Attachment K

RFP 27-87793

Medicaid Enrollment Broker Services – Statement of Work Attachment K

RFP 27-87793

Medicaid Enrollment Broker Services – Statement of Work

TABLE OF CONTENTS

EXECUTIVE SUMMARY

The Contractor will serve as the Indiana Family and Social Services Administration’s Office of Medicaid Policy and Planning’s (“FSSA”, “OMPP”, and the "State") Enrollment Broker for the Medicaid managed care programs, which include Hoosier Healthwise (HHW), the Healthy Indiana Plan (HIP), Hoosier Care Connect (HCC), and the managed Long-Term Services and Supports (LTSS) Indiana PathWays for Aging program. An “Enrollment Broker” means an individual or entity that performs choice counseling or enrollment activities, or both, per 42 CFR 438.810(a).

BACKGROUND AND CURRENT STATE

The Medicaid Enrollment Broker serves as an independent intermediary providing unbiased education, choice counseling, and plan assignment for Indiana Health Coverage Programs (IHCP) members. The Contractor will assist potential enrollees and active members with selecting or changing health plans for Medicaid managed care programs, which include Hoosier Healthwise, the Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging. The Contractor shall establish collaborative and operationally effective working relationships with other State contractors associated with the Indiana Health Coverage Programs with whom the Contractor must collaborate in order to support operations of IHCP and the duties of this Statement of Work, e.g., the Managed Care Organizations (MCOs), the Fiscal Agent, the Division of Family Resources (DFR), the Level of Care Assessor (LCAR), and the Indiana PathWays for Aging Member Support Services (MSS) vendor (see Section III.a.1.f.). The State shall provide the Contractor with the current roles and contact information for these contractors to enable coordination and shall notify the Contractor of any subsequent changes. The Contractor must coordinate with these contractors and ensure members who contact the enrollment broker can successfully make plan selections and/or are referred to the most appropriate entity based on their questions and needs.

PROGRAMS COVERED UNDER THIS CONTRACT

The following are the current Indiana Medicaid managed care programs and managed care organizations contracted by the State to provide them. As previously announced by the Indiana Family and Social Services Administration, the State will be undertaking a procurement of its Medicaid managed care programs. As such, the following is subject to change, and the Contractor will be responsible for providing plan selection based upon the composition of the Indiana managed care programs during the Contract term.

Hoosier Healthwise (HHW) and the Healthy Indiana Plan (HIP) Hoosier Healthwise is a health care program for low-income families, some pregnant women, and children in the State of Indiana. Hoosier Healthwise is a federally approved program administered by FSSA to provide reimbursement for reasonable and necessary medical care for persons meeting financial eligibility requirements. The contractor duties support the national efforts to ensure that Medicaid-eligible children enroll in the Hoosier Healthwise program.

HIP is a program created to provide health care coverage to low-income adults, including pregnant women. HIP members have access to one (1) of four (4) HIP benefit packages depending on eligibility and other factors: HIP Plus, HIP Basic, HIP State Plan, and HIP Maternity.

The design and goals of these programs are to ensure access to primary and preventive health care services, improve access to care, and encourage quality and continuity of care.

Individuals will be able to select an MCO on the application for both HHW and HIP. Once determined eligible, this selection will be transmitted from the FSSA DFR to the Medicaid Management Information System (MMIS), operated by the Fiscal Agent (MMIS Vendor). If a selection was not made on their application, these individuals will be auto assigned to an MCO.

The contracted MCOs within HHW and HIP are currently Anthem, CareSource, and Managed Health Services (MHS). Members will be linked to a Primary Medical Provider (PMP) by their selected MCO. The MCOs will be responsible for coordinating the health care service needs of their members.

The Contractor database shall separately track enrollees and potential enrollees who have received HIP enrollment counseling, including the number of individuals identified as medically frail (or who indicate they may have a qualifying condition), Section 1931, or TMA. At the time of RFP release, the State is also working with its federal partners at CMS on the HIP 3.0 waiver. If the composition of the program changes, the Contractor will be responsible for providing plan selection counseling based upon the approved CMS waiver.

Hoosier Care Connect (HCC) The Hoosier Care Connect program is a coordinated care program for Indiana’s Medicaid enrollees in the blind and disabled categories. Enrollees will select an MCO responsible for coordinating care with the member’s medical providers. HCC members will receive all Medicaid covered benefits in addition to care coordination services. Care coordination services will be individualized based on the member’s assessed level of need determined through a health screening conducted by the MCO.

Participation in the HCC program is mandatory for all members in the following aid categories:

· Blind

· Disabled

· MASI

· MED Works The design will support the goals of the program which include improved quality outcomes and consistency of care across the delivery system, enrollee choice, protections and access, coordination of care across the delivery system and care continuum, and flexible person-centered care.

Members will have the opportunity to select an MCO on the application for health care coverage. Once determined eligible, this selection will be transmitted from DFR to the MMIS.

Hoosier Care Connect members who do not make a selection on the application will be targeted for outreach, education and assistance in choosing a health plan by the Contractor. Individuals will receive a letter from the Contractor explaining their eligibility and the need to choose a health plan and will receive up to one (1) call from the Contractor to assist in plan selection. Those members that do not select an MCO within sixty (60) calendar days of the enrollment mailing will be auto assigned. See Section III.a.2.b.(2).i. for more information.

The contracted MCOs within HCC are currently Anthem, Managed Health Services (MHS) and United Healthcare (UHC). Members will be linked to a Primary Medical Provider (PMP) by their selected MCO. The MCO will be responsible for coordinating the health care service needs of their members.

Indiana PathWays for Aging Program The Indiana PathWays for Aging program is a coordinated care program for Indiana’s Medicaid enrollees who are 60 years of age and older and are eligible for Medicaid on the basis of age, blindness, or disability, and have limited income and resources. All individuals who are 60 years of age or older in the target eligibility categories are included unless they meet an exclusion. Enrollees include members who have a full Medicare benefit, those in nursing facilities up to 100 calendar days per House Enrolled Act 1277 (2026) and/or those who are receiving long-term services and supports (LTSS) in a home or community-based setting. The Indiana PathWays for Aging program design promotes alignment across a member’s Medicaid and Medicare Dual-Special Needs Plan (D-SNP.) The Contractor staff will be knowledgeable about Medicare and the Indiana Medicaid (IHCP) programs.

Participation in the Indiana PathWays for Aging is mandatory for all members in the following aid categories who are 60 years of age or above, including duals:

· Aged

· Blind

· Disabled

· Deemed eligible via Expedited Waiver Eligibility for the Indiana PathWays for Aging Waiver

· Nursing Facility Level of Care for PathWays for Aging Members have the opportunity to choose an MCO who has their PMP, specialist(s), and/or home-based health care provider in the MCO’s network. Members receive basic education about managed care, LTSS, and Medicare products such as those available for dual-eligible members from the Contractor. Basic education about LTSS includes giving information about care and service coordination available to members.

Members currently do not have the opportunity to select an MCO on their application, so all member plan selections will be completed by the Contractor. All PathWays members will be targeted for outreach, education and assistance in choosing a health plan by the Contractor. Individuals will receive a letter from the Contractor explaining their eligibility and the need to choose a health plan, and targeted populations will receive up to two (2) calls from the enrollment broker to assist in plan selection. See Section III.a.2.b.2.ii. for more information.

SCOPE OF WORK

OBJECTIVES OF ENGAGEMENT

Description of Enrollment Broker Tasks Helpline Systems The telephone helplines serve as a central point of information for the Medicaid programs described in Section II.a. The Contractor shall maintain and manage the existing Helplines for the Hoosier Healthwise, the Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging programs to address problems and answer questions that members and potential members have about the programs. The Contractor shall also conduct member education, and shall track, monitor, and report on various performance measures.

Educational Materials As deemed appropriate by the State, the Contractor must develop and distribute various educational materials. The Contractor must work with FSSA and other State contractors in the development and distribution of member education materials. Materials must be distributed within a timeframe that enables the enrollees to use the information in choosing among available options. Refer to Section III.a.2.d. for additional information on required materials the Contractor is responsible for.

Data Entry & Correspondence Contractor Representatives shall enter all relevant information into the Contractor database developed and maintained pursuant to Section III.a.4.a. and MMIS, as well as perform extensive data entry, tracking, accuracy monitoring, and database correction functions. The data entered by the Helpline Representatives is used for monitoring and tracking purposes and reporting on the operations of the managed care programs overall as well as the individual MCOs. The State may request reporting by managed care programs (HHW, HIP, HCC and Indiana PathWays for Aging); any such reporting, new or revised, requested to support ongoing program needs shall be provided at no additional cost to the State. For example, previous requests have included, but are not limited to, after call survey reports and dialer logic reports. Additional information on reporting can be found in Section III.a.2.a.(4).

Administrative Tasks The Contractor shall assist the State with ongoing program operation; and participate in various meetings, such as monthly status meetings with FSSA and related contractors, as well as all other meetings where the Contractor is requested to be present. The Contractor shall adhere to reporting requirements included in this contract.

In general, the Contractor staff shall have:

· Knowledge of the health care needs of the various IHCP programs and the skills for working with these populations;

· Knowledge and experience in Medicaid and LTSS managed health care commercial health care delivery systems;

· General knowledge of Medicare products available to dual-eligible individuals such as D-SNPs and Fee for Service (FFS) Medicare;

· The ability to develop, maintain, and use both an interactive, automated data system and a telephone helpline system;

· Exceptional interpersonal skills and the ability to work closely with physicians, other health care and home care providers, caseworkers with the DFR, and other FSSA contractors on member and provider issues and to educate both members and providers effectively; and

· Excellent conflict resolution and customer service skills.

The Contractor staff shall be knowledgeable about all of the Indiana Health Coverage Programs. It is essential for the Contractor staff to understand the differences and the unique characteristics of each of the populations served under the Indiana Health Coverage Programs to thoroughly and accurately assist callers who contact the enrollment broker.

Quality Improvement The Contractor shall track and resolve quality issues, participate in quality meetings as requested by the State and other aspects of the State’s quality strategy, as appropriate. See Section IV.a.5.b. for additional information on quality improvement activities.

Coordination Activities The Contractor is responsible for coordinating business efforts and processes at the State’s direction with other State contractors providing services such as, but not limited to: Enterprise Data Warehouse (EDW), MMIS, MCOs, LCAR, and MSS. This includes:

· Maintaining coordination methods to provide information to FSSA contractors as necessary to support the managed care programs;

· Coordinating and establishing protocols for call transfers and forwarding to necessary outside personnel;

· Providing feedback to the State and other contractors as necessary regarding identified issues; and

· Ensuring accuracy, completeness, and timeliness of all information provided.

Contractor Tasks Enrollment Broker Helpline Services Helpline Maintenance and Management The Contractor shall maintain and manage the existing Statewide toll-free Helpline number to assist members with MCO selections or MCO change requests, questions, concerns, or complaints. The Contractor must also maintain and manage the appropriate prompts feeding from the State’s toll-free number for HIP. The Contractor must follow its developed plan to ensure appropriate helpline maintenance and management as further described in this Section and Section VII.a.1. The Contractor’s Helpline staff must be prepared to respond to member and potential member concerns or issues including, but not limited to the following:

· Access to health care services;

· Identification or explanation of covered services;

· Special health care needs;

· Disease management services;

· Behavioral health;

· Care and service coordination (Indiana PathWays for Aging only);

· Care management (Hoosier Care Connect only);

· Procedures for submitting a member grievance or appeal;

· Potential fraud or abuse;

· Changing MCOs and impact if they have a D-SNP;

· Moving into and out of the programs;

· Referral options when an individual expresses an unmet need;

· Access to the LCAR;

· Access to the Indiana PathWays for Aging MSS vendor (“ombudsman”); and

· Tribal Enrollee & Hospice recipient Managed Care Opt-in at enrollment (and Opt-out anytime for Tribal members only) The Contractor will staff the Helplines that serve as the central point of information on all aspects of the programs. The Contractor must have an appropriate system in place to allow receipt of incoming call traffic, sophistication to route calls to designated resources, management software for monitoring and oversight of the staff and system, and robust reporting capabilities. The Contractor shall provide adequate staffing for the enrollment broker helplines to ensure that member inquiries and complaints are resolved in a timely manner and that vital program functions such as education and enrollment are provided efficiently and effectively. The Contractor shall ensure that Call Center staff treats each caller with dignity and respects the caller’s right to privacy and confidentiality. The Call Center staff shall greet callers and identify themselves by first name when answering.

The Contractor must staff the Helplines to provide sufficient “live voice” (a staff member answering and handling the calls) access to its members for, at a minimum, forty-five (45) hours a week, Monday through Friday 8:00 AM to 5:00 PM, Eastern Time Zone. The Helpline must offer language translation services for members whose primary language is not English (Spanish is the current prevalent second language) and must offer automated telephone menu options in English and Spanish.

The Contractor shall also make oral interpretation services available to the visually-impaired. The Contractor must provide members oral interpreter services in real time, either through their own interpreters or telephone services for languages other than English and other communication preferences. For example, the Contractor shall provide Telecommunications Device for the Deaf (TDD) services for hearing impaired members, oral interpreters and signers.

The Contractor must notify current and potential enrollees of availability of oral interpretation of written materials, as well as information in alternative formats and languages, and how to access those services. All information must meet the requirements of 42 CFR 438.10 as amended from time to time.

The general public, members and potential members, physicians, other health care and home care providers, and community agencies all use the current Helpline as their basic source of information regarding the Indiana Medicaid programs described in Section II.a. The Contractor must have the ability to provide and process “warm” transfers (staying on the phone line until the member is connected) to other IHCP agencies and contractors including MCOs, DFR, the Level of Care Assessor, the Indiana PathWays for Aging Member Support Services vendor, and the Fiscal Agent when necessary and appropriate.

The Contractor must also receive “warm” transfers from the Level of Care Assessor during “live” hours, and the Contractor must have the ability to complete three-way calls with the Level of Care Assessor, State staff, or other State designated entity for priority plan selections. The Contractor must maintain a system for tracking and reporting the number and type of members’ calls and inquiries it receives during business hours.

For members enrolled in Indiana PathWays for Aging, if the member requests assistance resolving issues with an MCO or filing a grievance or appeal regarding the services delivered by the MCO, the Contractor shall facilitate access to the Member Support Services vendor via “warm” transfer or referral. If the Member Support Services vendor cannot accept a “warm” transfer, the Contractor shall provide the member with instructions for contacting this vendor.

The Contractor must monitor its Helpline service and report its telephone service level performance to FSSA each month. Helpline services are subject to performance standards listed in Section VI.a.1. of this document.

Interactive Voice Response (IVR) The Contractor shall implement and maintain a State approved IVR system with fully integrated call routing functionality. The IVR shall redirect all non-enrollment broker calls to the correct entity or entity specific phone line, using routing logic and decision tree pathways approved by the State. The Contractor shall ensure the IVR is properly configured, tested, continuously monitored, and updated as needed to maintain accurate and efficient call routing in accordance with State requirements. Examples may include member questions for their MCO or provider questions about enrollment or billing. The Contractor is responsible for working with the State to maintain IVR recordings and update them as requested by the State. It is the Contractor’s responsibility to ensure all non-enrollment broker calls are being routed appropriately.

Call Recording and Monitoring The Contractor shall record all calls for quality control, program integrity and training purposes. Call Center staff shall advise callers that calls are monitored and recorded for quality assurance purposes. Call Center supervisors’ lines shall also be recorded. Administrative lines do not need to be recorded. The Contractor shall retain call recordings according to the State’s Data Classification & Records Retention schedules applicable to the data captured (e.g., PHI under HIPAA), and no longer than necessary. The Contractor shall document the applicable retention period in the approved Data Retention Schedule and implement secure deletion consistent with the Indiana Office of Technology Information Security Framework (IOT ISF).

The Contractor shall monitor at least five (5) “live” calls of each Call Center staff member on a monthly basis by listening to the conversation in progress. The Contractor shall use this monitoring to identify problems or issues that need to be addressed and for quality control and training purposes. The Contractor shall document and retain results of this monitoring and subsequent training and submit such documentation to the State upon request. As part of the required monthly reporting, the Contractor shall provide a blind sample of calls from each program to the State for review and feedback, supporting continuous improvement of call center performance. The State shall instruct the Contractor regarding the number of calls to be submitted each month.

Tracking and Reporting Helpline Representatives shall enter all relevant information into the Contractor database in accordance with Section III.a.4.a. and perform extensive data entry, tracking, and database correction functions. Member issues, complaints, just cause grievances, referrals and follow-ups are entered into and tracked via the database. The Contractor shall record the enrollee’s request for health plan counseling and document the enrollee’s choice in the Contractor’s call tracking system.

Updating Member Demographic Information & Verifying Eligibility The Contractor shall use MMIS as the source of truth to verify members’ addresses and telephone numbers and educate the member on how to update their information with DFR if the information collected differs from previous records. As per Section III.a.4.a., the Contractor shall also report any new addresses and phone numbers for the member to the DFR in the format and method dictated by the State.

The Contractor shall also use MMIS as the authoritative source of truth for resolving any eligibility-related questions.

All data entered by the Helpline Representatives is used for monitoring and tracking purposes and reporting on the operations of the managed care programs overall as well as the individual MCOs. The Contractor shall evaluate the adequacy and effectiveness of the Helpline coverage on a daily basis by gathering statistics related to the operation of the Helpline and preparing regular reports to the State as defined in Section III.b.1. and submitting those reports at the times required per each report definition.

Member Education Managed Care Enrollment Education The Helpline staff will provide all members and potential members with unbiased and neutral information on the managed care programs over the phone. All enrollee education, including call scripts and talking points, must be developed by the Contractor and approved by FSSA. Revisions to call scripts and talking points must be approved in advance by FSSA. In accordance with 42 CFR 438.10(e)(1) and (2), enrollment education must include, but not necessarily be limited to, the items noted below:

· Basic features of managed care;

· Unique features of managed care for LTSS;

· How to access the Medicaid health care system appropriately (i.e., keeping appointments, appropriate use of the emergency room, prior authorization requirements, understanding MCO rules, understanding which services need PMP approval, how to file a grievance, etc.);

· The importance of primary and preventive care and other health promotion services;

· Detailed, unbiased information about the MCOs and PMPs (to be developed in concert with the MCOs and FSSA);

· Medicare products including Fee-for-Service Medicare and Dual-Special Needs Plans (D-SNPs);

· Companion Medicare D-SNP products, which includes:

· Information about D-SNP/Indiana PathWays for Aging plan integration and alignment;

· Available D-SNP services offered (i.e., supplemental benefits; summary information contained in D-SNP Evidence of Coverage (EOC) and Statement of Benefits (SOB) documents) as compared with Indiana PathWays for Aging Medicaid plans; and

· Differences between Medicare service delivery systems (i.e., traditional Medicare, Medicare Advantage, Special Needs Plans, etc.).

· Where applicable, how to access the transportation benefits within the MCOs rules;

· Information about accessing the Indiana PathWays for Aging Member Support Services vendor including services provided and how to contact the vendor;

· Information for members of federally recognized tribes on how to opt-in or opt-out of managed care and the benefits of managed care, and;

· Information for individuals receiving hospice benefits at the point they are eligible for PathWays on how to opt-in to managed care.

Members of all four (4) programs may contact the enrollment broker for enrollment education. The Contractor's primary methods of engagement with individuals shall be via telephone and written notice. If, over the course of the Contract, an individual requests to enroll via an in-person or web-based medium (e.g., email), the Contractor shall make that method available to the individual. The Contractor shall obtain prior approval from the State before conducting any in-person enrollment assistance. Data on all such requests, including the method requested and the disposition of each request, shall be included in the Contractor’s required monthly reporting. At this time, the State anticipates only minimal demand for in-person or web-based enrollment options. To date, there have been no requests for in person or email-based enrollment assistance under the current Contract.

Whether the call is inbound or outbound, the enrollee shall have the opportunity to ask questions, must be given the Helpline number, and shall be encouraged to call again if they have further questions. If the member expresses an unmet social need, especially those for whom Medicaid enrollment will not be immediate (e.g., pending eligibility) the Contractor must be prepared to make an appropriate referral to entities including but not limited to Indiana 211, Area Agencies on Aging, DFR, the member’s Medicare plan, etc.

The Contractor is not required to maintain a provider list but must be able to direct the member to such information when necessary, including the Contractor utilizing the respective MCO’s online provider directory to look up provider details and share the information with the member upon request.

The Contractor must ensure they are using the most recent version of the FSSA-provided MCO Health Plan Summary sheet. The Contractor must be familiar with and utilize the summary sheet when helping members with plan selection and easily compare the MCOs.

Outbound Call Requirements for Hoosier Care Connect and Indiana PathWays for Aging Members The Contractor must attempt to conduct telephone interviews with new Hoosier Care Connect and new Indiana PathWays for Aging enrollees via outbound calling who have not already selected a plan or been contacted by the enrollment broker. Specific requirements are noted in this Section.

Similarly, at the State's discretion, outbound call populations may be paused or resumed at any time. These updates will be communicated by the State with the Contractor in writing, and the Contractor will confirm the effective date of these changes.

If calls are paused then resumed for any reason, the State will give a five (5) business days’ notice regarding the commencement of outbound calls in order to give the Contractor time to adjust staffing. Once notified, the Contractor must attempt to conduct telephone interviews with new Hoosier Care Connect and new Indiana PathWays for Aging enrollees via outbound calling who have not already selected a plan or been contacted by the enrollment broker. The Contractor shall maintain policies, procedures, and technological functionality to conduct outbound calls throughout the Contract term.

i. Hoosier Care Connect Outbound Call Requirements After receiving information about a Hoosier Care Connect individual from the State, the Contractor shall make required calls within ten (10) business days. The Contractor shall limit the number of Hoosier Care Connect outbound calls to one (1). Outbound calls shall be limited to those members who are designated as being on an HCC hold for plan assignment in MMIS.

ii. PathWays for Aging Outbound Call Requirements After receiving information about a PathWays for Aging individual from the State, the Contractor shall create and hold the outbound call task(s) until the individual is within thirty (30) calendar days of aging into the program. (E.g., If a member’s birth month is April, they will age in and begin PathWays coverage effective April 1; the outbound call shall be made around March 1, approximately 30 calendar days before the member ages in.)

The Contractor shall limit the number of PathWays outbound calls to up to two (2) if the member has an authorized representative, with one (1) call going to the member and one (1) to the authorized representative if the member was not reached on the first call. If the member does not have an authorized representative, only one (1) call shall be made to the member.

Indiana PathWays for Aging outbound phone outreach is limited to the following populations: non-D-SNP HCBS (waiver) members aging-in to the program.

Choice Counseling The Contractor shall provide each member with unbiased information to assist them in the selection of an MCO. The Contractor shall, at a minimum, supply the member with the following two (2) items of information:

· Detail on each of the MCOs available in the member’s county and the enhanced services they offer via the MCO health plan summary; and

· Detail on providers and PMPs (where applicable) available in the member’s county. Members shall be directed to information containing a provider listing and PMPs available in the member’s county if they so choose.

· For Indiana PathWays for Aging, provider details shall include home and community-based (HCBS) providers, other Long-Term Care providers such as nursing facilities, and specialist physicians.

· The Contractor must accept regular files from the MCOs that reflect their current Indiana PathWays for Aging networks as the plans continue to build and refine their provider networks.

· The Contractor will also receive a monthly list of contracted care and service coordinators for Indiana PathWays for Aging from the MCOs.

When a member indicates to the Contractor, he or she would like to see a specific healthcare provider, the Contractor shall utilize the MCOs online provider directory to determine if the requested provider is available in an MCO network(s), either as a specialist, PMP, nursing facility provider, HCBS provider, or other provider type. The Contractor shall inform the member of the provider's contracting status with each MCO and indicate the MCO will assist the member with seeing their chosen healthcare provider once the MCO assignment is effective. If the requested provider is not contracted with any MCO, the Contractor shall inform the member the provider is not enrolled with any MCO.

End of Call Surveys The Contractor shall conduct end of call surveys of consumers to evaluate their satisfaction and whether they were given sufficient information on the managed care plan options. The Contractor shall use the State’s four (4) question survey that asks about the satisfaction rate with the call. The survey must be conducted on a quarterly basis with a minimum of one hundred-fifty (150) completed surveys each quarter.

The Contractor may propose other methods to effectively educate current and potential managed care members and implement these methods as approved by the State.

Indiana PathWays for Aging Choice Counseling For Indiana PathWays for Aging, provider details shall include home and community-based service (HCBS) providers, other Long-Term Care providers such as nursing facilities, and specialist physicians.

Hoosier Care Connect Choice Counseling If a Hoosier Care Connect member indicates he or she wants to postpone an MCO selection until the provider joins the network, the Contractor shall advise the member this is permissible and shall provide instructions for calling the Contractor back to make an MCO selection. The Contractor shall also advise the member of the timeline in which an MCO selection must be made to avoid being auto assigned. Further, the Contractor shall encourage the member to also contact the requested provider to see if he or she would be willing to contract with an MCO.

Member Materials The Contractor must distribute materials as appropriate, to be used in conjunction with the Contractor's member education and enrollment facilitation responsibilities. All materials are the property of the State, though they may be developed in conjunction with the Contractor.

Annually, thirty (30) calendar days after the end of the calendar year, as part of its Quality Management and Improvement Plan Summary Report, the Contractor must submit a list of all member education and outreach materials it has used during the previous year and anticipates using in the upcoming year.

The Contractor shall notify enrollees:

· That oral interpretation is available for any language, including Spanish;

· That written information is available in prevalent languages (currently Spanish); and

· How to access interpretation services and written information.

The Contractor is responsible for translating new and revised materials into Spanish at no additional cost to the State, and the State must provide final approval before use.

Upon request by the member, the Contractor shall send out electronic brochures and educational information to current and potential members via e-mail to reduce the volume of mailings.

Postage for all mailed materials from the enrollment broker is to be billed at the postage passthrough rate.

Member materials may include the following:

MCO Health Plan Summaries The Contractor must ensure it is using the most recent version of the MCO Health Plan Summary sheet for each program (HIP, HHW, HCC, and Indiana PathWays for Aging). The Contractor must be familiar with and utilize the summary sheet when helping members with plan selection and easily compare the MCOs. The MCO Summary sheets provide comparative MCO information for (potential) enrollees, as required by 42 CFR 438.10(e)(2)(ii).

The Contractor must provide information specific to each MCO program operating in potential enrollee’s service area, such as:

· Benefits covered;

· Enhanced benefits each MCO offers;

· Cost sharing, if any;

· Benefits that are available under the State plan but are not covered under the Contract, including how and where the enrollee may obtain those benefits, any cost sharing, and, if applicable, how transportation is provided.

· For a counseling or referral service that the MCO does not cover because of moral or religious objections, the State must provide information about where and how to obtain the service.

A copy of the current health plan summary shall be sent with each Hoosier Care Connect welcome letter as well as the following Indiana PathWays for Aging Ongoing Notices:

· FFS Age In and HCBS Member Letter

· FFS Age In and Nursing Facility Letter

· FFS Age In Member Letter

· HCC Unaligned Age In Member Letter

· Hospice FFS Opt In Member Letter

· Hospice MCE Opt In Member Letter

Provider Lists The Contractor is not required to provide printed provider and PMP lists. However, the Contractor must be able to provide details on providers and PMPs available in the member’s county by utilizing MMIS and each MCO’s online provider directory to look up provider details and share the information with the member upon request. MCOs are required to develop provider directories and make printed copies available to members upon request. The Contractor must have policies and procedures in place to refer members to the MCOs, when requested, to obtain provider directories and information to assist in an enrollee’s selection of an MCO.

HIP Annual Health Plan Selection Period (Open Enrollment) Postcard or Letter Notification The Contractor shall mail postcards or letters to Healthy Indiana Plan members during the HIP annual health plan selection period (also called open enrollment). The Contractor will ensure the postcards or letters include general information that facilitates the member's understanding of the HIP program and must be updated, revised, and distributed as needed. The postcards or letters must be written at a fifth grade reading level and be approved in advance by the State. The postcards or letters will contain information requested by the State including but not limited to:

· How to change MCOs and the timeframe to do so;

· What will happen should a plan change not be requested; and

· Information about Just Cause plan changes.

Each year, prior to the annual health plan selection period, the State and the Contractor will mutually determine whether the notification will be issued as a letter or a postcard.

Hoosier Care Connect Welcome Notice The Contractor shall send notices created by the State for newly eligible Hoosier Care Connect members on an ongoing basis who did not select an MCO on their application and who is designated as being on an HCC hold for plan assignment in MMIS. Notices shall be sent within ten (10) calendar days of receiving the individual’s information from the State.

A copy of the current Hoosier Care Connect health plan summary shall be sent with each Hoosier Care Connect notice.

Indiana PathWays for Aging Notice Requirements The Contractor shall send notices created by the State for Indiana PathWays for Aging on an ongoing basis when members newly enroll in Indiana PathWays for Aging and for when members are set to age-in to the program. Notices shall be sent to the individual by the Contractor within ten (10) calendar days of receiving demographic information from MMIS. Notices must have specifically tailored messaging for individuals enrolled in D-SNP plans, as written and prepared by the State.

The types Indiana PathWays for Aging notices are as follows:

· Age-In Notices: These notices are for individuals aging into the program during ongoing operations and will include subsets of notices for aligned/unaligned plans, programs the individuals are coming from and for Native Americans and individuals receiving hospice at age-in. Notice types currently include:

· HCC Unaligned

· HCC Aligned

· FFS Age In

· FFS Age In and Aligned D-SNP

· FFS Age In and HCBS

· FFS Age In and Nursing Facility

· FFS Age In and Aligned D-SNP and HCBS

· Hospice

· AI/AN (American Indian/Alaska Native)

· Enrolled New Member Notices: These notices are sent to new enrollees whose application was approved that did not make a health plan selection and were auto-enrolled by the State, or they are coming from a different program outside of their age-in period.

· Annual Health Plan Selection Period: Annual health plan selection period notices (also called open enrollment notices) go to members when their annual health plan selection period commences, which aligns with Medicare open enrollment.

· Any other notice required by the State.

A copy of the current Indiana PathWays for Aging health plan summary shall be sent with each of the following notices:

· FFS Age In and HCBS Member Letter

· FFS Age In and Nursing Facility Letter

· FFS Age In Member Letter

· HCC Unaligned Age In Member Letter

· Hospice FFS Opt In Member Letter

· Hospice MCE Opt In Member Letter Other Materials The Contractor shall also produce, update, print, and distribute materials which provide information on specific topics, including, but not limited to, appropriate emergency room use, pharmacy use, the importance of keeping scheduled appointments, the importance of a medical home, and procedures for filing grievances. The topics and the distribution of the material will be developed at the direction of FSSA in conjunction with the MCOs. While this activity is not occurring under the current Contract, the State may request such materials to be developed or updated in the future.

Correspondence The Contractor must have the capacity to prepare accurate and thoroughly written responses to various inquiries. The Contractor must respond to ninety-eight percent (98%) of all written provider and recipient correspondence (inquiries) within five (5) business days of receipt of the written correspondence by the Contractor. The Contractor must respond to the remainder within ten (10) business days of receipt. This may involve coordination with other contractors. Written responses must be technically and grammatically accurate. The Contractor shall refer all questions from State and Federal legislators, the Governor, the FSSA Secretary, or news media inquiries to the FSSA Communications Director.

Member Enrollment & Disenrollment The Contractor shall assist in member enrollment and disenrollment. The Contractor shall administer all plan selection activities timely and with great attention to high-quality customer service according to the details in this Statement of Work. Members and/or a member’s authorized representative, when appropriate, also must receive appropriate education, enrollment, and choice counseling services.

Member Enrollment The Contractor shall conduct education, health plan choice counseling and enrollment functions for all programs (Hoosier Healthwise, the Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging) with individuals who call the helpline and with those individuals the State identifies as requiring outreach by the Contractor. After the member has received choice counseling and other education by the Helpline Representative, the Contractor shall record the program and/or MCO selection (as applicable) and the results of the conversation in the Contractor database as set forth in Section III.a.4.a. The Contractor must ensure that the MCO selection is also recorded in MMIS.

The Contractor shall have scripting to provide education and assist with plan selection. The Contractor shall inform members and authorized representatives when applicable on what MCOs contain their preferred PMP and/or other health care provider(s) to support their plan selection.

For individuals enrolled in D-SNP plans (Indiana PathWays for Aging), the Contractor shall have tailored messaging for D-SNP enrollment in Indiana PathWays for Aging and have tailored call scripts for D-SNP enrollees approved by FSSA.

The Contractor shall have scripting and logic for each program to support the resolution of multiple conflicting MCO selections. The Contractor shall match MCO selections on a daily basis and report matched MCO selections to MMIS.

If a member or authorized representative does not select a health plan, there will be an auto-assignment process in place directed by the State. Auto-assignment is not the responsibility of the Contractor.

Effective Dates for Newly Eligible Members Hoosier Healthwise and Hoosier Care Connect MCO selections for newly eligible enrollees are effective on either the 1st or the 15th of each month, depending on when the selection is recorded in MMIS.

For Hoosier Healthwise and Hoosier Care Connect:

· MCO selections entered between the 11th and the 25th of one month will be effective on the 1st of the next month.

· Example: Selections entered between May 11th and May 25th will be effective on June 1st.

· MCO selections for newly eligible enrollees entered into MMIS between the 26th of one month and the 10th of the second month will be effective on the 15th of that second month.

· Example: Selections entered between April 26th and May 10th will be effective on May 15th.

For HIP and Indiana PathWays for Aging, MCO selections are always effective the 1st of the month.

Indiana PathWays for Aging Member Enrollment Plan assignment for Indiana PathWays for Aging will favor plan alignment between Medicare and Medicaid to the greatest extent allowable. Other factors may be considered such as the residential provider of the member (if applicable). Individuals with a Medicare D-SNP will be automatically enrolled in the Medicaid PathWays plan offered by their same health plan. Should the individual seek to change their plan, the enrollment broker will refer Medicare D-SNP PBP (Plan Benefit Package) members to Medicare (the Medicare Broker) to conduct a plan change, after which the Medicaid product will be changed by the State. Changing D-SNP PBP Medicare plans will automatically update the members Indiana PathWays for Aging Medicaid plan.

The Contractor may continue to make plan changes for members enrolled in a Medicare D-SNP that is not associated with a designated PBP. The State will provide an annual listing of Medicare D-SNP PBPs to support this process.

To facilitate the ongoing enrollment process, the Contractor will receive information of pending Indiana PathWays for Aging eligible individuals, current fully Indiana PathWays for Aging eligible individuals and future (i.e., 90 calendar days prior, “age-in” members) fully Indiana PathWays for Aging eligible individuals daily along with demographic information, the authorized representative(s) if applicable, Medicare/D-SNP information, Level of Care (LOC), Nursing Facility residence and contact information, American Indian/Alaska Native (AI/AN) status, and hospice status.

Additionally, the Contractor will receive information about individuals who age-in and meet the criteria for the Indiana PathWays for Aging program 90 calendar days prior to their eligibility. Those that age-in may be FFS individuals, dual eligible members, waiver individuals, Nursing Facility residents, HCC members, HIP Members, and others. For individuals in a D-SNP plan, the Contractor will receive the individual’s D-SNP Plan and Medicare Identification number. If the information for a member’s D-SNP plan needs validating, the Contractor shall use MMIS to verify and check the D-SNP member’s plan enrollment status.

Plan selection can be made by calling the enrollment broker within ninety (90) calendar days of coverage start by a member or authorized representative or via the Contractor’s direct outreach to the individual as described in this Section, except for those with a Medicare D-SNP PBP who will be referred to the Medicare Broker or D-SNP of their choosing to make plan changes.

The Contractor must also accept calls from an individual who has not yet reached a pending status and document their selection and match this selection with the pending or fully eligible eligibility record.

The Contractor database shall separately track individuals who have received Indiana PathWays for Aging choice counseling.

American Indian or Alaska Native (Al/AN) Opt-in for HIP, HHW, HCC, and Indiana PathWays for Aging American Indians and Alaska Natives shall have the option to opt into or out of the program. Individuals who are eligible for Indiana PathWays for Aging and have a Native American Indicator (Tribal Indicator) must opt-in if they want to enroll in managed care, otherwise they will be assigned to FFS. For opt-in, the Contractor shall send an American Indian or Alaska Native (AI/AN) opt-in communication to Indiana PathWays for Aging members with verified status on pending or fully eligible records. If the Member opts-in the contactor shall enter the opt-in information.

In the other managed care programs (HIP, HHW, HCC), members with a Native American Indicator are automatically enrolled in managed care and must opt-out if they prefer not to participate.

When MMIS receives a fully eligible file as defined by OMPP and CoreMMIS for American Indian/Alaska Native (AI/AN) members who are enrolled in Indiana PathWays for Aging, MMIS will automatically end all MCO enrollment. MMIS will then send a daily report of these members to the Contractor.

For AI/AN members who choose to opt-in to managed care, the Contractor is responsible for entering the member’s plan selection or designation within two (2) business days of receiving the auto-stop notification, so MMIS can complete the auto-assignment.

If a member is already enrolled in managed care and is auto-stopped due to AI/AN status, the Contractor should override the auto-stop and…