Section 405 IAC 10-6-1 - Medically frail screeningAuthority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 1.
(a) An applicant or member shall be reviewed for medically frail status at any of the following times:(1) During the verification period if such member's responses on the initial health screening indicate the potential existence of a medically frail condition.(2) At any time during the benefit period if documentation, such as claims data or provider identification, demonstrates that the member may have a medically frail condition.(3) At any time if documentation demonstrates that the member may no longer have a medically frail condition.(4) At any time upon member request.(5) For a medically frail member, at least annually by the managed care organization for continued medically frail eligibility.(6) For an applicant that has been locked out pursuant to 405 IAC 10-10-12, a request for a lockout exemption based on a medically frail condition.(b) During calendar year 2015, beginning upon the date an individual identified as potentially medically frail in accordance with subsection (b) becomes a member, the managed care organization shall have a period of sixty (60) days to verify the member's medically frail status. For purposes of this section, this period is referred to as the verification period. Beginning in calendar year 2016, and for each subsequent year of the plan, the verification period shall be thirty (30) days.(c) A member identified as potentially medically frail in accordance with subsection (b) shall be enrolled in either HIP Plus or HIP Basic in accordance with 405 IAC 10-3-2 or 405 IAC 10-3-3, as applicable, until the medically frail verification is completed.(d) In order to verify a member's medically frail condition, the managed care organization shall consider one (1) or more of the following using a process approved by the office: (1) The member's initial health screen.(2) The member's health assessment.(3) The member's medical records.(4) The member's present or historical medical claims data.(5) Any other information relevant to the member's health condition.(e) If the managed care organization determines that a member is not medically frail or the managed care organization is unable to verify the member's medically frail status during the verification period, the member shall remain enrolled in either HIP Plus or HIP Basic in accordance with 405 IAC 10-3-2 or 405 IAC 10-3-3, as applicable.(f) An individual wishing to appeal a managed care organization's determination under this section shall first appeal to the managed care organization making the determination in accordance with 405 IAC 10-5-2. If, on appeal to the managed care organization, the managed care organization finds that the member is not medically frail, the member may appeal the finding to the state in accordance with 405 IAC 10-5-1.(g) The office may review the placement of a member who has been determined to be medically frail to determine whether the member meets the medically frail definition under 405 IAC 10-2-1(30) by considering any of the following: (1) The member's medical records.(2) Communication with or other outreach to the managed care organization, the member, or the member's provider or providers.(3) The member's past claims history, if available and accessible.(4) Other processes, as determined by the office.(h) If, under subsection (g), the office determines that a member is not medically frail, the member shall no longer receive HIP State Plan benefits and shall be transferred to: (1) HIP Plus if the member is currently enrolled in HIP State Plan Plus; or(2) HIP Basic if the member is currently enrolled in HIP State Plan Basic. An individual determined not medically frail under this subsection may appeal the determination directly to the state in accordance with 405 IAC 10-5-1.
Filed 5/18/2015, 12:34 p.m.: 20150617-IR-405140339FRAFiled 1/19/2018, 8:42 a.m.: 20180214-IR-405170484FRAErrata Filed 2/22/2018, 9:36 a.m: 20180307-IR-405180114ACAFiled 3/18/2019, 2:27 p.m.: 20190417-IR-405180371FRA