Indiana § 12-15-12-24 - Assessment metrics; transparency and accountability safeguards

§ 12-15-12-24. Assessment metrics; transparency and accountability safeguards

Sec. 24. The office of the secretary shall establish:

(1) metrics to assess:

(A) the quality of care provided under; and

(B) patient outcomes of; and

(2) transparency and accountability safeguards for;

the risk based managed care program for the covered population established by IC 12-15-13-1.8(c).

As added by P.L.215-2025, SEC.4.

IC 12-15-12.5Chapter 12.5. Managed Care for the Aging

12-15-12.5-1"Area agency" 12-15-12.5-2"Covered population" 12-15-12.5-3"Office" 12-15-12.5-4Covered population 12-15-12.5-5Level of care assessment for risk based managed care program

IC 12-15-12.5-1"Area agency" Sec. 1. As used in this chapter, "area agency" means an area agency on aging designated by the bureau of better aging under IC 12-10-1-4.

As added by P.L.167-2025, SEC.8. Amended by P.L.122-2026, SEC.59.

IC 12-15-12.5-2"Covered population" Sec. 2. As used in this chapter, "covered population" means all Medicaid recipients who meet the criteria set forth in section 4 of this chapter.

As added by P.L.167-2025, SEC.8.

IC 12-15-12.5-3"Office" Sec. 3. As used in this chapter, "office" includes the following:

(1) The office of the secretary of family and social services.

(2) A managed care organization that has contracted with the office of Medicaid policy and planning under this article.

(3) A person that has contracted with:

(A) the office of the secretary of family and social services; or

(B) a managed care organization described in subdivision (2).

As added by P.L.167-2025, SEC.8.

IC 12-15-12.5-4Covered population Sec. 4. An individual is a member of the covered population if the individual:

(1) is eligible to participate in the federal Medicare program (42 U.S.C. 1395 et seq.) and receives nursing facility services; or

(2) is:

(A) at least sixty (60) years of age;

(B) blind, aged, or disabled; and

(C) receiving services through one (1) of the following:

(i) The aged and disabled Medicaid waiver.

(ii) A risk based managed care program for aged, blind, or disabled individuals who are not eligible to participate in the federal Medicare program.

(iii) The state Medicaid plan.

As added by P.L.167-2025, SEC.8.

IC 12-15-12.5-5Level of care assessment for risk based managed care program Sec. 5. The office may contract with an area agency to:

(1) provide; and

(2) receive reimbursement for;

a level of care assessment for the risk based managed care program for the covered population through an area agency's aging and disability resource center.

As added by P.L.167-2025, SEC.8.

IC 12-15-12.7Chapter 12.7. Pathways for Aging Risk Based Managed Care Program

12-15-12.7-1"Program" 12-15-12.7-2Determination of reimbursement rates; prohibition 12-15-12.7-3Contract with nursing facilities 12-15-12.7-4Report concerning denial of claims 12-15-12.7-5Claims review permitted 12-15-12.7-6External review of claim denials required 12-15-12.7-7Payment, denial, or suspension of claims submitted by nursing facilities; time; interest

IC 12-15-12.7-1"Program" Sec. 1. As used in this chapter, "program" refers to the pathways for aging risk based managed care program established under IC 12-15-13-1.8 for a covered population.

As added by P.L.174-2025, SEC.41.

IC 12-15-12.7-2Determination of reimbursement rates; prohibition Sec. 2. (a) The office of the secretary shall determine the base reimbursement rate structure, methodology, and reimbursement rates that may be paid to a provider for the services rendered under the program.

(b) A managed care organization may not pay a provider less than the reimbursement rates established by the office of the secretary under this section.

As added by P.L.174-2025, SEC.41.

IC 12-15-12.7-3Contract with nursing facilities Sec. 3. (a) A managed care organization shall contract with any nursing facility that is:

(1) licensed under IC 16-28;

(2) certified by:

(A) the United States Department of Health and Human Services to provide services under the Medicare program; or

(B) the office of the secretary to provide services under the Medicaid program; and

(3) willing to contract with the managed care organization to provide the services under the same terms and conditions that are offered by the managed care organization to any other participating provider that has contracted with the managed care organization to provide that service for the program through June 30, 2029.

(b) A contract between a managed care organization and a provider to provide services under the program must include the reimbursement rates established by the office of the secretary under section 2 of this chapter.

As added by P.L.174-2025, SEC.41.

IC 12-15-12.7-4Report concerning denial of claims Sec. 4. (a) On a monthly basis, a managed care organization shall provide a report to the office of the secretary concerning the denial of claims. The report must specify denials by claim type for the previous month if the denials for the claim type total at least five percent (5%).

(b) The office of the secretary shall post the reports submitted under subsection (a) to the office of the secretary's website.

As added by P.L.174-2025, SEC.41.

IC 12-15-12.7-5Claims review permitted Sec. 5. The office of the secretary may conduct a claims review of claims submitted to a managed care organization for the covered population under the program.

As added by P.L.174-2025, SEC.41.

IC 12-15-12.7-6External review of claim denials required Sec. 6. The office of the secretary shall at least annually conduct external reviews of claim denials in the program by a managed care organization.

As added by P.L.174-2025, SEC.41.

IC 12-15-12.7-7Payment, denial, or suspension of claims submitted by nursing facilities; time; interest Sec. 7. (a) This section applies to claims submitted for payment under the program by a nursing facility participating in the program.

(b) The managed care organization shall pay, deny, or suspend each claim submitted by a nursing facility provider for payment under the program not later than:

(1) twenty-one (21) days after the claim was electronically filed; or

(2) thirty (30) days after a claim has been filed on paper;

from receipt by the managed care organization.

(c) If the managed care organization:

(1) fails to pay a clean claim in the time required under this section; or

(2) denies or suspends a claim that is subsequently determined to have been a clean claim when the claim was filed;

the managed care organization shall pay the provider interest on the Medicaid allowable amount of the claim as set forth in this section.

(d) Interest paid under subsection (c):

(1) accrues beginning:

(A) twenty-two (22) days from the date the claim is filed under subsection (b)(1); or

(B) thirty-one (31) days from the date the claim is filed under subsection (b)(2); and

(2) stops accruing on the date the managed care organization pays the claim.

(e) A managed care organization shall pay interest under subsection (c) to a provider at the rate established for Medicare overpayments and underpayments, as set forth in 42 CFR 405.378.

As added by P.L.174-2025, SEC.41.

IC 12-15-13Chapter 13. Provider Payment; General

12-15-13-0.1Application of certain amendments to chapter 12-15-13-0.4"Office" 12-15-13-0.5"Clean claim" 12-15-13-0.6"Clean claim" for purposes of IC 12-15-14 12-15-13-0.7Addition, deletion, or modification of locators 12-15-13-1Payment, denial, or suspension of claims submitted by nursing facilities; time; notice of suspension or denial 12-15-13-1.5Payment of interest on claims submitted by nursing facilities 12-15-13-1.6Payment, denial, or suspension of claims; notice of suspension or denial 12-15-13-1.7Timing of payment or denial of claims; payment of interest 12-15-13-1.8Covered population; exception; risk based managed care program; penalty payments 12-15-13-2Payments to providers; requirements; federal law or regulations specifying reimbursement criteria 12-15-13-3Repealed 12-15-13-3.5Recovery of overpayment to noninstitutional provider; appeal 12-15-13-4Recovery of overpayment to institutional provider; appeal 12-15-13-5Repealed 12-15-13-6Notices or bulletins; timing; noncompliance 12-15-13-7Permitted forms 12-15-13-7.2Use of diagnostic or procedure codes 12-15-13-8Expired 12-15-13-9Reimbursement for providers at federally qualified health centers and rural health clinics 12-15-13-10Home health agency provision of Medicaid services during Medicare enrollment period