PathWays Technical Report.pdf

April 2026

2025 Annual

EQR Technical Report Indiana Family and Social Services Office of Medicaid Policy and Planning Indiana PathWays for Aging Final

2025 ANNUAL EQRO TECHNICAL REPORT –Indiana PATHWAYS FOR AGING

Indiana FSSA Office of Medicaid Policy and Planning

Table of Contents List of Tables List of Figures Acknowledgements, Acronyms, and Initialisms Overview

OMPP Background Members OMPP Quality Strategy Overview OMPP Strategic Objectives for Quality Improvement Quality Strategy Evaluation and Conclusion EQR Activities

EQR Mandatory Activities CMS National Quality Strategy

Quality of Care Timeliness of Care Access to Care

Technical Report Guidelines EQRO Team

Protocol 1: Performance Improvement Project (PIP) Validation 22 Objectives Technical Methods of Data Collection and Analysis Description of Data Obtained Interventions Performance Measures and Measurement Scores Validation Results MY 2024 PIPs Strengths, Weaknesses, and Recommendations Improvements Since the MY 2023 PIP Validation Conclusions and Recommendations

Anthem Humana

UHC

Protocol 2: Performance Measure Validation (PMV) Objectives Technical Methods of Data Collection and Analysis

Performance Measures for Validation HEDIS® Measures for Validation

Description of Data Obtained CMS Measures CAHPS Measures

Data Integration, Data Control, and Performance Measure Documentation

Claims/Encounter Data System Enrollment/Eligibility Data System Provider Systems Data Integration, Software Integration, and Measure Development

Performance Measure Validation Status and Findings Summary

Performance Measures Additional Performance Measures CMS Measures CAHPS® Measures HEDIS® Measures

Improvements from 2024 PMV Strengths and Weaknesses Conclusions and Recommendations

Table of Contents

Indiana FSSA Office of Medicaid Policy and Planning

Protocol 3: Compliance Assessment (CA) Objectives Technical Methods for Data Collection and Analysis Description of Data Obtained Strengths and Weaknesses Performance Improvement Conclusions and Recommendations

Anthem Humana

UHC

Protocol 4: Annual Network Adequacy (ANA) Overview Objectives Geographic Network Adequacy Analysis

Objectives Methodology Data Collection Data Standardization Calculations Provider Network Adequacy by Geography Anthem Member Population Anthem Accessibility by Provider Type Humana Member Population Humana Accessibility by Provider Service Type UHC Member Population UHC Accessibility by Provider Service Type

Secret Shopper Survey Objectives Provider Sampling Methodology

Survey Procedure Survey Results Appointment Wait Times Provider Directory Inaccuracies

ANA Validation Strengths and Weaknesses Performance Improvements Conclusions and Recommendations

Anthem Humana

UHC

Protocol 5: Encounter Data Validation Overview Activity 1: Review of State Requirements

Data Standards State Standards

Activity 2: Review of Data Production Capacity ISCAT Review

Activity 3: Data Analysis Step 1: Data Quality Test Plan Step 2: Verification of Data Integrity Step 3: Generate and Review Analytic Reports Step 4: Compare Findings to State-Identified Benchmarks ... 119 Validation Results

Activity 4: Review of Medical Records Methodology Results

Activity 5: Submission of EQRO Findings

Table of Contents

Indiana FSSA Office of Medicaid Policy and Planning

Strengths and Weaknesses Performance Improvements Conclusions and Recommendations

Anthem Humana

UHC

2025 EQR Conclusions PIP Validation

PMV

CA

ANA

EDV

Appendix A | PIP Validation Findings ......................................... A-1 Appendix B | Detailed Analysis of Provider Network Access .. B-1

FSSA Indiana Health Care Plan Provider Enrollment Type and Specialty Matrix ......................................................................... B-1 Provider-to-Member Ratios by MCE ......................................B-11

Indiana FSSA Office of Medicaid Policy and Planning

List of Tables Table 1. Total Members by Month Table 2. PathWays Quality Strategy Initiatives Table 3. EQR Activities Conducted in 2025 Table 4. PIP Steps Table 5. PIP Validation Rating Criteria Table 6. PIP Topics Table 7. PIP Validation Status and Measurement Year Table 8. PIP Aim Statements and Populations Table 9. MY 2024 PIP Interventions Table 10. PIP Performance Measures Table 11. PIP Score and Validation Rating Table 12. PIP Strengths Table 13. PIP Weaknesses (AONs) Table 14. Performance Measure Validation Status Table 15. Performance Measures Table 16. Additional Performance Measures Table 17. Data Integration, Data Control, and Performance Measure Documentation Table 18. Key Performance Measure Review Results Table 19. 2025 PMV: Completion of Initial Health Needs Screening and Comprehensive Health Assessment Tool Table 20. 2025 PMV: Service Coordinators who Successfully Completed Person-Centered Competency Training Table 21. 2025 PMV: ICP Developed and Implemented within 90 Days for Members with Care Management Level of Service Table 22. 2025 PMV: Institution for Mental Disease Member Use Performance Measure Table 23. 2025 PMV: Dentists and Oral Surgeons Network Adequacy Table 24. 2025 PMV: HEDIS® Measures Table 25. PMV Strengths Table 26. PMV Weaknesses

Table 27. Compliance Standards Table 28. Compliance Rating Criteria Table 29. 2025 Compliance Standard Scores Table 30. 2025 File Review Score Table 31. CA Strengths by Standard Table 32. CA Weaknesses (AONs) by Standard Table 33. Accessibility by Provider Service Type Table 34. Secret Shopper Totals Table 35. Secret Shopper Unable to Reach Reasons Table 36. Secret Shopper Unable to Complete Reasons Table 37. Appointment Wait Time Compliance Table 38. Provider Directory Inaccuracies Table 39. Network Adequacy Rating Criteria Table 40. Network Adequacy Rating Table 41. ANA Strengths Table 42. ANA Weaknesses Table 43. MCE and OMPP Explanation of MCE’s Contracted Capitated Versus FFS Providers Table 44. Enrollee Volume Comparison Between MCEs and OMPP By Month Table 45. Enrollee Volume Comparison Between MCEs and OMPP By Month: SNF/NF Table 46. Total Distinct Encounters by Encounter Type: All Encounters Table 47. Total Encounters By Month Table 48. Total Distinct Encounters by Encounter Type: SNF/NF . 126 Table 49. Total Encounters By Month: SNF/NF Table 50. Timeliness of Adjudicated Claim Submissions Table 51. Average Number of Days and Range from Billed Date to Paid Date Table 52. Average Number of Days from Service Date to Paid Date

List of Tables

Indiana FSSA Office of Medicaid Policy and Planning

Table 53. Average Number of Days and Range from Billed Date to Paid Date: SNF/NF Table 54. Average Number of Days from Service Date to Paid Date:

SNF/NF

Table 55. Distribution by Medical Service Type —All Encounters . 133 Table 56. Distribution by Medical Service Type—SNF/NF Encounters Table 57. Claim Coding Logic Table 58. Top 10 Nursing Facility Procedure Codes Table 59. Completeness and Validity Rates — Professional Encounters Table 60. Completeness and Validity Rates — Institutional Encounters Table 61. Requested Encounters – Completeness

Table 62. MRR Results – Rendering Provider Validation Table 63. MRR Results – Billing Provider Validation Table 64. MRR Results – Date of Service Validation Table 65. MRR Results – Procedure Code Validation Table 66. MRR Results – Diagnosis Code Validation Table 67. EDV Strengths Table 68. EDV Weaknesses Table A-1. 2025 PIP Details for MCEs ............................................ A-1 Table B-1. FSSA Indiana Health Care Plan Provider Enrollment Type and Specialty Matrix ........................................................................ B-1 Table B-2. Anthem – Provider to Member Ratios ......................... B-11 Table B-3. Humana – Provider to Member Ratios ........................ B-13 Table B-4. UHC – Provider to Member Ratios .............................. B-16

Indiana FSSA Office of Medicaid Policy and Planning

List of Figures Figure 1. PIP Validation Score Comparison Figure 2. Anthem Member Population Figure 3. Dentists Figure 4. Gynecologists Figure 5. Non-Hospital Based Anesthesiologists Figure 6. Oral Surgeons Figure 7. Orthodontists Figure 8. SUD Providers Figure 9. Humana Member Population Figure 10. PMP – Physicians Figure 11. Cardiothoracic Surgeons Figure 12. Dentists Figure 13. Gynecologists

Figure 14. Oral Surgeons Figure 15. Orthodontists Figure 16. Pharmacy Figure 17. SUD Providers Figure 18. UHC Member Population Figure 19. Cardiothoracic Surgeons Figure 20. Dentists Figure 21. Diagnostic Testing Figure 22. Gynecologists Figure 23. Interventional Radiologists Figure 24. Orthodontists Figure 25. SUD Providers

Indiana FSSA Office of Medicaid Policy and Planning

Acknowledgements, Acronyms, and Initialisms1 AAP ........... Adults’ Access to Preventive/Ambulatory Health Services AHRQ ............................ Agency for Healthcare Research and Quality AHU .............................................................. Acute Hospital Utilization ANA ............................................................ Annual Network Adequacy Anthem ........... Blue Cross Blue Shield Anthem, Managed Care Entity AON ................................................................. Area of Noncompliance BH ............................................................................ Behavioral Health BPD ....................... Blood Pressure Control for Patients with Diabetes CA ................................................................. Compliance Assessment CAHPS® ....................................Consumer Assessment of Healthcare

Provider and Services CAP ................................................................... Corrective Action Plan CAU ..................................... Comprehensive Assessment and Update CBP ........................................................... Controlling Blood Pressure CFR ........................................................ Code of Federal Regulations CHAT ................................... Comprehensive Health Assessment Tool CHIP .......................................... Children's Health Insurance Program CMS .................................. Centers for Medicare & Medicaid Services CPT ................................................... Current Procedural Terminology CPU ............................................... Comprehensive Care Plan Update CY ................................................................................. Calendar Year DME ......................................................... Durable Medical Equipment EDQ .......................................................... Enterprise Data Warehouse EDU ................................................Emergency Department Utilization EDV ........................................................... Electronic Data Verification EDW ......................................................... Electronic Data Warehouse EED ............................................ Eye Exam for Patients with Diabetes

1 Other company and product names may be trademarks of the respective companies with which they are associated. The mention of such companies and product names is with due recognition and without intent to misappropriate such names or marks.

EQR ................................................................ External Quality Review EQRO ....................................... External Quality Review Organization ESRI ArcGIS™ ......... Environmental Systems Research Institute, Inc.

ArcGISTM EVV ............................................................ Electronic Visit Verification FFS .............................................................................. Fee-for-Service FSSA .................... Indiana Family and Social Services Administration FUA……………….…Follow-up After Emergency Department Visit for

Drug Abuse or Dependence FUH ........................ Follow-Up After Hospitalization for Mental Illness FUM .. Follow-Up After Emergency Department Visit for Mental Illness GD ............................................................................... General Dentist GSD ............. Glycemic Status Assessment for Patients with Diabetes GYN ................................................................................. Gynecologist HbA1c ......................................................................... Hemoglobin A1c HCBS .................................... Home- and Community-Based Services HEDIS®………………. Healthcare Effectiveness Data and Information Set, a registered trademark of the National Committee for Quality Assurance (NCQA)

HNS ............................................................... Health Needs Screening Humana .................. Humana Healthy Horizons, Managed Care Entity ICP ................................................................ Individualized Care Plan ID ...................................................................................... Identification IET .................. Initiation and Engagement of Alcohol and Other Drugs IMD ......................................................... Institution for Mental Disease ISCA/ISCAT ........... Information Systems Capability Assessment Tool KED .................... Kidney Health Evaluation for Patients with Diabetes LTSS ............................................. Long-Term Services and Supports

Acknowledgements, Acronyms, and Initialisms

Indiana FSSA Office of Medicaid Policy and Planning

MCE ................................................................... Managed Care Entity MCP ..................................................................... Managed Care Plan MLTSS .......................... Managed Long-Term Services and Supports MMIS ................................ Medicaid Management Information System MRR ............................................................... Medical Record Review MY .......................................................................... Measurement Year N ....................................................................... Number of Encounters NA ................................................................................. Not Applicable NABD .......................................... Notice of Adverse Benefit Decisions NCQA ................................ National Committee for Quality Assurance NDC ....................................................................... National Drug Code NF ................................................................................. Nursing Facility NFLOC .................................................. Nursing Facility Level of Care NPI ............................................................. National Provider Identifier NQ ................................................................................... Not Required NR ................................................................................... Not Reported OMPP ...................................... Office of Medicaid Policy and Planning P&P .................................................................... Policy and Procedure PathWays .................... Indiana’s PathWays to Aging Waiver Program PCP .................................................. Primary Care Provider/Physician PCR ....................................................... Plan All-Cause Readmissions PDF ........................................................... Portable Document Format PDSA ...................................................................... Plan-Do-Study-Act PIP ................................................. Performance Improvement Project

PMP .............................................................. Primary Medical Provider PMV .................................................. Performance Measure Validation QI ......................................................................... Quality Improvement Qsource® ............................................. EQRO, a registered trademark Roadmap ....................... Record of Administration, Data Management and Processes SAA ............... Adherence to Antipsychotic Medications for Individuals with Schizophrenia SCP .......................................................... Shared Care Plan with PCP SMC ....... Cardiovascular Monitoring for Persons with Cardiovascular

Disease and Schizophrenia SMD ........................... Diabetes Monitoring for Persons with Diabetes and Schizophrenia SMI .................................................................... Serious Mental Illness SNF .................................................................. Skilled Nursing Facility SPU ................................................................. Special Population Unit SQL .......................................................... Structured Query Language SSD ................ Diabetes Screening for Persons with Schizophrenia or

Bipolar Disorder Using Antipsychotic Medications SUD ............................................................... Substance Use Disorder TBD ......................................................................... To Be Determined UB ...................................................................................... Uniform Bill UHC ........... UnitedHealthcare Community Plan, Managed Care Entity UM ...................................................................Utilization Management

Indiana FSSA Office of Medicaid Policy and Planning

Overview In accordance with Title 42 Code of Federal Regulations (CFR) § 438.364, Qsource has produced this 2025 Annual External Quality Review Organization (EQRO) Technical Report to summarize the quality, timeliness, and accessibility of care furnished to members in the Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) Indiana PathWays for Aging (hereafter referred to as PathWays) program by the Managed Care Entities (MCEs). Indiana’s MCEs for PathWays include Blue Cross Blue Shield Anthem (hereafter referred to as Anthem), Humana Healthy Horizons (hereafter referred to as Humana), and UnitedHealthcare Community Plan (hereafter referred to as UHC).

OMPP contracted with Qsource to conduct External Quality Review (EQR) activities and ensure that the results of those activities are reviewed to perform an external, independent assessment and produce an annual report. Qsource serves as OMPP’s EQRO and prepared this 2025 Annual EQRO Technical Report to document the MCEs’ performance in providing services to enrollees, identify areas for improvement, and recommend interventions to improve the process and outcomes of care.

This section provides a brief history of OMPP, the population(s) served, member data for each MCE, OMPP’s quality improvement initiative descriptions, the mandatory EQR activities conducted by Qsource in 2025 (including targeted quality objectives), guidelines provided by the Centers for Medicare & Medicaid Services (CMS) for reporting EQR activities, and the intended utilization for this report.

OMPP Background The FSSA OMPP manages the administration of Medicaid health coverage programs for Indiana Hoosiers. OMPP’s new PathWays program, began on July 1, 2024, is aimed towards Hoosiers aged 60 or older who receive Medicaid or dual Medicaid/Medicare benefits. This program gives the qualifying member access to a care and services coordinator that helps the member receive the individualized care they need to remain independent in their own homes for as long as possible and age with dignity. This program expands Indiana’s Medicaid services, as well as their goal to safeguard distinct, susceptible populations throughout the state.

Three MCEs are contracted with the state of Indiana for the PathWays program:

♦ Anthem;

♦ Humana; and

♦ UHC.

Overview

Indiana FSSA Office of Medicaid Policy and Planning

Members Calendar Year (CY) 2024 was the first year for the PathWays program, having started on July 1, 2024. According to the March 2025 FSSA narrative on the monthly Medicaid financial report for December 2024, OMPP stated that, with the launch of the PathWays Program, enrollment of 116,785 individuals shifted from Medicaid fee-for-service and Hoosier Care Connect to the new PathWays managed care program. The year-to-date average monthly enrollment for PathWays from its inception through December 2024 is 116,971. The following table presents enrollment for 2024 since the inception of the program by month.

Table 1. Total Members by Month July-24 August-24 September-24 October-24 November-24 December-24

Anthem 44,428 44,740 44,898 45,121 44,821 45,003

Humana 35,441 35,331 35,326 35,347 35,085 35,098

UHC 36,762 36,942 36,947 36,973 36,709 36,854

Total 116,631 117,013 117,171 117,441 116,615 116,955

OMPP Quality Strategy Overview Under regulations at 42 CFR 438.340(a) and 42 CFR 457.1240(e), CMS requires state Medicaid agencies that contract with MCEs to develop and maintain a Medicaid quality strategy to assess and improve the quality of health care and services provided by MCEs.

In 2024, Indiana outlined specific quality initiatives for the PathWays programs. The initiatives outline global aims that OMPP has identified that support the objectives for all its programs. The initiatives are shown below.

1. Quality – Monitor quality improvement measures and strive to maintain high standards.

a. Improve health outcomes.

b. Encourage quality, continuity, and appropriateness of medical care.

2. Prevention – Foster access to primary and preventive care services with a family focus.

a. Promote primary and preventive care.

b. Foster personal responsibility and healthy lifestyles.

3. Cost – Ensure cost-effective medical coverage.

a. Deliver cost-effective coverage.

b. Ensure the appropriate use of health care services.

c. Ensure utilization management best practices.

2025 ANNUAL EQRO TECHNICAL REPORT–Indiana PATHWAYS FOR AGING

Indiana FSSA Office of Medicaid Policy and Planning

4. Coordination/Integration – Encourage the organization of patient activities to ensure appropriate care.

a. Integrate physical and Behavioral Health (BH) services.

b. Emphasize communication and collaboration with network providers.

OMPP Strategic Objectives for Quality Improvement The development of the PathWays quality strategy initiatives is based on identified trends in health care issues within the state of Indiana, attainment of the current quality strategy goals, close monitoring by OMPP of the MCEs’ performance and unmet objectives, and opportunities for improvement identified in the external quality review.

The initiatives are at the forefront of planning and implementation of this Quality Strategy. Ongoing monitoring will provide OMPP with quality-related data for future monitoring and planning. To this end, OMPP established the Five Pillars of Well Being, based off State health initiatives, input from external partners, the review of State and national data, and the needs of the population. These Five Pillars are aligned with the Medicaid Child and Adult Core Sets. Please note that the second pillar listed below is not applicable to the PathWays program members due to demographics; however, all Pillars are listed below for understanding of OMPP’s initiatives.

1. Behavioral Health – Improve health outcomes through preventive care and behavioral health condition management.

a. Improve use of preventive behavioral health screenings and follow up.

b. Improve care coordination and follow up for members with mental health and substance use disorders.

2. Maternal/Child Health – Improve the health and wellness of pregnant persons, new mothers, infants, and children.

a. Improve access to care for infants, children, and adolescents, with a focus on preventive and developmental screenings and well child visits.

b. Ensure early detection and follow up regarding prenatal and postpartum depression.

3. Oral Health – Improve oral health and prevent oral disease.

a. Improve access to dental services.

b. Increase utilization of annual dental visits to improve prevention of oral disease.

4. Chronic Conditions – Improve the health of members with chronic conditions.

a. Reduce complications for members diagnosed with diabetes.

b. Reduce emergency room utilization and inpatient readmission for members with chronic disease.

5. Care Coordination – Enhance care and service coordination between care settings.

a. Deliver person-centered services and supports.

b. Assure timely access to appropriate services and supports to enable participants to live in their setting of choice.

Indiana FSSA Office of Medicaid Policy and Planning

c. Increase outpatient provider visits and medication reviews after inpatient admission or transitions between level of care setting.

d. Reduce inpatient readmissions for physical and behavioral health.

Table 2 presents the strategic initiatives for each MCE, as well as past achievement results against the OMPP-established goals.

Because 2024 was the first year that the PathWays program was active, any measure relating to the Healthcare Effectiveness

Data and Information Set (HEDIS®) data was waived for the calendar year, as were many performance measures. These waived measures are listed in the table as Not Reported.

Reported measures will be considered baseline data for future comparisons. Likewise, goals will be identified for the measures relative to the baseline year; therefore, all goals are listed as To be Determined (TBD).

Table 2. PathWays Quality Strategy Initiatives Measure and Domain Methodology MCE Goal Baseline

Goal 1: Improve Health Outcomes Through Preventive Care and Behavioral Health Condition Management Measure: Follow-Up After Emergency Department Visit for Substance Use (FUA) 7-Day and 30-Day Follow-Up

Domain: Quality of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD* Not reported Humana

UHC

Measure: Follow-Up After Hospitalization for Mental Illness (FUH) 7-Day and 30-Day Follow-Up

Domain: Quality of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not reported Humana

UHC

Measure: Follow-Up After Emergency Department Visit for Mental Illness (FUM) 7-Day and 30-Day Follow-Up

Domain: Quality of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not reported Humana

UHC

Measure: Initiation and Engagement of Alcohol and Other Drug (IET) Total

Domain: Timeliness of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not reported Humana

UHC

Measure: Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)

HEDIS® measure using administrative data

Anthem TBD Not reported

Humana

Indiana FSSA Office of Medicaid Policy and Planning

Table 2. PathWays Quality Strategy Initiatives Measure and Domain Methodology MCE Goal Baseline

Domain: Timeliness of Care and Access to Care UHC

Measure: Diabetes Screening for Persons with Schizophrenia or Bipolar Disorder Using Antipsychotic Medications (SSD)

Domain: Quality of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Cardiovascular Monitoring for Persons with Cardiovascular Disease and Schizophrenia (SMC)

Domain: Quality of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Diabetes Monitoring for Persons with Diabetes and Schizophrenia (SMD)

Domain: Quality of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Goal 3: Improve Oral Health and Prevent Oral Disease Measure: Dentists and Oral Surgeons Network Adequacy

Domain: Quality of Care and Access to Care

OMPP-chosen performance measure using administrative data

Anthem

TBD

2.17%

Humana 76.09%

UHC 14.13%

Goal 4: Improve the Health of Members with Chronic Conditions Measure: Glycemic Status Assessment for Patients with Diabetes (GSD)

Domain: Timeliness of Care and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Blood Pressure Control for Patients with Diabetes (BPD) HEDIS® measure using administrative data Anthem

TBD Not Reported Humana

Indiana FSSA Office of Medicaid Policy and Planning

Table 2. PathWays Quality Strategy Initiatives Measure and Domain Methodology MCE Goal Baseline

Domain: Quality of Care, Timeliness of Care, and Access to Care

UHC

Measure: Eye Exam for Patients with Diabetes (EED)

Domain: Quality of Care, Timeliness of Care, and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Kidney Health Evaluation for Patients with Diabetes (KED)

Domain: Quality of Care, Timeliness of Care, and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Controlling Blood Pressure (CBP)

Domain: Quality of Care, Timeliness of Care, and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Adults’ Access to Preventive/Ambulatory Health Services (AAP)

Domain: Quality of Care, Timeliness of Care, and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Acute Hospital Utilization (AHU)

Domain: Quality of Care, Timeliness of Care, and Access to Care

HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Emergency Department Utilization (EDU)

Domain: Timeliness of Care and Access to Care HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Indiana FSSA Office of Medicaid Policy and Planning

Table 2. PathWays Quality Strategy Initiatives Measure and Domain Methodology MCE Goal Baseline

Goal 5: Improve Care Coordination Across the Entire Service Continuum Measure: Plan All-Cause Readmissions (PCR)

Domain: Timeliness of Care and Access to Care HEDIS® measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Managed Long-Term Services and Supports (MLTSS)-1 Medicaid Managed Long-Term Services and Supports Comprehensive Assessment and Update

Domain: Quality of Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: MLTSS-2 Medicaid Managed Long-Term Services and Supports Comprehensive Care Plan and Update

Domain: Access to Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: MLTSS-3 Medicaid Managed Long-Term Services and Supports Shared Care Plan with Primary Care Provider

Domain: Quality of Care and Access to Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: MLTSS-4 Medicaid Managed Long-Term Services and Supports Reassessment/Care Plan Update After Inpatient Discharge

Domain: Quality of Care and Access to Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: MLTSS-5 Screening, Risk Assessment, and Plan of Care to Prevent Future Falls

Domain: Quality of Care and Access to Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

Indiana FSSA Office of Medicaid Policy and Planning

Table 2. PathWays Quality Strategy Initiatives Measure and Domain Methodology MCE Goal Baseline

Measure: MLTSS-6 Medicaid Managed Long-Term Services and Supports Admission to a Facility from the Community

Domain: Access to Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: MLTSS-7 Medicaid Managed Long-Term Services and Supports Minimizing Facility Length of Stay

Domain: Access to Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: MLTSS-8 Medicaid Managed Long-Term Services and Supports Successful Transition after Long- Term Facility Stay

Domain: Quality of Care and Access to Care

CMS-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

UHC

Measure: Completion of Initial Health Needs Screening Within 30 Days or 90 Days of MCE Enrollment Based on Care Program; Comprehensive Health Assessment Tool (CHAT) and Health Needs Screening (HNS)

Domain: Quality of Care, Timeliness of Care, and Access to Care

OMPP-chosen performance measure using administrative data

Anthem

TBD

CHAT: 0.00%

HNS: 4.66%

Humana

CHAT: 4.94%

HNS: 5.44%

UHC

CHAT: 0.00%

HNS: 2.56%

Measure: Participants Who Report Knowing Who Their MCE Care Manager Is

Domain: Quality of Care, Timeliness of Care, and Access to Care

OMPP-chosen performance measure using administrative data

Anthem

TBD Not Reported Humana

Measure: Participants who, in the Last 3 Months, OMPP-chosen Anthem TBD Not Reported

Indiana FSSA Office of Medicaid Policy and Planning

Table 2. PathWays Quality Strategy Initiatives Measure and Domain Methodology MCE Goal Baseline

Reported that Their Service Plan Included Most or all of the Things that are Important to Them

Domain: Quality of Care and Access to Care performance measure using administrative data

Humana

UHC

Measure: Service Coordinators Who Have Successfully Completed Person-Centered Planning Competency Training Within 90 Days of Hire

Domain: Quality of Care, Timeliness of Care, and Access to Care

OMPP-chosen performance measure using administrative data

Anthem

TBD

99.00%

Humana 106%†

UHC 100%

Measure: Care Management Individualized Care Plan Developed and Implemented Within 90 Days of MCE Effective Date for Members with Care Management Level of Service

Domain: Access to Care

OMPP-chosen performance measure using administrative data

Anthem

TBD

0.15%

Humana 1.96%

UHC 3.38%

Measure: Care Management Individualized Care Plan Developed and Implemented Within 60 Days of MCE Effective Date for Members with Complex Care Management Level of Service

Domain: Access to Care

OMPP-chosen performance measure using administrative data

Anthem

TBD

1.21%

Humana 1.83%

UHC 3.48%

*To Be Determined (TBD).

†Per the MCE, this percentage is due to some service coordinators completing the training modules who were active for less than 60 days.

Quality Strategy Evaluation and Conclusion The Quality Strategy Initiatives positively indicate appropriate methods to gauge and track improvement across OMPP’s managed care services. Measures are in place to guide growth and service standards at specific, set points in time. These initiatives will allow OMPP and the MCEs to consistently track progress and utilize the results to improve the timeliness of care, the access to care, and the quality of care provided to members.

However, because 2024 was the first year that the PathWays

Indiana FSSA Office of Medicaid Policy and Planning program was active, many of the Quality Strategy Initiatives were unable to be analyzed due to a lack of data availability.

Therefore, Qsource cannot offer more specific evaluation or conclusions.

EQR Activities As outlined in Title 42 Code of Federal Regulations, Section 438, Part 358 (42 § 438.358), incorporated by 42 CFR § 457.1250, there are four mandated and six optional EQR activities. In addition, a state agency can assign other responsibilities to its designated EQRO. This section summarizes the activities that Qsource performed for OMPP in Measurement Year (MY) 2024, following the CMS External Quality Review Protocols (updated in 2023).

EQR Mandatory Activities Following the CMS Protocols published in February 2023, Qsource conducted the EQR activities shown in Table 3.

Table 3. EQR Activities Conducted in 2025 Protocol

# Activity Name Mandatory or Optional

Measurement Period

Validation of Performance

Improvement Projects Mandatory July 2024 – June

Validation of Performance

Measures Mandatory July 2024 –

December 2024

Table 3. EQR Activities Conducted in 2025 Protocol

# Activity Name Mandatory or Optional

Measurement Period

Review of Compliance with Medicaid and CHIP Managed Care

Regulations Mandatory July 2024 –

December 2024

Validation of Network Adequacy Mandatory Varied (See

Below)

Geographic Network Adequacy Analysis and Validation As of July 2025

Member-to Provider Ratio Analysis As of July 2025

Secret Shopper Survey As of July 2025

5 Encounter Data Validation Optional October 2024 –

December 2024

Under CMS requirements, Protocol 3 requires MCEs to undergo a review at least once every three years to determine MCE compliance with federal standards as implemented by the state.

OMPP has chosen to review all applicable standards every three years. Protocol 3 was performed in 2025, assessing all relevant standards.

Qsource maintained ongoing, collaborative communication with OMPP and provided technical assistance to the MCEs in their EQR activities. The technical assistance, which is also defined by 42 CFR § 438.358, consisted of targeted support through phone calls, webinars, written guides, and training. Finally, Qsource provided each MCE with an information packet

Indiana FSSA Office of Medicaid Policy and Planning explaining the EQR activities in greater detail and indicating the dates for data submission.

CMS National Quality Strategy Throughout the evaluation and validation of MCE activities, Qsource monitors each MCE’s compliance with federally mandated activities and assesses the quality, timeliness, and accessibility of services provided by the MCEs. Quality of Care, Timeliness of Care, and Access to Care are three domains of healthcare quality that must be present in all activities.

Quality of Care CMS describes quality of care as the degree to which preferred member health outcomes are likely to increase through the efforts of MCEs, along with their organizations and operations that provide enrollee services. OMPP required the MCEs to conduct performance improvement projects (PIPs), which included mechanisms to assess the quality and appropriateness of care provided to members. Each MCE was required to report on performance measures related to quality of care to the State.

OMPP asked the MCEs to meet targets for those performance measures. Qsource conducted Performance Measure Validation and Encounter Data Validation to determine if the MCEs met these quality performance measure targets.

Timeliness of Care For quality care to be effective, it must be delivered promptly.

Thus, various standards for timely care were monitored through MCE compliance with federal and state regulations. All program

PIPs validated by Qsource addressed the timeliness of care for enrollees: Home- and Community-Based Services (HCBS) Service Delivery, Care Coordination, and HCBS Service Planning. Qsource’s validation of performance measures evaluated timeliness measures determined by OMPP.

Additionally, Qsource’s validation of encounter data evaluated, among other things, the timeliness and accuracy of the data.

Access to Care Access to care is equally critical for member health outcomes as quality of care. The MCEs’ provider capacity is monitored through Annual Network Adequacy (ANA) evaluation, which assesses the availability of essential provider specialties by time and distance and how quickly enrollees can obtain needed appointments. Network adequacy was analyzed to determine if members’ access to care met requirements, and a Secret Shopper Survey was completed to ensure the members’ access matched the listed availability. Compliance with applicable federal, state, and contractual regulations also addressed access to care requirements, ensuring accessibility for all enrollees, including those with limited English proficiency and physical or mental disabilities. The MCEs’ PIPs are evaluated to ensure quality care and access to care for all enrollees.

Technical Report Guidelines Qsource is responsible for creating and producing this 2025 Annual EQRO Technical Report, which compiles the results of these EQR activities. To assist both EQROs and state agencies, CMS supplemented the requirements of 42 CFR § 438.364, as

Indiana FSSA Office of Medicaid Policy and Planning incorporated by 42 CFR § 457.1250, and provided guidelines in the 2023 EQR Protocols for producing annual technical reports.

The report includes the following EQR-activity-specific sections:

♦ Protocol 1. Validation of Performance Improvement Projects (PIPs)

♦ Protocol 2. Validation of Performance Measures (PMV)

♦ Protocol 3. Review of Compliance with Medicaid and CHIP Managed Care Regulations (CA)

♦ Protocol 4. Validation of Network Adequacy (ANA)

♦ Protocol 5: Encounter Data Validation (EDV)

Each EQR activity was conducted by Qsource to monitor each MCE’s compliance with federally mandated activities and to assess the quality, timeliness, and accessibility of care provided by the MCEs. This report includes the following results of these activities:

1. A brief description of the data collection, aggregation, and analyses for each of the EQR compliance activities;

2. A summary of findings from each review;

3. Strengths and weaknesses demonstrated by each MCE in providing healthcare services to members;

4. Recommendations for improving the quality of these services, including how OMPP can target goals and objectives within the quality strategy to support improvement better; and

5. Comparative information regarding the MCEs, where appropriate, consistent with CMS EQR Protocol guidance.

The 2025 Annual EQRO Technical Report provides OMPP with substantive, unbiased data on the MCEs and actionable recommendations toward performance improvement. This report is based on detailed findings that can be reviewed in the individual EQR activity reports provided to OMPP.

The Conclusions and Recommendations section of this report offers recommendations on how to utilize Qsource's findings.

The appendices provide additional EQR activity information:

♦ Appendix A | PIP Validation Findings ♦ Appendix B | Detailed Analysis of Provider

Network Access

EQRO Team The review team included the following staff:

♦ Jazzmin Kennedy, Qsource, Indiana EQR Program Manager

♦ Jill Edmondson, Qsource, EQRO Program Manager

♦ Christa Thompson, Qsource, Quality Improvement (QI) Advisor

♦ Frances Richardson, Qsource, Clinical QI Advisor

♦ Albert Kennedy, Qsource, Technical Writer

♦ Courtney Hall, Qsource, Technical Writer

♦ Fidencio Caballero, Qsource, Healthcare Data Analyst

♦ Kathy Haley, Myers and Stauffer

♦ Catherine Snider, Myers and Stauffer

Indiana FSSA Office of Medicaid Policy and Planning

Protocol 1: Performance Improvement Project (PIP) Validation Objectives The Balanced Budget Act of 1997 established certain managed care quality safeguards that were described by Title 42 of the Code of Federal Regulations, Section 438.320 (42 CFR § 438.320), which defines “external quality review” as the “analysis and evaluation … of aggregated information on quality, timeliness, and access to health care services.” These reviews, described in 42 CFR § 438.358, include four required external quality review activities, one of which is validating performance improvement projects.

As part of its external quality review contract with the Indiana FSSA OMPP, Qsource annually validates the PIPs of the MCEs providing services for the PathWays program members.

Qsource’s Annual PIP Validation Reports present validation findings by MCE.

The primary objective of PIP validation is to determine each PIP’s compliance with the requirements outlined in Title 42 of the CFR Section 438.330(d). MCEs must conduct PIPs that are designed to achieve, through interventions and remeasurement, significant and sustained improvement in clinical and nonclinical care areas that are expected to favor health outcomes and member satisfaction. PIP study topics must reflect enrollment in terms of demographic characteristics and, if applicable, in terms of the prevalence and potential consequences (risks) of disease and member needs for specific services. Each PIP must be completed within a timeframe that allows PIP success-related data in the aggregate to produce new information on quality of care every year. PIPs are further defined in 42 CFR § 438.330(d)(2) to include all the following:

♦ Measuring performance with objective quality indicators;

♦ Implementing interventions for quality improvement;

♦ Evaluating intervention effectiveness; and

♦ Planning and initiating activities to increase or sustain improvement.

Technical Methods of Data Collection and Analysis Qsource developed a PIP Summary Form (with accompanying PIP Summary Form Completion Instructions) and PIP Validation Tool to standardize the process by which each MCE delivered PIP information to OMPP and how that information is assessed. Qsource reviewed each PIP’s design and implementation using the PIP Summary Form submitted by the MCE and determined the PIP’s validation rating based on the percentage of compliance with the recently revised and published CMS’s EQR Protocol 1: Validation of Performance Improvement Projects (2023).

Each MCE was contractually required to submit PIP studies annually to OMPP as requested. PIPs should include the necessary documentation for submitted data collection, data

Performance Improvement Project Validation

Indiana FSSA Office of Medicaid Policy & Planning analysis plans, and an interpretation of all results. MCEs should also address threats to validity regarding data analysis. The guidance and methods for each of these steps were included in the PIP Summary Form and Summary Form Completion Instructions.

Per the Protocol, Qsource assessed the overall validity and reliability of the PIP methods and findings to determine whether or not it had confidence in the results. Qsource assigned two validation ratings based on its assessment of whether the PIP (1) adhered to acceptable methodology for all phases of design and data collection, conducted accurate data analysis and interpretation of PIP results, and (2) produced evidence of improvement. The ratings were scored on a scale of high, moderate, low, or no confidence. For the first validation rating, Qsource’s scoring methodology was based on the percentage of elements met out of all elements assessed. Each PIP involves nine required steps, and each step consists of elements essential to the successful completion of a PIP. The elements within each step were scored as Met, Not Met, or Not Applicable (NA). To assign the second validation rating, Qsource reviewed its assessments of the nine steps required from the protocol and assessed the relative strengths and weaknesses of the PIP and the extent to which they affected the confidence in the generalizability and usefulness of the PIP findings.

Table 4 lists the nine PIP steps used for assessing the PIP methodology.

Table 4. PIP Steps

1. Review the Selected PIP Topic

2. Review the PIP Aim Statement

3. Review the Identified PIP Population

4. Review the Sampling Method

5. Review the Selected PIP Variables and Performance Measures

6. Review the Data Collection Procedures

7. Review Data Analysis and Interpretation of PIP Results

8. Assess the Improvement Strategies

9. Assess the Likelihood that Significant and Sustained Improvement Occurred

Table 5 presents the rating criteria used for PIP validation based on the CMS EQR Protocol’s suggested rating scale.

Table 5. PIP Validation Rating Criteria Rating Criteria Rating 1

High Confidence Of all elements assessed, 90–100% were met across all activities.

Moderate Confidence Of all elements assessed, 80–<90% were met across all activities.

Low Confidence Of all elements assessed, 70–<80% were met across all activities.

No Confidence Less than 70% of all elements assessed were met.

Indiana FSSA Office of Medicaid Policy & Planning

Table 5. PIP Validation Rating Criteria Rating Criteria Rating 2

High Confidence The PIP achieved statistically significant improvement for all performance measures and interventions resulted in demonstrated improvement.

Moderate Confidence The PIP achieved statistically or non-statistically significant improvement for at least one measure.

Low Confidence The PIP did not demonstrate statistically or non-statistically significant improvement or none of the interventions resulted in demonstrated improvement.

No Confidence The PIP did not follow approved methodology or processes through the end date.

As part of the validation process, Qsource noted strengths, suggestions, and areas of noncompliance (AONs) for each MCE.

Strengths were noted when an MCE demonstrated particular proficiency in a given step and can be identified regardless of validation rating. Achieving “met” on elements in each step was the expected result. A strength was noted if the MCE went above and beyond the expected outcome of simply “meeting” an element. Suggestions were given when documentation for an evaluation element included the basic components to meet requirements, but enhanced documentation could demonstrate a stronger understanding of CMS protocols. Qsource determined AONs (Weaknesses) for those evaluation elements assessed as Not Met and, therefore, not in full compliance with CMS protocols. When any element of a PIP step received an AON, Qsource provided technical assistance to help the MCE follow CMS protocol and revise the PIP as needed to improve performance and, thereby, the efficacy of the PIP.

Description of Data Obtained The MCEs are required to produce PIPs for any Indiana programs administered. Qsource received the MCEs’ PIP Summary Forms on July 14, 2025, and assessed them for the following PIP topics, as found in Table 6.

The MCEs were assigned three PIP topics. Qsource received and validated PIP Summary Forms for the following PIP topics:

Table 6. PIP Topics PIP Topic Anthem Humana UHC

Care Coordination X X X

HCBS Service Delivery X X X

Indiana FSSA Office of Medicaid Policy & Planning

Table 6. PIP Topics Anthem Humana UHC

HCBS Service Planning X X X

Table 7 displays the PIP names, as chosen by the MCEs, the PIPs’ EQR validation status, and what measurement year the PIP is in.

Table 7. PIP Validation Status and Measurement Year

MCE PIP Title Validation Status Measurement Year

Anthem

Care Coordination Validated Baseline Year

HCBS Service Delivery Validated Baseline Year

HCBS Service Planning Validated Baseline Year

Humana

Care Coordination Validated Baseline Year

HCBS Service Delivery Validated Baseline Year

HCBS Service Planning Validated Baseline Year

UHC

Improving Care Coordination for Indiana PathWays for Aging HCBS Members Validated Baseline Year

HCBS Service Delivery Validated Baseline Year

Increasing Member Participation in HCBS Service Planning Validated Baseline Year

Each MCE tailored their chosen PIP topics to focus on their specific member populations with tailored aim statements.