Frequently Asked Questions

The Indiana Family and Social Services Administration will launch a new program in July 2024 for Hoosiers aged 60 and over who receive Medicaid (or Medicaid and Medicare) benefits. Research shows that most older adults - 75% or more - want to age at home and in their communities.

Health coverage in PathWays starts July 1, 2024.

You will get an enrollment letter in the mail, which will include a health plan comparison chart so that you can make a choice about which health plan is best for you.

To help you with the changes coming, FSSA will send you another letter 60 days before the start of the program to tell you which health plan will serve you. Your Medicaid health plan (Anthem, Humana or UnitedHealthcare) may also reach out to you 30 days before the start of the program with more information.

Call the Indiana PathWays for Aging Helpline at 87-PATHWAY-4 (877-284-9294) to select your PathWays Medicaid health plan. You can also call this number if you need help with choosing a Medicaid health plan. You will need to choose from Anthem, Humana or UnitedHealthcare.

When calling to select your PathWays health plan please have the following information on hand:

1. Medicaid ID or SSN ( can use case #)
2. The correct phone #, address and DOB on file with FSSA
3. Primary medical provider
4. HCBS & Waiver Services Providers (i.e. Adult Day Services)

The PathWays health plans will have an open network until dictated by the state.  Thus, the member can continue to use their providers as long as the provider remains an IHCP approved provider no matter the health plan selected.

You can call Member Support Services (MSS) at 877-738-3511 to discuss your options.

Your service plans will stay in place for 90 days from program implementation with no reductions in services; changes can only be made if you need additional services.

Your Medicaid services that have already been authorized, will stay authorized for up to 90 days.

You will get a letter 90 days before your 60th birthday.  This letter will tell you that you are eligible for the PathWays program.  It will also include information on your health plan or how to select a health plan.

Yes. Once the individual is disenrolled with PACE they would be eligible for PathWays.

Indiana PathWays for Aging is a Medicaid managed care program for Hoosiers aged 60 and over who receive Medicaid (or Medicaid and Medicare) benefits. Research shows that most older adults - 75% or more - want to age at home and in their communities.

A health plan is a health insurance company. Physicians, hospitals, and other healthcare providers, including waiver providers, enroll with a health plan to provide care for members. Indiana partners with health plan for its Indiana PathWays for Aging, Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect programs.

A health plan provides members with health care coverage. After a member chooses a health plan for their Medicaid program, they can get medical care from a variety of health care providers and in some cases, waiver providers. Health plans provide enhanced care coordination to help members navigate the variety of services for which they are eligible. Health plans also provide service coordination.

The PathWays health plans are Anthem, Humana, and UnitedHealthcare.

A care coordinator is a person who may contact you to create a personalized care plan based on your preferences and needs. They can also help answer questions about your health care and help you with your providers.

A Service Coordinator is a person who will work with you to create a personalized Service Plan to help coordinate your Home and Community-Based Services. The Service Plan will help develop a plan of care of services and supports that best meet your needs and goals.

A health assessment is a set of questions that ask about your personal behaviors, life-changing events, health goals and priorities, service coordination and overall health. Your health plan will use these assessments to create a personalized care plan based on your preferences and needs.

A service plan is a support plan, developed by a service coordinator, for assisting you in gaining access to long-term care services, as well as medical, social, housing, educational, and other supports. Not everyone in PathWays will need a service plan.

You can call Member Support Services (MSS) at 877-738-3511.

An individual can change their MCE under the following circumstances:

• Within 90 days of the individual’s initial PathWays enrollment
• During the annual health plan selection period which occurs mid-October through mid-December each year
• For “Just Cause.” Anytime you file a grievance with your health plan and the state finds that you have a good reason to change health plans you may change health plans based on "just cause."
• Anytime the individual’s Medicare and Medicaid plans are not the same, and they wish to change enrollment to have aligned coverage
• Once per calendar year for any reason at any time

To make a change or explore options, an individuals can contact the Indiana PathWays for Aging Helpline at 87-PATHWAY-4 (877-284-9294).

Care coordination services are available to every PathWays member.  Members who meet the functional eligibility requirements have access to service coordination and the additional services:

• Adult day services
• Adult family care
• Assisted living
• Attendant care
• Home modifications
• Health care coordination
• Home-delivered meals
• Nutritional supplements
• Personal emergency response systems
• Respite
• Specialized medical equipment
• Structured family care
• Transportation
• Vehicle modifications

All of the PathWays health plans are currently working to contract with providers so their directories may not be up to date, but the state is working to ensure members will still be able to see their current providers regardless of which health plan they choose.

Caregivers can call the member’s PathWays health plan.  The health plan can provide resources to support you and the PathWays member.

After the initial enrollment into a health plan in early 2024, your health plan selection period for Pathways is mid-October to mid-December annually. This is also open enrollment for Medicare.

You can also call the Indiana PathWays for Aging Helpline at 87-PATHWAY-4 (877-284-9294) during the open enrollment to change your health plan. The health plan selection period for Pathways is mid-October to mid-December annually.

The Member Support Services program is available to all PathWays members to help them, their caregivers, and families resolve questions or problems and serve as a source of assistance, advice, and advocacy. Member Support Services can be reached at 877-738-3511.

The Program of All-Inclusive Care to the Elderly (PACE) was implemented by the state of Indiana to provide quality community-based care for Indiana Health Coverage Programs (IHCP) members who:

• Are 55 years old or older
• Are certified by the state to qualify for nursing home level of care
• Are able to live safely in the community at the time of enrollment
• Live in a PACE service area

The PACE program is operated by PACE organizations who manage the care delivery system.

PathWays is a managed care program for Indiana Medicaid members that are:

• 60 years of age and older
• Are eligible for a full-coverage aged, blind or disabled category (with or without Medicare)
• Can be receiving long-term support services including:
• Resides in a nursing or long-term care facility
• Are approved for an Aged and Disabled waiver
• Can be on the Behavioral and Primary Health Coordination program

The PathWays program is operated within the managed care delivery system by health insurance companies. The MCEs for the PathWays program are Anthem, Humana, and UnitedHealthcare. PathWays members can receive home and community-based services as well as medical services.

PACE will continue to operate independently from the PathWays program. When PathWays enrollment begins, individuals already participating in PACE can stay in PACE and should experience no disruption in service. PACE members are also excluded from PathWays enrollment marketing, so they should not receive any direct notices about switching programs.

After PathWays begins operating, individuals who newly meet the eligibility requirements for both PACE and PathWays will be able to choose which program to enroll with. Further, the entity responsible for conducting Nursing Facility Level of Care (NFLOC) assessments and determinations will provide "intake counseling" to help individuals navigate options such as PACE and PathWays if they have a NFLOC or ensure they are referred to the appropriate place if they do not meet NFLOC.

It is possible. Once the individual is disenrolled with PACE they would be eligible for PathWays.

Individuals enrolled in PACE and who wish to continue in PACE do not need to do anything to retain PACE. They are excluded from PathWays direct outreach, and from PathWays auto-assignment.

There are payer specific business rules and limitation indicators on the state enrollment file. The PACE program participants have a specific enrollment indicator that distinguishes them from other Medicaid programs.

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-5pm. 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.

No, the MCEs will continue to pay at least what FFS pays and members are protected from being billed for any remaining balance.

If a member did not choose a plan by the end of April, they were assigned to a plan. The Enrollment Broker (Maximus) will assist members in selecting and changing their MCE. The Enrollment Broker is independent and not affiliated with any 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. 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.

PathWays is for individuals who are 60 years of age and older and are eligible for Medicaid based on age, blindness, or disability. Individuals can also be those in a nursing facility, and those who are receiving long-term services and supports in a home or community-based setting. Individuals in PathWays may also have Medicare at the same time.

If you are enrolled into the PathWays program, you will receive a letter from the Division of Family Resources or the Enrollment Broker.

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

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

You can first apply for Medicaid online, print an application, or have an application mailed to you via the FSSA Benefits Portal https://fssabenefits.in.gov/bp/#/, or contact an Indiana Navigator https://in.accessgov.com/idoi/Forms/Page/idoi/find-a-navigator/1.

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

Functional Eligibility means that you require assistance with at least three activities of daily living such as help with eating, dressing, toileting, etc. or that you are unable to care for yourself medically.

Enrollment into the PathWays program is automatic for those who meet the Medicaid eligibility requirements and are 60 years of age or older.  However, if you are a member of a recognized tribe or currently receiving hospice services, you will have the option to opt-in to the program.

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.

Yes. Once the individual is disenrolled with PACE they would be eligible for PathWays.

Individuals enrolled in PACE and who wish to continue in PACE do not need to do anything to retain PACE. They are excluded from PathWays direct outreach, and from PathWays auto-assignment.

Health plans offer the same basic benefits but can vary in their added benefits. Depending on your situation and health needs, one plan may suit you better than another. It’s important to review your options and select the plan that’s right for you.

You can choose a health plan by calling 87-PATHWAY-4 (1-877-284-9294).  You will be provided counseling on which health plan would best meet your needs.

Yes! Having the same health plan for Medicare and Medicaid will better coordinate your care and supports.

You will want to make sure that you choose a health plan that includes your doctor.  You can call the Indiana PathWays for Aging Helpline at 87-PATHWAY-4 (877-284-9294) to discuss your options.

If you are an enrolled PathWays member, you should call your health plan (Anthem, Humana or UnitedHealthcare) or go online to their website to research which providers are in that health plan's network. Members can also call 87-PATHWAY-4 (877-284-9294) and ask.

If you are just joining PathWays and want to make sure you choose a health plan that includes your doctor, call 87-PATHWAY-4 (877-284-9294) to discuss your options.

You will want to make sure that you choose a health plan that includes your doctor. You can call the Indiana PathWays for Aging Helpline at 87-PATHWAY-4 (877-284-9294) to discuss your options.

You can call the Indiana PathWays for Aging Helpline at 87-PATHWAY-4 (877-284-9294) to discuss your options.

You must call your health plan’s transportation broker (similar to a dispatching service) or call your health plan directly at least 48 hours in advance. The transportation broker arranges rides to and from the medical appointment. There are no mileage or frequency limits (such as annual limits), however prior authorization may be required for longer trips or more than 20 one-way trips per member per year.

PathWays provides the standard Medicaid benefits including coverage for medical expenses such as doctor visits, hospital care, therapies, medications, prescriptions, and medical equipment. The benefits also include preventive care, such as regular check-ups, and mental health and substance abuse treatment.

You will continue to receive the same Medicaid benefits in the PathWays program.

Each of the PathWays health plans offer additional services to their members. Call your health plan directly to see what additional benefits are available to you.

Home and community-based services are services for eligible individuals who choose to remain in their home as an alternative to residing in a long-term care institution, such as a nursing facility. These services assist a person to be as independent as possible and live in the least restrictive environment possible while maintaining safety in the community.

You will want to contact your health plan (Anthem, Humana or UnitedHealthcare) to discuss your options.  Your health plan will do health assessments and refer you to a service coordinator to determine your functional eligibility to receive the supports your need to stay at home.

You will want to contact your health plan (Anthem, Humana or UnitedHealthcare) to discuss your options.  Your health plan will conduct health assessments and refer you to determine your functional eligibility to receive the supports you need in a nursing home.

No, you will not have any copayments in PathWays. However, you may have copayments as part of your Medicare plan.

Yes, you will have transportation in PathWays to any covered non-emergency medical service, as well as pharmacy and durable medical supply pick-ups and transport related to hospital discharges.  If you are an enrolled PathWays member, you should call your health plan (Anthem, Humana or UnitedHealthcare) to schedule a ride. Your health plan and service coordinator can also work with your attendant care provider to schedule rides.

Care coordination services are available to every PathWays member.  Members who meet the functional eligibility requirements have access to service coordination and the additional services:

• Adult day services
• Adult family care
• Assisted living
• Attendant care
• Home modifications
• Health care coordination
• Home-delivered meals
• Nutritional supplements
• Personal emergency response systems
• Respite
• Specialized medical equipment
• Structured family care
• Transportation
• Vehicle modifications

The Enrollment Broker’s helpline is open M-F 8am-5pm. Outbound calls can be made any time the helpline is open and will be dependent on their inbound call volume.

Your PathWays Medicaid health plan will work with your Medicare health plan to coordinate your care.  This can include connecting your medical and community supports that you need. Your PathWays health plan can also help you get access to services not covered by Medicare.

• PathWays dual eligible enrollment options

Yes. A person can be eligible for both Medicaid and Medicare and receive benefits from both programs at the same time.

A Dual Eligible Special Needs Plan is a type of health insurance plan. It’s for people who have both Medicaid and Medicare. If that’s you, you’re “dual-eligible.”

You can get information on D-SNPs by contacting the State Health Insurance Assistance Program (SHIP) at (800) 452-4800 to speak to a counselor.  SHIP is a free counseling program for people with Medicare. You can get one-on-one assistance in person, on the phone, or virtual.

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.

Nursing facility residents have a primary care provider who may or may not employed by the nursing facility. This does not vary based Medicare or Medicaid coverage

If a member is in a D-SNP Medicare product the member will have the opportunity to continue in that D-SNP for 6 months post Medicaid loss. Once that member meets the 6 month window and has not regained Medicaid eligibility again then the member will be moved to Traditional Medicare or another Medicare Advantage plan if they choose. Members that lose their Medicaid eligibility should work with SHIP, an insurance agent, or a Medicare Advantage health plan regarding their Medicare choices.

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.

Individuals who qualify for both Medicare and Medicaid at the same time, are “Dual Eligible.”

A Dual Eligible Special Needs Plan (D-SNP) is a type of health insurance plan. It’s for individuals who have both Medicaid and Medicare at the same time. D-SNP is a type of Medicare Advantage plan.

Medicare is a national health insurance program run by the federal government. It's for individuals aged 65 years and older.

Some individuals with certain disabilities or conditions who are under the age of 65 may be eligible for Medicare.

There are different parts of Medicare which help cover specific services:

• Medicare Part A (Hospital Insurance) – Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
• Medicare Part B (Medical Insurance) – Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
• Medicare Part D (Prescription Drug Coverage) - Helps cover the cost of prescription drugs (including many recommended shots or vaccines).

Medicaid is a federal and state program that gives health coverage to qualifying individuals with limited resources and income.

Medicare Advantage (also known as “Part C”) is a type of Medicare health plan offered by a private company that contracts with Medicare. These plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t cover. There are different types of Medicare Advantage plans.

D-SNP is a type of Medicare Advantage plan. There are also other Medicare Advantage plans such as:

• Health Maintenance Organization (HMO) Plan
• Preferred Provider Organization (PPO) Plan
• Private Fee-for-Service (PFFS) Plan
• Medical Savings Account (MSA) Plan

Also known as Original Medicare, this is coverage managed by the federal government and not managed by a private insurance company.

Medicare and Medicaid are two different programs.  Both are managed by separate entities and have different eligibility requirements.

Medicare eligibility requirements:

• Individuals need to be a U.S. citizen or a legal resident age 65 or older. Individuals may also be able to get Medicare earlier if there is a certain disability or condition.

Medicaid eligibility requirements:

• Individuals are under age 65 and meet the requirements for low-income families, pregnant women and children, receiving Supplemental Security Income (SSI), disability or another special situation.
• Individuals are at least 65 years old, are blind or disabled, meet the income and asset limits.

A coordinated benefit is a benefit that both Medicare and Medicaid cover. Coordination of benefits ensures the correct insurance plan has the primary payment responsibility and the extent to which other plans will contribute when an individual is covered by more than one plan.

Individuals can get information on D-SNPs by contacting the State Health Insurance Assistance Program (SHIP) at (800) 452-4800 to speak to a counselor.  SHIP is a free counseling program for people with Medicare. Individuals can get one-on-one assistance in person, on the phone, or virtual.

Nursing facility residents have a primary care provider who may or may not employed by the nursing facility. This does not vary based Medicare or Medicaid coverage

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.

D-SNPs are available in most states in the U.S., but not all states. Indiana D-SNP enrollment is based on verification that an individual is eligible for both Medicare and full Medicaid health coverage.

D-SNP health plans offer care coordination and provide supplemental benefits to their beneficiaries. They are designed to meet the specific needs of dually eligible individuals.

Individuals can enroll in a D-SNP during the annual enrollment period, during open enrollment and one time per quarter.

D-SNPs typically allow their members a 6-month grace period after losing Medicaid eligibility during which the individual may remain in the D-SNP.

Individuals can change D-SNP plans quarterly through a Special Election Period (SEP) and during the annual enrollment period (AEP) and during open enrollment.  They may also change plans if they have a change in status. For example, if they lose Medicaid eligibility or move out of the service area of the D-SNP, they can change their plan.

Yes! Having the same health plan for Medicare and Medicaid will better coordinate care and supports.

After the initial enrollment into a health plan in 2024, the health plan selection period for Pathways is mid-October to mid-December annually. This is also open enrollment for Medicare.

No, you can either join a regular Medicare Advantage plan or enroll in original Medicare.

Members can change health plans:

• Anytime during their first 90 days in PathWays
• Anytime their Medicare and Medicaid health plans are not the same
• Annually during the PathWays health plan selection period (mid-October-mid December)
• Once per calendar year for any reason
• Anytime using the just cause process

Yes. Individuals in a D-SNP and PathWays will be able to receive extra benefits available to them through both programs.

Exclusively aligned enrollment refers to a dually eligible individual who enrolls with the same Indiana PathWays for Aging Medicaid health plan as their Medicare D-SNP.  For example, if an individual is currently enrolled in Anthem’s D-SNP plan, the individual will be auto enrolled with Anthem for their Indiana PathWays for Aging Medicaid benefits. The result is increased coordination of Medicare and Medicaid benefits which provides enrollees an optimal member experience

If an individual is enrolled in PathWays and becomes eligible for Medicare, they will be default enrolled in the D-SNP plan that is the same as their Indiana PathWays for Aging Medicaid health plan. For example, if an individual is enrolled with Anthem to receive their Medicaid benefits through the Indiana PathWays for Aging program, they will be default enrolled in Anthem’s D-SNP when they become eligible for Medicare.

PathWays members will not be automatically enrolled into a D-SNP. However, if they are enrolled in a D-SNP, the member will be automatically assigned to the Pathways health plan that is sponsored by the same health plan as their D-SNP.

If an individual is enrolled with a PathWays for Aging Medicaid health plan and they become eligible for Medicare, the individual will be default enrolled in the D-SNP plan that is the same as their Indiana PathWays for Aging Medicaid health plan.

Yes, D-SNPs in Indiana will be statewide and able to enroll individuals throughout the state

D-SNPs are a health plan for individuals who are eligible for both Medicare and Medicaid.  It’s an all-in-one plan that combines your Medicare Part A, and Part B, Medicare Part D and your Medicaid.

No, if a member becomes ineligible for Medicaid they will be allowed to continue in their D-SNP plan for up to 6 months. During the 6 month period, the member may contact SHIP for assistance in choosing a new Medicare plan that works best for them.

As protected by federal statute, all dual eligible individuals will have freedom of choice to enroll in their preferred Medicare plan, which include Special Needs Plans (D-SNP, C-SNP, I-SNP); conventional Medicare Advantage plans (non-SNP); and Original Medicare (fee-for-service).

Members who become eligible for Medicare after enrolling in Pathways, will be default-enrolled into the D-SNP with the same company as their selected Pathways health plan; however, in such instances, a member will be notified about how to opt-out of default enrollment and enroll in a different Medicare service delivery system of their choice.

No matter what Medicare plan the member selects, the Pathways program requires coordination of benefits to the greatest extent possible between the Pathways Medicaid health plan and the member's Medicare health plan.

Alignment specifically refers to aligning membership for Pathways in a Medicare Advantage D-SNP but is only applicable when the member chooses to enroll in a D-SNP instead of traditional Medicare (also known as original Medicare) or a non-D-SNP Medicare Advantage Plan.

If a member is enrolled in a D-SNP then they will be automatically assigned to the aligned PathWays Medicaid health plan.

The PathWays Medicaid health plan will coordinate benefits and work with the Medicare health plan to coordinate care. This can include connecting medical and community supports. The PathWays health plan can also help get access to services not covered by Medicare.

Pathways enrollment is not impacted by the member's choice of Medicare.  Individuals who are 60 years or older and receive Medicaid benefits will be enrolled in PathWays.

D-SNP members who turn 60 years old are allowed to stay with that plan until the end of the year. At the end of the year , the D-SNP plan will crosswalk the member over to the appropriate plan.

If the member wants to move to the appropriate plan before the end of the year after they turn 60, they can work with that D-SNP to transition.

No, members who are dually eligible will keep their Medicare choice and be able to choose any Medicare product that works best for them. There are no differences in a PathWays member's options, whether or not they are a long term nursing facility resident. Members should work with SHIP, an insurance agent, or a Medicare Advantage health plan to discuss what type of Medicare product best works for them.

Dual eligible members will keep their Medicare choice and be able to choose any Medicare product that works best for them. Members should work with SHIP, an insurance agent, or heath plan to discuss what type of Medicare product best works for them.

If a member is dual eligible and receives transportation benefits through their Medicare product they must utilize that service first before the MCE transportation broker.

No, PathWays members who are dually eligible will keep their Medicare choices and will be able to select any Medicare product that works best for them. Members should work with SHIP or an insurance agent to discuss what type of Medicare product best works for them.

The PathWays Medicaid health plan will work with a member’s Medicare health plan to coordinate care.  This can include connecting medical and community supports a member’s needs. The PathWays health plan can also help a member get access to services not covered by Medicare.

Yes, the D-SNP and PathWays health plans will assign a care coordinator or a service coordinator to the member to assist in managing and coordinating the treatment plan.

If a member experiences issues with their home health provider, the member can reach out to their PathWays health plan and submit a grievance.

Most the member's medical care is coordinated through their Medicare Plan, which provides primary coverage for most medical services.

Most of the member's LTSS/HCBS needs will still be coordinated by their Pathways Service Coordinator.

The member's Pathways health plan will also designate one single point of coordination on the member’s ICT for members who are enrolled in an aligned Dual Special Needs Plan (D-SNP) to coordinate member care across Medicare and Medicaid.

Payment of Medicare premiums will continue to be managed and paid directly by the State. There are no changes planned regarding the payment of premiums. The MCEs are required coordinate benefits appropriately for members depending on their MSP (QMB or SLMB). The MCEs will be responsible for any coverage of Medicare deductibles, co-insurance, or copays and as mentioned, reimbursement depends on each MCE’s fee schedule.

If members choose to enroll in an aligned D-SNP (i.e., the D-SNP and PathWays MCE have the same parent company), members will have a single, integrated Member ID card for Medicaid and Medicare coverage. Unaligned members will continue to have different ID cards

Part D Extra Help will not be affected at all as prescription coverage will continue to be provided by either their Medicare Advantage plan or Medicare Part D plans, not PathWays.

If a member has a Medicare product that is not a D-SNP, the PathWays MCE is required to coordinate benefits to their greatest extent possible.

FSSA recommends working with SHIP or an insurance agent regarding Medicare choices.

The only out-of-pocket costs that a member may have, are federally established co-pay for drugs under Part D.

Some individuals may have a monthly patient liability if they reside in a nursing facility or a monthly waiver liability if they receive home and community-based services through the PathWays waiver. The Division of Family Resources will notify the individual if there is a liability requirement.

Medical costs included in Medicare are covered by the D-SNP plan.