Quality Strategy Plan.pdf

Indiana Health Coverage Programs 2024-2027 Quality Strategy Plan

Prepared by:

Indiana Family & Social Services Administration Office of Medicaid Planning and Policy

Submitted to CMS: June 1, 2024

Final Revision Effective: June 1, 2024

Annual Update Effective: June 1, 2025

The previous version of the Quality Strategy Plan was published on June 1, 2022

2024-2027 IHCP Quality Strategy Plan

Table of Contents

SECTION I. Introduction and Overview

Introduction

Overview of Indiana Health Coverage Programs

SECTION II. OMPP Quality Management

Quality Management Structure

Development and Review of Quality Strategy Plan

Public Comment Process

Updating the Quality Strategy

Significant Changes

Review and Evaluation of the Quality Strategy

Summary of External Quality Review Organization Recommendations

SECTION III. Managed Care Goals and Objectives

Quality Metrics and Performance Targets

Goals and Objectives

SECTION IV. Quality of Care

Measurement and Improvement Standards

Performance Improvement Projects

Pay for Outcomes Performance Measures

Public Posting of Quality Measures and Performance

Transition of Care Policy

Disparities Plan

MCE Health Equity Monitoring

Identification of Persons who need Long-term Services and Supports or Persons with Special Health Care Needs

SECTION V. Assessment and Oversight

Monitoring and Compliance

Quality and Appropriateness of Care

National Performance Measures

Network Adequacy and Availability of Services

Availability of Services

Maintain and Monitor Network of Appropriate Providers

Assurances of Adequate Capacity and Services

Coordination of Benefits and Continuity of Care

Coverage and Authorization of Services

Intermediate sanctions

Structure and Operations Standards

Provider Enrollment and Disenrollment

Member Information

Confidentiality

Grievance systems

Sub-contractual Relationships and Delegation

MCE Health Information Systems

External Quality Review Arrangements

SECTION VI. Improvements and Interventions

Improvements

Adult and Child Quality Measures

SECTION VII. OMPP 2024 Initiatives

Standard Monitoring Compliance for 2024

Hoosier Healthwise

Healthy Indiana Plan

Hoosier Care Connect

Indiana PathWays for Aging

Right Choices Program

Initiatives for 2025

Policy Governance

Monitoring and Reporting Quality

Health Equity

Smoking Cessation

MCE Alignment

Substance Use Disorder

Appendix I: History and Overview of Managed Care Programs

Hoosier Healthwise

Healthy Indiana Plan

Hoosier Care Connect

Indiana PathWays for Aging

Traditional Medicaid Populations

Appendix II: Historical Timelines

Risk-Based Managed Care

Hoosier Healthwise

Healthy Indiana Plan & Enhanced Services Plan

Care Select

Hoosier Care Connect

Indiana PathWays for Aging

Appendix III: Indiana Health Coverage Program Specific Goals and Objectives

Hoosier Healthwise

Healthy Indiana Plan

Hoosier Care Connect

Indiana PathWays for Aging

Appendix IV: OMPP Quality Committee Descriptions

Appendix V: Summary of Public Comments

Glossary

List of Tables Table 1. Indiana Medicaid Health Coverage Programs

Table 2. External Quality Review Recommendations

Table 3. Quality Strategy Goals and Objectives ................................. Error! Bookmark not defined.

Table 4. Hoosier Healthwise 2024 Performance Improvement Projects

Table 5. Healthy Indiana Plan 2024 Performance Improvement Projects

Table 6. Hoosier Care Connect 2024 Performance Improvement Projects

Table 7. Indiana PathWays for Aging 2024 Performance Improvement Projects

Table 8. 2024 P4O Measures by Program

Table 9. Hoosier Healthwise P4O Measure Overview

Table 10. Healthy Indiana Plan P4O Measure Overview

Table 11. Hoosier Care Connect P4O Measure Overview

Table 12. 2021-2023 Sanctions and/or Corrective Actions Imposed on MCEs

Table 13. Cross-cutting Interventions for Managed Care Programs

Table 14. Quality Committee Descriptions

List of Figures

Figure 1. FSSA IHCP Organizational Structure

Figure 2. OMPP Quality Committee Governance Structure*

Figure 3. Process Flow for Quality Strategy Plan Renewal Development

Figure 4. Five Pillars of Well Being

Figure 5. Quality Measure Categories

Figure 6. Sources of Input to the Quality Management Improvement Workplan

SECTION I. Introduction and Overview

Introduction

The Indiana Family and Social Services Administration (FSSA) is the state agency responsible for administering the Indiana Health Coverage Programs (IHCP) under Medicaid. The vision of the agency is to ensure that “All Hoosiers live in fully engaged communities and reach their greatest emotional, mental and physical well-being,” while adhering to the agency’s mission “To compassionately serve our diverse community of Hoosiers by dismantling long-standing, persistent inequity through deliberate human services system improvement.”

Under the direction of FSSA, the Office of Medicaid Policy and Planning (OMPP) is responsible for administering the Medicaid programs for the State of Indiana. OMPP partners with managed care entities (MCEs) to provide administrative services for the Indiana Health Coverage Programs including Hoosier Healthwise (HHW), Hoosier Care Connect (HCC), Healthy Indiana Plan (HIP), and, effective July 1, 2024, Indiana PathWays for Aging (PathWays). The structure of the managed care programs offered by OMPP are outlined in Figure 1 below. Indiana provides Children’s Health Insurance Program (CHIP) benefits through managed care under the HHW program as a combination Medicaid expansion and separate CHIP program, which is addressed in this quality strategy plan

(QSP).

Figure 1. FSSA IHCP Organizational Structure

In accordance with 42 Code of Federal Regulations (CFR) 438.340(a) and 42 CFR 457.1240(e), the state implements and maintains a QSP that establishes the methods for improving the delivery of Medicaid services throughout the state. The QSP aligns with the agency's objective to enhance the emotional, mental, and physical wellness of Hoosiers. It outlines the state’s managed care quality priorities, goals, and objectives to improve the health outcomes of Hoosiers and make Indiana a healthier state. The QSP serves as guidance for the Managed Care Entities on which to base their quality improvement program including their program goals and objectives. This quality strategy will also help to guide the state’s Performance Improvement Projects (PIPs), as part of Quality Assessment and Performance Improvement (QAPI) programs; state directed payments; annual External Quality Reviews; approach to using core measure sets and other quality indicators, and other aspects of the state’s quality management activities.

This QSP is the start of a three-year strategy plan that outlines the state’s quality improvement goals and objectives for the Indiana Health Coverage Programs. The QSP takes into consideration the needs of the population through multiple avenues such as partner engagement (including MCEs), community, public comment, state agencies, advocacy groups, and data collection. The QSP establishes top priorities, areas for improvement, and performance metrics to evaluate effectiveness. The QSP is being revised as part of the federal requirement 42 CFR 438.340 (b)(10) to address significant changes in the quality strategy plan. The implementation of the Indiana PathWays for Aging program effective July 1, 2024, as well as various updates including revised quality metrics (pay for outcomes, performance measures, and performance improvement projects) initiated the significant changes necessary to revise the QSP.

Overview of Indiana Health Coverage Programs

Indiana is actively enhancing the lives of its Medicaid managed care members by strategically focusing on timely healthcare access, quality improvement, and cost management. This is of particular importance given the large proportion of Hoosiers who are served by Indiana Medicaid.

According to the U.S. Census Bureau, the population of Indiana in 2023 was estimated at 6,862,199 million.1 As of December 2023, 2,012,389 individuals were enrolled in Indiana Medicaid (including CHIP), meaning almost 1 in 3 Hoosiers are enrolled in Medicaid.2 Of those Medicaid enrollees, 1,660,942 individuals (82.5%) are enrolled under an MCE.3

As of July 1, 2024, the State of Indiana will contract with six risk-based managed care entities (referred to as MCEs in Indiana) to administer the various Indiana Health Coverage programs. The MCEs contracted with the state include:

• Anthem Insurance Companies, Inc., d/b/a Anthem Blue Cross and Blue Shield (Anthem)

• Arcadian Health Plan, d/b/a Humana Healthy Horizons in Indiana (Humana)

• CareSource

• Coordinated Care Corporation, Inc., d/b/a Managed Health Services

• MDwise, Inc., and

1 https://www.census.gov/quickfacts/fact/table/IN

2 https://www.in.gov/fssa/ompp/forms-documents-and-tools2/medicaid-monthly-enrollment-reports/ 3 Ibid.

https://www.census.gov/quickfacts/fact/table/IN https://www.in.gov/fssa/ompp/forms-documents-and-tools2/medicaid-monthly-enrollment-reports/

• UnitedHealthcare Insurance Company, d/b/a United Healthcare Community Plan (United).

The MCEs are expected to achieve the goals and objectives set forth by OMPP and manage the care of members enrolled in the IHCP programs they administer. Effective July 1, 2024, the state will begin delivering long-term services and support (LTSS) through managed care under the Indiana PathWays for Aging program. Indiana PathWays for Aging MCEs are required to cover the full range of Medicaid services to their members, and to operate a companion dual-eligible special needs plan (D-SNP) exclusively aligned to their Medicaid plan in calendar year 2026 to provide services to members dually eligible for Medicaid and Medicare. Until then MCEs and D-SNP plans will be aligned.

Table 1 Demonstrates the different types of MCEs available in Indiana Medicaid, the programs they administer, the populations they serve, and the authority under which they operate.

Table 1. Indiana Medicaid Health Coverage Programs4

Program Name Populations Served4 Managed Care

Authority Managed Care Entity Services Covered

Children’s Health Insurance Program

(CHIP)

Children up to age 19 1115(a) 1932(a)

Anthem Managed Health Services MDwise CareSource

Physical Health Behavioral Health Vision Dental Pharmacy

Hoosier Healthwise

Children up to age 19 and pregnant individuals

1115(a) 1932(a)

Anthem Managed Health Services MDwise CareSource

Physical Health Behavioral Health Vision Dental Pharmacy Non-Emergent Transportation

Healthy Indiana Plan

Individuals ages 19 to 64 who meet specific income levels

1115(a) Anthem Managed Health Services MDwise CareSource

Physical Health Behavioral Health Vision Dental Pharmacy Non-Emergent Transportation

Hoosier Care Connect

Individuals aged 65 years or older, blind, or disabled who are not eligible for Medicare, do not reside in an institution, and do not receive home- and

1915(b)(1), (b)(4) Anthem Managed Health Services UnitedHealthcare

Physical Health Behavioral Health Vision Dental Pharmacy Non-Emergent Transportation

4 There is one federally-recognized tribe in Indiana, the Pokagon band of Potawatomi, and individuals who are American Indian/Alaksa Native (AI/AN) may elect to enroll into managed care (voluntary enrollment).

Program Name Populations Served4 Managed Care

Authority Managed Care Entity Services Covered community-based services through a waiver5 Some foster care children

Indiana PathWays for Aging

Individuals aged 60 years or older, blind, or disabled with or without Medicare

1915(b)(1), (b)(4) 1915(c)

Anthem Humana UnitedHealthcare

Physical Health Behavioral Health Vision Dental Pharmacy Long Term Support Services

5 Effective July 1, 2024, members who meet the eligibility criteria for the PathWays for Aging program will transition from Hoosier Care Connect to PathWays.

SECTION II. OMPP Quality Management

Quality Management Structure

OMPP is ultimately responsible for the development and review of the state’s QSP. An interdisciplinary team formed within OMPP, led by the Clinical Operations Quality Improvement Department, assists in the development of the QSP. The Clinical Operations Quality Improvement Department provides oversight and ongoing monitoring of the quality activities and performance metrics associated with the QSP. OMPP’s quality committee governance structure is outlined in Figure 2 below, and additional information including a description of each of the quality committees can be found in Appendix IV.

Figure 2. OMPP Quality Committee Governance Structure*

*This structure contains current and proposed elements that may evolve over time to address the needs of the Medicaid program and implementation of the Indiana PathWays for Aging Care Program.

Development and Review of Quality Strategy Plan The QSP must be reviewed and updated every three years. The steps that OMPP follows to review and update the QSP are outlined in Figure 3 below.

Figure 3. Process Flow for Quality Strategy Plan Renewal Development

As part of OMPP’s continuous quality improvement efforts related to updating the quality strategy, the state established a set of overarching goals that apply across all the managed care programs.

Performance targets are then refined based on examination of historical performance. This approach recognizes that contracted MCEs and providers serve in multiple healthcare programs and that by aligning priorities across programs, OMPP can increase the likelihood of achieving the desired performance because the state, the MCEs, and the providers can concentrate their efforts around these priority areas.

Resources from the following may be taken into consideration as part of the renewal development process [See Figure 3]:

• Advisory committees

• Community/Advocacy Groups

• Data collection and trends

• External Quality Review technical reports

• Federal regulations

• Financial/Budget

• Health Equity Plan

• State and Federal legislation

• Medicaid managed care contracts

• National quality metrics (HEDIS ®®, Child Core Set, Adult Core Set. etc.)

• Pay for outcomes

• Performance metrics

• Public

• Quality program descriptions, evaluations, and work plans

• State agencies

• State initiatives

• Statutory reporting

The final version of the QSP is posted to the FSSA Medicaid Policy website in the Quality and Outcomes Reporting Section:

https://www.in.gov/fssa/ompp/quality-and-outcomes-reporting/

Public Comment Process

The state provides the QSP for public comment prior to submitting it to the Centers for Medicare and Medicaid Services (CMS) for review. The public comment process includes obtaining input from the Medicaid Advisory Committee, members, and other community partners. The QSP is also provided to the recognized Tribe in Indiana, the Pokagon band of Potawatomi, as part of the public comment period in accordance with the state’s tribal consultation policy. OMPP posted the draft QSP for public comment on 04/15/2024. Following the public comment and tribal consultation period, comments are taken into consideration and updates are made to the QSP at the discretion of OMPP.

A summary of the comments received during the public comment and tribal consultation periods, as well as information on how the QSP was refined based on input, is included in Appendix V. OMPP then submits the revised QSP to CMS for review and revises the quality strategy based on CMS feedback as necessary prior to the QSP being finalized and posted on the FSSA website.

Updating the Quality Strategy Significant Changes

OMPP conducts an annual review of the QSP to determine if updates are necessary. Based on the annual review, if there are significant changes to the QSP, OMPP follows the process for submission to CMS. The only exception is if it occurs in a renewal year.

OMPP defines a significant change as:

https://www.in.gov/fssa/ompp/quality-and-outcomes-reporting/

• A modification that occurs to an Indiana Medicaid program goal, objective, or priority (other than modifications done for clarity).

• Implementation of new managed care authorities o State plan authority [Section 1932(a)] o Waiver authority [Section 1915 (a) and (b)] o Waiver authority [Section 1115].

• Procurement of a new MCE or change in MCEs; or

• Adding new population(s) to the managed care program.

The following are not considered significant change:

• Modifications to performance measures, quality metrics, performance improvement projects, or targets based on annual evaluation; or

• Adjustments made to quality measures due to changes in technical specifications, retirement, or implementation of new measures.

Review and Evaluation of the Quality Strategy

In accordance with 42 CFR 438.340, OMPP will review and update the quality strategy every three years. Indiana has historically evaluated its quality strategy plan every year and adjusted performance measures and targets according to the needs of Indiana Medicaid members. This includes an annual evaluation of the pay for outcome (P4O) measures. This annual evaluation ensures that there is a continuous improvement process in the efforts made by the Medicaid MCEs to improve year over year quality performance.

Lastly, evaluation of and updates to the quality strategy takes into consideration the recommendations provided by an External Quality Review Organization (EQRO). The EQRO evaluates the performance measures, performance improvement projects (PIPs), and other focus areas on an annual basis. They provide their recommendations for improvement and share their results with the Managed Care Entities. In addition, it is the intention that OMPP Clinical Operations Quality Department will facilitate a full program evaluation. Part of the evaluation consists of an annual review of the MCEs quality program evaluations. Program evaluations are taken into consideration as part of the oversight of the MCEs Quality Assessment and Performance Improvement programs. Recommendations for quality improvement based on evaluation are shared with the MCEs as part of the oversight process.

Summary of External Quality Review Organization Recommendations

OMPP updates the quality strategy taking into consideration the recommendations provided by the EQRO pursuant to 42 CFR 438.364. In 2022, OMPP contracts with QSource to conduct the required External Quality Reviews for HHW, HCC, HIP and CHIP. A summary of their findings and recommendations can be found in Table 2 below.

Table 2. External Quality Review Recommendations

Topic EQRO Recommendation OMPP Response

Quality Improvement Project Validation

Improvements are needed in the submission of QIP data and progress measurement;

OMPP should continue to monitor QIPs to ensure quality, timeliness, and access to care for members.

OMPP has adjusted the quarterly templates for the QIPs for better monitoring and to provide timely feedback to the MCEs.

Performance Measure Validation

No deficiencies were noted in the MCE’s processes for data collection and performance measure reporting.

OMPP will continue to monitor the performance measure evaluation and address any deficiencies as identified.

Annual Network Adequacy

MCEs should be proactive in monitoring and adding providers to their network to ensure a robust provider network, ensure provider lists in member materials are correct, and ensure PMP network adequacy by targeting counties identified with additional assessments.

OMPP will continue to monitor MCEs for an issue related to network adequacy through routine reporting as outlined in the MCE Reporting Manual.

In addition to the overall recommendations outlined above, QSource identified specific recommendations for individual MCEs in their 2024 External Quality Review (EQR) Technical Report. These recommendations can be found in the EQR posted publicly at https://www.in.gov/fssa/ompp/quality-and-outcomes-reporting/.

SECTION III. Managed Care Goals and Objectives

Quality Metrics and Performance Targets

FSSA is committed to improving the lives of Hoosiers to reach their greatest emotional, mental, and physical well-being. To achieve this vision, OMPP has established Five Pillars of Well Being (Five Pillars) each with its own goal and objectives. The expectations are that the MCEs will begin to incorporate the Five Pillars into their quality improvement program from the date of the QSP posting.

The Five Pillars will remain in effect for the length of this current QSP which is in effect through 2027.

The Five Pillars were developed based on review of state and national data, state health initiatives, input from external partners, and needs of the population. The goals and objectives for each pillar are measurable, take into consideration the health status of all populations in the state served by the MCEs, and were determined based on review of quality metrics (e.g., HEDIS ®), P4Os, external quality review, consumer surveys (e.g., CAHPS), and trends in health care data within the state. To support the program goals and objectives, OMPP also aligns with the Medicaid and Child and Adult Core Sets.

Figure 4 outlines the Five Pillars, goals, and objectives

Figure 4. Five Pillars of Well Being

Calendar Years 2024-2027

As part of the QSP, OMPP has identified categories of quality measures each with its own targets that will be used to evaluate the Indiana Health Coverage Programs on an annual basis. The quality measure categories OMPP has identified are as follows [see Figure 5]:

• Watch Metrics are defined as quality metrics with significant changes in the metric specifications or that have been newly developed. Baseline measures where data may not be available will also be included in this category. These measures will be placed under the watch metric category until enough data is obtained for consideration into other categories.

For example:

o Controlling Blood Pressure (CBP): There are proposed changes to the 2025 HEDIS ® Blood Pressure Measure include broadening the criteria for hypertension diagnosis and introducing a new blood pressure target (<130/80 mm Hg). Due to significant changes this measure could fall under a watch metric in 2025.

o Breast Cancer Screening- (BCS-E): NCQA is considering adding individuals 40–49 years of age to the measure, and stratifying performance rates by 40–49 and 50–74 years for all product lines, for HEDIS ® MY 2025. Due to the proposed changes this measure would be considered for a watch metric.

• Early Indicator Metrics are defined as quality metrics that will be used to monitor potential progress towards performance measurement goals. These metrics may indicate a deficiency or area for potential improvement. For example:

o Prenatal Depression Screening and Follow Up (PND-E) and Postpartum Depression Screening and Follow-Up (PDS-E) are NCQA depression care quality measures included in HEDIS ® . These measures identify potential risks for depression for early intervention.

• Process and Outcomes Measures are defined as quality measures that may be measured, compared, and trended to national and state performance over time or linked to specific targets. MCE performance will be evaluated using Process and Outcomes measures.

• Pay for outcomes (P4O) are a subset of process and outcomes measures. They are defined as quality measures so that OMPP has determined MCEs may receive additional compensation if certain conditions are met. MCE performance will be evaluated using P4Os.

Figure 5. Quality Measure Categories

Goals and Objectives Table 3 Outlines the specific goals and objectives that OMPP has identified for continuous quality improvement, the process and outcomes quality measures that will be monitored, the measure source, and which managed care program the specific measure is applicable to are outlined below.

The goals, objectives, and measures outlined below take into consideration the health status of all populations served by the MCEs.

Table 3.1 Reflects the early indicator metrics, baseline performance, targets, and managed care program that are specific to the early indicators. These metrics will be used to monitor progress towards the process and outcome quality measures.

Table 3.2

Statewide baseline performance and performance target information for each measure can be found in Appendix II

Table 3. Quality Strategy Goals and Objectives X= care program that measure applies Objective Objective Description Process and Outcomes Quality Measures Measure Source Managed Care Program

HHW HIP HCC

Indiana PathWays for Aging

Goal 1: Improve health outcomes thorugh preventive care and behavioral health condidtion management Follow-Up After Emergency Department Visit for Substance

Use (FUA)t*

7-Day and 30 Day Follow-Up

Follow-Up after Hospitalization for Mental Illness (FUH)t*

1.1 7-Day and 30 Day Follow-Up

Follow-Up After Emergency Department Visit for Mental

Illness (FUM)t* 7-Day and 30 Day Follow-Up

HEDIS ® X X X X

Initiation and Engagement of Alcohol and other Drug (IET)t - Total

HEDIS ® X X X X

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)

HEDIS ® X X X X

Metabolic Monitoring for Children and Adolescents on Antipsychotic (APM-E) All three rates

1.2 Improve the use of preventive behavioral health screenings and follow up to screenings

Diabetes Screening for Persons with Schizophrenia or

Bipolar Disorder Using Antipsychotic Medications (SSD)t

HEDIS ® X X X X

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

HEDIS ® X X X X

Diabetes Monitoring for Persons with Diabetes and Schizophrenia (SMD)

HEDIS ® X X X X

X X

X X

HEDIS ® X X X XImprove care coordination and follow up for members with behavioral health and substance use disorders

HEDIS ®

HEDIS ® X X

Objective Objective Description Process and Outcomes Quality Measures Measure Source Managed Care Program

HHW HIP HCC

Indiana PathWays for Aging

Goal 2: Improve the health and wellness of pregnant persons, new mothers, infants, and children

2.1 Ensure early detection and follow up regarding prenatal and postpartum depression

Timeliness of Prenatal Care (PPC-1)* HEDIS ® X X

Postpartum Care (PPC-2)* HEDIS ® X X Well-Child Visits in the First 30 Months of Life- 0-15 months and 15-30 months (W30)* HEDIS ® X

2.2

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

Child and Adolescent Well-Care Visits (WCV)* HEDIS ® X

Childhood Immunization Status- Combo 10(CIS-E)* HEDIS ® X

Immunizations for Adolescents (IMA-E)* HEDIS ® X

Goal 3: Improve oral health and prevent oral disease

3.1 Preventing oral disease Oral Evaluation, Dental Services (OED)* HEDIS ® X X X

3.2 Improve access to dental services Dentists and Oral Surgeons Network Adequacy OMPP X X X X

Objective Objective Description Process and Outcomes Quality Measures Measure Source Managed Care Program

HHW HIP HCC

Indiana PathWays for Aging

Goal 4: Improve the health of members with chronic conditions Glycemic Status Assessment for Patients with Diabetes

(GSD)

HEDIS ® X X X X

4.1

Improve the health and reduce complications for members diagnosed with diabetes and other chronic conditions

Blood Pressure Control for Patients with Diabetes (BPD) HEDIS ® X X X X

Eye Exam for Patients with Diabetes (EED) HEDIS ® X X X X

Kidney Health Evaluation for Patients with Diabetes (KED) HEDIS ® X X X X

Controlling High Blood Pressure (CBP) HEDIS ® X X X X Adults’ Access to Preventive/Ambulatory Health Services

(AAP)

HEDIS ® X X X X

4.2

Reduce emergency room utilization and inpatient readmissions for members with chronic conditions

Acute Hospital Utilization (AHU) HEDIS ® X X X X

Emergency Department Utilization (EDU) HEDIS ® X X X X

Objective Objective Description Process and Outcomes Quality Measures Measure Source Managed Care Program

HHW HIP HCC

Indiana PathWays for Aging

Goal 5: Improve care coordination across the entire service continuum

Plan All-Cause Readmissions (PCR)* HEDIS ® X X X X

5.1 Reduce the number of inpatient readmissions for physical and behavioral health

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

Discharge▲

CMS X

MLTSS-5: Screening, Risk Assessment, and Plan of Care to

Prevent Future Falls▲

CMS X

Completion of Initial Health Needs Screening within 30 days or 90 Days of MCE Enrollment based on care program

OMPP X X X X

Participants who Report Knowing who Their MCE Care Manager is

CAHPS X

5.2 Ensure smooth transitions

between level of care settings

MLTSS-3: Medicaid Managed Long-Term Services and

Supports Shared Care Plan with Primary Care Provider▲

CMS X

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

Stay▲

CMS X

5.3 Deliver person-centered services

and supports

Service Coordinators who Have Successfully Completed Person-centered Planning Competency Training within 90 days of Hire

OMPP X

Participants who, in the Last 3 Months, Reported that Their Service Plan Included Most or all of the Things that are Important to Them

CAHPS X

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

OMPP X

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

OMPP X

5.4

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

MLTSS-1: Medicaid Managed Long-Term Services and

Supports Comprehensive Assessment and Update▲

CMS X

MLTSS-2: Medicaid Managed Long-Term Services and

Supports Comprehensive Care Plan and Update▲

CMS X

MLTSS-6: Medicaid Managed Long-Term Services and

Supports Admission to a Facility from the Community▲

CMS X

MLTSS-7: Medicaid Managed Long-Term Services and

Supports Minimizing Facility Length of Stay▲

CMS X

Note: Performance measures specific to the LTSS population are included in the performance objectives listed above.

tMandatory measure included in 2025 Core Set of Adult Health Care Quality Measures for Medicaid6 *Mandatory measure included in 2025 Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP7 ▲Measure included in the 2024 HCBS Quality Measure Set 8

Table 3.1 Early Indicator Metrics, Baseline, and Target

X = care program metric applies

Early Indicator Metrics, Baseline, and Target

Goal 1: Improve health outcomes through preventive care and behavioral health condition management

Early Indicator Metric

Baseline Performance Calendar Year 2022

Performance Target (Calendar Year 2025)

HHW HCC HIP

Indiana

PathWays for Aging

Grievances related to Behavioral Health

Not reported

100% of member grievances within thirty

(30) calendar days of receipt of the grievance

X X X X

6 https://www.medicaid.gov/medicaid/quality-of-care/downloads/2025-adult-core-set.pdf 7 https://www.medicaid.gov/medicaid/quality-of-care/downloads/2025-child-core-set.pdf 8 https://www.medicaid.gov/sites/default/files/2022-07/smd22003.pdf https://www.medicaid.gov/sites/default/files/2022-07/smd22003.pdf

Goal 1: Improve health outcomes through preventive care and behavioral health condition management- continued

Performance Calendar Year 2022

Performance Target (Calendar Year 2025)

HHW HCC HIP

Indiana

PathWays for Aging

Care and Complex Case Management Report – Physical and Behavioral Health Conditions of Interest

Average Days

HCC: 64.5

HHW: 41.7

HIP: 45.3

TBD X X X

Member Access to Providers (BH) 100% 100% X X X

Inpatient Utilization Report: Mental Health Discharges and Substance Use Discharges

Avg. Length of Stay (Days)

HCC: 7

HHW: 6

HIP: 6

5-7 days X X X

Quality of Care & Quality of Services related to Behavioral Health

New

TBD X X X

Goal 2: Improve the health and wellness of pregnant persons, new mothers, infants, and children

Baseline Performance (Calendar Year 2021)

Performance Target (Calendar Year 2025 )

HHW HCC HIP

Indiana

PathWays for Aging

Prenatal Depression Screening and Follow-Up

(PND-E)- HEDIS ®

HHW: 2.69%

HIP: 4.79%

HHW: 66%,

75%

HIP: 50%,

50%, 66%

HCC: 50%,

66%

X X

Postpartum Depression Screening and Follow-Up

(PDS-E) - HEDIS ® HHW: 5.26%

HIP: 5.04%

HHW: 50%,

75%

HIP: 50%, 66%

HCC: 50%

Care and Complex Case Management Report – Physical and Behavioral Health Conditions of Interest:

Pregnancy & Specific to Children and Adolescents

Enrolled:

HCC: 2

HHW: 29

HIP: 105

TBD

X X X

Goal 2: Improve the health and wellness of pregnant persons, new mothers, infants, and children-Continued

Baseline Performance (Calendar Year 2021)

Performance Target (Calendar Year 2025 )

HHW HCC HIP

Indiana

PathWays for Aging

Member Access to Providers (OB/GYN, PMP) 100% 100% X X X

Inpatient Utilization Report: Vaginal and Cesarean Delivery Discharges

Avg LOS Vaginal Delivery:

HCC: 3 Days

HHW: 2 Days

HIP: 2 Days

Avg LOS Cesarean Delivery:

HCC: 5 Days

HHW: 3 Days

HIP: 3 Days

Vaginal

2 Days

Cesarean

3 Days

X X X

Tobacco Cessation TBD

Table 3.1 Early Indicator Metrics, Baseline, and Target

Goal 3: Improve oral health and prevent oral disease

Performance (Calendar Year 2023)

Performance Target (Calendar Year 2025)

HHW HCC HIP

Indiana

PathWays for Aging

Oral Evaluation, Dental Services- HEDIS ®

HCC: 49.13%

HIP: 28.6%

HWW: 48.13%

HHW: 50%,

HIP:33%,

50%

HCC: 50%

X X X X

Member Access to Providers (Dental/Oral Surgeon) 100% 100% X X X X

Goal 4: Reduce complications and improve health of members with chronic conditions

Performance (Calendar Year 2023)

Performance Target (Calendar Year 2025)

HHW HCC HIP

Indiana

PathWays for Aging

Care and Complex Case Management Report – Physical and Behavioral Health Conditions of Interest: Chronic Condition

Total Enrolled:

HHC: 1652

HHW: 606

HIP: 1522

Avg. Participation Days

HCC: 53.3

HHW: 41

HIP: 40

TBD X X X

Disease Management Report- Physical and Behavioral Health Conditions of Interest

Total Enrolled

HCC: 8,834

HHW: 8,640

HIP: 54,643

TBD X X X X

Member Access to Providers (Specialists) 100% 100% X X X X

Goal 5: Reduce the number of inpatient readmissions for physical and behavioral health & ensure smooth transitions between level of care settings

Performance (Calendar Year 2025)

Performance Target (Calendar Year 2026)

HHW HCC HIP

Indiana

PathWays for Aging

Inpatient Admission for Chronic Conditions of Interest: Asthma, COPD, CHF, CAD, and Diabetes

TBD TBD

X X X X

Table 3.2 List of Watch Metrics ✓= care program metric applies

Watch Metric HHW HIP HCC Indiana PathWays for Aging

Social Need Screening and Intervention (SNS-E)- HEDIS ® ✓ ✓ ✓

Breast Cancer Screening (BCS-E)- HEDIS ® ✓ ✓ ✓ ✓

Getting Care- Health Plan CAHPS

Getting Needed Care (Usually + Always) ✓ ✓ ✓ ✓

Getting Care Quickly (Usually + Always) ✓ ✓ ✓ ✓

Table 3.2 List of Watch Metrics Continued ✓= care program metric applies

Satisfaction With Plan Physicians- Health Plan CAHPS

Rating of Personal Doctor (9 + 10), ✓ ✓ ✓ ✓

Rating of Specialist Seen Most Often (9 + 10) ✓ ✓ ✓ ✓

Coordination of Care (Usually + Always) ✓ ✓ ✓ ✓

SECTION IV. Quality of Care

Measurement and Improvement Standards

The State prioritizes delivering high quality healthcare to all Medicaid members. Effective performance monitoring and data analysis play crucial roles in evaluating how MCEs uphold and enhance the quality of care provided throughout Indiana. OMPP monitors reportable measures, which may include HEDIS ®, Adult and Child Core Sets, HCBS Quality metrics, state initiatives, and national quality standards. Collaborating with MCEs, OMPP establishes common definitions and ensures consistent adherence to specifications and/or state requirements for uniformity across MCEs.

MCE statutory reporting is monitored by OMPP on a monthly, quarterly, and annual basis. Data is analyzed for trends, variances, and consistency. OMPP Clinical Operations Quality Team routinely meets with the MCEs to address quality performance.

OMPP determines how MCEs quality performance will be evaluated and identifies which metrics will be reported on the Quality and Outcomes Reporting website, such as HEDIS ®. The posted reports are meant to be an equal comparison of quality across all MCEs and care programs.

MCEs will be providing Long Term Support Services (LTSS) through the Indiana PathWays for Aging care program. Quality related assurances and sub assurances will be monitored to ensure that the quality of services being provided meet expectations. An example of how health and welfare sub assurances will be monitored is provided below.

Example of LTSS Monitoring of Health and Welfare

Health and Welfare Sub Assurance

Monitoring

The state, on an ongoing basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect, and exploitation.

The state utilizes a single critical incident reporting system to monitor and address critical incidents and identify potential cases of abuse, neglect, and exploitation.

OMPP categorizes P4Os by program, as shown in Tables 4-7. A performance measure can be applicable to multiple health care programs. Each year, OMPP reviews and approves drafts of the upcoming year's Quality Assessment and Performance Improvement (QAPI) Work Plans, along with performance improvement projects (PIPs). OMPP continues to work with the MCEs to identify sources of input to the QAPI. Figure 6 below illustrates a minimum of six sources used for input into the QAPI: the External Quality Review, HEDIS ® outcomes, CAHPS® outcomes, P4O results, and other identified areas for improvement. Gaps in any of these sources should be addressed in the MCE’s QAPI as well as any additional areas identified by OMPP.

Figure 6. Sources of Input to the Quality Management Improvement Workplan

MCEs must evaluate the effectiveness of their quality strategy and plan for the next year by investigating current member service utilization. This monitoring involves data mining at the MCE level, reviewing data reports from the state fiscal agent, and referrals from providers. Individuals with extensive utilization undergo additional assessment for suitability in Indiana's restricted card program, the Right Choices Program. Alternatively, they may be considered for enrollment in their MCE’s disease management, care management, or complex case management programs.

Individuals who underutilize appropriate health care services are encouraged to participate in preventive care services, and their primary medical providers (PMPs) are provided with gaps in care reports to increase the utilization of preventive care.

Health need screening tools are used to identify individuals early with special healthcare needs, and MCEs must offer tailored programs for disease management, care management, and complex case management to address these specific needs.

Each year, OMPP outlines performance quality measures including HEDIS ®. Targets for HEDIS ® measures are reviewed annually as well as considered for update whenever new NCQA benchmarks become available. The state recognizes that performance improvement is an ongoing process and evaluates quality targets on an annual basis including any changes to NCQA benchmarks.

Contract amendments occur on an annual basis, or more frequently as needed if program changes occur. The pay for outcomes program is reviewed and updated as needed during the annual contract process. Pay for outcome measures may be adjusted based on national benchmarks or changes with technical specifications.

The contracted MCEs may be eligible for supplementary compensation upon achieving or surpassing the predetermined metrics outlined for pay for outcome measures. Such additional compensation is subject to the MCEs’ complete and timely satisfaction of its obligations under the applicable state fiscal year contract. This includes timely submission of the contracted MCEs’ HEDIS ® Report for the measurement year, the Certified HEDIS ® Compliance Auditor’s attestation, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) report, as well as timely submission of other reports detailed in the MCE Reporting Manual.

Consumer self-reported surveys enable OMPP to collect data from the distinctive viewpoint of Medicaid members, providing valuable insights into their experiences and perspectives. Like many other state Medicaid agencies, OMPP has elected to use various forms of CAHPS® to assess member experience. Each MCE is required to submit a final report from its survey vendor to OMPP each calendar year.

Performance Improvement Projects Each MCE must implement and maintain a minimum of two performance improvement projects (PIPs); one clinical and one non-clinical in nature. The PIP topics, goals, and objectives may be mandated by the state. Each PIP will remain in effect for three years unless OMPP decides otherwise.

The MCEs must develop and submit draft PIPs by October 31 for the prospective year. OMPP offers feedback to MCEs as necessary regarding PIPs. OMPP may provide technical assistance and feedback to plans, specifically addressing the measurability of identified interventions. It is expected that PIPs will receive a minimum of 80% compliance rate from the annual EQR review. If MCEs fail to meet this expectation corrective action plans may be implemented.

OMPP requires standard processes for submission Performance Improvement Projects (PIPs) from the contracted MCEs.

• PIP template: Contracted MCEs are required to use a standard template for submission of PIPs. This includes both quarterly and annual submissions.

• PIPs: Contracted MCEs must use the OMPP developed standard template for quarterly submissions of their PIPs. Annual submission to the EQR is provided in a format provided by the external quality review organization.

Tables 4-7 outline the PIPs that each MCE plans to implement in the calendar year 2024. In 2024 prior year PIP topics were retired. MCEs were provided three topics for PIPs: Maternal/Child Health, Diabetes, and Member Satisfaction. The MCEs could choose which clinical topic they wanted to address but were required to have member satisfaction as their non-clinical PIP. The PIPs for the HHW, HIP, and HCC managed care programs were submitted by the MCEs and are unique to each plan. For the first year of the program, the PIPs for the Indiana PathWays for Aging program were determined by the state. Additional information about performance improvement projects can be found in the annual EQR Technical Reports posted publicly at https://www.in.gov/fssa/ompp/quality-and-outcomes-reporting/.

Table 4. Hoosier Healthwise 2024 Performance Improvement Projects

Hoosier Healthwise PIP Topic PIP Aim PIP Intervention(s) MDwise Goal: Improve the health of members with chronic conditions Diabetes Increase the enrollment of members with diabetes in the following MDwise programs: Disease Management, Care Management, and Case Management, to ensure proper monitoring of glycemic index. Enrollment is classified as a member who has received an assessment and a care plan.

Members identified through the Health Needs Screen will receive a referral to our care management team to offer and engage in disease, care, or complex case management services.

By completing a direct referral, engagement will be streamlined to CM services to assist with appointment adherence. This data is a part of what is reported, due to multiple referral sources for identification and engagement of members with diabetes. This referral process allows MDwise to use the John Hopkins Predictive Modeling program to prioritize members based on acuity.

Referrals are automatically generated when a member has an inpatient hospital stay. Our prior authorization team will also create Care Management referrals for when members have been identified with diabetes, requesting services be reviewed for prior authorization. As a part of this outreach will be gathering demographics, type of prior authorization and if those members had successful outreach and engagement in Disease, Care or Complex Case Management. While not a direct correlation to GSD, it does have an impact on early identification of members who would need to have a glycemic screening completed.

PIP Topic PIP Aim PIP Intervention(s)

The MDwise Care Management team will conduct outreach to members who have been identified as being seen in the emergency room and have a diabetic related diagnosis code associated with the visit. These members will receive at least (2) calls and a letter to engage them with DM, CM or CCM services.

Members with diabetes will be contacted by care outreach and connected with a Community Health Worker if they reside in Allen, Marion, Monroe, or Lake counties. Eligible members will receive telephone and in-person visits to connect them to providers and resources, if needed, to manage their diabetes care.

Goal: Improve the health and wellness of pregnant persons, new mothers, infants, and children Infant and maternal health

Improve access to obstetric and gynecological care for pregnant members during and within 84 days of giving birth.

Members identified through the HNS will receive a warm transfer to our care management team to offer and engage in case management services. By doing a warm transfer, it will help streamline engagement into CM services to assist with appointment adherence. This data will only be one piece of what is reported due to multiple referral sources to identify and engage pregnant members.

Members identified through the NOP daily reporting will receive outreach from our care management team to offer and engage in case management services. This report allows us to identify members who have already completed their first OB visit and are established with a pregnancy provider. This data will only be one piece of what is reported due to multiple referral sources to identify and engage pregnant members.

Members identified through the My Healthy Baby weekly reporting receive outreach from our care management team to offer and engage in case management services. This report allows us to identify members who have confirmed their pregnancy with a support service. This data will only be one piece of what is reported due to multiple referral sources to identify and engage pregnant members.

Goal: Improve member satisfaction Member satisfaction Increase member satisfaction, as measured by the number of member complaints, member grievances, and aggregation of self-reported member surveys, e.g. CAHPS, in relation to their access to services.

Utilize MDwise Quality Outreach Representatives to engage members with MDwise via telephone.

Utilize mailers and postcards to engage members with MDwise.

Utilize text message campaigns to engage members with MDwise.

Anthem Goal: Improve the health of members with chronic conditions

Improving member outcomes

• Improve quality of SDOH and member whole health data in MY 2024 through the use of Azara with rural FQHCs

• Improve outcomes for members in rural providers’ panels with an asthma, diabetes, or cardiovascular disease diagnosis in MY 2024 through regular ongoing engagement with a provider quality consultant

• Contract with Azara (data aggregator) for FQHCs and implement analytic and data-sharing processes to identify members and their SDOH needs

• Match identified provider groups with provider quality consultant with expertise to address areas of opportunity

• Provide providers with best practice strategies to increase member compliance for targeted metrics

Goal: Improve the health of members with chronic conditions Improving diabetes control

• Increase HbA1c control in previously non-compliant members in MY 2024 through the distribution of home HbA1c test kits and telephonic support

• Increase HbA1c control in previously non-compliant members in MY 2024 through distribution of home HbA1c test kits in tandem with support from a CHW trained in diabetes management

• Increase HbA1c control in eligible members in MY 2024 through member incentives and increased access to fresh fruits and vegetables

• Decrease diabetes related emergency department visits and inpatient visits for identified and participating members compared to a control

• Secure home based A1c test kit vendor

• Finesse CHW diabetes education protocol

• Disease management program

• Fruit and vegetable enhanced benefit group through diabetes management tools, coaching, and incentives

MHS

Goal: Improve the health of members with chronic conditions Diabetes • Increase the proportion of adults with diabetes who have an annual eye exam

• Increase the proportion of adults with successful management of blood pressure/hypertension

Reduction in maternal and infant mortality

• Increase proportion of pregnant women who are enrolled in SSFB (Start Smart for Baby)

• Reduce hospital admissions for high-risk OB members

Goal: Improving Member Satisfaction Improving member satisfaction

• Increase proportion of positive responses from MCD members who contact MHS with question/issue/concern

• Improve rate for MHS Health Plan Rating CareSource Goal: Improving Member Satisfaction Improve member satisfaction with health plan

Improve member reported satisfaction in the health plan through increased member engagement in and utilization of enhanced benefits

Implement a new Member Services matrix to proactively offer available benefits to members and improve the process for informing and linking members to enhanced benefits during inbound and outbound member calls

Improve access to annual kidney health evaluations for members diagnosed with diabetes

Improve the compliance rate for annual kidney evaluation for members ages 18-85 years diagnosed with type 1 or type 2 diabetes through targeted provider education and decision support tools

Deliver a targeted provider education campaign to improve the rate of adoption and member access to the recommended annual kidney health evaluation

Goal: Improve the health and wellness of pregnant persons, new mothers, infants, and children Improve outcomes for pregnant members who are at-risk for preeclampsia

Reduce the rate of preterm births for pregnant members at-risk for preeclampsia through implementation of a proactive prenatal interdisciplinary systematic case review

Form a Prenatal Interdisciplinary Review Team (PIRT) to act as a surveillance hub to perform a systematic case review for pregnant members at-risk for preeclampsia

Table 5. Healthy Indiana Plan 2024 Performance Improvement Projects

Healthy Indiana Plan PIP Topic PIP Aim PIP Intervention(s) MDwise Goal: Improve the health of members with chronic conditions Diabetes Increase the enrollment of members with diabetes in the following MDwise programs: Disease Management, Care Management, and Case Management, to ensure…