Senior care organization group pulls out of managed care, leaving future uncertain

Negotiations between a group representing senior care organizations and the insurers tasked with overseeing the state's summer transition of long-term care services collapsed earlier this month after the two sides couldn't come to an agreement — but the impact is still unclear for older Hoosiers.

The state insists it's on track to launch its Medicaid managed care program for Hoosiers over the age of 60 by July 1, but others aren't so certain following the end of talks between the two parties.

"I'm deeply concerned that this program is not ready for implementation as we get closer to the July 1st start date," Rep. Greg Porter said in a recent release, calling for more state action to support senior care organizations.

The Community Care Hub of Indiana was a partnership between the state's sixteen Area Agencies on Aging (AAAs), the decades-old local organizations tasked with easing Hoosier burdens as they age by connecting them with resources such as home health aides or transportation.

As one entity, Community Care Hub conferred with the three Managed Care Entities (MCEs) contracted by the state to launch Indiana's PathWays for Aging, a managed care Medicaid program that will impact every senior Hoosier who depends on Medicaid for services.

But according to Tauhric Brown, Community Care Hub and the MCEs couldn't come to a consensus after technology woes and state intervention on a rate recommendation.

"The rate is so low that we're just not able to make that make sense," Brown said. "… I do not believe that any of the AAAs will be able to enter into a contract with the MCEs at that."

Brown is one of Community Care Hub's leaders and the CEO of central Indiana's CICOA Aging & IN-Home Solutions, the latter of which covers just over one-quarter of the state's population.

The Family and Social Services Administration, or FSSA, previously said it recommended the rate of $112 – a 41 percent cut from the $189.54 rate AAAs get now for different but overlapping duties – to "facilitate swift negotiations" with the three behemoth insurers selected as managed care entities.

But the senior care organizations insist they can't make the rate work and warned it would jeopardize their futures – saying it would hurt the seniors with whom they've cultivated relationships for years.

"… if AAAs are not involved, that linkage, that continuity between a member and a case manager – that has existed in many instances for decades – is broken. And the person that gets hurt in that scenario is the member," Brown said.

How did we get here?

Most of Indiana's Medicaid programs are considered to be managed care, meaning the state pays a predictable, flat rate for an outside entity to coordinate care and services with one major exception: long-term supports and services for aged or disabled Hoosiers.

Currently this program is fee for service, meaning the state gets charged piecemeal for every service a senior Hoosier might need.

AAAs are designed to be the first call for a senior Hoosier looking for some extra assistance, whether it's getting meals, socializing or finding a home health aide.

The senior care organizations primarily provide case management for Hoosiers on the Aged & Disabled Waiver, but the managed care companies are using AAAs for service coordination, creating a personalized plan to coordinate home- and community-based services.

The duties are similar but different enough for FSSA to suggest the $112 rate, rather than the $189.54 it offers for case management. That lower rate jumps up to $128 if performance measures are met.

FSSA said the Aged and Disabled waiver Care Management rate assumed a caseload of one care manager to 44 clients while the PathWays Service Coordination under managed care had a ratio of one manager to 65 clients.

Brown said CICOA currently had a ratio of one manager to 65 clients.

But the rate was just one motivation for pulling out, Brown said, in addition to the technological challenge of creating a statewide portal for all AAAs and MCEs. It was Brown's understanding that one MCE wouldn't transition and thus it failed a state readiness review, meaning that there's no way to easily transfer a case between AAAs.

Instead, each AAA will have its own access point to three different MCEs – if they even choose to contract with one another.

"With (16) different organizations doing the same process, there's going to be variance. And so if you have a tool that allows you to minimize that variance and have a very coordinated approach, that's a home run," Brown said. "Without the tool being prevalent … you can't be successful from the AAA side because there's nothing monitoring and ensuring that referrals are received (and acted on)."

FSSA didn't confirm why the tool, called Implify, failed its readiness review.

Last week during a stakeholder call the state acknowledged that MCEs each had their own portals but said they were "working with the MCEs to develop a better unified process."

Recent public comments from FSSA

In a Thursday call with over 1,500 stakeholders, FSSA emphasized that "all benefits will remain the same" for participating Hoosiers.

"There will not be any decrease of benefits in the transition of going to PathWays. If anything, you'll get added benefits …" said Kimberly Bremer, the state's director for Hoosier Care Connect and PathWays.

Dually eligible Hoosiers, or those on both Medicare and Medicaid, would potentially benefit from having one managed care entity overseeing all of their services, for example.

The transition and impact on AAAs has attracted bipartisan criticism from sitting lawmakers, most recently from Porter. In an April 17 release, Porter praised AAAs and called on FSSA to allocate more funding for the senior care organizations.

"Rarely is the shift from localized to one-size-fits-all care good for the everyday person. I have great concerns that this will prove the same here," Porter said. "Our state's 16 AAAs would be paid less to work more while big insurance companies come in and make a profit."

Two days later, Porter questioned Indiana Medicaid Director Cora Steinmetz about AAAs, managed care and attendant care during a State Budget Committee.

"I've had conversations with AAAs and there are no details … I know we're working on it, we're progressing on it. But July 1st is going to be here quicker than we anticipate and I'm just highly alarmed by what is going to happen," Porter said.

Steinmetz responded to Porter's questioning, which included several concerns about attendant care, by pointing to FSSA resources online and directing families to their care managers. As for managed care, she said plan selection is currently underway and encouraged senior Hoosiers to call their enrollment brokers.

"The state is working really closely with our managed care partners … to determine what level of interest that the AAAs and independent care management companies will have in the service coordination to ensure that we have really strong programmatic protections in place for our members on July 1 and beyond," Steinmetz said in a response to another AAA question.

Porter concluded after questioning that he felt "like the vendors don't know what they need to know. I just have very little confidence – zero confidence – at this point that it's moving forward."

What's next?

Both Brown and FSSA noted that MCEs can contract directly with individual AAAs for service coordination. The state noted MCEs could also contract with the senior care organizations to provide something other than service coordination.

"(The Office of Medicaid Policy and Planning) is working closely with the MCEs to ensure they are prepared for care and service coordination. MCEs are actively in discussions with interested AAAs and care management entities. FSSA will continue to monitor all contractual requirements leading up to go-live," FSSA said in a statement.

FSSA wouldn't confirm the state's timeline for the insurers to secure service coordinators, nor would it comment on the process should one-on-one contracts fail as well.

MCEs are required by FSSA to contract with AAAs for 50 percent of their service coordination. Brown said he believed the MCEs would be required to apply for a state waiver on that requirement if they don't reach 50 percent but FSSA wouldn't confirm.

For CICOA, Brown said the central Indiana AAA would still operate the same for any clients under the age of 60, the cutoff age for PathWays, as well as the CHOICE program, which provides some services to those who aren't qualified for the Medicaid waiver.

"If we decide not to enter into that space, it is going to be a hit financially for us. But the business and need – the mission – will still have to continue because of all the lives, all the older adults that depend on organizations like ours," Brown said. "I'm a little more optimistic than some of my peers … we have to pivot and we have to think about our businesses differently. And understand that this is survival mode.

"None of us like it, but it is what it is."