Nursing Facility and Hospital Frequently Asked Questions

In spring 2024, the enrollment broker (Maximus) will send notices through the mail to each eligible member currently served through Indiana Medicaid about the transition to PathWays. The notice will have contact information for the member including a phone number for questions to select a health plan as well as the PathWays website. Maximus will also call members and mail copies of the notices to authorized representatives. Additionally, FSSA will be conducting member engagement across Indiana during March 2024 to answer questions from members about notices as well as any other transition questions.

If the nursing facility is the Authorized Representative on file for the member, the nursing facility can assist the member select an MCE. If the member has a designated health care representative or a court appointed power of attorney or guardian, MCE selection decisions are made by these individuals.

Providers will check their patients’ Medicaid eligibility and MCE enrollment using the IHCP portal. Member MCE enrollment changes are effective on the first of the month. IHCP requires providers to verify member eligibility on the date of service, using the Eligibility Verification on the IHCP Portal, or through Interactive Voice Response system, or through approved vendor software for 270/271 batch. At a minimum LTSS providers should verify member eligibility and enrollment at the beginning of each calendar month.

Providers must be an approved IHCP provider before they can contract with an MCE.  However, the State encourages providers to reach out to the MCEs in the interim to discuss the contracting process.

An atypical provider refers to those that provide home and community-based services.  Not all atypical providers will have an NPI and in those instances the LPI will be acceptable as part of contracting with the MCEs.

Each MCE is required to have Provider Representatives and Provider Claims Educators for HCBS and LTSS providers, and a dedicated provider services helpline. MCEs have different staffing and support models to fulfill these requirements. Some MCEs may assign an account manager and others will have different contact methods for providers.

The MCEs will work with members to identify in-network providers in their area and coordinate with those providers.

Providers can find assigned MCE by verifying the members Medicaid eligibility. The eligibility record includes information on MCE enrollment. IHCP requires providers to verify member eligibility on the date of service, using the Eligibility Verification on the IHCP Portal, or through Interactive Voice Response system, or through approved vendor software for 270/271 batch. At a minimum LTSS providers should verify member eligibility at the beginning of each calendar month.

Members will begin receiving welcome packets from their assigned MCE during the month of June. Providers can check with the individuals they serve to confirm MCE assignment.

As part of the Comprehensive Health Assessment process, the MCE will work with the member and collect and review medical and educational information, as well as family and caregiver input, as appropriate, to identify the member’s care strengths, health needs and available resources. The Comprehensive Health Assessment may include, but is not limited to, a review of the member’s claims history and contact with the member and/or member’s family, their informal caregiver, PMP (if applicable), or other significant providers with the consent of the member.

Individuals will have a minimum of 60 days to select an MCE prior to being auto-assigned and auto-assignment will occur a minimum of 60 days before program go-live. This prospective assignment process has been designed to facilitate advanced care planning and ensure sufficient transition activities. MCE auto-assignment will occur by May 1, 2024.

Service plans are reviewed at least every 90 days and on an annual basis. Members are assessed upon enrollment with an MCE and are reassessed when there is a change in status and annually based on their NFLOC redetermination date. Changes and updates to an individual’s service plan are determined on the results of the individual’s assessment and reassessment.

The helpline is open M-F 8am-7pm. Outbound calls can be made any time the helpline is open, and will be dependent on their inbound call volume.

It does not affect the individual’s Medicare benefits. PathWays is a Medicaid managed care program designed to better coordinate care with an individual’s Medicare plan.

From July 1, 2024-December 31, 2024 individuals may be with one managed care entity, such as UHC for Medicaid, and also receiving their Medicare Advantage D-SNP benefits from Anthem. Beginning January 1, 2025, individuals can either be in an aligned managed Medicaid and Medicare Advantage D-SNP, such as Anthem for PathWays and Anthem for Medicare. Or individuals can be unaligned and choose a managed Medicaid health plan such as Anthem and be enrolled in traditional Medicare.

QMB coverage is not restricted to in-state services. Providers are never allowed to balance bill a beneficiary with QMB or QMB+ coverage for any Part A or Part B services. This does not necessarily mean IHCP or the PathWays MCEs will cover these costs, but regardless, the member cannot be billed.

PathWays MCEs will be responsible for payment of Medicare cost share.  Indiana Medicaid sets a minimum fee schedule. MCEs set their own reimbursement at or above that level, so any crossover payment is dependent on each MCE’s reimbursement. For members remaining in FFS, IHCP recently updated our Professional Fee Schedule to be set at 100% of the Medicare rate. See bulletin BT2023149.

PathWays claims for SCU/Vent Addon will use the revenue codes posted in IHCP bulletin BT202380. https://www.in.gov/medicaid/providers/files/bulletins/BT202380.pdf.
These codes will only pay if there is a corresponding room and board revenue code included on the claim.

In accordance with 405 IAC 1-14.7-7(c), FSSA has designated facilities that have received approval as a Special Care Unit (SCU). The list of approved SCUs and the add on rate for the period of 7/1/2023 through June 30, 2025 is located here.

Yes. IHCP policy states - Payment is based on the lower of the submitted charge or the rate on file minus copayment and third-party liability (TPL) amounts. Reference to this policy can be found here.

In the future rare instance of a retroactive rate change that could have claim impact, providers will need to replace the impacted claims with the new billed charges. Alternatively, if providers are aware that there will be a new rate published retroactively for the date of service, the provider can submit the original claim with the anticipated rate to ensure their claim is reprocessed and paid when there is a claims sweep following the loading of retroactive rates.

Medicaid eligibility and PathWays enrollment are separate but related events. If an individual is found eligible for Medicaid, the eligibility is retroactive to the date of their application, and their PathWays enrollment will be effective on the first day of the month in which they were determined Medicaid eligible. The retroactive eligibility between the application date and the enrollment effective date is covered via Fee-for-Service, as is any additional retroactive eligibility up to 3 months prior to the application date. Fee-for-Service claims will continue to be processed by Gainwell. When an individual applies for Medicaid and it looks like they may be eligible for PathWays, Maximus (the enrollment broker) will send them a letter letting them know they are potentially eligible for the PathWays program and instructing them to select an MCE. Members select MCEs for PathWays by calling Maximus. If the member does not select an MCE they are auto assigned to an MCE. The selection and assignment processes take place during the eligibility determination period. The effective date of enrollment is the same whether an MCE is assigned or selected during the eligibility determination period.

No. Medicaid recipients who are seeking admission to a Medicaid-certified Nursing Facility and are using Medicaid as their pay source, regardless of the length of stay, require a Level of Care (LOC) assessment and eligibility determination.  A nursing facility LOC determination serves as the prior authorization for nursing facility admissions and continued stays.

Anthem: Email: INMLTSSProviderRelations@anthem.com; Phone: 833-569-4739
Humana: Email: InMedicaidProviderRelations@humana.com; Phone: 866-274-5888
UnitedHealthcare: Email: in_providerservices@uhc.com; Phone: 877-610-9785

For the first two years of the PathWays program, MCEs must accept claims from both contracted and not contracted providers. This is referred to as an open network. During this period, even if a provider does not contract with an MCE, the provider will be able to bill and get paid for covered services. After the 2nd year, MCEs can request to close their network if they meet network adequacy and only allow participation by contracted providers. FSSA will review such requests and either approve or deny them. If FSSA approves network closure, enrollees will need to get services from contracted providers in their PathWays MCE’s provider network.
Although contracting with the MCEs is not required for the first two years, there are benefits to contracting:

• Faster access to provider portals
• Will appear in the provider directory
• Members will be encouraged to use network providers
• Dedicated Provider Education and Outreach representatives that are available to assist providers with day-to-day program inquiries

Additionally, for the first three years of the PathWays program, MCEs must contract with any willing LTSS provider who meets licensure and IHCP enrollment criteria and is willing to accept the provisions of the MCE’s contract. Following the end of the third year of PathWays, the MCEs may implement selective contracting, though still must meet network adequacy standards.

Each of the PathWays MCEs offers multiple claims submission options including:

• Paper claims submission
• Electronic submission via data entry in the MCEs’ Provider Portals
• Electronic EDI submission through an EDI Clearinghouse,

Where providers submit claims for PathWays enrollees depends on whether an enrollee has Medicare coverage, and if they do, where an enrollee gets their Medicare coverage:

• If an enrollee does not have Medicare coverage, providers will submit claims for Medicaid covered services to the enrollee’s PathWays MCE.
• If an enrollee is enrolled in the same PathWays MCE for both their Medicare and Medicaid coverage, providers will submit claims to the enrollee’s PathWays MCE, and the MCE will process it in consideration of Medicare and Medicaid coverage combined. However, providers will need to bill certain services on separate claims specifying whether the bill is for a Medicare covered service or a Medicaid covered service. This is the case for nursing facility claims which will require separate claims for Medicare covered skilled stays using Type of Bill 21x and for Medicaid covered skilled and custodial stays using Type of Bill 651.
• If an enrollee is enrolled in a PathWays MCE for only their Medicaid coverage and receives their Medicare benefits through Medicare fee-for-service, in most cases providers will submit claims for Medicare covered services to Medicare, and PathWays MCEs will receive and process Medicare Crossover Claims from the Medicare Administrative Contractor. Providers will submit claims for services only covered by Medicaid to the PathWays MCE.
• If an enrollee is enrolled in a Medicare Advantage Plan or a non-PathWays D-SNP, providers will submit claims for Medicare covered services to the Medicare Advantage Plan or non-PathWays D-SNP and submit a claim to the PathWays MCE for any crossover amounts accompanied by the Medicare EOB. Providers will submit claims for services only covered by Medicaid to the PathWays MCE.
  • Non-PathWays D-SNPs are only an option through 2024. In 2025 people who had received their Medicare coverage through a non-PathWays D-SNP will have to elect another option. Their options include:
    • A PathWays aligned D-SNP
    • Medicare Fee-for-Service
    • A Medicare Advantage Plan

The PathWays MCE Payor IDs are:

• Anthem= 00130 – 837I and 00630–837P
• Humana= 61101
• United Healthcare= 87726

Use these Payor IDs regardless of whether a service is covered by Medicare or Medicaid, or both.

Whether there is a Medicare Crossover Claim depends on where an enrollee gets their Medicare coverage:

• If an enrollee has aligned enrollment, is enrolled in the same PathWays MCE for both their Medicare and Medicaid coverage, there is no Medicare Crossover Claim. Providers will submit a single claim to the PathWays MCE, and the MCE will process it in consideration of Medicare and Medicaid coverage combined.
• If an enrollee is enrolled in a PathWays MCE for only their Medicaid coverage and receives their Medicare benefits through Medicare fee-for-service, in most cases the PathWays MCEs will receive and process Medicare Crossover Claims from the Medicare Administrative Contractor.
• If an enrollee is enrolled in a Medicare Advantage Plan or a non-PathWays D-SNP for their Medicare benefit, the provider needs to submit a crossover claim to the PathWays MCE accompanied by the EOB from the Medicare Advantage plan or non-PathWays D-SNP.

PathWays MCEs must update their claims system within 30 days following the issuance of updated rates by FSSA.

Yes, an individual having the same health plan for Medicare and Medicaid will better coordinate their care and supports.

Members can change their health plan by calling 87-PATHWAY-4 (1-877-284-9294). They can change their health plan for the following reasons:

• within 90 days of starting PathWays
• any time their Medicare and Medicaid plans are not the same
• once per calendar year for any reason at any time
• using the just cause process
• During the health plan selection period (mid-October to mid-December)

PathWays enrollees that also have Medicare have several options for how they get coverage of their Medicare benefits.

• They can choose to enroll in the aligned PathWays MCE’s D-SNP plan to maximize coordination and streamline their interactions with health plans
• They can choose to receive the Medicare through traditional Medicare (fee-for-service)
• They can choose to enroll in a Medicare Advantage plan
• If they already in a non-PathWays MCE’s D-SNP they can stay in that plan through 2024 and will need to choose another option for their Medicare benefits for 2025

Yes. All PathWays enrollees will get their Medicaid covered benefits through their PathWays MCE. PathWays enrollees that also have Medicare have several options for how they get coverage of their Medicare benefits.

• They can choose to enroll in the aligned PathWays MCE’s D-SNP plan to maximize coordination and streamline their interactions with health plans
• They can choose to receive the Medicare through traditional Medicare (fee-for-service)
• They can choose to enroll in a Medicare Advantage plan
• If they already in a non-PathWays MCE’s D-SNP they can stay in that plan through 2024 and will need to choose another option for their Medicare benefits for 2025

Yes. If a Medicaid eligible person is not eligible for full Medicare benefits but meets the other PathWays eligibility criteria, they will be enrolled in PathWays.

No. Some populations 60 and over are excluded from PathWays. These include:

• Partial dually eligible Medicare beneficiaries
• DDRS waiver recipients
• TBI waiver recipients,
• ICF/IDD residents
• PACE members
• RCAP members
• Anyone not eligible for full Medicaid benefits, for example, Package E Medicaid which only covers emergent services
  There are also some populations 60 and over who can opt-in to PathWays such as American Natives and Alaska Native and individuals receiving hospice services prior to age 60.

PathWays enrollees that also have Medicare have several options for how they get coverage of their Medicare benefits.

• They can choose to enroll in the aligned PathWays MCE’s D-SNP plan to maximize coordination and streamline their interactions with health plans
• They can choose to receive the Medicare through traditional Medicare (fee-for-service)
• They can choose to enroll in a Medicare Advantage plan
• If they already in a non-PathWays MCE’s D-SNP they can stay in that plan through 2024 and will need to choose another option for their Medicare benefits for 2025

Yes. All PathWays enrollees will get their Medicaid covered benefits through their PathWays MCE. PathWays enrollees that also have Medicare have several options for how they get coverage of their Medicare benefits.

• They can choose to enroll in the aligned PathWays MCE’s D-SNP plan to maximize coordination and streamline their interactions with health plans
• They can choose to receive the Medicare through traditional Medicare (fee-for-service)
• They can choose to enroll in a Medicare Advantage plan
• If they already in a non-PathWays MCE’s D-SNP they can stay in that plan through 2024 and will need to choose another option for their Medicare benefits for 2025

Yes. Dual eligibles under the age of 60 will not be in PathWays. PathWays is only for individuals 60 years and older who are eligible for full Medicaid benefits including individuals receiving HCBS services through the Aged and Disabled Waiver, individuals residing in nursing facility, and individuals receiving full Medicare benefits.

Sometimes. Patient liability is calculated as part of the eligibility determination process. However, patient liability can change based on changes in an eligible’s circumstances. When an eligible’s patient liability increases, the eligible must be given notice, and the change is effective the first of the month after the date of the notice of action, so is prospective and would not require claim reprocessing. When an eligible’s patient liability decreases, the new amount is normally effective the first of the month following reporting and verification and is intended to be prospective. However, there is a cutoff date near the end of the month for processing these changes. If the verification occurs after the cutoff date for processing the change, the effective date of the new amount is unaffected, but the change would be processed and implemented after the effective date and could result in the need to re-process claims.

No. Some populations 60 and over are excluded from PathWays. These include:

• Partial dually eligible Medicare beneficiaries
• DDRS waiver recipients
• TBI waiver recipients,
• ICF/IDD residents
• PACE members
• RCAP members
• Anyone not eligible for full Medicaid benefits, for example, Package E Medicaid which only covers emergent services
  There are also some populations 60 and over who can opt-in to PathWays such as American Natives and Alaska Native and individuals receiving hospice services prior to age 60.

The Enrollment Broker’s helpline is open M-F 8am-7pm. Outbound calls can be made any time the helpline is open and will be dependent on their inbound call volume.

A provider must be an approved IHCP provider before they can execute a contract with an MCE. However, the State encourages providers to reach out to the MCEs in the interim to discuss the contracting process.

Yes. If the claim denial was based on an error on the initially submitted claim, a provider can submit a corrected claim as soon as they learn of the denial.

There will be no changes to the current requirements for short-term admissions to a skilled nursing facility (SNF) after July 1st. Medicaid recipients who are seeking a skilled short-term admission to a Medicaid-certified Nursing Facility and are using Medicaid as their payer source, require a short-term Level of Care (LOC) assessment and eligibility determination approval for a 30, 60, 90, 120 calendar day stay. The short-term LOC will have an end date depending on the number of days approved. A short-term LOC determination serves as the prior authorization for nursing facility admissions and continued stays that fall within the dates listed on the LOC approval.

Yes. Hospice providers should continue to follow the general directions for completing the UB-04 claim form or electronic submission and use the hospice-specific billing information found in the IHCP Hospice Service Provider Module.

There is no requirement for MCEs to allow such overrides of timely filing requirements and they may use the date stamp from the clearinghouse to enforce timely filing requirements.

The service location name and address where the patient was seen are required and the address must match the service location address currently on file with the MCEs for the group or billing provider. Provider name is not a requirement to process the claim.

Providers can check the status of a submitted claim in the MCEs’ Provider Portals.

Please contact the PathWays MCEs to determine whether any re-enrollment is needed; whether separate FTE enrollment is required for the Medicaid PathWays MCE and the aligned Medicare D-SNP, and whether an entity can have more than on bank set up to receive EFT payments.

Anthem: Email: INMLTSSProviderRelations@anthem.com; Phone: 833-310-3775

Humana: Email: InMedicaidProviderRelations@humana.com; Phone: 866-274-5888

UnitedHealthcare: Email: in_providerservices@uhc.com; Phone: 877-610-9785

MCEs are required to pay all claims using the NPI number. As long as the provider’s profile is accurate, the EFT payment will align with the provider’s NPI.

Yes. Please refer to the IHCP FQHC Provider Reference Module here.

Providers can input a date range on a claim. This cannot be a future date range.

Yes. Providers can register for and use the MCE’s Provider Portals to monitor claims status even if they do not use the portals to submit claims.

Yes. Non-network providers can register for and use the Pathways MCEs’ Provider Portals.

When authorization is required, the process depends on the member’s status.

• For Medicaid only non-dual eligible PathWays enrollees, the provider will need to follow the PathWays MCE prior authorization process.
• For dual eligible enrollees with aligned enrollment (in the same PathWays MCE for both their Medicare and Medicaid coverage), the provider will submit one authorization request for both Medicare and Medicaid following the MCE prior authorization process.
• For dual eligible enrollee with non-aligned enrollment (enrolled in a PathWays MCE for Medicaid benefits but another payor for Medicare benefits), the provider will need to submit authorization requests to the Medicare payor for Medicare covered benefits, and authorization requests to the PathWays MCE for services only covered by Medicaid.

There will be no change to the current process for readmission to a skilled nursing facility (SNF) after July 1^st. The resident must have a current nursing facility level of care (NF LOC) on file to reside in a long-term care facility. The nursing facility level of care acts as the authorization to receive Medicaid covered services in the nursing facility.

A Service Coordinator is a person who will work with an individual to create a personalized Service Plan to help coordinate their Home and Community-Based Services (HCBS). The Service Plan will help develop a plan of care of services and supports that best meet the individual’s needs and goals.

Each MCE, Anthem, Humana and UnitedHealthcare (UHC) will have their own staffing structure.  However, all MCEs are required to employ a full-time Care Coordination Manager and a Service Coordination Administrator to oversee staffing of care and service coordination dedicated to the PathWays program.

MCE compliance will be assessed through FSSA review of staff trainings and regulatory reporting.

FSSA’s expectations of care and service coordinators is to ensure any outside clinical care and social services a member needs in a nursing facility are coordinated for the member. If a member wishes and is able to transition to a home and community-based setting, the care and service coordinator are responsible for leading the integrated care team to support a successful discharge, which means ensuring that the person has in-home supports when returning home. Additionally, the care and service coordinator are required to support an individual transitioning into a nursing facility (long-term or short-term stay). Care and service coordinators are not permitted to be incentivized or rewarded for transitioning members out of nursing facilities, and MCEs are not allowed to establish a minimum number of members that must be transitioned back to the community. Care and service coordinators will only explore community-based options for members who have the ability and/or desire to transition from a nursing facility to the community, and the decision is based on the individual’s needs and preferences.

Nursing facilities should provide the MCEs their facility’s preferred contacts for care coordinators and service coordinators.  OMPP expects the MCEs to honor nursing facilities requests regarding contacting and develop staff polices for outreaching facilities.

For all MCEs in the PathWays program, care coordinators and service coordinators are required to complete in-person visits with the resident. The care coordinator and service coordinator will visit in-person annually. The service coordinator will visit with the member in-person to assist with coordinating any outside supports needed by the resident as well as nursing facility.

Any virtual calls should be the request of the resident and it is expected that the MCE will work with the nursing facility to coordinate the virtual visit.

Care coordinators are not performing hands-on clinical care nor are they making clinical decisions for members. They are coordinating medical activities to support the member while service coordinators coordinate HCBS services.

While there is not language directly requiring nursing facility experience, care and service coordinators either have a clinical background in health care coordinating clinical type services for individuals, or an individual who has previous experience working in a field with older adults coordinating long-term services and supports.

No. The service and care coordinators will act as a liaison and connector between the individual, provider(s), and the MCE. These positions work for the MCE and should not be doing any activities that are part of the SNF's requirements when providing services to their patients.

No. Providers do not need to include patient liability amounts on a claim. The PathWays MCEs have patient liability information from Core MMIS and can apply this to claims received.

PathWays MCEs will deduct the full amount of patient liability from the first claim for a month if the claim amount satisfies the patient liability.

Yes. For the PathWays MCEs, the TIN is required on the 1500 and UB04 as part of the unified billing format.

All PathWays MCEs will require bill type 21x for Medicare skilled stays and 651 for Medicaid stays (skilled and custodial).

Sandata is FSSA’s electronic visit verification (EVV) platform. If a provider uses the Sandata State-sponsored EVV platform, then no, Sandata will not send the provider’s claims to the PathWays MCE, and a provider will need to submit their claims to the MCE or through an electronic clearinghouse. If a provider uses a different EVV vendor/platform the provider should engage with their vendor to determine whether that vendor offers claims submission.

Yes. A provider can use a third-party billing company for some billing services, but bill other services in-house for the PathWays program.

The billing requirements for this service are not changing. IHCC must be part of the individual’s person centered service plan for the claim to pay.

OMPP does not have any interaction or involvement with Medicare plans that are not D-SNPs. MCEs are required to coordinate with members’ Medicare plans regardless of the plan type, including ACOs. In addition to any services or benefits provided by the ACO, the PathWays MCE should also be managing care and coordinating services.

LTAC is a Medicare covered service and Medicare is the primary payer. LTAC Hospitals should bill Medicare as primary, and if there is any patient cost sharing from deductibles, this should crossover to the PathWays MCE. If Medicare denies the LTAC stay, the provider would need to include the Medicare LTAC denial with the claim to the PathWays MCE.

In rare instances, claims filed beyond the 90-day filing limit can be considered for reimbursement if the proper supporting documentation is submitted with the claim.

MCEs claim processing systems have logic to match members using other data elements such as address and date of birth when there are different names on file with Medicare and Medicaid.

For any presumptive eligibility period, Medicaid coverage is under fee-for-service and Medicaid claims should be submitted to Gainwell. If the individual is subsequently determined to be Medicaid eligible as a PathWays enrollee, their full Medicaid eligibility will be retroactive to the date of application, and their PathWays enrollment will be effective the first day of the month in which the eligibility determination was made. For Medicaid covered services provided prior to the PathWays enrollment effective date, providers should submit fee-for-service claims to Gainwell. For Medicaid covered services provided on or after the PathWays enrollment effective date, providers should submit claims to the patient’s PathWays health plan.

Example: A person gains presumptive eligibility on 7/20. they apply for full Medicaid on 8/20. They are determined to be eligible on 9/20. Their Medicaid eligibility under fee-for-service is from 7/20 through 8/31. Their PathWays enrollment will be effective 9/1.

The MCE contracts are in process of being fully executed and FSSA is awaiting final CMS approval. Once these two items are complete, IHCP we will post the contracts to the transparency portal.

Providers will use the PathWays MCEs’ Provider Portals to view patient liability and waiver liability information.

The IHCP Portal continues to be the source of truth for Medicaid eligibility, and providers can see their patients’ MCE enrollment there. Other functions, such as claims submission and claims status check, will be conducted in the MCEs’ Provider Portals.

Modifiers can be in any order on claims.

Modifiers can be in any order on claims.

FSSA has redesigned the nursing facility rate setting process. Rates will now be issued on prospective basis twice a year. In the rare instance of a retroactive rate change that could have claim impact, providers will need to replace the impacted claims with the new billed charges. Alternatively, if providers are aware that there will be a new rate published retroactively for the date of service, the provider can submit the original claim with the anticipated rate to ensure their claim is reprocessed and paid when there is a claims sweep following the loading of retroactive rates.

Skilled nursing facility providers with all-inclusive, case mix adjusted rates issued by the Office of Medicaid Policy and Planning are not required to include private pay charges on the claim. Providers should always bill the days of service using the state issued Medicaid rate for those dates of service.

No. Providers and facilities can be involved in the assessment with the consent of the member but need not be the authorized representative.

Functional and financial eligibility for the waiver and Medicaid, will remain the same with the launch of PathWays.

For individuals who are 59 and under who receive Medicaid and reside in a nursing facility or receive home and community-based services, they will continue to receive Medicaid through fee-for-service.

Medicaid eligibility processes will remain the same. If an individual no longer meets functional and/or financial eligibility for the Aged and Disabled Waiver, the individual has rights to appeal the decision. If the appeal is denied, then the individual is required to private pay for assisted living services or obtain different housing. If the determination is due to no longer meeting financial eligibility, the individual may be required to spend-down assets or pay a waiver liability. Additionally, for individuals who do not qualify for Medicaid waiver, the individuals may be connected with their local area agency on aging to assist with alternative non-Medicaid services as well as other community resources.

Members must renew their coverage every year. Members can do this by visiting their local Division of Family Resources office or through their portal account at https://fssabenefits.in.gov/bp/#/. Their health plan (Anthem, Humana or UnitedHealthcare) can also assist the member in renewing their coverage.

Members must renew their coverage every year. Members can do this by visiting their local Division of Family Resources office or through their portal account at https://fssabenefits.in.gov/bp/#/. Their health plan (Anthem, Humana or UnitedHealthcare) can also assist the member in renewing their coverage.

Every 12 months members are required to complete the eligibility redetermination process. This includes financial and medical eligibility. If something changes with a member’s information, FSSA may send a request that requires a response to continue eligibility before the 12-month period ends. FSSA may ask again for members to verify their income and their assets.

Yes, there is a standard program income and asset limit.

If applying for HCBS or Nursing Facility waiver there are special income and asset limits.
https://www.in.gov/medicaid/members/apply-for-medicaid/eligibility-guide/#Aged__Blind__and_Disabled

An atypical provider is one that provides home and community-based services. Not all atypical providers will have an NPI and in those instances the Legacy Provider Identifier (LPI) will be acceptable as part of contracting with the MCEs and should be included on claims.

Medicare only providers must be IHCP attested as provider type 37, specialty 370 – Medicare-Only Provider. Once a Medicare only provider is IHCP attested, they can bill the PathWays MCEs for Medicare deductible and coinsurance amounts owed by Medicaid.

Consistent with 42 CFR 447.45, MCEs must process electronically submitted clean claims, and issue payment within 21 days from receipt. MCEs must process electronically submitted clean HCBS claims, and issue payment within 7 business days from receipt. MCEs must process all clean paper claims and issue payment within 30 days from receipt.

Rehab hospitals may need to submit claims to a specific MCE instead of Gainwell. Rehab hospitals will need to contract with an MCE after the first two years of PathWays operations. MCEs will be allowed to close their networks after two years if they meet network adequacy.

No. This is an optional field on the claim form and the MCEs will not deny claims if the NOA/Prior Auth number is not included on the claim.

PathWays MCEs use the definitions of clean claim at IC 12-15-13-0.5 and IC-15-13-0.6 for nursing facilities. These definitions comply with the federal definition of clean claim at 42 CFR447.45 that specifies that, “Clean claim means one that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in a State's claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.”

Yes.  All PathWays MCEs must require the same information on the claim forms. The MCEs are developing a training resource that will include the following:

1. The fields required to submit for adjudication and
2. The information required for each required field. Please also refer to each MCE’s specific submission requirements and options.

An electronic remittance advice, or ERA, is an explanation from a health plan to a provider about a claim payment. An ERA explains how a health plan has adjusted claim charges based on factors like:

• Contracts
• Secondary payers
• Benefits
• Expected copays and co-insurance
  Under HIPAA, all payers, including Medicare, are required to use claims adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) approved by X12 recognized code sets. Payers are not allowed to use their own proprietary codes to explain any adjustment in the claim payment.
  The Department of Health and Human Services (HHS) has adopted one standard for ERA transactions: X12 835 TR3 TRN Segment, for data content of the Addenda Record of the CCD+.
  Health plans are required to input the X12 835 TR3 TRN Segment into Field 3 of the Addenda Record of the CCD+. The TRN Segment in the Addenda Record of the CCD+ should match the TRN Segment in the associated ERA that describes the payment. Using the same TRN Segment helps to match the payment to the correct remittance advice, a process called re-association.
  Each PathWays MCE can provide guidance and instruction on what is on their Remittance Advice and how to read it. Further information can be found on the CMS and HHS websites:
• Health Care Payment and Remittance Advice - https://www.cms.gov/medicare/coding-billing/electronic-billing/health-care-payment-remittance-advice
• Understanding Your Remittance Advice Reports - https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/ICNMLN8788099-final_0.pdf
• Remittance Advice Resources and FAQs - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICN905367TextOnly.pdf

Auto-assignment for individuals who did not select an MCE occurred May 1, 2024 and the timing is the same for all PathWays enrollees. This prospective assignment process is designed to facilitate advanced care planning and ensure sufficient transition activities.

In accordance with 405 IAC 1-14.7-7(b), FSSA has designated facilities that have received approval to operate a qualified Ventilator program. The list of facilities with approved Medicaid Ventilator Programs and the add on rate for the period of 7/1/2023 through 6/30/25 is located here.

An eligible dual member will continue to have Medicare choice once moved into Indiana PathWays for Aging. Members are able to choose a Medicare product that  best fits their needs, whether that is Traditional Medicare, a non-SNP (Special Needs Plan) Medicare Advantage plan or a SNP.

PathWays members in hospice will have the option to remain in FFS Medicaid or choose to move to one of the MCEs.  For those who choose to remain in FFS, their care will be managed much as it is today with the AAAs and OMPP coordinating services.

All Medicare plans are required to meet CMS requirements regarding the services that they cover. If a change in service covered has occurred it would be a change requirement coming from CMS not the State of Indiana.

Medicare Advantage plans including D-SNPs contract directly with home health agencies and negotiate rates directly. The state does not play any part in determining D-SNP payment rates.

Yes. Dual eligibles under the age of 60 will not be in PathWays. PathWays is only for individuals 60 years and older who are eligible for full Medicaid benefits including individuals receiving HCBS services through the Aged and Disabled Waiver, individuals residing in nursing facility, and individuals receiving full Medicare benefits.

Yes. If a Medicaid eligible person is not eligible for full Medicare benefits but meets the other PathWays eligibility criteria, they will be enrolled in PathWays.

Providers should contact each of the MCEs to inquire about their contract amendments. MCEs sent contract amendments in late 2023 and early 2024. All providers currently contracted with the MCEs should have received their contract amendment by now. You can contact the MCEs at the contact info below:

• Anthem: Email: INMLTSSProviderRelations@anthem.com; Phone: 833-310-3775
• Humana: Email: InMedicaidProviderRelations@humana.com; Phone: 866-274-5888
• UnitedHealthcare: Email: in_providerservices@uhc.com; Phone 877-610-9785

This is not a new population to Medicaid. Hospitals who take traditional Medicaid, HCC Medicaid, HIP, traditional Medicare, and Medicare Advantage beneficiaries today, are currently serving the prospective PathWays population.

HAF is not changing and will continue to pay as it does today.

Rehab hospitals may need to submit claims to a specific MCE instead of Gainwell. Rehab hospitals will need to contract with an MCE after the first two years of PathWays operations. MCEs will be allowed to close their networks after two years if they meet network adequacy.