Concerns with Indiana's PathWays Program Implementation

Application for 1915(b) Waiver: Draft IN.017.00.02 - Dec 31, 2025

Email to: INPathWays@fssa.in.gov

Attention: Holly Cunningham Piggott

Date: 8/1/2025

Program Overview and Current Concerns

The implementation of Indiana’s PathWays for Aging program under the 1915(b) waiver was initiated with commendable goals: enhancing care coordination, improving health outcomes, and achieving efficiencies in delivering long-term services and supports. However, since the full transition to the managed care model in July 2024, the program has been plagued by systemic and persistent failures by Managed Care Entities (MCEs). Left unaddressed, these challenges threaten the program’s foundational goals and the well-being of its beneficiaries, and now demand immediate and decisive intervention.

Confusing and Misleading Program Naming

The current naming of the waiver as “PathWays” is problematic and unnecessarily confusing. Indiana’s broader long-term care initiative is also titled “PathWays for Aging,” making it extremely difficult for stakeholders, caregivers, and even professionals to distinguish between the Medicaid State Plan services and the 1915(c) waiver services.

This overlap:

• Creates barriers during enrollment, care planning, and public comment.

• Causes confusion about whether the waiver replaces or supplements the state plan.

• Undermines transparency and leads to misinformation.

Recommendation: Rename the State Plan to a more distinct and descriptive title—such as "AgeWell," "GoldenPath," or "PathForward"—to ensure clear differentiation between the State Plan services and the home- and community-based waiver services, making it easier for families, providers, and individuals to understand the distinct offerings.

Systemic Failures Under 1915(b) Managed Care Operations

Since the July 2024 rollout of PathWays under the 1915(b) managed care waiver, Indiana’s Managed Care Entities (MCEs) have demonstrated a widespread pattern of failure in meeting basic contractual obligations, especially around provider reimbursement and support services.

Major Failures Reported:

• Claims & Payment Failures: 

Provider agencies and nursing facilities, report significant delays in receiving reimbursement for approved services—often lasting several months. In many cases, claims remain entirely unpaid, despite repeated resubmissions and confirmation of authorization, placing unsustainable financial strain on providers and threatening service continuity for members.

• Inconsistent Claims Processing: 

Adjudication timelines vary across MCEs, with denials often issued without clear reasoning.

• Threats to Service Continuity: 

These financial pressures are driving smaller providers toward no longer accepting Pathways clients, disrupting critical care services for PathWays members across the state.

• Increased Administrative Complexity and Lack of Standardization: 

Providers now navigate multiple, conflicting Managed Care Entity (MCE) procedures for authorizations, documentation, and billing—without any increase in reimbursement to offset the added burden. Notice of Action (NOA) processes are not standardized across MCEs, with inconsistent formats, delivery methods, and timelines. In some cases, NOAs are delayed, missing critical information, or sent only to members, leaving providers unable to initiate services or confirm coverage. This fragmented approach increases administrative overhead, delays care, and undermines coordination.

• Additional Administrative Burden: 

Providers and participants face:

• • • Long hold times to speak with MCE representatives.

    • Unhelpful automated systems requiring overly specific identifiers.

    • Staff who lack authority or training to resolve claims or network issues.

• Waitlists Still Growing and Delays in Service Start: 

Despite PathWays’ stated goal of reducing waitlists, thousands remain in limbo, experiencing months-long delays in receiving Notices of Action (NOAs) required to begin services. Providers frequently report not receiving NOAs in a timely manner, making it impossible to initiate care—even when a participant is otherwise ready. Unlike prior waiver practices, retroactive coverage is no longer being applied, meaning that individuals are left without critical services while they wait, with no reimbursement available for providers who attempt to step in early.

• Member Transition Confusion: 

Individuals transitioning from the Health & Wellness (H&W) Waiver to PathWays often struggle to understand new processes, verify whether their existing providers are in-network, or identify their assigned care coordinator under the MCE. Participants previously had direct phone numbers for their case managers but are now rerouted through centralized call systems, leading to confusion, delays, and a loss of the personal connection and continuity that many relied on for support.

• Regulatory Implications: 

Indiana is not meeting federal standards under 42 CFR §§ 447.45 and 438.114, which require prompt payment, network adequacy, and continuity of care. The state must enforce MCE accountability and ensure compliance with HCBS access rules.

Inadequate Member and Provider Support

Stakeholders across the board report that PathWays support systems—particularly call centers and MCE personnel—are failing to provide meaningful assistance.

Key Issues:

• Call Center Ineffectiveness: While automated systems may answer quickly, it is extremely difficult to speak with a knowledgeable human, and wait times are excessive. Live agents often lack the tools or training to answer benefit, eligibility, or claims questions.

• Automated System Barriers: MCE automated phone systems require callers to provide specific identifying information before routing to a live representative—but if the information is unavailable or doesn’t match system records, the call is automatically disconnected. This prevents both members and providers from getting assistance—even for simple, non-confidential questions such as verifying contact information, confirming plan enrollment, or asking about general processes. These unnecessary access barriers create widespread frustration and delay resolution of time-sensitive issues.

• Care Coordinator Invisibility: Many members do not know who their assigned coordinator is. Coordinators are perceived as under-engaged, with caseloads too high to provide individualized support.

• Perceived State Awareness Gap: Despite FSSA’s monitoring efforts (e.g., call center metrics or “secret shopper” calls), providers feel the state is not fully aware of the real-world breakdowns experienced daily by families and providers.

The PathWays program, as currently implemented, has veered sharply away from its intended mission of person-centered, aging-in-place care. Instead of improving outcomes and access, it has introduced widespread service delays, administrative dysfunction, and provider instability that directly harm thousands of Hoosiers.

Recommendations:

Indiana must take immediate, systemic corrective actions to bring the program back into alignment with federal standards, provider sustainability, and member well-being. This includes:

1. System Clarity and Oversight

   • Rename the waiver or State Plan initiative to reduce confusion and improve transparency for the public.

   • Strengthen state oversight by conducting regular, public-facing compliance reviews of MCE performance, including:

   • Dashboards detailing non-compliance findings,

   • Measurable Corrective Action Plans (CAPs) with deadlines,

   • Ongoing progress updates, and

   • Evaluation of service outcomes and effectiveness.
     
     

2. MCE Contract Accountability

   • Initiate formal contract reviews with all MCEs, and be prepared to invoke termination clauses in cases of continued non-performance or material breach.

   • Explore alternative administrative models if MCEs remain unable to meet fundamental responsibilities such as timely reimbursement, consistent authorization practices, and beneficiary support.
     
     

3. Access to Coordinated and Responsive Support

   • Require universal live operator access: All MCEs must ensure callers—both members and providers—can reach a trained representative within five minutes. This includes a general inquiries option for simple, non-confidential questions that do not require member-specific data.

   • Establish and enforce service-level agreements (SLAs): These must include wait time metrics, escalation procedures, and participant satisfaction tracking.

   • Cap care coordinator caseloads and require that participants receive a direct phone number or extension—not a call center queue—to reach their assigned coordinator or case manager.

   • Implement a statewide escalation pathway: A centralized FSSA ombudsman or escalation unit must be created to handle unresolved issues across MCEs, with authority to intervene and resolve time-sensitive matters.
     
     

4. Provider Support and Transparency

• Establish a dedicated FSSA Provider Support Team: This team must be accessible, knowledgeable, and authorized to assist with credentialing delays, unpaid claims, authorization confusion, and documentation barriers. Providers need a centralized resolution hub—not scattered contact points across MCEs.

• Publish transparent MCE performance data: FSSA must regularly share publicly accessible updates about claim processing, complaints, appeals, and service gaps—not just through associations like IAHHC, but directly on its website.
  
  

The continued tolerance of these systemic failures has created a crisis—one that erodes trust, jeopardizes access to care, and threatens the financial survival of community-based providers. Indiana must act now to enforce accountability, restore program integrity, and uphold its commitment to delivering equitable, person-centered Medicaid services.

Thank you,

Julie McGill