in-20240925-IR-405240180FRA: DIGEST MANAGED CARE RULE

Final Rule LSA Document #24-180 DIGEST Sec. 1. The office shall adopt and promulgate this article to set forth regulating the office's Medicaid managed care programs, which consist of: 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. 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. 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: 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. Sec. 2. "Adverse action" has the same meaning as "adverse benefit determination" as defined at 42 CFR 438.400(b). 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. Sec. 4. "American Indian/Alaska Native" has the meaning set forth at 405 IAC 10-2-1(2). Sec. 5. "Appeal" means a request for an adverse action review or a decision by an MCO related to a covered service. 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. Sec. 7. "CHIP" has the meaning set forth at 405 IAC 11-1-4. 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: Sec. 9. "Claim" means a formal payment request for benefits received or services rendered. 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. 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. Sec. 12. "Contract" means a contract between the office and an MCO. 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. 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. Sec. 15. "Day" means a calendar day unless otherwise specified. Sec. 16. "Disenrollment" means discontinuing of an enrollee's eligibility to receive covered services through an MCO. 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: Sec. 18. "Emergency medical condition" has the meaning set forth at 42 CFR 438.114. Sec. 19. "Emergency services" has the meaning set forth at 42 CFR 438.114. 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. Sec. 21. "Enrollment broker" means the entity the office uses to enroll persons in a managed care organization. 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. 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. Sec. 24. "Grievance" has the meaning set forth at 42 CFR 438.400(b). 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. 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. Sec. 27. "Healthy Indiana Plan" or "HIP" means the program defined at 405 IAC 10-2-1(37). 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. Sec. 29. "Hoosier Care Connect" or "HCC" means the statewide Medicaid managed care program for: Sec. 30. "Hoosier Healthwise" or "HHW" has the definition set forth at 405 IAC 11-1-7. 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: 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. Sec. 33. "Level of care assessor" or "LOCA" means the entity contracted with the office to perform intake counseling. Sec. 34. "Managed care organization" or "MCO" has the meaning set forth at 405 IAC 10-2-1(28). 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. Sec. 36. "Managed long term services and supports" or "MLTSS" means delivering long term services and supports through Medicaid managed care programs. Sec. 37. "Mandatory enrollment" means mandatory participation in a managed care program as set forth in this article. Sec. 38. "Medicaid rehabilitation option" or "MRO" has the meaning set forth at 405 IAC 5-21.5-1. 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. Sec. 40. "Member" means a person certified by the office as eligible for Medicaid or CHIP. 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. Sec. 42. "Primary medical provider" or "PMP" means a primary care physician or other licensed health practitioner practicing state law who is responsible for: Sec. 43. "Poststabilization care services" has the meaning set forth at 42 CFR 438.114. Sec. 44. "Prior authorization" has the meaning set forth at 405 IAC 10-2-1(44). 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. 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. 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. 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. 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. Sec. 50. "Qualifying individual" or "QI" means a member whose Medicaid benefits include paying the member's Medicare Part B premium. Sec. 51. "Referral" means: Sec. 52. "Self-referral" means the way an MCO enrollee may access certain services without referral from the enrollee's PMP. 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. 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. 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. Sec. 56. "Supplemental security income" or "SSI" means the federal cash assistance program of direct financial payments to individuals who: Sec. 57. The enrollment area for the managed care programs set forth in this article is the state of Indiana. Sec. 58. (a) An MCO shall operate a grievance and appeals system that includes at least: (b) An MCO shall operate the grievance process in subsection (a)(1) under the following requirements and time frames: (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: (d) An MCO shall operate the appeals process in subsection (a)(4) under the following requirements and time frames: (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. 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: (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: (j) The following are reasons members of a managed care program operated by the office are disenrolled from the program: 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: 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: (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: (i) The office may determine drugs in subsection (h) based on the following: (j) MCOs may request the office to review eligible drugs detailed in subsection (h) to be delivered outside the capitated managed care arrangement. 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. 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: (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: Sec. 3. Individuals enrolled in HIP shall receive services as set forth at 405 IAC 10-7. 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: 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. Sec. 6. An MCO for HIP shall meet the direct access requirements at 405 IAC 14-6-8. Sec. 7. Medical necessity requirements for HIP are as provided at 405 IAC 10-2-1(31). Sec. 8. An MCO for HIP shall meet the requirements regarding second opinions at 405 IAC 14-6-10. 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: (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: (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: (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. Sec. 10. (a) An MCO shall cover emergency services as follows: (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. 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: 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. 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. Sec. 14. Claims processing and reimbursement as set forth at 405 IAC 14-4-14, applies to HIP MCOs. 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: (b) Individuals may choose to participate in HCC if they are enrolled in Medicaid based on eligibility as one (1) of the following: (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: 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: Sec. 3. Individuals enrolled in HCC shall receive the traditional Medicaid services outlined in 405 IAC 5. 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: Sec. 5. An MCO for HCC shall meet the self-referral requirements at 405 IAC 14-6-7. Sec. 6. An MCO for HCC shall meet the direct access requirements at 405 IAC 14-6-8. Sec. 7. For a service to be covered under HCC, it must be medically necessary as defined at 405 IAC 5-2-17. Sec. 8. An MCO for HCC shall meet the requirements regarding second opinions at 405 IAC 14-6-10. 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. (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: (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. (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: (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: (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. Sec. 10. (a) An MCO shall cover emergency services as follows: (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. (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) 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. 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: 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. 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. (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) 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. 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. (c) The MCO shall pay or deny a clean claim, as defined at 405 IAC 14-2-10, within: (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: (h) The timely filing limits in subsection (g) are automatically waived by the MCO in certain instances that include: Sec. 1. (a) Individuals enrolled in Medicaid are mandatorily enrolled in an HHW MCO if they are in any of the following categories: (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: 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. (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 in sections 5 and 6 of this rule. (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: (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: 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. 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: 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. (c) HHW self-referral services and limitations are as follows: Sec. 6. An MCO for HHW shall meet the direct access requirements at 405 IAC 14-6-8. Sec. 7. For a service to be covered under HHW, it must be medically necessary as defined at 405 IAC 5-2-17. Sec. 8. An MCO for HHW shall meet the requirements regarding second opinions at 405 IAC 14-6-10. 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. (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) The MCO shall follow the office's UM hierarchy, which includes the following: (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. (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: (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: (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. Sec. 10. (a) An MCO shall cover emergency services as follows: (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. (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) 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. 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: 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. 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 for 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) 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. Sec. 14. Claims processing and reimbursement, as set forth at 405 IAC 14-4-14, applies to HHW MCOs. 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: (b) Members meeting any of the following are excluded from PathWays managed care enrollment: (c) The following individuals meeting the PathWays criteria described in subsection (a) may opt into the PathWays program: 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: (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: Sec. 3. (a) To enroll in PathWays, a prospective member eligible for Medicare shall: (b) A member who becomes Medicare eligible after enrolling in PathWays must enroll in each part of Medicare the are eligible for. 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; (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). 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. 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: Sec. 7. (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. (c) PathWays self-referral services and limitations are as follows: 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. (c) An MCO shall have an established mechanism to ensure access services prescribed under subsections (a) and (b). 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. 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. Sec. 11. (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, 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. (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: (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: (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: (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. Sec. 12. (a) An MCO shall cover emergency services as follows: (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. (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) 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 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) 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. 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: 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: (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: (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. 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. 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: (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: (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: (j) The timely filing limits in subsection (i) are automatically waived by the MCO in certain instances, which include: