Medicaid meeting considers progress, concerns about various programs

A handful of lawmakers on Wednesday questioned the state's administration of Medicaid plans that will undergo a transformational change this summer, with topics ranging from a program waitlist, elder care and services for families with disabled children.

The Family and Social Services Administration (FSSA), which oversees Medicaid, hosted a meeting highlighting the near-completion of the Medicaid unwinding process along with the switch to managed care for aging beneficiaries – moves impacting hundreds of thousands of Hoosiers.

The unwinding process encompasses the way in which the state redetermined Medicaid eligibility for 2.2 million enrollees after federal protections protecting members expired in early 2023. The yearlong review culled at least 241,000 Hoosiers from the rolls.

And while Sen. Shelli Yoder had high praise for the state's handling of the unwinding of COVID-19 Medicaid protections, she had sharper criticism for other actions.

"We can see the amount of effort that it has taken to get it right in the unwinding but we do not take that same care with our families and people with long-term disabilities in Indiana when we made the decision to change the (Aged and Disabled) waiver," said the Bloomington Democrat. "So many families … they don't know what's going on. They haven't had clear communication. And I think it's just strictly because you're moving too fast."

FSSA changes to attendant care under the Aged and Disabled (A&D) waiver curbed state payments to parents with severely disabled children, who were getting paid a living wage to provide unskilled care at home. However, after program costs ballooned, the agency abruptly halted the program earlier this year and families will transition to a lower-paying system in the coming weeks – pending an ongoing lawsuit.

Yoder, along with Indianapolis Democrat Sen. Fady Qaddoura, West Lafayette Democrat Rep. Chris Campbell and New Albany Republican Rep. Ed Clere, pointedly asked the state agency to account for several perceived shortcomings.

Medicaid Director Cora Steinmetz juggled several concerns from the lawmakers, all of whom are members of the Medicaid Advisory Committee.

The April implementation of a waitlist for certain services for aged and disabled Hoosiers caused concern for Qaddoura, the state senator from Indianapolis. The state maintains just over 50,500 waiver slots and anticipates expanding to 55,000 in the 2025 fiscal year, which starts on July 1.

"No one was receiving services on the A&D waiver and then added to a waitlist. The waitlist is for new entrants," Steinmetz said, noting that several eligibility factors determined one's waitlist placement. "… we will be transparent as we move forward with that … once we have some clarity around the number of individuals."

Steinmetz didn't give Qaddoura, who is a former FSSA employee, a firm figure on the number of people on the waitlist, citing the complicating eligibility factors.

Qaddoura shared the story of a constituent who "spent down" their assets in order to qualify for Medicaid, which covers long-term services like nursing homes and home health aids while Medicare does not. Medicaid is a government health coverage program for the poor while Medicare is designed to serve the elderly – though many senior Hoosiers rely on both programs to meet their health care needs.

Even after spending their assets, this person was placed on the waitlist even though they don't have the financial footing to pay for long-term care themselves, Qaddoura said.

"These individuals are now being put in a very difficult position," he said, describing someone trying to plan for their long-term health care needs. "There are real life implications for citizens and providers."

On top of the waitlist concerns, the state is transitioning its current long-term supports and services offerings to managed care, meaning it'll pay Managed Care Entities (MCEs) a flat rate to cover member health benefits rather than individually paying for claims.

Steinmetz and others insist the PathWays for Aging program will roll out on July 1, as planned, after contracting with some individual Area Agencies on Aging (AAAs) as service coordinators.

AAAs protested the agency-suggested rate for service coordination, which at $112 was 41 percent lower than current rates for different but overlapping duties, but MCEs stuck by the proposal.

Roughly half of the state's 16 AAAs, longtime senior care organizations that perform case management for FSSA, opted to negotiate with the MCEs, which includes insurance giants like Anthem Blue Cross and Blue Shield, Humana Health Horizons in Indiana and United Healthcare Community Plan.

Clere, an advocate for AAAs who has repeatedly expressed his concerns about MCEs, said he didn't see how the system could be ready for a July launch with so few AAAs serving as service coordinators – a vital component of the managed care rollout.

Steinmetz and others seemed to be more confident.

"Although the contractual negotiations are still ongoing … we've made it clear that since the (joint AAA negotiating organization) opted not to participate in the network, that … (MCEs) must make a good faith effort to contract individually with as many AAAs as possible," she said, noting that MCEs could also employ some internal service coordinators. "… we are monitoring very, very closely their staff levels, their hiring levels for service coordinators."

Clere also said he'd heard that Anthem, in particular, was requiring AAAs sign expansive non-disclosure agreements (NDAs) – something he felt shouldn't be allowed.

"It flies in the face of transparency," Clere said. "If an NDA is allowed, it will leave the AAA that agrees to an NDA isolated and helpless and unable to talk with peers or stakeholders about their experience or problems."

FSSA leaders indicated that NDAs might be to protect "proprietary information," to which Clere said NDAs would then need to be narrowed.

"A broad NDA only benefits the MCE at the expense of – not only the AAA, but consumers the AAA is serving," Clere concluded.

In response to questions from Rep. Campbell, Steinmetz reassured committee members that any NDA would not impact the state's claims processing review and auditing.

"That's Medicaid data and that is our data," Steinmetz said, acknowledging that Wednesday's meeting was the first time she'd heard about potential NDAs. "We're going to take that back and do some more investigation and talk with our Anthem colleagues to get a better understanding of that."