices in early 2024 advising them to choose a Managed Care Entity (MCE) to coordinate their health coverage under the state's Pathways for Aging program.

The program is set to go live by July. With a potential $15 billion worth of contracts, the Family and Social Services Administration (FSSA) wants to do everything it can to ease the transition to managed care from fee-for-service for Hoosiers utilizing long-term supports and services, like home health aides or nursing homes.

But not everyone is convinced it's the right move and some wonder what the cost will be for the mishmash of smaller entities currently providing services for older Hoosiers, as demonstrated in a Wednesday Medicaid Advisory Committee.

"I hope (managed care) will be successful; I want it to be successful," said Rep. Ed Clere, R-New Albany. "I am willing to do anything that I can do to help make it successful but I'm afraid it's going to be a train wreck."

Proponents for managed care emphasize cost savings and funding nursing home alternatives such as home- and community-based services. Additionally, they say MCEs can better coordinate the benefits and coverage differences between Medicare and Medicaid. Estimates predict more than 80% of enrollees will qualify for both programs but the programs vary in their coverage areas.

For example, Medicare, despite covering elderly and disabled populations, doesn't pay for extended long-term care services but income-dependent Medicaid does.

"… Today, we don't have that kind of coordination and it's very fragmented and often operates in silos," said Holly Piggot-Cunningham, the director of care programs with FSSA's Office of Medicaid Policy and Planning.

A new program for aging Medicaid recipients

Every other Medicaid program offered by the state falls under the managed care model, which pays a flat, up-front fee per enrollee rather than piecemeal payments per service provided.

Beneficiaries currently receiving long-term care in a nursing home or in their community will need to choose between Anthem Blue Cross and Blue Shield, Humana Healthy Horizons and United Healthcare Community Plan by April 2024.

State officials hope the pivot away from fee-for-service care will incentivize the growth of home- and community-based services, which the majority of elderly Hoosiers reportedly desire over institutional care. Indiana spends 23% of its Medicaid funding for such services, compared to the national average of 53%.

"We don't want to eliminate (the option) if someone wants to be in a nursing facility … but we want to make sure that people who want to age in place or want to age in the community or in their home or with their children or their adult children have that opportunity," Piggot-Cunningham said.

Still, legislators on the committee had concerns about the rollout of managed care and how it would be shared with an estimated 130,000 members, many of whom have hearing or vision impairments and need assistance to complete sign-ups.

FSSA acknowledged that, in addition to broadcast advertisements and letters, it would rely heavily on Area Agencies on Aging (AAAs).

But those same programs will potentially take a toll when MCEs oversee the program, which will take over the case management responsibilities AAAs currently have.

Clere said he appreciated the work of FSSA to implement the program but heard from AAAs — the entities FSSA said it had coordinated the rollout with — about the disadvantages.

"I remain very concerned about the disparity between what I'm hearing from the AAAs and what I'm hearing in this meeting and other meetings. I think this has been driven too much by the MCEs," Clere said, adding that "political pressure" may be influencing the historic launch in Gov. Eric Holcomb's final year in office.

"Right now, my AAA is working on Angel Tree boxes for seniors. I'm afraid we're going to lose things like that because the MCEs are not going to do Angel Tree boxes in southern Indiana and the AAAs at some point, a couple of years out, may no longer have the revenue from case management to subsidize those other functions," Clere said.

Updates on maternal mortality initiatives

Also on the agenda were updates on several maternal health initiatives funded by legislation coupled with the state's passage of a near-total abortion ban, shared by Maria Finnell, the agency's chief medical officer and a pediatrician by training

Under the Hoosier Families First Fund, a total of $4.5 million has been distributed to organizations in 36 counties with monies geared toward: increasing vitamin K awareness, increasing doula services, supporting mobile outreach units and expanding home visiting programs.

One key investment would implement Medicaid payments to doulas, a role that provides physical and emotional support to a mother through pregnancy and childbirth, but is only covered in a handful of states.

"They are not necessarily community health workers but nor does the model we have set up as far as reimbursement work for their workforce," Finnell said. "… there's a draft plan that's coming together that we have yet to discuss and receive but the hope is that when there is a doula reimbursement advisory board in place, that there's some recommendations that can be put in front of them."

FSSA is also looking at whether there's a way to bill Medicaid for home visiting services under programs like My Healthy Baby, which provides personalized guidance to mothers and aims to reduce the state's high infant and maternal mortality rates.

Indiana has one of the highest rates of maternal mortality in a nation with one of the highest maternal death rates for wealthy countries worldwide.

One factor contributing to Indiana's rate is the high number of mothers with substance and opioid use disorders, something the Pregnancy Promise Program hopes to tackle.

Treating pregnant mothers for SUD, OUD

The 2022 report from the Maternal Mortality Review Committee found that 92 women died postpartum in 2019, roughly one-third of whom died from an overdose. The Indiana Department of Health hasn't indicated when the 2023 report will be published, despite inquiries from the Indiana Capital Chronicle.

Pregnant women or those Hoosiers who have had a baby within the last three months and qualify for Medicaid coverage are eligible for the program, which has 675 enrollees in 86 counties — the highest number of enrollees for the pilot program nationwide.

Finnell noted some shortcomings for the program, such as racial disparities between women diagnosed with opioid use disorder and acceptance rates.

"This program really has an incredible retention percentage. Ninety-four% of the mothers that participate are staying in the program," Finnell said. "Ninety-two% of infants are discharged home with their mother following birth and not into foster care or something along those lines."

Additionally, 82-85% of children are born at a healthy weight and spend fewer days in observation postpartum, often a necessity for children born with neonatal abstinence syndrome related to their mother's drug use.

"We're looking right now… trying to figure out why," Finnell said about the optimistic report. "You volunteer to do the program so it's obviously probably some selection (bias) … right now we're trying to do a comparison with similar women not in the program.

"But yes, I agree … we are thrilled about this number and what is happening in the program," Finnell continued.

Finnell said some of the success came from not only addressing a mother's medical needs but also looking at social and housing needs. Additionally, within one to three days postpartum someone connects with the mother to discuss available treatment and mental health services.