Overview
Providing home care services to Medicaid Waiver recipients is not only a great way to serve your community and help those in financial need, but also a spectacular business opportunity to grow your bottom line.
Unlike private pay clients, Medicaid Waiver clients are often approved for many hours (between 30-60 is typical) but stay with your agency for numerous years, regardless of economic factors. Especially now that the state of Indiana increased the reimbursement rates by over $30/hr, the opportunity is tremendous but with great opportunity comes a higher degree of understanding required. On that note, there are a ton of rapid changes that you need to be aware of.
Electronic Visit Verification (EVV)
As part of the federal requirements for the 21st Century Cures Act, Indiana’s IHCP has contracted with Sandata as the state-sponsored system and the EVV aggregator to communicate shift information to the state. The following information must be present for EVV data to be complete:
- Date of Service
- Location of Service
- Individual providing service
- Type of service
- Individual receiving service
- Time the service begins and ends
In addition to the Sandata solution, many providers opt to use a third-party EVV vendor. In using a third-party vendor, the provider must ensure that whichever software they choose can integrate with Sandata through a testing process (see Preparation Guide).
For anyone already serving Medicaid Waiver clients, this isn’t new information, but what is new is that IHCP turned on enforcement from November 15, 2023 through December 15, 2023 as a test and plan to turn it on permanently in April 2024. What this means is that any claim that does not have matching EVV data will be automatically denied.
Because of this, it is critical to have a system in place to review your claims and compare them against your EVV data before April of this year. Otherwise, you risk falling out of compliance with the state and quickly racking up a large amount of AR from shifts that were given. IHCP allows providers to edit their EVV data for situations like this by using reason codes. The most common reasons we have found for our providers are:
- Caregiver forgot to clock in/out
- Changes in service code
- Overnight shifts
- Multiple shifts in one day being flagged as a duplicate
Switch to MCE Model
The second major change in Indiana is the implementation of Indiana’s PathWays for Aging Program. Currently, Indiana’s Department of Aging offers two waivers for recipients to receive Home and Community Based Services (HCBS): the Aged and Disabled waiver and the Traumatic Brain Injury Waiver. This is scheduled to change this July (2024) to the PathWays for Aging program. Indiana residents over the age of 60 and who are eligible for Medicaid will be enrolled in PathWays.
This will only affect recipients of the Aged and Disabled Waiver for now so the recipients of the Traumatic Brain Injury Waiver will remain unchanged.
For Medicaid Waiver providers, this transition means changing to a managed care model. Recipients will be receiving their coverage for the PathWays program through one of three managed care entities (MCEs). The three MCEs are:
- Anthem
- Humana
- United Healthcare
These entities will be the payer and care coordinators for the PathWays program so as you provide shifts for your clients, your claims will need to be sent to whichever MCE that client is covered under instead of through the familiar state IHCP portal.
There are two different portals that providers need to set up depending on the payer. For Anthem and Humana, providers will need to use the Availity portal. For United Healthcare, providers will need to use their proprietary system: UnitedHealthcare Provider Portal.
These portals will allow you to submit claims, view client authorizations, download remittance advice, communicate with the MCE and manage their provider profile.
The most important thing to know about working with MCEs is that each payer will have its own quirks and processes so you and your team will need to be prepared to learn each payer. This also includes difficulties with posting payments as each payer will have its own remittance advice and its own payment schedule. What was once a one-stop shop, will now be three different systems.
For more information about the transition and contracting with the MCEs, click here.
Additional Regulation
Indiana is one of the more communicative states when it comes to their Medicaid Waiver programs so providers should expect periodic updates through their bulletins. The most recent update comes with two changes. The first of which, changes the information providers must include in their claims.
In addition to all information required previously, providers must also submit the name of the caregiver and the relationship (Parent of minor child, Spouse, or Other). Beginning March 1, 2024, any claims without this information will be automatically denied.
The other major change is that clients may not receive services from both the Structured Family Caregiving Waiver and another waiver program. Beginning March 1st, if a recipient has any claims from the Structured Family Caregiving Waiver, any other kinds of claims for Personal care, homemaker, or respite services will be automatically denied. It is crucial that your schedulers are made aware of this change as you absolutely do not want to lose out on potential income as a result.
Conclusion
With government payers, the only constant is the fact that things are always changing, and that’s why you not only want to stay on top of the various changes but also want to have someone watching over your back. Having a reliable ally like Paradigm is beneficial as our expertise ensures that you not only remain informed about the latest developments but also receive proactive guidance to anticipate and respond effectively to changes. Get started with Paradigm by filling out the form below or book a call with us here.
About the Author: As a Medicaid and VA expert at Paradigm, Jacob has consulted with hundreds of home care providers across the country and is widely considered a subject matter expert when it comes to 3rd Party Payers in home care. He thrives on building impactful relationships with agency owners that want to achieve sustainable growth through increasing their VA, Medicaid, or Medicare Advantage censuses. Although a far cry from his time spent as a professional tuba player, Jacob now enjoys reading, throwing pottery, and tending to his plants.
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