Medicaid advisory panel weighs in on HIP lawsuit, PathWays transition

Legislators on the state’s Medicaid Advisory Committee spent hours Wednesday questioning state officials about Indiana’s ongoing lawsuit over provisions of the Healthy Indiana Plan as well as progress reports on the state’s transition to managed care, otherwise known as PathWays.

Of the lawmakers who spoke up during the meeting, all urged the Family and Social Services Administration, or FSSA, to drop POWER Account contributions under the Healthy Indiana Plan in favor of reducing barriers to coverage. (Power stands for Personal Wellness and Responsibility.)

“POWER Accounts are barriers to care and the General Assembly—first and foremost—intended to expand health coverage to those that are eligible,” said Bloomington Sen. Shelli Yoder, a Democrat. “It is my hope that we do away with those barriers and provide the coverage that is available to Hoosiers.”

Others who spoke in favor of striking the premiums include New Albany Rep. Ed Clere, a Republican, as well as Democrats Sen. Fady Qaddoura, of Indianapolis, and Rep. Chris Campbell, of West Lafayette.

Additionally, many shared stories from constituents, including providers, experiencing difficulties under the PathWays transition.

“Please understand that we are under immense pressure (from) our constituents to find answers and responses to real life cases,” Qaddoura said. “The data that you presented on that presentation might not fully articulate the human need of these individuals who are living under extreme anxiety.”

HIP lawsuit update

A 2019 lawsuit seeking to curb the state’s use of POWER Account contributions under HIP was revived after the state sought to reinstate the premium-like charges for moderate-income Hoosiers using the insurance program this year after a pandemic pause. However, a federal judge ruled the overseeing agency erred in allowing Indiana to require such contributions in June.

Employees with FSSA presented an annual report on HIP Wednesday with the assumption that their appeal would prevail. On Tuesday, parties in the lawsuit agreed to a limited stay but FSSA will still seek an appeal and full stay.

Indiana Medicaid Director Cora Steinmetz said she was limited in what she could say due to the ongoing lawsuit, but spoke broadly about HIP oversight and the litigation.

If the state lost its appeal, “We certainly will have to cross that if and when that happens. And are definitely preparing for eventualities, but are doing our best to maintain the status quo for the program.”

The initial lawsuit included other aspects of HIP, such as prohibitions on non-emergency medical transportation and a lack of retroactive coverage. The partial stay from Tuesday allows FSSA to continue with those provisions but blocks the state from requiring POWER Accounts.

The state appeal of the June decision says that Indiana law required FSSA to charge the contributions. Hoosiers who couldn’t pay the contributions, it said, would be reassigned to HIP Basic, a lower level plan that doesn’t include vision or dental coverage — among other benefits.

But Rep. Ed Clere, of New Albany, said the 2016 law requiring such contributions also gave the agency secretary the ability to change HIP if it is “required by federal law or regulation.”

“I just think it’s unfortunate—to say the least—to take away those benefits from hundreds of thousands of Hoosiers because of one interpretation of statute when there certainly is the reasonable opportunity to interpret it differently,” said Clere, a Republican. “No one has made a power account contribution in more than four years, and the sky hasn’t fallen, right?”

Bloomington Sen. Shelli Yoder, a Democrat, observed that none of the state’s general fund goes toward HIP expenses—rather, the federal government covers 90% of costs and the remaining 10% is paid for with tobacco taxes and hospital assessment fees.

Charging the contributions appears to cost the state more as an administrative burden than it reaped from the charges, which vary from as little as $1 to $20 per month, said Sen. Fady Qaddoura, an Indianapolis Democrat.

“… I have not seen studies of any significant correlation with improved health with the few dollars that (HIP enrollees) pay,” Qaddoura added.

Tracey Hutchings-Goetz, an advocate with Hoosier Action, said the “churn” created by Medicaid members losing coverage due to non-payment of POWER Account contributions added an additional $400 to $600 cost per member when the state had to re-enroll those beneficiaries.

“HIP is an essential part of Indiana’s health and economic infrastructure, just like our roads and our bridges. HIP ensures Hoosiers can go to work, young people can pursue their dreams and go to school, and parents can take care of their families,” Hutchings-Goetz told the committee.

Hoosier Action is one of several organizations that urged FSSA to do away with the charges and also allow Medicaid members to access the HIP Plus coverage regardless of payment in a letter earlier this month.

PathWays transition progress

On PathWays, Holly Cunningham Piggot—the director of care programs overseeing the transition—detailed the ways the state will continue to monitor managed care entities following the July 1 launch date.

“Now that we’re in the real, live environment, we need to see that those things are really working,” Cunningham Piggot said.

Such efforts include “secret shopper” calls to see how calls are addressed and onsite audits as well as weekly and monthly regulatory reports.

For the first 45+ days since launching, the most common call reasons were members seeking care and service coordination contact information followed by requests for medical supplies, transportation and/or meals. Home health care prior authorization requests and pharmacy inquiries also appeared on the top call reasons list shared Wednesday.

Between July 1 and Aug. 17, the member helplines across the three managed care companies received more than 56,600 calls. Over 95% of those calls were answered live within 30 seconds across all companies—higher than the 85% minimum required by the state.

Each managed care entity also reported their percentage of abandoned calls, which must be below 5% to meet the state’s performance standards. Each reported less than 1% of their calls were abandoned.

Cunningham Piggot said a PathWays issue resolution tracker followed up on emails sent to a specific address at FSSA, INPathWays@fssa.in.gov, as well as those compiled by a third party contractor.

“… my team, we review the issues tracker daily. And then for outstanding items, we get with the MCEs to make sure that they’re doing follow up,” Cunningham Piggot said. “We have logged over 400 issues to date, and we have closed over 300 of those issues. And will continue to use this process until we feel comfortable that it’s not needed.”

In particular, Cunningham Piggot said that some claims had been submitted using the wrong provider identification number as well as duplication of submitted claims and the implementation of electronic visit verification reporting.

“We have seen an increase in the percentage of paid claims since July 1 … we still have work to do, there’s no doubt about it,” Cunningham Piggot said.

For example, in light of the news that some waiver transportation claims weren’t being reimbursed for some PathWays members, Cunningham Piggot said that one managed care company reported it hadn’t configured its system correctly and would be reprocessing claims. The other two entities said the claims were submitted without the appropriate modifier.

Nearly all, or 98%, of claims were adjudicated within 21 days, she shared, adding that companies had tried to work with the submitted claims rather than requiring providers to resubmit.

This didn’t square with what Rep. Robin Shackleford, a Democrat from Indianapolis, said she heard from providers in her district.

“… what we’re hearing from providers is that there’s been a true delay in getting these claims processed,” Shackleford said.

Shackleford has an insurance background and asked detailed questions about providers following Cunningham Piggot’s presentation, including care coordinator staffing and incorporating Medicaid data into the All Payers Claims Database.

Half of checking claims processing has been ensuring managed care entities have their systems set up properly while the other half has been re-educating providers on submissions, Cunningham Piggot said.

Steinmetz said that the next advisory committee meeting would provide another update on PathWays—which could include a more detailed breakdown of reported issues and secret shopper takeaways. That meeting is scheduled for Nov. 20.