Nursing Facility Frequently Asked Questions

If nursing facilities have residents who are 60 and over receiving Medicaid or Medicaid and Medicare (dually eligible), then these individuals will transition to Indiana PathWays for Aging. These identified individuals will enroll with one of Indiana’s three PathWays managed care entities, Anthem, Humana, or UnitedHealthcare (UHC).

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.

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

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)

A care coordinator is a person who may contact an individual to create a personalized care plan based on their preferences and needs. They can also help answer questions about the individual’s health care.

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.

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 (LTSS) in a home or community-based setting. Individuals in PathWays may also have Medicare at the same time.

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

The PathWays Medicaid health plan will work with the member’s Medicare health plan to coordinate their care. This can include connecting them to medical and community supports.

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.