405 IAC 14 — ARTICLE 14. MEDICAID AND CHIP MANAGED CARE

TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

ARTICLE 14. MEDICAID AND CHIP MANAGED CARE

Rule 1

405 IAC 14-1-1 405 IAC 14-1-1 Intent of article

Rule 1. General Provisions

405 IAC 14-1-1 Intent of article

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 1. The office shall adopt and promulgate this article to set forth regulating the office's Medicaid managed care programs, which consist of:

(1) the Healthy Indiana Plan;

(2) Hoosier Care Connect;

(3) Hoosier Healthwise; and

(4) the Indiana PathWays for Aging.

(Office of the Secretary of Family and Social Services; 405 IAC 14-1-1; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-1-2 405 IAC 14-1-2 Reference to Code of Federal Regulations

405 IAC 14-1-2 Reference to Code of Federal Regulations

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 2. A reference to a provision of the Code of Federal Regulations means the October 1, 2021 edition. The provisions are incorporated by reference. Copies may be obtained from the Government Printing Office, 732 North Capitol Street NW, Washington, D.C. 20401 or are available for review and copying at the Indiana Family and Social Services Administration, Office of General Counsel, Indiana Government Center South, Room W451, 402 West Washington Street, Indianapolis, IN 46204.

(Office of the Secretary of Family and Social Services; 405 IAC 14-1-2; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-1-3 405 IAC 14-1-3 Reference to United States Code

405 IAC 14-1-3 Reference to United States Code

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 3. A reference to a provision of the United States Code means a provision effective January 5, 2023. The provisions are incorporated by reference. Copies may be obtained from the Government Printing Office, 732 North Capitol Street NW, Washington, D.C. 20401 or are available for review and copying at the Indiana Family and Social Services Administration, Office of General Counsel, Indiana Government Center South, Room W451, 402 West Washington Street, Indianapolis, IN 46204.

(Office of the Secretary of Family and Social Services; 405 IAC 14-1-3; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-1-4 405 IAC 14-1-4 CMS approval

405 IAC 14-1-4 CMS approval

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15; IC 12-17.6-2

Sec. 4. (a) Contracts must meet the applicable requirements under state and federal law, including the requirements under 42 CFR part 434.

(b) A policy established in this article requiring federal approval is void if CMS:

(1) denies or does not provide federal financial participation for the policy; or

(2) disapproves the policy.

(Office of the Secretary of Family and Social Services; 405 IAC 14-1-4; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

Rule 2

405 IAC 14-2-1 405 IAC 14-2-1 Applicability

Rule 2. Definitions; All Managed Care Programs

405 IAC 14-2-1 Applicability

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 1. Unless otherwise specifically defined in this rule, the definitions in this rule, 405 IAC 1-1-1, and 405 IAC 5-2 apply throughout this article.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-1; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-2 405 IAC 14-2-2 "Adverse action" defined

405 IAC 14-2-2 "Adverse action" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 2. "Adverse action" has the same meaning as "adverse benefit determination" as defined at 42 CFR 438.400(b).

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-2; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-3 405 IAC 14-2-3 "Aligned enrollment" defined

405 IAC 14-2-3 "Aligned enrollment" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 3. "Aligned enrollment" means full benefit dual eligible beneficiaries enrollment in a dual eligible special needs plan (D-SNP), whose Medicaid benefits are covered under the MCO's Medicaid contract and the D-SNP's Medicare Advantage organization, the D-SNP's parent organization, or an entity owned and controlled by the D-SNP's parent organization.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-3; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-4 405 IAC 14-2-4 "American Indian/Alaska Native" defined

405 IAC 14-2-4 "American Indian/Alaska Native" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 4. "American Indian/Alaska Native" has the meaning set forth at 405 IAC 10-2-1(2).

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-4; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-5 405 IAC 14-2-5 "Appeal" defined

405 IAC 14-2-5 "Appeal" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 5. "Appeal" means a request for an adverse action review or a decision by an MCO related to a covered service.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-5; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-6 405 IAC 14-2-6 "Capitated payment" defined

405 IAC 14-2-6 "Capitated payment" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 6. "Capitated payment" means a monthly payment to the MCO on behalf of each enrollee for providing health services under the contract. Payment is made regardless of whether the enrollee receives services during the month.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-6; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-7 405 IAC 14-2-7 "CHIP" defined

405 IAC 14-2-7 "CHIP" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 7. "CHIP" has the meaning set forth at 405 IAC 11-1-4.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-7; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-8 405 IAC 14-2-8 "Choice counseling" defined

405 IAC 14-2-8 "Choice counseling" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 8. "Choice counseling" means the providing unbiased information on managed care plans, or provider options and answers to related questions and access to personalized assistance, to:

(1) help members understand the materials provided by an MCO or the state;

(2) answer questions about each option available; and

(3) help with enrolling in an MCO.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-8; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-9 405 IAC 14-2-9 "Claim" defined

405 IAC 14-2-9 "Claim" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 9. "Claim" means a formal payment request for benefits received or services rendered.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-9; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-10 405 IAC 14-2-10 "Clean claim" defined

405 IAC 14-2-10 "Clean claim" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 10. "Clean claim" means a claim received by an MCO for adjudication that does not require further information, adjustment, or alteration by the provider of the services to be processed and paid.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-10; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-11 405 IAC 14-2-11 "Code of Federal Regulations" or "CFR" defined

405 IAC 14-2-11 "Code of Federal Regulations" or "CFR" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 11. "Code of Federal Regulations" or "CFR" means the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the federal government.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-11; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-12 405 IAC 14-2-12 "Contract" defined

405 IAC 14-2-12 "Contract" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 12. "Contract" means a contract between the office and an MCO.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-12; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-13 405 IAC 14-2-13 "Covered service" defined

405 IAC 14-2-13 "Covered service" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 13. "Covered service" means a service or an item an MCO must arrange to provide and pay for on an enrollee's behalf under the terms of a contract executed between the MCO and the office.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-13; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-14 405 IAC 14-2-14 "Credentialing" defined

405 IAC 14-2-14 "Credentialing" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 14. "Credentialing" means the process of obtaining, verifying, and evaluating information regarding applicable licensure, accreditation, certification, educational, and practice requirements to determine whether a provider has the required credentials to deliver specific covered services to enrollees.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-14; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-15 405 IAC 14-2-15 "Day" defined

405 IAC 14-2-15 "Day" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 15. "Day" means a calendar day unless otherwise specified.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-15; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-16 405 IAC 14-2-16 "Disenrollment" defined

405 IAC 14-2-16 "Disenrollment" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 16. "Disenrollment" means discontinuing of an enrollee's eligibility to receive covered services through an MCO.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-16; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-17 405 IAC 14-2-17 "Dual eligible member" defined

405 IAC 14-2-17 "Dual eligible member" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 17. "Dual eligible member" means an individual eligible for both Medicare and Medicaid benefits. The term includes the following types of dual eligible members:

(1) A QMB DAUL (QMB Plus or QMB Only).

(2) A non-QMB DUAL low income beneficiary (SLMB+ or other full benefit dual eligible member).

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-17; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-18 405 IAC 14-2-18 "Emergency medical condition" defined

405 IAC 14-2-18 "Emergency medical condition" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 18. "Emergency medical condition" has the meaning set forth at 42 CFR 438.114.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-18; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-19 405 IAC 14-2-19 "Emergency services" defined

405 IAC 14-2-19 "Emergency services" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 19. "Emergency services" has the meaning set forth at 42 CFR 438.114.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-19; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-20 405 IAC 14-2-20 "Enrollee" defined

405 IAC 14-2-20 "Enrollee" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 20. "Enrollee" means a member enrolled with an MCO for the purpose of receiving IHCP services the MCO is responsible for under its contract with the state.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-20; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-21 405 IAC 14-2-21 "Enrollment broker" defined

405 IAC 14-2-21 "Enrollment broker" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 21. "Enrollment broker" means the entity the office uses to enroll persons in a managed care organization.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-21; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-22 405 IAC 14-2-22 "Federally qualified health center" or "FQHC" defined

405 IAC 14-2-22 "Federally qualified health center" or "FQHC" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 22. "Federally qualified health center" or "FQHC" means an entity certified by CMS to meet the FQHC requirements under 42 U.S.C. 1395x(aa)(3) and enrolled as a provider by the office.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-22; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-23 405 IAC 14-2-23 "Fee-for-service" or "FFS" defined

405 IAC 14-2-23 "Fee-for-service" or "FFS" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 23. "Fee-for-service" or "FFS" means a reimbursement model in which either a member is not enrolled with an MCO, or a provider is reimbursed based on a fee schedule for defined services.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-23; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-24 405 IAC 14-2-24 "Grievance" defined

405 IAC 14-2-24 "Grievance" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 24. "Grievance" has the meaning set forth at 42 CFR 438.400(b).

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-24; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-25 405 IAC 14-2-25 "Health and wellness waiver" or "H&W waiver" defined

405 IAC 14-2-25 "Health and wellness waiver" or "H&W waiver" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 25. "Health and wellness waiver" or "H&W waiver" means the waiver operated by the state under Section 1915(c) of the Social Security Act allowing the state to provide an alternative to nursing facility admission for adults and persons of any age with a disability.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-25; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-26 405 IAC 14-2-26 "Health maintenance organization" or "HMO" defined

405 IAC 14-2-26 "Health maintenance organization" or "HMO" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 26. "Health maintenance organization" or "HMO" means a public or private organization licensed as a managed care organization or prepaid health plan under IC 27-13.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-26; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-27 405 IAC 14-2-27 "Healthy Indiana Plan" or "HIP" defined

405 IAC 14-2-27 "Healthy Indiana Plan" or "HIP" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 27. "Healthy Indiana Plan" or "HIP" means the program defined at 405 IAC 10-2-1(37).

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-27; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-28 405 IAC 14-2-28 "Home and community based services" or "HCBS" defined

405 IAC 14-2-28 "Home and community based services" or "HCBS" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 28. "Home and community based services" or "HCBS" means services provided as an alternative to long term care institutional services in a nursing facility or an ICF-IID, or to delay or prevent placement in a nursing facility or ICF/IID.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-28; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-29 405 IAC 14-2-29 "Hoosier Care Connect" or "HCC" defined

405 IAC 14-2-29 "Hoosier Care Connect" or "HCC" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 29. "Hoosier Care Connect" or "HCC" means the statewide Medicaid managed care program for:

(1) members less than sixty (60) years of age and eligible for Medicaid based on blindness or disability; and

(2) certain foster care children.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-29; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-30 405 IAC 14-2-30 "Hoosier Healthwise" or "HHW" defined

405 IAC 14-2-30 "Hoosier Healthwise" or "HHW" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 30. "Hoosier Healthwise" or "HHW" has the definition set forth at 405 IAC 11-1-7.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-30; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-31 405 IAC 14-2-31 "Indiana health coverage programs" or "IHCP" defined

405 IAC 14-2-31 "Indiana health coverage programs" or "IHCP" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 31. "Indiana health coverage programs" or "IHCP" means the collective Indiana Medicaid programs, administered by the family and social services administration, that provide health care services for low income children and adults, including those individuals that are:

(1) aged;

(2) blind;

(3) disabled;

(4) pregnant; and

(5) meeting other eligibility requirements.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-31; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-32 405 IAC 14-2-32 "Intermediate care facility for individuals with intellectual disabilities" or "ICF-IID" defined

405 IAC 14-2-32 "Intermediate care facility for individuals with intellectual disabilities" or "ICF-IID" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 32. "Intermediate care facility for individuals with intellectual disabilities" or "ICF-IID" means a facility providing care and services to individuals with intellectual disabilities or related conditions as defined in 42 U.S.C. 1396d.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-32; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-33 405 IAC 14-2-33 "Level of care assessor" or "LOCA" defined

405 IAC 14-2-33 "Level of care assessor" or "LOCA" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 33. "Level of care assessor" or "LOCA" means the entity contracted with the office to perform intake counseling.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-33; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-34 405 IAC 14-2-34 "Managed care organization" or "MCO" defined

405 IAC 14-2-34 "Managed care organization" or "MCO" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 34. "Managed care organization" or "MCO" has the meaning set forth at 405 IAC 10-2-1(28).

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-34; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-35 405 IAC 14-2-35 "Managed care program" defined

405 IAC 14-2-35 "Managed care program" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 35. "Managed care program" means a managed care delivery system operated by the office as authorized under section 1915(a), 1915(b), 1932(a), or 1115(a) of the Social Security Act.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-35; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-36 405 IAC 14-2-36 "Managed long term services and supports" or "MLTSS" defined

405 IAC 14-2-36 "Managed long term services and supports" or "MLTSS" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 36. "Managed long term services and supports" or "MLTSS" means delivering long term services and supports through Medicaid managed care programs.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-36; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-37 405 IAC 14-2-37 "Mandatory enrollment" defined

405 IAC 14-2-37 "Mandatory enrollment" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 37. "Mandatory enrollment" means mandatory participation in a managed care program as set forth in this article.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-37; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-38 405 IAC 14-2-38 "Medicaid rehabilitation option" or "MRO" defined

405 IAC 14-2-38 "Medicaid rehabilitation option" or "MRO" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 38. "Medicaid rehabilitation option" or "MRO" has the meaning set forth at 405 IAC 5-21.5-1.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-38; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-39 405 IAC 14-2-39 "MED Works" defined

405 IAC 14-2-39 "MED Works" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 39. "MED Works" means the Medicaid program allowing individuals with a disability who work to keep Medicaid coverage, and in which individuals pay a premium on a sliding fee scale based on their income.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-39; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-40 405 IAC 14-2-40 "Member" defined

405 IAC 14-2-40 "Member" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 40. "Member" means a person certified by the office as eligible for Medicaid or CHIP.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-40; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-41 405 IAC 14-2-41 "PathWays" or "Indiana PathWays for Aging" defined

405 IAC 14-2-41 "PathWays" or "Indiana PathWays for Aging" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 41. "PathWays" or "Indiana PathWays for Aging" , for purposes of this article, means the office's statewide managed care program for Medicaid enrollees at least sixty (60) years of age and eligible for Medicaid based on age, blindness, or disability, including those who have a full Medicare benefit, are in a nursing facility, and are receiving LTSS in a home or community based setting.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-41; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-42 405 IAC 14-2-42 "Primary medical provider" or "PMP" defined

405 IAC 14-2-42 "Primary medical provider" or "PMP" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 42. "Primary medical provider" or "PMP" means a primary care physician or other licensed health practitioner practicing state law who is responsible for:

(1) providing preventive and primary health care to enrollees;

(2) initiating referrals for specialist care; and

(3) maintaining continued patient care.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-42; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-43 405 IAC 14-2-43 "Poststabilization care services" defined

405 IAC 14-2-43 "Poststabilization care services" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 43. "Poststabilization care services" has the meaning set forth at 42 CFR 438.114.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-43; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-44 405 IAC 14-2-44 "Prior authorization" defined

405 IAC 14-2-44 "Prior authorization" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 44. "Prior authorization" has the meaning set forth at 405 IAC 10-2-1(44).

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-44; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-45 405 IAC 14-2-45 "Qualified disabled working individual" or "QDWI" defined

405 IAC 14-2-45 "Qualified disabled working individual" or "QDWI" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 45. "Qualified disabled working individual" or "QDWI" means the category of Medicaid eligibility for disabled individuals with incomes are less than two hundred percent (200%) of the federal poverty level and whose Medicaid benefits cover paying Medicare Part A premium only.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-45; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-46 405 IAC 14-2-46 "Qualified Medicare Beneficiary-Also" or "QMB-Also" defined

405 IAC 14-2-46 "Qualified Medicare Beneficiary-Also" or "QMB-Also" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 46. "Qualified Medicare Beneficiary-Also" or "QMB-Also" means a member who receives Part A Medicare with income is below one hundred percent (100%) of the federal poverty level and whose Medicaid benefits pay Medicare copayments and coinsurance amounts for medical services covered by Medicare, including copayments for Medicare approved skilled nursing home care, as well as Medicare Part B premiums for eligible members.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-46; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-47 405 IAC 14-2-47 "Qualified Medicare beneficiary dual eligible member" or "QMB DUAL" defined

405 IAC 14-2-47 "Qualified Medicare beneficiary dual eligible member" or "QMB DUAL" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 47. "Qualified Medicare beneficiary dual eligible member" or "QMB DUAL" means the category of Medicaid eligibility for aged, blind, or disabled individuals entitled to Medicare Part A with incomes less than one hundred percent (100%) of the federal poverty level and who have assets less than twice the SSI asset limit. Medicaid benefits for these individuals include payment of Medicare premiums, coinsurance, and deductibles only.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-47; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-48 405 IAC 14-2-48 "Qualified Medicare beneficiary only" or "QMB Only" defined

405 IAC 14-2-48 "Qualified Medicare beneficiary only" or "QMB Only" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 48. "Qualified Medicare beneficiary only" or "QMB Only" means a member with Medicaid benefits limited to paying the member's Medicare Part A and Part B premiums, as well as deductibles and coinsurance or copayment for Medicare covered services only.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-48; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-49 405 IAC 14-2-49 "Qualified Medicare beneficiary plus" or "QMB Plus" defined

405 IAC 14-2-49 "Qualified Medicare beneficiary plus" or "QMB Plus" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 49. "Qualified Medicare beneficiary plus" or "QMB Plus" means a member whose Medicaid benefits include paying the member's Medicare premiums, deductibles, and coinsurance or copayment on Medicare covered services, as well as traditional Medicaid benefits.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-49; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-50 405 IAC 14-2-50 "Qualifying individual" or "QI" defined

405 IAC 14-2-50 "Qualifying individual" or "QI" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 50. "Qualifying individual" or "QI" means a member whose Medicaid benefits include paying the member's Medicare Part B premium.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-50; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-51 405 IAC 14-2-51 "Referral" defined

405 IAC 14-2-51 "Referral" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 51. "Referral" means:

(1) a verbal;

(2) a written;

(3) a telephonic;

(4) an electronic; or

(5) an in-person;

request for health services.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-51; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-52 405 IAC 14-2-52 "Self-referral" defined

405 IAC 14-2-52 "Self-referral" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 52. "Self-referral" means the way an MCO enrollee may access certain services without referral from the enrollee's PMP.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-52; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-53 405 IAC 14-2-53 "Specified low income Medicare beneficiary only" or "SLMB Only" defined

405 IAC 14-2-53 "Specified low income Medicare beneficiary only" or "SLMB Only" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 53. "Specified low income Medicare beneficiary only" or "SLMB only" means a member whose benefits are limited to paying the member's Medicare Part B premium only.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-53; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-54 405 IAC 14-2-54 "Specified low income Medicare beneficiary plus" or "SLMB+" defined

405 IAC 14-2-54 "Specified low income Medicare beneficiary plus" or "SLMB+" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 54. "Specified low income Medicare beneficiary plus" or "SLMB+" means a member whose benefits include paying the member's Medicare Part B premium, as well as traditional Medicaid benefits throughout each month of eligibility, including deductibles, coinsurance, and copays, except for Medicare Part D.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-54; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-55 405 IAC 14-2-55 "State plan" defined

405 IAC 14-2-55 "State plan" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 55. "State plan" means the agreement between the office and CMS regarding operating the Indiana Medicaid program under the requirements of Title XIX of the Social Security Act.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-55; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-56 405 IAC 14-2-56 "Supplemental security income" or "SSI" defined

405 IAC 14-2-56 "Supplemental security income" or "SSI" defined

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 56. "Supplemental security income" or "SSI" means the federal cash assistance program of direct financial payments to individuals who:

(1) are at least sixty-five (65) years of age;

(2) are blind; or

(3) have a disability administered by the Social Security Administration under Title XVI of the Social Security Act.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-56; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-57 405 IAC 14-2-57 Enrollment area

405 IAC 14-2-57 Enrollment area

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 57. The enrollment area for the managed care programs set forth in this article is the state of Indiana.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-57; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-58 405 IAC 14-2-58 Grievances and appeals

405 IAC 14-2-58 Grievances and appeals

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 4-21.5-3-33; IC 12-15-28; IC 12-15-44.5; IC 12-17.6-2; IC 27-8-29-12; IC 27-13-10.1-1

Sec. 58. (a) An MCO shall operate a grievance and appeals system that includes at least:

(1) a grievance process;

(2) expedited review procedures;

(3) access to an external grievance procedure;

(4) an appeals process; and

(5) access to the state's fair hearing system prescribed in 405 IAC 1.1.

(b) An MCO shall operate the grievance process in subsection (a)(1) under the following requirements and time frames:

(1) Members must be allowed to file grievances orally or in writing under 42 CFR 438.402.

(2) Members may file a grievance regarding any matter other than those meeting the definition of an adverse benefit determination or adverse action.

(3) Grievances may be filed at any time after the matter related to the grievance occurs.

(4) The MCO shall acknowledge receiving each grievance within three (3) business days. Acknowledgement is not required to be written unless requested by the member; however, if the member requests written acknowledgement, the acknowledgement must be made within five (5) business days after receiving request.

(5) The MCO shall make a decision on nonexpedited grievances as quickly as possible, but not more than thirty (30) calendar days after receiving a grievance. This time frame may be extended up to fourteen (14) calendar days if additional time is needed to resolve the matter. If the time frame is extended, for an extension not requested by the member, the MCO shall give the member written notice of the reason for the delay. The MCO shall give the member written notice of any extension within two (2) calendar days after the extension, including the:

(A) reason for the extension; and

(B) member's right to file a grievance if they disagree with the extension.

(6) The MCO shall provide an expedited grievance review, which shall be resolved within forty-eight (48) hours after it is received, on member request, or, if following the resolution time frame of thirty (30) calendar days may seriously jeopardize the member's:

(A) the life or health; or

(B) ability to regain maximum function.

(7) If the MCO denies a request for an expedited grievance review under subdivision (6), they shall:

(A) transfer the grievance to the standard grievance time frame;

(B) make a reasonable effort, including a phone call to the member, to provide the member with prompt oral notice of the denial; and

(8) The MCO shall respond in writing to a member within five (5) business days after resolving a grievance or an expedited grievance. The resolution notice must include:

(A) notice of the member's right to file an appeal;

(B) the process for requesting an appeal;

(D) the right to continue benefits during the appeal, as long as the request complies with the timeliness standards at 405 IAC 1.1;

(E) an explanation that the member may have to pay for care received if an adverse appeal decision is made; and

(F) for grievances related to a member's request to change MCOs, information on how to request a plan change.

(c) Under IC 27-13-10.1-1 and IC 27-8-29-12, an MCO shall maintain an external grievance procedure for resolving decisions related to:

(1) an adverse utilization review determination;

(2) an adverse determination of medical necessity; or

(3) a determination that a proposed service is experimental or investigational, which is operated under the following requirements and time frames:

(A) Members must first finish the MCO's grievance and appeals process.

(B) An external review under this subsection does not inhibit or replace the member's right to appeal an MCO decision to a state fair hearing.

(C) A member may seek external review by an independent review organization, and that process may run concurrently with a state fair hearing.

(D) Within one hundred twenty (120) calendar days after the date of the MCO's decision on the member's appeal, a member, or a member's representative, may file a written request for reviewing the MCO's decision by an independent review organization.

(E) An independent review organization shall render a decision to uphold or reverse the MCO's decision within seventy-two (72) hours for an expedited appeal, or fifteen (15) business days for a standard appeal. The determination made by the independent review organization is binding on the MCO.

(d) An MCO shall operate the appeals process in subsection (a)(4) under the following requirements and time frames:

(1) A member, and under 42 CFR 438.402, a provider acting on behalf of the member and with the member's written consent, shall have sixty (60) calendar days after the date of an adverse benefit determination notice to file an appeal.

(2) Under 42 CFR 438.406, the MCO shall ensure oral requests seeking to appeal an adverse benefit determination are treated as appeals.

(3) The MCO shall acknowledge receiving each standard appeal within three (3) business days.

(4) The MCO shall make a decision on standard, nonexpedited appeals within thirty (30) calendar days after reviewing the appeal. This time frame may be extended up to fourteen (14) calendar days under 42 CFR 438.408(c). If the time frame is extended, for an extension not requested by the member, the MCO shall give the member written notice of the reason for the delay.

(5) The MCO shall maintain an expedited review process for appeals, which provides for resolution within forty-eight (48) hours after receiving it, unless this time frame is extended under 42 CFR 438.408(c), when the MCO or member's provider determines that pursuing the standard appeals process may seriously jeopardize the member's life, health, or their ability to attain, maintain, or regain maximum function.

(6) Under 42 CFR 438.410, if the MCO denies the request for an expedited resolution of a member's appeal under subdivision (5), the MCO shall:

(A) transfer the appeal to the standard thirty (30) calendar day time frame;

(B) give the member written notice of the denial within two (2) days after the expedited appeal request; and

(7) Under 42 CFR 438.408, written notice of appeal disposition is given within five (5) business days after resolution to the member and, where appropriate, the provider. For an expedited resolution notice, the MCO shall also make reasonable efforts to provide oral notice. The written notice of the resolution must include:

(A) the results of the resolution;

(B) the date the resolution was completed; and

(i) the right to request an external grievance as detailed in subsection (c) and state fair hearing;

(ii) the procedures and how to request an external grievance or State fair hearing;

(iii) the right to request to receive benefits while the hearing is pending, including instructions on how to make the request;

(iv) notification that the member may be held liable for the cost of those benefits if the state hearing upholds the MCO's adverse benefit determination; and

(v) for appeals related to a member's request to change MCOs, information on how to request a just cause plan change.

(e) If the office, as defined at 405 IAC 1-1-1(12), takes an adverse action an individual or entity believes was erroneous, the individual or entity may request an administrative hearing under 405 IAC 1.1, which is governed by the procedures and time limits set forth in 405 IAC 1.1.

(f) A member who believes an MCO has taken an erroneous action must first complete the MCO's internal appeals procedure under subsection (d) before requesting an appeal with the office.

(g) After completing an MCO's internal appeals procedures, a member may request an administrative hearing under 405 IAC 1.1 not later than the time frame set forth in 405 IAC 1.1-1-3 after the date the MCO resolves of the appeal.

(h) Requests made under subsection (g) are governed by the procedures and time limits set forth in 405 IAC 1.1.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-58; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-59 405 IAC 14-2-59 Enrollment and disenrollment

405 IAC 14-2-59 Enrollment and disenrollment

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 59. (a) Individuals applying for Medicaid coverage who are not receiving SSI benefits will have an opportunity to select their choice of MCO on their Medicaid application or through the enrollment broker, while SSI recipients are automatically eligible for Indiana Medicaid coverage without a separate application.

(b) The office's enrollment broker shall provide information and assistance with MCO selection to enrollees who do not select an MCO at the time of application, and SSI recipients who are not required to submit a Medicaid application, under 42 CFR 438.810(b).

(c) The enrollment broker must be conflict free and meet all applicable state and federal law requirements, including 42 CFR 438.810 as amended May 6, 2016.

(d) Individuals who do not select an MCO are auto-assigned to an MCO under auto-assignment methodology.

(e) Contracted MCOs for each of the office's managed care programs shall accept individuals eligible for enrollment in the order in which they apply without restriction, and shall not, based on health status or needing for health care services, discriminate against individuals eligible to enroll.

(f) Contracted MCOs for each of the office's managed care programs shall not discriminate against, or use a policy or practice that causes discrimination against, individuals eligible to enroll based on the following:

(1) Race.

(2) Color.

(3) National origin.

(4) Sex.

(5) Sexual orientation.

(6) Gender identity.

(7) Disability.

(g) Members who become eligible for coverage through any of the office's managed care programs may be eligible for coverage retroactive for up to three (3) months after their application date as set forth in 405 IAC 2. Retroactive coverage periods will be in the FFS program. Members in any of the office's managed care programs receive FFS coverage through the effective eligibility approval date, at which time they are assigned to an MCO.

(h) Except as provided in subsection (g), a newborn whose mother is enrolled with an MCO on the date of the child's birth is assigned to the mother's MCO, retroactively effective to the newborn's date of birth.

(i) Members in any of the office's managed care programs may request to change MCOs they are enrolled in as follows:

(1) 405 IAC 10-8-2 provides the requirements for a HIP member changing MCOs.

(2) HCC members may request to change MCOs at the following times:

(A) Without cause during the initial enrollment period, which is within ninety (90) days after enrollment.

(B) Without cause at least one (1) time each calendar year after the initial enrollment period.

(3) HHW members may request to change MCOs at the following times:

(A) Without cause during the initial enrollment period, which is within ninety (90) days after enrollment.

(B) Without cause at least one (1) time each calendar year after the initial enrollment period.

(4) PathWays members may request to change MCOs at the following times:

(A) Without cause during the initial enrollment period, which is within ninety (90) days of enrollment.

(B) Without cause at least one (1) time each calendar year after the initial enrollment period.

(D) At any time the member's Medicare and Medicaid plans become unaligned.

(E) During the plan selection period aligned with the annual Medicare open enrollment window held mid-October through mid-December, with the change to be effective the following calendar year.

(j) The following are reasons members of a managed care program operated by the office are disenrolled from the program:

(1) Individuals are disenrolled from HIP, HCC, HHW, or PathWays if the individual:

(A) loses eligibility for the program;

(B) is no longer a resident of Indiana; or

(2) In addition to the reasons in subdivision (1), individuals are disenrolled from the respective managed care program based on the following program specific factors:

(A) 405 IAC 10-4-10 sets forth the reasons individuals are disenrolled from the HIP program.

(B) An individual is disenrolled from HCC if:

(i) the individual is admitted for a long term stay in an institutional setting;

(ii) the individual is admitted to an ICF/IID;

(iii) the individual becomes enrolled in an HCBS waiver operated by the office;

(iv) the individual begins receiving psychiatric treatment in a state hospital; or

(v) unless covered by an EPSDT exception, the individual is receiving treatment in a psychiatric residential treatment facility.

(i) the individual is admitted for a long term stay in an institutional setting;

(ii) the individual is admitted to an ICF/IID;

(iii) the individual begins receiving hospice services;

(iv) the individual becomes enrolled in an HCBS waiver operated by the office;

(v) the individual begins receiving psychiatric treatment in a state hospital; or

(vi) unless covered by an EPSDT exception, the individual is receiving treatment in a psychiatric residential treatment facility.

(D) An individual is disenrolled from PathWays if:

(i) the individual begins receiving psychiatric treatment in a state hospital;

(ii) the individual is admitted to an ICF/IID; or

(iii) the individual begins receiving services under an HCBS waiver operated by the office other than the PathWays 1915(c) waiver.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-59; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-60 405 IAC 14-2-60 PMP selection and assignment

405 IAC 14-2-60 PMP selection and assignment

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-44.5-9; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-15-44.5; IC 12-17.6-2

Sec. 60. (a) After enrollment with an MCO, an enrollee shall have the right to choose a PMP of their choice from the eligible providers in the MCO's contracted network.

(b) An MCO shall assist enrollees in choosing a PMP if the enrollee desires.

(c) Unless an enrollee elects otherwise, an enrollee's PMP is located within thirty (30) miles from the enrollee's residence.

(d) An enrollee who does not select a PMP shall be assigned to a PMP by the MCO within thirty (30) calendar days after the enrollee's MCO enrollment. This subsection does not apply to HCC.

(e) MCOs are required to consider, at minimum, any earlier provider relationships when making the enrollee's PMP assignment under subsection (d).

(f) An MCO may use auto-assignment factor, as well as earlier provider relationships as required under subsection (e), when assigning an enrollee a PMP. These additional factors must be reviewed by the office before to implementation.

(g) After an MCO assigns an enrollee to a PMP, the MCO shall notify the enrollee of the assignment in writing, including the:

(1) assigned PMP;

(2) enrollee's right to change the PMP; and

(3) way the enrollee may change the PMP.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-60; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-2-61 405 IAC 14-2-61 Drug coverage

405 IAC 14-2-61 Drug coverage

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 61. (a) An MCO shall follow the office's Statewide Uniform Preferred Drug List (SUPDL).

(b) An MCO shall have a policy allowing at least a seventy-two (72) hour emergency supply of a covered outpatient prescription drug, as required under 42 U.S.C. 1396r- 8(d)(5)(B), without needing prior authorization.

(c) An MCO shall use a pharmacy and therapeutics committee that meets regularly to make recommendations for changes to drugs not on the SUPDL.

(d) Under CMS-2390-F and 42 CFR 438.210, an MCO shall demonstrate prescription drug coverage consistent with the amount, duration, and scope of the FFS program. This includes the following:

(1) The MCO shall engage with the office to develop medically necessary prior authorization criteria for Indiana Medicaid and CHIP enrollees.

(2) The MCO shall carry out the universal criteria in subdivision (1) into the MCO's program and may not use more restrictive criteria, including quantitative and nonquantitative treatment limits.

(e) An MCO shall maintain an over-the-counter (OTC) drug formulary and pharmacy supplements formulary the same items included in the FFS OTC drug formulary, and pharmacy supplements formulary and as updated by the drug utilization review board. Additions to the MCO OTC drug formulary are required to only be from participating rebating labelers.

(f) An MCO may choose to contract with the office's pharmacy benefit manager contractor for pharmacy claims processing.

(g) An MCO shall carry out a process to allow member access to medically necessary non-SUPDL drugs.

(h) Legend drugs may be delivered outside the capitated managed care arrangement if they:

(1) meet the requirements at 405 IAC 5-24-3; and

(2) are determined by the office to be better delivered through FFS and not to be included in the capitated managed care arrangement due to clinical or financial reasons based on the considerations listed in subsection (i).

(i) The office may determine drugs in subsection (h) based on the following:

(1) Substantial supplemental drug rebates.

(2) Potential and actual prior authorization criteria alignment issues.

(3) Correlating diagnosis related group and hospital assessment fee carve-outs.

(4) Impact planning:

(A) orphan drugs or orphan-like drugs;

(B) capitation rate allocation based on:

(i) capitation payment waste; and

(ii) disproportionate capitation allocation; and

(i) reinsurance costs and availability;

(ii) disproportionate use and reimbursement across plans; and

(iii) MCO request.

(j) MCOs may request the office to review eligible drugs detailed in subsection (h) to be delivered outside the capitated managed care arrangement.

(Office of the Secretary of Family and Social Services; 405 IAC 14-2-61; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

Rule 3

405 IAC 14-3-1 405 IAC 14-3-1 Member enrollment

Rule 3. Healthy Indiana Plan

405 IAC 14-3-1 Member enrollment

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 1. (a) Enrollment in a HIP MCO is mandatory for individuals identified at 405 IAC 10-4-1.

(b) American Indian/Alaska Native enrollees who would otherwise be mandatorily enrolled in managed care under subsection (a) may choose to receive services through FFS as further detailed at 405 IAC 10-4-7.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-1; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-2 405 IAC 14-3-2 Provider enrollment, credentialing, and PMP requirements

405 IAC 14-3-2 Provider enrollment, credentialing, and PMP requirements

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 2. (a) The office considers a provider eligible to participate in HIP when the provider enrolls with the office.

(b) A HIP provider eligible and required to enroll with the office as a provider must first be enrolled with the office as a provider before providing services to members. After the provider enrolls with the office, the provider may contract with any MCO providing services to HIP members.

(c) An MCO shall have written credentialing, provisional credentialing, and recredentialing policies and procedures in place for ensuring all contracted providers hold current state licensure and are enrolled with the office.

(d) An MCO shall demonstrate compliance with 42 CFR 438.208, specifically in ensuring that each member has a PMP responsible for providing an ongoing source of primary care appropriate to a member's needs, including coordinating each member's physical and behavioral health care and making necessary referrals.

(e) A referral from a member's PMP is required when the member receives physician services from a provider other than their PMP, unless the service is a self-referral or direct access service as set forth at sections 5 and 6 of this rule.

(f) An MCO shall ensure access to a PMP at least thirty (30) miles from the member's residence.

(g) Provider types that may serve as HIP PMPs include:

(1) internal medicine physicians;

(2) general practitioners;

(3) family medicine physicians;

(4) pediatricians;

(5) obstetricians;

(6) gynecologists; and

(7) endocrinologists, if primarily engaged in internal medicine.

(h) Providers eligible to serve as a PMP may contract with more than one (1) MCO to serve as a PMP, or may serve as a PMP in at least one (1) MCO and as a specialist with at least one (1) other MCO.

(i) An MCO shall have a mechanism in place to ensure the MCO's contracted PMPs:

(1) provide or arrange for covering covered services twenty-four (24) hours a day, seven (7) days a week;

(2) have a mechanism in place to offer members direct contact in English and Spanish with their PMP, or the PMP's qualified clinical designee, through a toll free telephone number twenty-four (24) hours a day, seven (7) days a week; and

(3) provide "live voice" coverage after normal business hours, which may include an answering service or a shared call system with other medical providers.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-2; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-3 405 IAC 14-3-3 Covered services

405 IAC 14-3-3 Covered services

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 3. Individuals enrolled in HIP shall receive services as set forth at 405 IAC 10-7.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-3; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-4 405 IAC 14-3-4 Managed care carve-outs

405 IAC 14-3-4 Managed care carve-outs

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 4. Individuals enrolled in HIP shall receive covered services described in section 3 of this rule through a capitated managed care arrangement, through the MCO in which the individual is enrolled, except for the following covered services, which are delivered outside the capitated managed care arrangement and delivered through the FFS program:

(1) Medicaid rehabilitation option at 405 IAC 5-21.5.

(2) Adult mental health habilitation services at 405 IAC 5-21.6.

(3) Behavioral and primary health care coordination at 405 IAC 5-21.8.

(4) Child mental health wraparound services at 405 IAC 5-21.7.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-4; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-5 405 IAC 14-3-5 Self-referral

405 IAC 14-3-5 Self-referral

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 5. (a) An MCO shall include self-referral providers in their contracted networks.

(b) Self-referral services and limitations for HIP are set forth at 405 IAC 10-7-11.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-5; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-6 405 IAC 14-3-6 Direct access

405 IAC 14-3-6 Direct access

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 6. An MCO for HIP shall meet the direct access requirements at 405 IAC 14-6-8.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-6; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-7 405 IAC 14-3-7 Medical necessity

405 IAC 14-3-7 Medical necessity

Authority: IC 12-15-1-10; 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 7. Medical necessity requirements for HIP are as provided at 405 IAC 10-2-1(31).

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-7; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-8 405 IAC 14-3-8 Second opinions

405 IAC 14-3-8 Second opinions

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 8. An MCO for HIP shall meet the requirements regarding second opinions at 405 IAC 14-6-10.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-8; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-9 405 IAC 14-3-9 Utilization management

405 IAC 14-3-9 Utilization management

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5; IC 27-1-37.5-17

Sec. 9. (a) An MCO shall operate and maintain its own utilization management (UM) program based on the requirements and limitations in this section.

(b) Through the MCO's UM program, an MCO may place appropriate limits on coverage of services based on medical necessity or utilization control criteria, if the services furnished can reasonably be expected to achieve their intended purpose.

(c) Under 42 CFR 438.210(a)(3)(ii), an MCO shall not arbitrarily deny or reduce the amount, duration, or scope of required services solely because of a member's diagnosis, type of illness, or condition.

(d) An MCO shall follow the office's UM hierarchy, which includes the following:

(1) Compliance with applicable federal requirements.

(2) Compliance with applicable Indiana law.

(3) Compliance with the Indiana Medicaid state plan.

(4) Compliance with any applicable Indiana Administrative Code requirements.

(5) Use Medicaid FFS policies for the following services:

(A) Applied behavioral analysis therapy.

(B) Drug testing.

(D) Hysterectomies.

(E) RELiZORB.

(F) Speech-generating devices.

(G) Spinal stenosis.

(H) Transplants.

(I) Bariatric procedures.

(J) Oxygen usage.

(6) Noncustomized national clinical guidelines, of which the MCO may choose InterQual or Milliman Care Guidelines (MCG), but must use the full suite of review criteria in these platforms, including using the applicable MCG or InterQual guideline instead of an MCO derived UM policy or criteria if an item or a service is covered by MCG or InterQual.

(7) MCO developed criteria, which must be preapproved by the office before to carry out the criteria.

(8) Professional society guidelines.

(9) Professional references or guidance by subject matter expert published peer reviewed literature.

(10) Best standards of care, guided by published peer reviewed literature.

(e) The MCO shall require providers to use the Indiana health coverage program prior authorization request form developed by the office for services requiring prior authorization.

(f) The MCO's program must allow a provider the right for a peer to peer utilization review under IC 27-1-37.5-17.

(g) The MCO shall give written notice to a member and provider of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements of 42 CFR 438.404.

(h) The MCO shall notify a member of standard authorization decisions as quickly as needed by the member's health condition, not to exceed five (5) calendar days after a request for services, unless otherwise provided in 405 IAC 5-3-14. An extension of up to fourteen (14) calendar days is permitted if the:

(1) member or provider requests an extension; or

(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.

(i) Whenever a provider indicates, or the MCO determines, that following the standard time frame may seriously jeopardize a member's life, health, or ability to attain, maintain, or regain maximum function, the MCO shall make an expedited authorization decision and give notice as quickly as needed by the member's health condition not later than forty-eight (48) hours after receiving the service request. The MCO may extend the forty-eight (48) hours by up to fourteen (14) calendar days if the:

(1) member or provider requests an extension; or

(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.

(j) An extension granted under subsections (h) and (i) requires written notice to the member, which must include the reason for the extension and the member's right to file a grievance.

(k) Unless otherwise provided in 405 IAC 5-3-14, if the MCO fails to respond to a member's prior authorization request within five (5) calendar days after receiving the necessary documentation, the authorization is considered to be granted.

(l) Prior authorization requirements for HIP are further detailed at 405 IAC 10-7-12.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-9; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-10 405 IAC 14-3-10 Emergency and poststabilization care services

405 IAC 14-3-10 Emergency and poststabilization care services

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12-17; IC 12-15-44.5

Sec. 10. (a) An MCO shall cover emergency services as follows:

(1) The MCO shall not require prior authorization for the service.

(2) The MCO shall not require the emergency care provider to be contracted with the MCO.

(3) Services must be available to members twenty-four (24) hours a day, seven (7) days a week.

(4) Services must comply with the requirements under IC 12-15-12, including applying the prudent layperson standard for applying emergency and poststabilization care services policy outlined in this section.

(b) An MCO shall include urgent care clinics in the MCO's contracted provider networks, which must be made available to members not less than eleven (11) hours each day Monday through Friday and no less than five (5) hours each day on weekends.

(c) An MCO shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act regulations at 42 CFR 489.24, given to a member who presents to an emergency department with an emergency medical condition.

(d) The MCO shall reimburse both in-network and out-of-network HIP providers for covered services at a rate not less than the minimum fee schedule rate set by the state under 405 IAC 1-8-3.

(e) The MCO may choose to use a list of diagnosis codes to initially determine whether a service may be an emergency but must, at a least, use the emergency department autopay list developed by the office.

(f) An MCO shall cover post-stabilization care services for members under federal requirements at 42 CFR 438.114(e) and 42 CFR 422.113(c), and state law at IC 12-15-12-17.

(g) HIP emergency room visits are subject to the requirements at 405 IAC 10-7-9.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-10; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-11 405 IAC 14-3-11 Enhanced services

405 IAC 14-3-11 Enhanced services

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 11. (a) HIP MCOs are encouraged to cover enhanced programs and services beyond those services covered in HIP designed to create a commercial market experience and encourage member participation in HIP Plus, as defined at 405 IAC 10-2-1(22).

(b) A program or service offered by the MCO under subsection (a) must:

(1) be approved by the office before the MCO initiates the service or program; and

(2) comply with requirements related to member incentives and inducements set forth in the MCO's contract with the office, and relevant state and federal rules.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-11; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-12 405 IAC 14-3-12 Continued care

405 IAC 14-3-12 Continued care

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 12. An MCO shall provide ninety (90) calendar days of continued care for preexisting drug regimens and service authorizations for new HIP members transitioning to the MCO from another coverage source.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-12; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-13 405 IAC 14-3-13 Out-of-network services

405 IAC 14-3-13 Out-of-network services

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 13. (a) An MCO may limit its coverage to services provided by in-network providers upon the MCO meeting network access standards related to providing necessary covered medical services within designated time, distance, and access standards set forth in the MCO's contract with the office. This ability to limit to in-network providers is based on the requirements in sections 5, 10, and 12 of this rule.

(b) If an MCO cannot meet the network access standards described in subsection (a), the MCO shall authorize and pay for a member to receive services by a provider not contracted with the MCO under 42 CFR 438.206(b)(4).

(c) The cost to a member for out-of-network services shall be not greater than it would be if the services were furnished by a provider contracted with the MCO under 42 CFR 438.206(b)(5).

(d) An MCO shall reimburse out-of-network providers at a rate not less than the minimum fee schedule rate established by the state under 405 IAC 1-8-3.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-13; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-3-14 405 IAC 14-3-14 Claims processing and reimbursement

405 IAC 14-3-14 Claims processing and reimbursement

Authority: IC 12-15-1-10; IC 12-15-44.5-9

Affected: IC 12-15-12; IC 12-15-44.5

Sec. 14. Claims processing and reimbursement as set forth at 405 IAC 14-4-14, applies to HIP MCOs.

(Office of the Secretary of Family and Social Services; 405 IAC 14-3-14; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

Rule 4

405 IAC 14-4-1 405 IAC 14-4-1 Member enrollment

Rule 4. Hoosier Care Connect

405 IAC 14-4-1 Member enrollment

Authority: IC 12-15-1-10

Affected: IC 12-15-12

Sec. 1. (a) Individuals enrolled in Medicaid based on eligibility as one (1) of the following are mandatorily enrolled in an MCO through HCC if they are less than sixty (60) years of age and do not have a nursing facility or psychiatric residential treatment facility level of care:

(1) Blind.

(2) Disabled.

(3) SSI recipients.

(4) MED Works.

(b) Individuals may choose to participate in HCC if they are enrolled in Medicaid based on eligibility as one (1) of the following:

(1) Children receiving adoption assistance.

(2) Foster children.

(3) Former foster children, between eighteen (18) and twenty-six (26) years of age, enrolled as of their eighteenth birthday.

(c) American Indian/Alaska Native members of a federally recognized tribe meeting the HCC mandatory enrollment criteria in subsection (a) may choose to receive services through FFS.

(d) Members meeting any of the following are excluded from HCC managed care enrollment:

(1) Individuals enrolled in an HCBS waiver operated by the office.

(2) Individuals dually eligible for Medicare and Medicaid.

(3) Residents of an ICF/IID.

(4) Individuals enrolled in the family planning eligibility program.

(5) Residential care assistance program enrollees.

(6) Women needing treatment for breast or cervical cancer who are eligible under 1902(a)(10)(A)(ii)(XVIII) of the Social Security Act.

(7) Individuals eligible for emergency services only.

(8) Refugees.

(9) Money Follows the Person grant enrollees.

(10) Individuals receiving psychiatric treatment in a state hospital.

(11) Individuals with long term stays in an institutional setting.

(12) Unless covered by an EPSDT exception, individuals receiving treatment in a psychiatric residential treatment facility.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-1; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-2 405 IAC 14-4-2 Provider enrollment, credentialing, and PMP requirements

405 IAC 14-4-2 Provider enrollment, credentialing, and PMP requirements

Authority: IC 12-15-1-10

Affected: IC 12-15-12

Sec. 2. (a) The office considers a provider eligible to participate in HCC when the provider enrolls with the IHCP.

(b) An HCC provider eligible and required to enroll with the office as a provider must first be enrolled with the office as a provider before providing services to members. After the provider enrolls with the office, the provider may contract with any MCO providing services to HCC members.

(c) An MCO shall have written credentialing, provisional credentialing, and recredentialing policies and procedures in place for ensuring that contracted providers hold current state licensure and are enrolled with the office.

(d) An MCO shall ensure access to an ongoing source of care appropriate to a member's clinical condition at least thirty (30) miles from the member's residence.

(e) If an MCO chooses to operate a PMP model for HCC, providers eligible to serve as a PMP may contract with more than one (1) MCO to serve as a PMP, or may serve as a PMP in at least one (1) MCO and as a specialist with at least one (1) other MCO.

(f) A PMP, if applicable, or provider that is otherwise a source of ongoing care, shall be available to see members at least three (3) days a week for at least twenty (20) hours a week at any combination of not more than two (2) locations.

(g) An MCO shall have a mechanism in place to ensure the MCO's contracted PMPs, if applicable, or providers that are otherwise a source of ongoing care:

(1) provide or arrange for covering covered services twenty-four (24) hours a day, seven (7) days a week;

(2) have a mechanism in place to offer members direct contact in English and Spanish with their provider, or the provider's qualified clinical designee, through a toll free telephone number twenty-four (24) hours a day, seven (7) days a week; and

(3) provide "live voice" coverage after normal business hours, which may include an answering service or a shared call system with other medical providers.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-2; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-3 405 IAC 14-4-3 Covered services

405 IAC 14-4-3 Covered services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 3. Individuals enrolled in HCC shall receive the traditional Medicaid services outlined in 405 IAC 5.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-3; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-4 405 IAC 14-4-4 Managed care carve-outs

405 IAC 14-4-4 Managed care carve-outs

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 4. Individuals enrolled in HCC shall receive the covered services described in section 3 of this rule through a capitated managed care arrangement, through the MCO in which the individual is enrolled, except for the following covered services, which are delivered outside the capitated managed care arrangement and delivered through FFS:

(1) Medicaid rehabilitation option at 405 IAC 5-21.5.

(2) Adult mental health habilitation services at 405 IAC 5-21.6.

(3) Behavioral and primary health care coordination at 405 IAC 5-21.8.

(4) Child mental health wraparound services at 405 IAC 5-21.7.

(5) Individualized family services plans.

(6) Individualized education plans.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-4; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-5 405 IAC 14-4-5 Self-referral

405 IAC 14-4-5 Self-referral

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 5. An MCO for HCC shall meet the self-referral requirements at 405 IAC 14-6-7.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-5; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-6 405 IAC 14-4-6 Direct access

405 IAC 14-4-6 Direct access

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 6. An MCO for HCC shall meet the direct access requirements at 405 IAC 14-6-8.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-6; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-7 405 IAC 14-4-7 Medical necessity

405 IAC 14-4-7 Medical necessity

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 7. For a service to be covered under HCC, it must be medically necessary as defined at 405 IAC 5-2-17.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-7; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-8 405 IAC 14-4-8 Second opinions

405 IAC 14-4-8 Second opinions

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 8. An MCO for HCC shall meet the requirements regarding second opinions at 405 IAC 14-6-10.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-8; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-9 405 IAC 14-4-9 Utilization management

405 IAC 14-4-9 Utilization management

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12; IC 27-1-37.5-17

Sec. 9. (a) An MCO shall operate and maintain its own utilization management (UM) program based on the requirements and limitations in this section.

(b) Through the MCO's utilization management (UM) program, an MCO may place appropriate limits on covering services based on medical necessity or utilization control criteria, if the services furnished can reasonably be expected to achieve their intended purpose.

(d) An MCO shall follow the office's UM hierarchy, which includes the following:

(1) Compliance with applicable federal requirements.

(2) Compliance with applicable Indiana law.

(3) Compliance with the Indiana Medicaid state plan.

(4) Compliance with any applicable Indiana Administrative Code requirements.

(5) Using Medicaid FFS policies for the following services:

(A) Applied behavioral analysis therapy.

(B) Drug testing.

(D) Hysterectomies.

(E) RELiZORB.

(F) Speech-generating devices.

(G) Spinal stenosis.

(H) Transplants.

(I) Bariatric procedures.

(J) Oxygen usage.

(7) MCO developed criteria, which must be preapproved by the office before carrying out the criteria.

(8) Professional society guidelines.

(9) Professional references or guidance by subject matter expert published peer reviewed literature.

(10) Best standards of care, guided by published peer reviewed literature.

(e) The MCO requires providers to submit the Indiana health coverage program prior authorization request form developed by the office for services requiring prior authorization.

(f) The MCO's program must allow a provider the right for a peer to peer utilization review under IC 27-1-37.5-17.

(1) member or provider requests an extension; or

(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.

(1) member or provider requests an extension; or

(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.

(j) An extension granted under subsections (h) and (i) requires written notice to the member, which must include the reason for the extension and the member's right to file a grievance.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-9; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-10 405 IAC 14-4-10 Emergency and poststabilization care services

405 IAC 14-4-10 Emergency and poststabilization care services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 10. (a) An MCO shall cover emergency services as follows:

(1) The MCO shall not require prior authorization for the service.

(2) The MCO shall not require the emergency care provider to be contracted with the MCO.

(3) Services must be available to members twenty-four (24) hours a day, seven (7) days a week.

(b) An MCO shall include urgent care clinics in the MCO's contracted provider networks, which must be made available to members not less then eleven (11) hours each day Monday through Friday and no less than five (5) hours each day on weekends.

(d) Non-physician emergency care providers who do not have a contract with the MCO are reimbursed at not more than one hundred percent (100%) of the Medicaid fee schedule rate set by the state under 405 IAC 1-8-3, unless other payment arrangements are made, while physician services are reimbursed at one hundred percent (100%) of the prior year Medicare rates.

(e) The MCO shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent.

(f) An MCO shall cover poststabilization care services for members under federal requirements at 42 CFR 438.114(e) and 42 CFR 422.113(c), and state law at IC 12-15-12-17.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-10; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-11 405 IAC 14-4-11 Enhanced services

405 IAC 14-4-11 Enhanced services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 11. (a) HCC MCOs are encouraged to cover enhanced programs and services beyond those services covered in HCC that are designed to enhance the general health and quality of life of the MCO's HCC members, including programs addressing preventive health, risk factors, or quality of life.

(b) A program or service offered by the MCO under subsection (a) must:

(1) be approved by the office before the MCO initiates the service or program; and

(2) comply with the requirements related to member incentives and inducements set forth in the MCO's contract with the office and relevant state and federal laws.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-11; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-12 405 IAC 14-4-12 Continued of care

405 IAC 14-4-12 Continued of care

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 12. An MCO shall provide ninety (90) calendar days of continued care for preexisting drug regimens and service authorizations for new HCC members transitioning to the MCO from another coverage source.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-12; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-13 405 IAC 14-4-13 Out-of-network services

405 IAC 14-4-13 Out-of-network services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 13. (a) An MCO may limit its coverage to services provided by in-network providers after the MCO meets network access standards related to providing necessary covered medical services within designated time, distance, and access standards set forth in the MCO's contract with the office. This ability to limit to in-network providers is based on the requirements in sections 5, 10, and 12 of this rule.

(c) The cost to a member for out-of-network services shall be not greater than it would be if the services were furnished by a provider contracted with the MCO under 42 CFR 438.206(b)(5).

(d) A MCO shall reimburse both in-network and out-of-network providers for covered services at a rate not less than the minimum fee schedule rate set by the state under 405 IAC 1-8-3.

(e) Out-of-network physician services are reimbursed at one hundred percent (100%) of the prior year Medicare rates.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-13; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-4-14 405 IAC 14-4-14 Claims processing and reimbursement

405 IAC 14-4-14 Claims processing and reimbursement

Authority: IC 12-15-1-10

Affected: IC 12-15-12; IC 12-15-13; IC 12-15-21-3; IC 27-13-36.2-3

Sec. 14. (a) The MCO shall reimburse providers for covered medically necessary services rendered to the MCO's members under the claims processing and confidentiality standards set forth in IC 12-15-13-1.5, IC 12-15-13-1.6, and IC 12-15-13-1.7, unless the MCO and provider agree to an alternate payment schedule and method.

(b) The MCO shall process claims from providers under 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), which require the MCO to ensure the receipt date is the date the MCO receives the claim, as indicated by the date stamp on the claim, while the payment date is the date of the check or other form of payment.

(1) twenty-one (21) calendar days after receiving an electronically filed clean claim; and

(2) thirty (30) calendar days after receiving paper claims.

(d) If the MCO fails to pay or deny a clean claim, irrespective of whether the provider submitting the claim is contracted with the MCO, within the time frames in subsection (c) and later reimburses for any services itemized in the claim, the MCO shall also pay the provider interest at the rate set forth in IC 12-15-21-3(7)(A). This interest is paid on clean claims paid late that the MCO is responsible for, unless the MCO and provider have made alternate written payment arrangements.

(e) The MCO shall reject or deny unclean claims within one (1) year after receiving the claims.

(f) The MCO shall meet the requirements and provider notification of claim deficiencies timelines set forth in IC 27-13-36.2-3.

(g) The time limit for submitting claims to the MCO are as follows:

(1) one hundred eighty (180) days after the service date for claims submitted by a provider not contracted with the MCO; and

(2) generally ninety (90) calendar days after the service date for claims submitted by a provider contracted with the MCO, with the filing limit further established in the MCO's contract with the office.

(h) The timely filing limits in subsection (g) are automatically waived by the MCO in certain instances that include:

(1) office error;

(2) eligibility changes, including retroactivity; or

(3) any other condition established by the office.

(Office of the Secretary of Family and Social Services; 405 IAC 14-4-14; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

Rule 5

405 IAC 14-5-1 405 IAC 14-5-1 Member enrollment

Rule 5. Hoosier Healthwise

405 IAC 14-5-1 Member enrollment

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-17.6-2

Sec. 1. (a) Individuals enrolled in Medicaid are mandatorily enrolled in an HHW MCO if they are in any of the following categories:

(1) Children.

(2) Pregnant women.

(3) Low income families.

(b) Enrollment in an HHW MCO is mandatory for individuals enrolled in CHIP.

(c) American Indian/Alaska Native enrollees otherwise mandatorily enrolled in managed care under subsection (a) or (b) may choose to receive services through FFS.

(d) Members meeting any of the following are excluded from HHW managed care enrollment:

(1) Individuals enrolled in an HCBS waiver operated by the office.

(2) Individuals receiving hospice services.

(3) Individuals receiving psychiatric treatment in a state hospital.

(4) Wards and foster children.

(5) Children receiving adoption assistance.

(6) Undocumented persons.

(7) ICF/IID residents.

(8) Nursing facility residents.

(9) Psychiatric residential treatment facility residents, unless covered by an EPSDT exception.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-1; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-2 405 IAC 14-5-2 Provider enrollment and credentialing

405 IAC 14-5-2 Provider enrollment and credentialing

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-17.6-2

Sec. 2. (a) The office considers a provider eligible to participate in HHW when the provider enrolls with the office.

(b) A HHW provider eligible and required to enroll with the office as a provider must first be enrolled with the office as a provider before providing services to members. After the provider enrolls with the office, the provider may contract with any MCO providing services to HHW members.

(f) The MCO shall ensure access to a PMP at least thirty (30) miles from the member's residence.

(g) Provider types that may serve as HHW PMPs include:

(1) internal medicine physicians;

(2) general practitioners;

(3) family medicine physicians;

(4) pediatricians;

(5) obstetricians;

(6) gynecologists;

(7) endocrinologists, if primarily engaged in internal medicine; and

(8) physician assistants.

(h) Providers eligible to serve as a PMP may contract with more than one (1) MCO to serve as a PMP, or may serve as a PMP in at least one (1) MCO and as a specialist with at least one (1) other MCO.

(i) An MCO shall have a mechanism in place to ensure the MCO's contracted PMPs:

(1) provide or arrange for covering covered services twenty-four (24) hours a day, seven (7) days a week;

(3) provide "live voice" coverage after normal business hours, which may include an answering service or a shared call system with other medical providers.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-2; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-3 405 IAC 14-5-3 Covered services

405 IAC 14-5-3 Covered services

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

Sec. 3. (a) Individuals enrolled in HHW based on Medicaid eligibility shall receive the traditional Medicaid services outlined in 405 IAC 5.

(b) Individuals enrolled in HHW based on CHIP eligibility shall receive covered CHIP services outlined in 405 IAC 13.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-3; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-4 405 IAC 14-5-4 Managed care carve-outs

405 IAC 14-5-4 Managed care carve-outs

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

Sec. 4. Individuals enrolled in HHW shall receive the covered services in section 3 of this rule through a capitated managed care arrangement, through the MCO in which the individual is enrolled, except for the following covered services, which are delivered outside the capitated managed care arrangement and delivered through FFS:

(1) Medicaid rehabilitation option at 405 IAC 5-21.5.

(2) Adult mental health habilitation services at 405 IAC 5-21.6.

(3) Behavioral and primary health care coordination at 405 IAC 5-21.8.

(4) Child mental health wraparound services at 405 IAC 5-21.7

(5) Individualized family services plans.

(6) Individualized education plans.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-4; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-5 405 IAC 14-5-5 Self-referral

405 IAC 14-5-5 Self-referral

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-11; IC 12-15-12; IC 12-17.6-2; IC 25-10-1-1; IC 25-22.5; IC 25-24; IC 25-29

Sec. 5. (a) An MCO shall include self-referral providers in their contracted networks.

(b) Self-referral services are those that do not require a referral by an enrollee's PMP or other authorization by the MCO, and for which members may self-refer to any provider enrolled with the office qualified to provide the service.

(1) Emergency services are covered without needing prior authorization or an existing MCO contract with the emergency care provider.

(2) Urgent care services.

(3) Family planning services may be provided by a provider contracted with the office qualified to provide the family planning service, including providers not in the MCO's network.

(4) Immunizations are self-referral to a provider enrolled with the office.

(5) Podiatric services may be provided by a provider licensed under IC 25-22.5 or IC 25-29 who has entered into a provider agreement with the office under IC 12-15-11.

(6) Psychiatric services may be provided by a provider licensed under IC 25-22.5 who has entered into a provider agreement with the office under IC 12-15-11.

(7) Eye care services, except surgical services, may be provided by a provider licensed under IC 25-22.5 or IC 25-24 who has entered into a provider agreement with the office under IC 12-15-11.

(8) Diabetes self-management services are self-referral if given by a self-referral provider.

(9) Chiropractic services may be provided by a licensed chiropractor when given within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-3 by a provider who has entered into a provider agreement with the office under IC 12-15-11.

(10) Routine dental services may be provided by a licensed dental provider contracted with the MCO who has entered into a provider agreement with the office under IC 12-15-11.

(11) Nonpsychiatric behavioral health services are self-referral when provided by a provider contracted with the MCO. This includes mental health, substance abuse, and chemical dependency services given by mental health specialty providers.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-5; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-6 405 IAC 14-5-6 Direct access

405 IAC 14-5-6 Direct access

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

Sec. 6. An MCO for HHW shall meet the direct access requirements at 405 IAC 14-6-8.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-6; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-7 405 IAC 14-5-7 Medical necessity

405 IAC 14-5-7 Medical necessity

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

Sec. 7. For a service to be covered under HHW, it must be medically necessary as defined at 405 IAC 5-2-17.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-7; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-8 405 IAC 14-5-8 Second opinions

405 IAC 14-5-8 Second opinions

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12

Sec. 8. An MCO for HHW shall meet the requirements regarding second opinions at 405 IAC 14-6-10.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-8; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-9 405 IAC 14-5-9 Utilization management

405 IAC 14-5-9 Utilization management

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2; IC 27-1-37.5-17

Sec. 9. (a) An MCO shall operate and maintain its own utilization management (UM) program based the requirements and limitations in this section.

(b) Through the MCO's UM program, the MCO may place appropriate limits on covering services based on medical necessity or utilization control criteria, if the services furnished can reasonably be expected to achieve their intended purpose.

(d) The MCO shall follow the office's UM hierarchy, which includes the following:

(1) Compliance with applicable federal requirements.

(2) Compliance with applicable Indiana law.

(3) Compliance with the Indiana Medicaid state plan.

(4) Compliance with applicable Indiana Administrative Code requirements.

(5) Using Medicaid FFS policies for the following services:

(A) Applied behavioral analysis therapy.

(B) Drug testing.

(D) Hysterectomies.

(E) RELiZORB.

(F) Speech-generating devices.

(G) Spinal stenosis.

(H) Transplants.

(I) Bariatric procedures.

(J) Oxygen usage.

(7) MCO developed criteria, which must be preapproved by the office before carrying out of the criteria.

(8) Professional society guidelines.

(9) Professional references or guidance by subject matter expert published peer reviewed literature.

(10) Best standards of care, guided by published peer reviewed literature.

(e) The MCO requires providers to submit the Indiana health coverage program prior authorization request form developed by the office for services requiring prior authorization.

(f) The MCO's program must allow a provider the right for a peer to peer utilization review under IC 27-1-37.5-17.

(1) member or provider requests an extension; or

(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.

(1) member or provider requests an extension; or

(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.

(j) An extension granted under to subsections (h) and (i) requires written notice to the member, which must include the reason for the extension and the member's right to file a grievance.

(k) Unless otherwise provided in 405 IAC 5-3-14, if an MCO fails to respond to a member's prior authorization request within five (5) calendar days after receiving the necessary documentation, the authorization is considered to be granted.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-9; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-10 405 IAC 14-5-10 Emergency and poststabilization care services

405 IAC 14-5-10 Emergency and poststabilization care services

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

Sec. 10. (a) An MCO shall cover emergency services as follows:

(1) The MCO shall not require prior authorization for the service.

(2) The MCO shall not require the emergency care provider to be contracted with the MCO.

(3) Services are available to members twenty-four (24) hours a day, seven (7) days a week.

(b) An MCO shall include urgent care clinics in the MCO's contracted provider networks, which must be made available to members not less then eleven (11) hours each day Monday through Friday, and not less than five (5) hours each day on weekends.

(d) Non-physician emergency care providers who do not have a contract with the MCO shall be reimbursed at no more than one hundred percent (100%) of the Medicaid fee schedule rate set by the state under 405 IAC 1-8-3, unless other payment arrangements are made, while physician services are reimbursed at one hundred percent (100%) of the prior year Medicare rates.

(e) The MCO shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent.

(f) Emergency and poststabilization care services, as set forth at 405 IAC 14-6-12, apply to HHW MCOs.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-10; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-11 405 IAC 14-5-11 Enhanced services

405 IAC 14-5-11 Enhanced services

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

Sec. 11. (a) HHW MCOs are encouraged to cover enhanced programs and services beyond those services covered in HHW that are designed to enhance the general health and quality of life of the MCO's HHW members, including programs addressing preventive health, risk factors, or quality of life.

(b) A program or service offered by the MCO under subsection (a) must:

(1) be approved by the office before the MCO's initiates the service or program; and

(2) comply with the requirements related to member incentives and inducements set forth in the MCO's contract with the office and relevant state and federal rules.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-11; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-12 405 IAC 14-5-12 Continued care

405 IAC 14-5-12 Continued care

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

Sec. 12. An MCO shall provide for ninety (90) calendar days of continued care for preexisting drug regimens and service authorizations for new HHW members transitioning to the MCO from another coverage source.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-12; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-13 405 IAC 14-5-13 Out-of-network services

405 IAC 14-5-13 Out-of-network services

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2

(c) The cost to a member for out-of-network services shall be not greater than it would be if the services were furnished by a provider contracted with the MCO under 42 CFR 438.206(b)(5).

(d) The MCO shall reimburse both in-network and out-of-network providers for covered services at a rate not less than the minimum fee schedule rate set by the state under 405 IAC 1-8-3.

(e) Out-of-network physician services are reimbursed at one hundred percent (100%) of the prior year Medicare rates.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-13; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-5-14 405 IAC 14-5-14 Claims processing and reimbursement

405 IAC 14-5-14 Claims processing and reimbursement

Authority: IC 12-15-1-10; IC 12-17.6-2-11

Affected: IC 12-15-12; IC 12-17.6-2

Sec. 14. Claims processing and reimbursement, as set forth at 405 IAC 14-4-14, applies to HHW MCOs.

(Office of the Secretary of Family and Social Services; 405 IAC 14-5-14; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

Rule 6

405 IAC 14-6-1 405 IAC 14-6-1 Member enrollment

Rule 6. Indiana PathWays for Aging

405 IAC 14-6-1 Member enrollment

Authority: IC 12-15-1-10

Affected: IC 12-15-12

Sec. 1. (a) Individuals at least sixty (60) years of age enrolled in Medicaid based on eligibility under one (1) of the following categories are mandatorily enrolled in an MCO through the PathWays managed care program, including those meeting age requirements and are served on the PathWays waiver operated by the office under Section 1915(c) of the Social Security Act or are in a nursing facility:

(1) Aged (MA A).

(2) Blind (MA B).

(3) Disabled (MA D).

(4) SSI recipients (MASI).

(5) MED Works (MADW, MADI).

(6) Full benefit dually-eligibles (QMB-Also, SLMB-Also, and FBDE).

(b) Members meeting any of the following are excluded from PathWays managed care enrollment:

(1) Individuals enrolled in an HCBS waiver operated by the office other than the PathWays 1915(c) waiver.

(2) Partial benefit dual eligibles.

(3) ICF/IID residents.

(4) Individuals who have chosen to enroll in the Program of All-Inclusive Care for the Elderly.

(5) Individuals under sixty (60) years of age.

(6) End state renal disease Section 1115 Demonstration enrollees.

(7) Residential care assistance program enrollees.

(8) Refugees.

(9) Enrollees with a traumatic brain injury in an out-of-state treatment facility.

(10) Individuals receiving psychiatric treatment in a state hospital.

(c) The following individuals meeting the PathWays criteria described in subsection (a) may opt into the PathWays program:

(1) American Indian/Alaska Native members of a federally recognized tribe.

(2) Individuals receiving participant directed home care services under 1915(c) waiver authority.

(3) Individuals receiving hospice services after becoming sixty (60) years of age or receiving hospice services after initial implementation of PathWays July 1, 2024, regardless of the individual's age.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-1; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-2 405 IAC 14-6-2 Provider enrollment, credentialing, and PMP requirements

405 IAC 14-6-2 Provider enrollment, credentialing, and PMP requirements

Authority: IC 12-15-1-10

Affected: IC 12-15-12

Sec. 2. (a) The office considers a provider eligible to participate in PathWays when the provider enrolls with the office.

(b) A PathWays providers eligible and required to enroll with the office as a provider must first be enrolled with the office as providers before providing services to members. After the provider enrolls with the office, the provider may contract with any MCO providing services to PathWays members.

(c) Providers delivering HCBS to PathWays members shall meet the office's provider criteria and be certified by the office.

(d) An MCO shall have written credentialing, provisional credentialing, and recredentialing policies and procedures in place for ensuring that contracted providers hold current state licensure and are enrolled with the office.

(e) An MCO shall demonstrate compliance with 42 CFR 438.208, specifically in ensuring that each member has a PMP responsible for providing an ongoing source of primary care appropriate to the member's needs, including coordinating each member's physical and behavioral health care and making any necessary referrals.

(f) A referral from a member's PMP is required when the member receives physician services from a provider other than their PMP, unless the service is a self-referral or direct access service as set forth at sections 7 and 8 of this rule.

(g) The MCO shall ensure access to a PMP at least thirty (30) miles from the member's residence.

(h) Provider types that may serve as PathWays PMPs include:

(1) internal medicine physicians;

(2) general practitioners;

(3) family medicine physicians;

(4) gynecologists;

(5) endocrinologists, if primarily engaged in internal medicine;

(6) geriatricians;

(7) physician assistants; and

(8) advanced practice nurse.

(i) Providers eligible to serve as a PMP may contract with more than one (1) MCO to serve as a PMP, or may serve as a PMP in at least one (1) MCO and as a specialist with at least one (1) other MCO.

(j) A PMP shall be available to see members at least three (3) days a week for at least twenty (20) hours a week at any combination of not more than two (2) locations.

(k) An MCO shall have a mechanism in place to ensure the MCO's contracted PMPs:

(1) provide or arrange for covering services twenty-four (24) hours a day, seven (7) days a week;

(3) provide "live voice" coverage after normal business hours, which may include an answering service or a shared call system with other medical providers.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-2; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-3 405 IAC 14-6-3 Medicare election

405 IAC 14-6-3 Medicare election

Authority: IC 12-15-1-10

Affected: IC 12-15-12

Sec. 3. (a) To enroll in PathWays, a prospective member eligible for Medicare shall:

(1) enroll in and remain enrolled in, each part of Medicare they are is eligible for, including Medicare Part A, Part B, and Part D; or

(2) obtain all Medicare Part A, Part B, and Part D benefits, if eligible, from the MCO's special needs plan.

(b) A member who becomes Medicare eligible after enrolling in PathWays must enroll in each part of Medicare the are eligible for.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-3; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-4 405 IAC 14-6-4 LTSS functional eligibility

405 IAC 14-6-4 LTSS functional eligibility

Authority: IC 12-15-1-10

Affected: IC 12-10-11.5-4; IC 12-15-12

Sec. 4. (a) In addition to meeting general Medicaid eligibility criteria, otherwise eligible individuals receiving long term services and supports (LTSS) must have a nursing facility level of care, as determined by the InterRAI assessment, and meet the requirements under IC 12-10-11.5-4.

(b) Initial level of care assessment is completed using the interRAI assessment by the office's LOCA and shall not be conducted by an MCO.

(c) The LOCA shall provide information about the available HCBS and LTSS services the State offers, describing the program, including;

(1) how managed care works;

(2) covered benefits; and

(3) provider networks;

and supporting individuals in connecting with the enrollment broker, for each individual referred for a level of care assessment, at least sixty (60) years of age and either Medicaid enrolled or determined to be likely eligible for Medicaid.

(d) After an enrollee's enrollment with an MCO under PathWays, the enrollee's assigned MCO is responsible for ensuring the enrollee has a current and accurate level of care as determined by the interRAI Assessment under the MCO's contract with the office.

(e) The MCO responsibility in subsection (d) includes at least an annual redetermination of an enrollee's level of care for any enrollee receiving LTSS. It may also include a postenrollment redetermination shortly after enrollment, or a redetermination required by a change in the enrollee's condition.

(f) For an individual receiving LTSS and admitted to a nursing facility and is reasonably expected to no longer meet nursing facility level of care criteria within a period of thirty (30), sixty (60), ninety (90), or one hundred twenty (120) days, the MCO shall ensure the enrollee's level of care is reassessed during the respective period.

(g) The enrollee's MCO shall not complete the level of care determination or reassessment but shall work with the office's LOCA and the enrollee to ensure the level of care is determined at least annually, and as otherwise required in subsections (d) through (g).

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-4; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-5 405 IAC 14-6-5 Covered services

405 IAC 14-6-5 Covered services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 5. (a) Individuals enrolled in PathWays shall receive the traditional Medicaid services outlined in 405 IAC 5.

(b) In addition to the services in subsection (a), individuals enrolled in PathWays meeting a nursing facility level of care, as determined under section 4 of this rule, are eligible to receive HCBS waiver services.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-5; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-6 405 IAC 14-6-6 Managed care carve-outs

405 IAC 14-6-6 Managed care carve-outs

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 6. Individuals enrolled in PathWays shall receive the covered services described in section 5 of this rule through a capitated managed care arrangement through the MCO in which the individual is enrolled, the following covered services, which are delivered outside the capitated managed care arrangement and delivered through FFS:

(1) Medicaid rehabilitation option at 405 IAC 5-21.5.

(2) Adult mental health habilitation services at 405 IAC 5-21.6.

(3) Behavioral and primary health care coordination at 405 IAC 5-21.8.

(4) Covered nonlegend, over-the-counter, drugs, as set forth at 405 IAC 5-24.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-6; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-7 405 IAC 14-6-7 Self-referral

405 IAC 14-6-7 Self-referral

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-11; IC 12-15-12; IC 25-10-1-1; IC 25-22.5; IC 25-23-1-1; IC 25-24; IC 25-29

Sec. 7. (a) An MCO shall include self-referral providers in their contracted networks.

(1) Emergency services are covered without needing prior authorization or an existing MCO contract with the emergency care provider.

(2) Urgent care services.

(3) Family planning services may be provided by a provider contracted with the office qualified to provide the family planning service, including providers not in the MCO's network.

(4) Immunizations are self-referral to a provider enrolled with the office.

(5) Podiatric services may be provided by a provider licensed under IC 25-22.5 or IC 25-29 who has entered into a provider agreement with the office under IC 12-15-11.

(6) Psychiatric services may be provided by a provider licensed under IC 25-22.5 who has entered into a provider agreement with the office under IC 12-15-11.

(7) Eye care services, except surgical services, may be provided by a provider licensed under IC 25-22.5 or IC 25-24 who has entered into a provider agreement with the office under IC 12-15-11.

(8) Diabetes self-management services are self-referral if given by a self-referral provider.

(9) Chiropractic services may be provided by a licensed chiropractor when given within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1 by a provider who has entered into a provider agreement with the office under IC 12-15-11.

(10) Routine dental services may be provided by a licensed dental provider contracted with the MCO who has entered into a provider agreement with the office under IC 12-15-11.

(A) Outpatient mental health clinics.

(B) Community mental health centers.

(D) Licensed psychologists.

(E) Health services providers in psychology.

(F) Licensed social workers.

(G) Licensed clinical social workers.

(H) Psychiatric nurses.

(I) Independent practice school psychologists.

(J) Advanced practice nurses under IC 25-23-1-1(b)(3), credentialed in psychiatric or mental health nursing by the American Nurses Credentialing Center.

(K) Persons holding a master's degree in social work, marital and family therapy, or mental health counseling.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-7; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-8 405 IAC 14-6-8 Direct access

405 IAC 14-6-8 Direct access

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 8. (a) Under federal requirements at 42 CFR 438.206(b)(2), an MCO serving the PathWays program must provide female PathWays members with direct access to a women's health specialist within the MCO's network for covered care necessary to provide routine and preventive health care services to women. This access is in addition to a female member's designated primary care source if that source is not a health specialist.

(b) Under federal requirements at 42 CFR 438.208(c), an MCO serving the PathWays program must allow PathWays a member with special needs, determined to need a course of treatment or regular care monitoring, to directly access a specialist for treatment appropriate for the member's condition and identified needs.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-8; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-9 405 IAC 14-6-9 Medical necessity

405 IAC 14-6-9 Medical necessity

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 9. For a service to be covered under the PathWays program, it must be medically necessary as defined at 405 IAC 5-2-17.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-9; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-10 405 IAC 14-6-10 Second opinions

405 IAC 14-6-10 Second opinions

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 10. (a) Under federal requirements at 42 CFR 438.206(b)(3), an MCO shall comply with any member request for a second opinion from a qualified professional.

(b) If the MCO's contracted provider network does not include a provider qualified to give a second opinion as requested by a member, the MCO shall arrange for the member to obtain a second opinion from a provider outside the MCO's network, at no cost to the member.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-10; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-11 405 IAC 14-6-11 Utilization management

405 IAC 14-6-11 Utilization management

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12; IC 27-1-37.5-17

Sec. 11. (a) An MCO shall operate and maintain its own utilization management (UM) program based on the requirements and limitations in this section.

(c) Under 42 CFR 438.210(a)(3)(ii), the MCO shall not arbitrarily deny or reduce the amount, duration, or scope of required services solely because of a member's diagnosis, type of illness, or condition.

(d) The MCO shall follow the office's UM hierarchy, which includes the following:

(1) Compliance with applicable federal requirements.

(2) Compliance with applicable Indiana law.

(3) Compliance with the Indiana Medicaid state plan.

(4) Compliance with applicable Indiana Administrative Code requirements.

(5) Using of Medicaid FFS policies for the following services:

(A) Applied bedhavioral analysis therapy.

(B) Drug testing.

(D) Hysterectomies.

(E) RELIZORB.

(F) Speech-generating devices.

(G) Spinal stenosis.

(H) Transplants.

(I) Bariatric procedures.

(J) Oxygen usage;.

(7) MCO developed criteria, which must be preapproved by the office before carrying out the criteria.

(8) Professional society guidelines.

(9) Professional references or guidance by subject matter expert published peer reviewed literature.

(10) Best standards of care, guided by published peer reviewed literature.

(e) The MCO shall require a provider to submit the Indiana health coverage program prior authorization request Form developed by the office for services requiring prior authorization.

(f) An MCO's program must allow a provider the right for a peer to peer utilization review under IC 27-1-37.5-17.

(g) An MCO must give written notice to a member and provider of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements of 42 CFR 438.404. PathWays members enrolled in an aligned DSNP must be given a single integrated decision notice under the requirements in 42 CFR 422.629.

(h) The MCO shall notify members of standard authorization decisions as quickly as needed by the member's health condition, not to exceed five (5) calendar days after the request for services, unless otherwise provided in 405 IAC 5-3-14. An extension of up to fourteen (14) calendar days is permitted if the:

(1) member or provider requests an extension, or

(2) MCO provides justification to the office of a need for more information and explains how the extension is in the member's best interest.

(i) Whenever a provider indicates, or the MCO determines, that following the standard time frame may seriously jeopardize a member's life, health, or ability to attain, maintain, or regain maximum function, the MCO shall make an expedited authorization decision and give notice as quickly as needed by the member's health condition not later than forty-eight (48) hours after receiving of the service request. The MCO may extend the forty-eight (48) hours by up to fourteen (14) calendar days if the:

(1) member or provider requests an extension, or

(2) MCO provides justification to the office of a need for more information and explains how the extension is in the member's best interest.

(j) An extension granted under subsections (h) and (i) requires written notice to the member, which must include the reason for the extension and the member's right to file a grievance.

(k) Unless otherwise provided in 405 IAC 5-3-14, if an MCO fails to respond to a member's prior authorization request within five (5) calendar days after receiving the required documentation, the authorization is considered to be granted.

(l) For authorization requests related to HCBS, the MCO shall make an expedited authorization decision and give notice to the member within twenty-four (24) hours after the decision to deny authorization for services contained in the member's service plan. There are no conditions under which the MCO may extend that time frame.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-11; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-12 405 IAC 14-6-12 Emergency and poststabilization care services

405 IAC 14-6-12 Emergency and poststabilization care services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12-17

Sec. 12. (a) An MCO shall cover emergency services as follows:

(1) The MCO shall not require prior authorization for the service.

(2) The MCO shall not require the emergency care provider to be contracted with the MCO.

(3) Services are available to members twenty-four (24) hours a day, seven (7) days a week.

(b) An MCO shall include urgent care clinics in the MCO's contracted provider networks, which are made available to members not less than eleven (11) hours each day, Monday through Friday, and not less than five (5) hours each day on weekends.

(e) The MCO shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent.

(f) The MCO may choose to use a list of diagnosis codes to initially determine whether a service may be an emergency but shall, at least, use the emergency department autopay list developed by the office.

(g) An MCO shall cover poststabilization care services for members under federal requirements at 42 CFR 438.114(e) and 42 CFR 422.113(c), and state law at IC 12-15-12-17.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-12; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-13 405 IAC 14-6-13 Enhanced services

405 IAC 14-6-13 Enhanced services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 13. (a) PathWays MCOs are encouraged to cover enhanced programs and services beyond those services covered in PathWays designed to enhance the general health and quality of life of the MCO's PathWays members, including programs addressing preventive health, risk factors, or quality of life.

(b) A program or service offered by the MCO under subsection (a) must:

(1) be approved by the office before the MCO initiates the service or program; and

(2) comply with the requirements related to member incentives and inducements set forth in the MCO's contract with the office, and the relevant state and federal laws.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-13; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-14 405 IAC 14-6-14 Continued of care

405 IAC 14-6-14 Continued of care

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 14. (a) In the first year of the PathWays program, an MCO shall provide for one hundred twenty (120) calendar days of continued of care for all pre-existing drug regimens for new PathWays members enrolled with the MCO.

(b) After the first year of the PathWays program, an MCO shall provide for ninety (90) calendar days of continued of care for all pre-existing drug regimens for new PathWays members enrolled with the MCO.

(c) In the first year of the PathWays program, an MCO shall provide continued of care for the authorizing Medicaid state plan services, as well as choice of providers for one hundred twenty (120) days. For purposes of this requirement, when receiving PathWays members from another MCO, FFS, or commercial coverage, the MCO shall honor the previous care authorizations for one (1) of the following durations, whichever comes first:

(1) One hundred twenty (120) calendar days after the member's enrollment date with the MCO.

(2) The rest of the earlier authorized dates of service.

(3) Until the approved units of service are finished.

(d) In the first year of the PathWays program, an MCO shall provide continued care for a member who meets HCBS level of care and has an existing care plan approved by the office or another MCO, by:

(1) honoring the existing care plan for ninety (90) calendar days after the date of the member's enrollment with the MCO; and

(2) allowing a member to continue with the member's current medical or HCBS provider if the provider is not a contracted provider with the MCO for at least one hundred twenty (120) days, as long as the provider is enrolled with the office as a provider.

(e) After the first year of the PathWays program, the continued care provided under subsection (c) is ninety (90) days after the date of the member's enrollment with the MCO, while the time frame for honoring an existing care plan remain the same as identified in subsection (d)(1).

(f) Skilled nursing facilities are an exception to the continued care periods otherwise identified in this section. An MCO shall provide for continued care at a member's skilled nursing facility for the duration of the program, as long as the member chooses to remain in the facility and continues to meet skilled nursing facility level of care.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-14; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-15 405 IAC 14-6-15 Out-of-network services

405 IAC 14-6-15 Out-of-network services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12

Sec. 15. (a) An MCO may limit its coverage to services provided by in-network providers after the MCO meets network access standards related to providing required covered medical services within designated time, distance, and access standards set forth in the MCO's contract with the office. This ability to limit to in-network providers is based on the requirements under in sections 7, 12, and 14 of this rule.

(b) IF MCO cannot meet the network access standards described in subsection (a), the MCO shall authorize and pay for a member to receive services by a provider not contracted with the MCO under 42 CFR 438.206(b)(4).

(c) The cost to a member for out-of-network services shall be not greater than it would be if the services were furnished by a provider contracted with the MCO under 42 CFR 438.206(b)(5).

(d) The MCO shall reimburse both in-network and out-of-network providers for covered services at a rate not less than the minimum fee schedule set by the state in 405 IAC 1.

(e) Out-of-network physician services are reimbursed at one hundred percent (100%) of the prior year Medicare rates.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-15; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)

405 IAC 14-6-16 405 IAC 14-6-16 Claims processing and reimbursement

405 IAC 14-6-16 Claims processing and reimbursement

Authority: IC 12-15-1-10

Affected: IC 12-15-12; IC 12-15-13; IC 12-15-21-3; IC 27-13-36.2-3

Sec. 16. (a) For the first five (5) years the PathWays program is in operation, the following providers contracted with the office are reimbursed by an MCO at a rate not less than the FFS rate for the same service, regardless of whether the provider is contracted with the MCO:

(1) Skilled nursing facilities.

(2) Home health providers.

(3) Hospice providers.

(4) HCBS providers.

(b) The MCO shall reimburse providers not contracted with the MCO at the rates specified in section 15(d) of this rule.

(c) The MCO shall reimburse providers for covered medically necessary services given to the MCO's members under the claims processing and confidentiality standards set forth in IC 12-15-13-1.5, IC 12-15-13-1.6, and IC 12-15-13-1.7, unless the MCO and provider agree to an alternate payment schedule and method.

(d) The MCO shall process claims from providers under 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), which require the MCO to ensure the receipt date is the date the MCO receives the claim, as indicated by the date stamp on the claim, while the payment date is the date of the check or other form of payment.

(e) The MCO shall pay or deny a clean claim, as defined at 405 IAC 14-2-10, within the following:

(1) Electronically filed clean claims within twenty-one (21) calendar days after receiving a claim.

(2) Paper claims within thirty (30) calendar days after receiving a claim.

(f) If the MCO fails to pay or deny a clean claim, irrespective of whether the provider submitting the claim is contracted with the MCO, within the time frames described in subsection (e) and later reimburses for any services itemized in the claim, the MCO shall also pay the provider interest at the rate set forth in IC 12-15-21-3(7)(A). This interest is paid on clean claims paid late that the MCO is responsible, unless the MCO and provider have made alternate written payment arrangements.

(g) The MCO shall reject or deny unclean claims within thirty (30) days after receiving a claim.

(h) The MCO shall meet the requirements and provider notification of claim deficiencies timelines set forth in IC 27-13-36.2-3.

(i) The time limit for submitting claims to the MCO are as follows:

(1) Six (6) months after the date of service for claims submitted by a provider not contracted with the MCO.

(2) Generally ninety (90) calendar days after the date of service for claims submitted by a provider contracted with the MCO, with the filing limit further established in the MCO's contract with the office.

(j) The timely filing limits in subsection (i) are automatically waived by the MCO in certain instances, which include:

(1) office error;

(2) eligibility changes, including retroactivity; or

(3) any other condition established by the office.

(Office of the Secretary of Family and Social Services; 405 IAC 14-6-16; filed Aug 30, 2024, 11:42 a.m.: 20240925-IR-405240180FRA)