“I never would have pursued this program... it doesn't make sense for the population it serves.”

— Mitch Roob, FSSA Secretary

Indiana Public Media · WFYI · Jun 10, 2025

“This is the first time Medicaid has ever been used like this... a new covenant.”

— Mitch Roob, FSSA Secretary

Indiana Capital Chronicle · May 15, 2026

“The August 2026 procurement combines all four programs and ~1.4M Hoosier lives into a single bid cycle.”

— FSSA Jan 30, 2026 presentation

Indiana Capital Chronicle · Becker's Payer Issues · Feb 4, 2026

“The free lunch is over.”

— Braun administration

WISH-TV · Mar 2026

“I'm surprised we got listed publicly while we are working on our appeal... they said our care plans weren't up to par.”

— Eric Deitchman, CEO Tendercare Home Health

Indiana Capital Chronicle · WFYI · Apr 23–24, 2026

“We don't see the savings.”

— Provider associations · advocates

Indiana Capital Chronicle · Feb 13, 2026

“Indiana Medicaid relies heavily on drug rebate revenue... when claims run through 340B, the state loses those rebates.”

— Mitch Roob, FSSA Secretary

Indiana Capital Chronicle · May 1, 2026

“We are scared.”

— Top Indiana lawmakers

Yahoo News / Indianapolis Star · Dec 2024

Notice comprehension is unmeasured

F1 step 8 · F2 step 9 · F9 step 1 · H1 step 10

Eligibility notices, renewal forms, and adverse-action letters are produced by IEDSS at scale. Plain-language compliance has not been independently audited post-EO 25-60. A notice the member doesn't understand is functionally a notice they can't respond to.

Per-notice readability scores; comprehension testing results.

Document upload is where 78% of procedural disenrollment happens

F2 step 5 · H1 step 5

Missing uploads, wrong document type, image quality, mismatch between uploaded doc and requested item. Bottleneck isn't caseworker capacity — it's producing the right document, in the right format, on the right schedule.

Per-document-type rejection rate; share of disenrollments from doc-mismatch vs no-response.

Channel mismatch: phone capped, portal excludes low-digital-literacy

F1 step 1 · F2 step 4

DFR call center capacity caps the phone channel. Rural digital access caps the portal channel. Paper-by-mail is slowest. Members who need a channel that doesn't work for them are stranded.

Per-channel response rate distribution.

Plan selection: auto-assignment dominates over informed choice

F1 step 9 · H10 step 2

Auto-assignment fills the silence when members don't actively choose. MDwise exit auto-assigns to Anthem · CareSource · MHS unless the member acts. Algorithm opaque.

% who actively chose vs accepted auto-assignment; equity outcomes.

Appeals non-exercise: members walk away rather than fight

F9 step 1 · F9 step 4

Adverse notice triggers a 60-day window, but appeal exercise rate is uncharacterized. Procedural disenrollments during unwinding likely produced an under-appeal pattern.

Per-notice-type appeal exercise rate; representation rate at fair hearing.

NEMT access post-Rose: still being rebuilt

H8 step 5

Rose v. Becerra vacated HIP's NEMT waiver. Standard NEMT requirements now apply to HIP. March 2026 appellate ruling: HIP 2.0 operative except Indiana lacks authority to collect POWER premiums or terminate HIP Plus for non-payment.

Per-MCE NEMT operational implementation cadence; network depth.

Language access is uncharacterized

F1 · F2 · F9 throughout

Spanish, Burmese, and Haitian Creole are Indiana's largest non-English speaker populations. IEDSS workflow language coverage and notice translation quality are not publicly documented.

Per-language workflow completeness; LEP error rates.

HCBS waiver waitlist: 11,296 with 714 invitations/month

H5 step 1 · F8 step 1

Waitlist depth reflects intake throughput — not slot capacity. AAAs (Area Agencies on Aging) own intake; per-AAA throughput is the binding constraint.

AAA-by-AAA intake throughput; per-region waitlist depth.

Care continuity at MCE transitions

H10 step 4 · H2 step 9 · F6 step 6

MDwise exit Jan 1, 2026 requires in-progress PAs honored, ongoing therapies continued. The Aug 2026 RFP transition (Jan 1, 2029) will repeat this at far larger scale across all four programs.

PA honor period rules; care-continuity protocol.

Long-stay NF resident transition (HEA 1277)

F8 step 9 · H5 step 11

Effective July 1, 2027, residents >100 days carve back from PathWays to FFS. Care managers change; payment structure changes; provider relationships persist but contracts shift. 14 months of transition planning needed.

Transition plan; member transition mechanics.

PA across 5 MCE portals + Acentra — 6 different systems

F6 step 2 · F6 step 3

Provider must navigate Acentra Atrezzo (FFS) plus a separate PA portal at Anthem, CareSource, MHS, Humana, and UnitedHealthcare. CMS-0057-F full FHIR PA API (Jan 1, 2027) forces standardization but isn't built yet.

Per-MCE PA cycle time; per-MCE denial rate.

Credentialing duplication across 5 MCEs

F3 step 6

Same provider, 5 different MCE credentialing processes after CoreMMIS enrollment. No cross-MCE reciprocity. Driver of provider directory inaccuracy.

Cross-MCE credentialing reciprocity status; directory accuracy rate.

Suspended-claim queue is the manual workaround layer

F4 step 5 · F4 step 6

Failed-edit claims suspend in CoreMMIS for human review. Queue depth and resolution time aren't publicly tracked.

Suspension rate; resolution time.

Prompt-pay variance prompted HEA 1474

F4 step 7

42 CFR §447.45 requires 90% clean claims paid in 30 days, 99% in 90 days. PathWays providers complained publicly about claim-processing time; legislature responded with HEA 1474 setting MCO payment / denial / suspension standards plus interest owed on missed deadlines.

30-day vs 90-day compliance rate per program; HEA 1474 enforcement mechanics.

EVV reconciliation is batch, not real-time

F8 step 4 · H4 step 3

Sandata captures EVV in real time, but reconciliation against claims is typically nightly batch. The latency gap is exactly the audit signal that produced the $200M attendant-care audit. Documentation gaps + EVV non-compliance is the common surface.

EVV-to-claim match rate; alternate-vendor (HHAeXchange et al.) data quality.

Audit defensibility: documentation gaps survive provider contest

H4 step 6 · F10 step 6

Audit findings survive provider contest because documentation gaps are evidentiary. National reversal rate <30%. Once an audit lands, the provider's exposure is mostly locked in.

Indiana-specific reversal rate.

Ownership-disclosure burden for entity providers

F3 step 2

5%+ owners, managing employees, indirect owners — the disclosure chain at enrollment and revalidation is complex. Gaps in disclosure are pattern-detectable post-payment but burdensome at intake.

Disclosure-failure rate; revalidation-cycle de-enrollment rate.

Site-visit & fingerprint completion for moderate/high-risk providers

F3 step 3

§455.450 risk-level screening adds unannounced site visits (moderate) and fingerprint background (high). Completion rates aren't publicly tracked.

Per-risk-level completion timeline.

NF payment cycle delays: $462M across 496 nursing homes

F8 step 6 · H5 step 8

PathWays NF quarterly payments have stalled because CMS hasn't approved the FY2026 methodology (state submitted June 2025, CMS still asking questions). $1B/year program, two quarterly payments delayed. The 'One Big Beautiful Bill' Act (H.R. 1, July 2025) added wrinkles.

Per-NF payment-delay distribution; cause split (MCE / CMS-method / state).

Behavioral health network: all 92 counties shortage areas

F5 step 6

BH network adequacy is the most-failed access category nationally. Indiana's all-92-counties shortage designation amplifies it. MCE network reports don't separately track BH adequacy in a way the public can audit.

Per-MCE BH network depth; access wait times.

Sub-capitation to delegated providers loses encounter visibility

F5 step 4 · F8 step 5

When MCEs sub-capitate to large delegated provider groups, service encounters often don't fully flow back into CoreMMIS. National pattern; Indiana-specific impact not publicly characterized.

Sub-capitation arrangements in PathWays and the other three programs.

First-90-day error rate for newly enrolled providers

F3 step 7

Newly enrolled providers face a learning curve on Indiana-specific edits, PA criteria, and prompt-pay paperwork. First-90-day claim error rate is not publicly tracked.

First-90-day error rate.

340B reimbursement change: $60M / yr at stake

F7 step 5 · PRC18

FSSA proposed (Feb 2026) to end Medicaid reimbursement for 340B-purchased drugs; effective July 1, 2026. Estimated savings rose from $20M to ~$60M/year. FQHCs were exempted May 1, 2026 after pushback. Hospitals still affected.

How the rule will affect drug acquisition cost reporting; per-hospital revenue impact.

CoreMMIS legacy code (1991 lineage)

F4 step 4 · F4 step 5 · F5 step 4

Claims engine in service since 1991 (HP → DXC → Gainwell). Accumulated technical debt; vendor-only knowledge. Edit version control, edit change cadence, integration brittleness are opaque to the state.

Code-base health metrics; modernization roadmap; vendor knowledge-transfer status.

IEDSS ↔ CoreMMIS interface latency

F1 step 10 · F2 step 10

Eligibility decisions flow from IEDSS (Deloitte) to CoreMMIS (Gainwell) — but interface latency and sync semantics aren't publicly characterized.

Sync latency; failure-mode handling.

Batch encounter reconciliation MCE → CoreMMIS

F5 step 4 · F5 step 5 · F8 step 7

MCE encounter submissions to CoreMMIS are largely batch flat-file. Reject-and-resubmit cycles add latency. Cascades into rate setting, T-MSIS, and audit detection.

Per-MCE encounter reject rate; reconciliation cycle time.

EVV-to-claim match latency

F8 step 4

Real-time EVV capture meets batch claim adjudication. Match-window discrepancies, alternate-vendor format variance, missing service-location records — all surface post-payment as audit signal.

Per-vendor data quality; match-window error pattern.

FHIR readiness gap (CMS-0057-F)

F6 step 2 · H9 step 1

CMS-0057-F mandates PA decision timeframes (Jan 1, 2026: 72-hr expedited / 7-day standard) and full FHIR PA API (Jan 1, 2027). Indiana's FHIR-readiness status across CoreMMIS, MCEs, and Acentra isn't publicly documented.

Per-system FHIR readiness status; vendor commitments in the RFP.

Federal Data Services Hub failure handling

F1 step 4 · H1 step 2

USCIS SAVE response variance, IRS response timing, SSA confirmation lag — each produces a manual-review queue when verification doesn't auto-confirm.

Manual-review queue depth; USCIS-failure rate.

IEDSS rules engine version control is opaque

H1 step 8

Rules engine (Deloitte; Cúram lineage) handles MAGI/non-MAGI logic plus H.R. 1 work-req plus SEA 2 exemptions plus SB 1 immigration disclosure. Release cadence, IV&V process, and version-vs-data mismatch handling are not public.

Release cadence; IV&V scope.

CoreMMIS edit version cadence

F4 step 4

Front-end edit changes shift rejections — but the edit change log isn't public. Providers learn about edits when their claims start rejecting.

Edit change cadence; pre-change provider notification.

Zero confirmed Indiana MES modules on CMS SMC repository

H9 step 6

Indiana has zero modules certified on the public CMS SMC repository as of this read. 90/10 DDI + 75/25 M&O federal match rides on certification. Aug 2026 RFP is the inflection point.

Module list; outcome set; submission cadence vs July 2026 deadline.

Member master consistency: IEDSS source of truth, CoreMMIS receives

F1 step 10

When IEDSS and CoreMMIS disagree on member status, resolution mechanics are not publicly characterized. Disagreements typically surface as claim denials, capitation errors, MCE-side member confusion.

Disagreement rate; resolution latency.

T-MSIS data quality depends on encounter quality upstream

F11 step 1 · F11 step 2

T-MSIS pull from CoreMMIS + IEDSS is downstream of encounter quality (T3) and member-master consistency (T10). CMS T-MSIS DQ assessments score states; Indiana's scoreboard isn't public.

Indiana's T-MSIS DQ scores from CMS.

API gateway / ESB patterns not publicly documented

Throughout — no specific step

Integration between IEDSS, CoreMMIS, Sandata, Acentra, OptumRx, MCE systems, Federal Data Hub is undocumented in public records. Each vendor pair is bilateral.

Integration architecture; API catalog.

AI/ML pattern detection capability is rules-based + retrospective

F10 step 9 · H4 step 10

FSSA OPI pattern detection is largely rules-based and retrospective. Pre-payment integrity logic that catches at submit would shift the entire integrity posture.

Current MFADS capability map; ML/AI roadmap.

Multi-schedule overlap on renewals (annual + quarterly × 2)

F2 step 1 · H1 step 1 · H6 step 7

The same HIP enrollee can face: annual MAGI renewal + H.R. 1 quarterly work-req verification + SB 1 quarterly check + SEA 2 exemption refresh + EO 25-60 manual proof. Five touch-points per year per member is a workflow load no peer state attempts.

How many Hoosiers fall in multi-schedule overlap; FSSA dedup plan.

Manual document reconciliation queue (the 13th layer)

F2 step 6 · H1 step 6

After upload, documents flow into a caseworker review queue across 92 county DFR offices. Workflow itself unchanged; 400 new staffers added on top.

Per-county queue depth; per-staffer throughput.

Ex parte renewal rate is unmeasured publicly

F2 step 2 · H1 step 2

National post-PHE ex parte success rate ~41% (KFF). Indiana's rate uncharacterized publicly. Ex parte success is the cheapest, most reliable lever for procedural disenrollment reduction.

Indiana's ex parte rate.

Per-county DFR queue depth invisible

F2 step 6 · H1 step 6 · H6 step 4

Eligibility ops run across 92 county DFR offices. Load is unequally distributed. Queue depth by county not publicly reported.

Per-county queue depth.

FSSA OPI ↔ MFCU ↔ OIG referral mechanics opaque

F10 step 8 · H4 step 8

Referral criteria, declination criteria, coordination practices between FSSA OPI, AG MFCU (Whitmire), and HHS OIG are not publicly documented.

Referral volume; declination rate.

Settlement-vs-litigation policy not public

F10 step 7 · H4 step 7

Audit findings typically settle 20–40% off extrapolation. Indiana's settlement-vs-litigation policy isn't publicly characterized — meaning the political and fiscal accountability loop for the $200M attendant-care audit is opaque.

Indiana settlement-vs-litigation policy.

Forecast variance attribution methodology

H7 step 5

Post-2023 monthly Medicaid financial reports give earlier signal — but variance attribution (volume vs PMPM vs casemix vs rate-setting) requires consistent methodology. Not publicly documented.

Variance attribution methodology consistency.

RFP requirements design (IBM/ACS lesson)

H2 step 4

IBM/ACS failed because requirements didn't specify what was actually needed. The Aug 2026 RFP design window is the lowest-cost intervention point in the $68B cycle.

Pre-bid technical advisory function; evaluation criteria.

CMS approval timing as critical-path dependency

H2 step 7 · H6 step 2 · H8 step 6

SEA 2 1115 amendment, Aug 2026 RFP selection memo, post-Rose architecture, PathWays NF methodology — all gated by CMS approval. CMS internal SLAs aren't publicly characterized.

CMS internal SLAs; pre-approval engagement.

Sub-capitation contractual visibility

F5 step 4

MCEs sub-capitate to large delegated provider groups; FSSA contractual visibility into these arrangements is not publicly characterized. Aug 2026 RFP should require disclosure.

Sub-cap arrangements and FSSA's contractual access.

Cross-MCE credentialing reciprocity

F3 step 6

Each MCE re-credentials. No reciprocity. Provider directory accuracy suffers.

Cross-MCE reciprocity efforts.

HEA 1277 transition planning (14 months out)

F8 step 9 · H5 step 11

Long-stay carve-out effective July 1, 2027. Transition planning has 14 months. Member transition mechanics, provider re-contracting, care continuity all undefined publicly. Also: standalone assisted-living waiver application due September 1, 2026.

Transition plan timeline.

MDwise post-mortem absent

H10 step 8

MDwise exit Jan 1, 2026 is the operational dry run for the Aug 2026 RFP transition. A documented post-mortem doesn't yet exist publicly.

Whether FSSA is capturing MDwise lessons in real time.

Encounter file reject-and-resubmit cycle latency

F5 step 5

When MCE encounter files fail CoreMMIS ingestion, resubmission cycles add days to weeks. Rate setting and federal reporting work on stale data.

Reject rate; resubmission cycle time.

AAA-by-AAA intake throughput drives the waitlist

H5 step 1 · F8 step 1

The 11,296 waiver waitlist with 714 invitations/month is an intake problem, not a slot capacity problem. Per-AAA throughput is the binding constraint.

Per-AAA throughput.

Notice readability auditing

F9 step 1

Adverse-action notices drive whether appeals are exercised. Post-EO 25-60 notice content has new requirements; quality of execution is uncharacterized.

Per-notice readability score.

FSSA Hearings capacity vs H.R. 1 disenrollment wave

F9 step 5

ALJ caseload is finite. If H.R. 1 produces a disenrollment surge, appeals will follow with a lag — and capacity needs to be forecast against it.

ALJ caseload trend.

340B reimbursement reform — $60M/yr at stake

F7 step 5 · PR13

FSSA proposed (Feb 2026) to end Medicaid reimbursement for 340B-purchased drugs, effective July 1, 2026. Savings estimate rose from $20M to ~$60M/year. FQHCs exempted May 1, 2026 after pushback. Hospitals (especially DSH/safety-net) still affected.

Per-hospital revenue impact; safety-net access downstream effects.

Policy implementation sequencing

H6 step 6 · H8 step 6 · H2 step 4

H.R. 1 outreach window (Jun 30 – Aug 31, 2026) lands BEFORE SEA 2 1115 amendment likely CMS-approved. Aug 2026 RFP issuance lands DURING H.R. 1 implementation window. CMS PA-metrics public-disclosure deadline (Mar 31, 2026) already passed.

Sequencing strategy; staggered rollout options.

Pre-payment integrity logic not yet built

H4 step 10 · F10 step 9

Indiana operates a reactive audit posture: detect, audit, recoup. Pre-payment integrity logic (claim edit + EVV validation at submit) would shift entire posture from post-payment recoupment to prevention.

Pre-payment integrity roadmap; current MFADS capability.

Document handling at renewal

The single most consequential operational seam in Indiana Medicaid. It's where members are disenrolled procedurally (78%), where technology meets workflow (document store, rules engine, county-level queues), and where new policy load (H.R. 1, SB 1, EO 25-60) is being absorbed without restructuring.

EVV reconciliation + audit defensibility

Real-time EVV capture meets batch claim reconciliation. The latency gap is exactly what produces the $200M attendant-care audit signal. Pre-payment integrity + real-time reconciliation is the single highest-leverage upgrade across three lenses.

PathWays in year 2 — payment cycle, encounter quality, transition planning

Encounter data quality is the binding constraint on rate setting, federal reporting, sub-capitation accountability, NF payment cycles, and the HEA 1277 long-stay transition. Roob's June 2025 'I never would have pursued this' statement and the $462M / $300M-over-budget data converge on this seam.

Aug 2026 procurement design window

The RFP is where every operational future decision compounds: SMC certification, FHIR readiness, integration architecture, transition mechanics, sub-cap visibility, MDwise lessons. The 90-day pre-RFP window is the highest-leverage moment in the entire $68B cycle.

Drug rebate / 340B / pharmacy financial loop

FSSA's 340B reimbursement-end proposal (Feb 2026, eff July 1, 2026) ties pharmacy carve-in to managed care, MDRP rebate flow, hospital DSH economics, and safety-net member access. FQHC carve-out from the change (May 1, 2026) shows the political compromise space. The largest single under-the-radar reform Indiana has proposed in 2026.

Appeal exercise & due process

If members don't understand notices, don't exercise appeals, and ALJ capacity isn't sized for the H.R. 1 disenrollment wave, due process becomes a paper right. Pattern is hardest to see because it's measured by absence — people walking away rather than fighting.

CoreMMIS legacy + interface latency

Indiana's claims infrastructure has 35 years of accumulated code, with edit changes, integration patterns, and member-master consistency rules that are vendor-only knowledge. The Aug 2026 RFP is the inflection point — but Indiana can't write a tight RFP for a system whose internals are opaque to the state itself.