Section 12-15-13-1.8 - Covered population; risk based managed care program; claims submission testing; workgroup; time period; temporary emergency financial assistance program; assistance payments; reconciliation; violation(a) As used in this section, "covered population" means all Medicaid recipients who meet the criteria set forth in subsection (b).(b) An individual is a member of the covered population if the individual: (1) is eligible to participate in the federal Medicare program (42 U.S.C. 1395 et seq.) and receives nursing facility services; or(2) is: (A) at least sixty (60) years of age;(B) blind, aged, or disabled; and(C) receiving services through one (1) of the following:(i) The aged and disabled Medicaid waiver.(ii) A risk based managed care program for aged, blind, or disabled individuals who are not eligible to participate in the federal Medicare program.(iii) The state Medicaid plan.(c) The office of the secretary may implement a risk based managed care program for the covered population.(d) The office of Medicaid policy and planning and the managed care organizations that intend to participate in the risk based managed care program established under subsection (c) shall conduct a claims submission testing period before the risk based managed care program is implemented under subsection (c).(e) The office of Medicaid policy and planning shall convene a workgroup for purposes of this section. The members of the workgroup shall consist of the fiscal officer of the office of Medicaid policy and planning, representatives of managed care organizations that intend to participate in the risk based managed care program established under subsection (c) who are appointed by the director, and provider representatives appointed by the director. The workgroup shall do the following: (1) Develop a uniform billing format to be used by the managed care organizations participating in the risk based managed care program established under subsection (c).(2) Seek and receive feedback on the claims submission testing period conducted under subsection (d).(3) Advise the office of Medicaid policy and planning on claim submission education and training needs of providers participating in the risk based managed care program established under subsection (c).(4) Develop a policy for defining "claims submitted appropriately" for the purposes of subsection (g)(1) and (g)(2).(f) Subsections (g) through (k) apply during the first two hundred ten (210) days after the risk based managed care program for the covered population is implemented under subsection (c).(g) The office of Medicaid policy and planning shall establish a temporary emergency financial assistance program for providers that experience financial emergencies due to claims payment issues while participating in the risk based managed care program established under subsection (c). For purposes of the program established under this subsection, a financial emergency exists:(1) when the rate of denial of claims submitted in one (1) billing period by the provider to a managed care organization exceeds fifteen percent (15%) of claims submitted appropriately by the provider to the managed care organization under the risk based managed care program;(2) when the provider, twenty-one (21) days after appropriately submitting claims to a managed care organization under the risk based managed care program, has not received payment for at least twenty-five thousand dollars ($25,000) in aggregate claims from the managed care organization;(3) when, in the determination of the director, the claim submission system of a managed care organization with which the provider is contracted under the risk based managed care program experiences failure or overload; or(4) upon the occurrence of other circumstances that, in the determination of the director, constitute a financial emergency for a provider.(h) To be eligible for a payment of temporary emergency financial assistance under the program established under subsection (g), a provider:(1) must have participated in the claims submission testing period conducted under subsection (d) for all managed care organizations with which the provider is contracted under the risk based managed care program established under subsection (c); and(2) must submit to the office of Medicaid policy and planning a written request that includes all of the following: (A) Documentation providing evidence of the provider's financial need for emergency assistance.(B) Evidence that the provider's billing staff participated in claims submission education and training offered through the risk based managed care program established under subsection (c).(C) Evidence that the provider participated in the claims submission testing period conducted under subsection (d) for all managed care organizations with which the provider is contracted under the risk based managed care program established under subsection (c).(D) Evidence of a consistent effort by the provider to submit claims in accordance with the uniform billing requirements developed under subsection (e)(1).(i) The office of Medicaid policy and planning:(1) shall determine whether a provider is experiencing a financial emergency based upon the provider's submission of a written request that meets the requirements of subsection (h)(2); and(2) shall make a determination whether a provider is experiencing a financial emergency not more than seven (7) calendar days after it receives a written request submitted by a provider under subsection (h)(2).(j) If the office of Medicaid policy and planning determines that a provider is experiencing a financial emergency for purposes of the program established under subsection (g), it shall direct each managed care organization with which the provider is contracted under the risk based managed care program established under subsection (c) to provide a temporary emergency assistance payment to the provider. A managed care organization directed to provide a temporary emergency assistance payment to a provider under this subsection shall provide the payment in not more than seven (7) calendar days after the office directs the managed care organization to provide the payment. The amount of the temporary emergency assistance payment that a managed care organization shall make to a provider under this subsection is equal to seventy-five percent (75%) of the monthly average of the provider's long-term services and supports Medicaid claims for the six (6) month period immediately preceding the implementation of the risk based managed care program under subsection (c), adjusted in proportion to the ratio of the managed care organization's covered population membership to the total covered population membership of the risk based managed care program established under subsection (c).(k) Upon issuing any payment of a temporary emergency assistance to a provider under subsection (j), a managed care organization shall set up a receivable to reconcile the temporary emergency assistance funds with actual claims payment amounts. A managed care organization shall reconcile the temporary emergency assistance payment funds with actual claims payment amounts on the first day of the month that is more than thirty-one (31) days after the managed care organization issues the temporary emergency assistance funds to the provider. If a temporary emergency assistance payment is issued to a provider, managed care organizations are still required to meet contract obligations for reviewing and paying claims, specifically claims that total a payment in excess of the temporary emergency assistance payment reconciliation. However, if a managed care organization fails to comply with a directive of the office of Medicaid policy and planning under subsection (j) to provide a temporary emergency assistance payment to a provider, the failure of the managed care organization: (1) is a violation of the claim processing requirements of the managed care organization's contract; and(2) makes the managed care organization subject to the penalties set forth in the contract, including payment of interest on the amount of the unpaid temporary emergency assistance at the rate set forth in IC 12-15-21-3(7)(A).Added by P.L. 136-2024,SEC. 38, eff. 3/13/2024.Added by P.L. 131-2024,SEC. 10, eff. 3/13/2024.Added by P.L. 17-2024,SEC. 3, eff. 7/1/2024.