The renewal & verification workflow that produced the 78% procedural disenrollment rate — now carrying H.R. 1 quarterly, SB 1 quarterly, and EO 25-60 end-of-self-attestation simultaneously.

Application or renewal trigger fires

IEDSS scheduler + DFR

Into IEDSS workflow queue

Four schedules now running on overlapping populations: 12-mo MAGI renewal · 12-mo non-MAGI renewal · H.R. 1 quarterly work-req check (HIP) · SB 1 quarterly verification. Same member may face 3+ events per year.

How many Hoosiers fall in multi-schedule overlap; no FSSA disclosure of intersection volume.

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Ex parte attempt against existing data

IEDSS rules engine (Deloitte)

Federal Data Services Hub (IRS · SSA · USCIS SAVE · Equifax) + DWD wage feed

Ex parte success rate not public. National post-PHE ex parte rate ~41% (KFF). If Indiana is at the national rate, ~59% of renewals enter the human-touch funnel.

Indiana's specific ex parte success rate; which data sources IEDSS queries for cash/gig/self-employment income.

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North Carolina achieves 99% ex parte success — among the highest in the nation — using SSA + IRS + state wage data on auto-renewal. NC final procedural disenrollment rate during the unwinding: 12% (Indiana: 78%). Aggressive automation, not more staffers, drives the gap. Arizona and New Mexico also have data-driven ex parte models. — KFF · NC Medical Society · NC Health News

Pre-populated renewal form generated (if ex parte fails)

IEDSS form module

USPS mail + portal notification if opted in

Mail-based renewal is the dominant channel; address staleness is a known national driver of procedural disenrollment.

Portal opt-in rate; address-change reconciliation cadence with USPS NCOA; mail-return rate.

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Member responds via one of five channels

Member, optionally with navigator (FQHC, certified counselor)

Response routes to IEDSS document store or DFR call center

Phone channel capped by DFR call center capacity. Online channel limited by digital literacy + bandwidth in rural counties. Paper-by-mail channel slowest, no read receipt.

Per-channel response rate; median response time; channel split by demographic.

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Documents uploaded (income proofs, ID, residency, etc.)

Member

IEDSS document store; reconciliation queue for DFR caseworker

This is the step where the 78% procedural disenrollment rate concentrates: missing uploads, wrong document type, image quality, mismatch between uploaded doc and requested item.

Per-document-type rejection rate; share of disenrollments from doc-mismatch vs no-response; CV/OCR usage in document classification.

March 2024 — of 9,608 Hoosiers terminated procedurally, 4,500 simply did not respond and FSSA had no other data; 2,748 didn't respond but were determined ineligible through other data; 2,360 provided incomplete information. Indiana's procedural-disenrollment rate held at 78% versus a national 69%. — Indiana Capital Chronicle · KFF unwinding tracker · May 2024

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Caseworker reconciles documents to IEDSS request

DFR caseworker (one of ~92 county offices)

Back to IEDSS verification step or to member for re-submit

Queues vary by county; 400 new eligibility checkers being added (50 onboarded by late April 2026); workflow itself unchanged. Adding humans to an unchanged workflow is the most expensive way to learn the bottleneck is procedural.

Per-county queue depth; new-staffer training completion rate; per-staffer throughput targets.

FSSA is hiring 400 employees to check eligibility of 560K HIP enrollees ahead of H.R. 1 work requirements — 50 onboarded as of late April 2026. — Indiana Capital Chronicle · WTHI · Apr 29, 2026

Few states publish per-county DFR queue depth — but NC's ePASS consolidates Medicaid + SNAP + TANF + Child Care into a single statewide workflow, removing the per-county variability Indiana's 92-county DFR model carries. — NC DHHS ePASS

Income & data re-verification

IEDSS

Federal Data Services Hub + DWD

DWD wage data lags ~1 quarter behind real time. Self-employment, gig, and cash income largely invisible to DWD. EO 25-60 ended self-attestation — so where DWD has no record, members must produce documentation, raising the manual proof burden.

% of members with income not coverable by DWD/FDH; manual proof completion rate.

EO 25-60 'Make Indiana Healthy Again' ended self-attestation and mandates interagency data matching to flag ineligible enrollees. — Governor's Office · EO 25-60 · Apr 15, 2025

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MAGI / non-MAGI rules re-evaluate eligibility

IEDSS rules engine (Deloitte; Cúram lineage)

Internal — produces eligibility decision

Rules engine version & change-log not public. H.R. 1 work-req logic, SEA 2 exemption rules, SB 1 immigration disclosure rules all being added in 2025–2026.

Rules-engine IV&V process; release cadence; failure mode if rule version mismatches data version.

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H.R. 1 work-requirement check (HIP only, quarterly)

IEDSS work-req module + 400 new DFR staffers

Compliance pass / fail / exemption-claimed

80 hours/month threshold + 5 exemption categories (caregiver, pregnancy, SUD, disability, etc.) + 3-month lookback × ~560K HIP enrollees × 4 cycles/year = ~2.24M compliance evaluations/year. SEA 2 1115 amendment still pending CMS approval.

Exemption documentation cadence (how often must caregiver status be re-proven?); CMS approval timing of the 1115 amendment.

H.R. 1 (the 'One Big Beautiful Bill Act,' July 2025) requires verification of work-requirement compliance 'on an ongoing basis and at least quarterly.' Federal implementation deadline January 1, 2027. — CMS · KFF tracker · 2025–2026

Arkansas (2018) is the cautionary tale: 18,000 lost coverage in 7 months under work req; 97% of those removed were actually compliant or exempt — they lost coverage because of confusion and reporting failures, not policy non-compliance. Federal court halted the program in April 2019. Georgia Pathways (since July 2023): 4,900 enrolled vs. 240K projected — about 2%; GAO found program spent more on admin than care; Georgia is now moving to verify only at application + annual renewal. — NEJM · Urban Institute · ProPublica · KFF

Notice generated (continued · disenrolled · pending)

IEDSS notice generator + DFR

USPS mail + portal

Notice plain-language compliance and member comprehension are upstream determinants of appeal exercise. Pre-2023 audits flagged notice readability.

Notice receipt rate; comprehension rate; per-program notice variants.

CMS has exercised enforcement discretion to give states until June 3, 2026 to comply with procedural-disenrollment account-transfer and combined-notice requirements; full compliance with all regulations required by December 31, 2026. — CMS · GAO-24-106883 · 2025–2026

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Disenrollment flows to CoreMMIS member master

IEDSS → CoreMMIS interface

X12 834 to MCEs; eligibility flag in CoreMMIS

Procedural-vs-substantive disenrollment breakdown not publicly published per program. CMS PEAK data captures some of it but with a 6-month lag.

Per-program procedural disenrollment rate (HHW vs HIP vs HCC vs PathWays separately).

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North Carolina's final procedural disenrollment rate at the end of the unwinding was 12% — only Maine had a lower rate. NC operates an ePASS-driven consolidated workflow + 99% ex parte rate; this combination produced the lowest preventable-loss rate in the country. Indiana's 78% procedural rate sits at the opposite pole. — KFF · NC Health News

Appeal pathway opens (90-day window)

FSSA Hearings (ALJ); Aid pending if filed in time

Internal MCE appeal first for managed care; state fair hearing

Appeal capacity at FSSA Hearings post-unwinding not publicly characterized. ALJ caseload trend not disclosed.

Appeal rate; aid-pending compliance rate; reversal rate at fair hearing.

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The 78% procedural disenrollment rate isn't caseworker failure or member negligence — it's the product of a multi-gate workflow where each gate has a small failure probability and the failures compound across millions of events. Adding 400 people to a workflow whose bottleneck is at steps 5–7 (document handling) doesn't solve the bottleneck; it just adds intake capacity around it. EO 25-60's end of self-attestation pushes more events into the manual-proof funnel, where doc-matching is the binding constraint. H.R. 1 and SB 1 layer quarterly cadences onto a system that struggles with annual renewals.

The August 2026 master procurement combines all four managed care programs (HHW + HIP + HCC + PathWays) into a single bid, target contract start January 1, 2029. Aggregate value ~$68B; ~1.4M Hoosier lives in scope.

Procurement strategy & scope decisions

FSSA OMPP + State CIO Lenard + OMB Hershman

Internal alignment with Governor's Office

Strategy publicly under-disclosed: bundled vs unbundled MCO contracts; carve-in/carve-out decisions; modular vs monolithic MMIS approach.

Whether dental/vision/BH carve-outs are on the table; whether pharmacy carve-out is being reconsidered (CA/NY model).

FSSA Jan 30, 2026 presentation: the procurement combines all four programs at once with aggregate $68B value. The four programs together serve 1.4M people. More information 'won't be available until closer to its release early this fall.' — Indiana Capital Chronicle · Becker's Payer Issues · OPEN MINDS · Feb 4, 2026

Pennsylvania (April 2, 2026): Commonwealth Court ORDERED a rebid of all Community HealthChoices managed-LTSS contracts after finding the procurement process was flawed, including bid-scoring issues. This is the most recent procurement-failure cautionary tale and directly relevant to Indiana's evaluation framework. — OPEN MINDS · PA Commonwealth Court

APD/IAPD package prepared for CMS

FSSA CIO Arrowood + CMCS DSG (Baltimore)

Submission to CMS Region 5 with copy to DSG

Mandatory new SMC templates (APD, OAPD, AoA, Intake Form) effective July 1, 2026. Submission after that date must use them.

Whether Indiana's APD is already in template-ready form; CMS pre-approval timing.

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Procurement Vehicle (Indiana Department of Administration)

IDOA + FSSA

Vendor competition mechanics; mandatory new SMC procurement standards

Procurement template alignment — Indiana's IDOA forms must absorb CMS's new SMC requirements without losing state-law conformity.

Pre-bid conference scheduling; mandatory vendor briefing requirements.

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RFP issuance (target: August 2026)

IDOA + FSSA OMPP

Posted to Indiana's eProcurement portal; CMS-0057-F compliance language baked in

RFP design window is the lowest-cost intervention point in the entire $68B cycle. Bad requirements compound for 10 years.

Whether MES modular requirements are written tightly enough to drive certification, or loose enough to invite scope creep.

Target RFP issuance: August 2026. Indiana to rebid all four MCO contracts (HHW, HIP, HCC, PathWays) in a single procurement. — Indiana Capital Chronicle · Feb 4, 2026

MACPAC: typical state Medicaid managed-care procurement takes 18–24 months. Indiana's ~30-month window (Aug 2026 → Jan 2029) is on the higher end — appropriate given the scale, but the time can erode quickly under protest. Best practice: strengthen evaluation frameworks, clarify scoring criteria, emphasize transparency and defensibility. — MACPAC · SHVS Toolkit

Bidder Q&A and amendments

FSSA + IDOA

Q&A responses posted publicly; amendments shape final bid

Q&A is where the bidder community renegotiates the RFP. Indiana's history is sparse public Q&A; CMS expects deeper engagement.

Pre-bid bidder pool composition; incumbent-vs-challenger ratio.

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Proposals received & evaluated

FSSA evaluation committee + IDOA observers

Scoring against published evaluation criteria

Evaluation committee composition; presence of independent technical evaluators; CMS attendance at scoring discussions.

Whether the IBM/ACS lesson is institutionally reflected in the evaluation criteria.

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Florida SMMC re-procurement (April 13, 2024): AHCA awarded 6-year contracts to 5 MCOs effective Oct 1, 2024 through Dec 31, 2030 — covering 3.4M enrollees with combined MMA + LTC services. Pennsylvania's Community HealthChoices procurement, by contrast, was ORDERED REBID by the Commonwealth Court on April 2, 2026 due to bid-scoring flaws. The contrast is in evaluation defensibility. — FL AHCA · OPEN MINDS · PA Commonwealth Court

Bidder selection & CMS pre-approval review

FSSA + CMS Region 5 + CMCS DSG

CMS reviews selection memo, contract draft, IAPD update

CMS approval is a critical-path dependency. Region 5 → DSG → OCIIO routing.

CMS internal SLA for review of a $68B selection.

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Contract negotiation & execution

FSSA OMPP + selected MCEs + General Counsel Stover

Signed contracts with SMC template adherence + CMS-0057-F binding language

Contract clauses on encounter data quality, SMC certification timing, sub-capitation visibility, audit cooperation, and termination triggers.

Whether encounter data quality is contractually tied to capitation withholds.

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Transition planning (~24 months)

FSSA OMPP + new MCEs + Gainwell + Deloitte + Maximus

Run-out plans for outgoing arrangements; cutover plans for new

Transition is where IBM/ACS-class failures originate. Data migration, member re-assignment, provider re-contracting, MMIS interfaces, encounter pipelines.

IV&V structure; readiness review milestones; CMS go/no-go gates.

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Iowa IA Health Link (2016): RFP-to-launch compressed to <12 months; CMS twice postponed the launch for 'inadequate provider networks and communication.' AmeriHealth Caritas exited mid-cycle in 2017. Branstad's $232M savings projection actualized at ~$47M (20% of target). Illinois HealthChoice (Jan 2018): baked 90-day member transition + 180-day out-of-network provider transition into the template — Indiana's MDwise honor window matches this national norm. — IA HHS · IL HFS · Health Management

Contract start date (January 1, 2029)

FSSA + new MCEs

Live operations; CMS go-live reporting

Day-one operational risk: member auto-assignment notices, provider network adequacy, claims pipeline, encounter pipeline. Indiana's largest single transition.

Whether parallel operations / staged cutover is planned.

Roob: target for new contracts to be effective January 1, 2029. — Indiana Capital Chronicle · Feb 4, 2026

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First-year SMC certification cycle

FSSA CIO + vendor + CMS

Module certification submissions to CMS SMC repository

Modules certified BEFORE contract start earn 75% M&O match from day one. Modules certified after cost the state the difference until certified.

Indiana's module certification roadmap; which modules will be ready by 1/1/2029.

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Procurements at this scale fail in the requirements phase, not the build phase. The IBM/ACS contract failed because the requirements didn't specify what was actually needed; the corrective lessons were drawn in 2009 and have not yet been re-tested at this scale. Two windows determine the next decade: the RFP design (now through August 2026), and the transition (Jan 2027 through Dec 2028). Both are short. The CMS-0057-F deadlines (PA decision timeframes Jan 2026, full FHIR API Jan 2027) and SMC template mandate (July 2026) all pre-date contract start, so they must be designed into the RFP rather than negotiated in.

Indiana's first post-PHE hospital rate restructuring. $1.866B SDP, tiered ACR (158% rural / 125% high-commercial / 100% physician). CMS approved Apr 28 + May 1, 2026.

Hospital Assessment Fee design & legislative approval

Indiana General Assembly + IHA + FSSA

HAF rate set; legislative authority granted

HAF must satisfy 42 CFR §433.68 broad-based / uniform / hold-harmless tests. Hold-harmless test is the most-litigated.

Per-hospital HAF impact; net financial position by hospital class.

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47 states had hospital provider taxes in FY 2025 (KFF) — Indiana joins 22 states adding MCO taxes in FY 2026 (Nebraska also added in FY26). H.R. 1 'significantly limits states' ability to impose or raise taxes on health care providers' going forward — meaning Indiana's hospital-tax architecture (now at the 6% federal limit) sits in the shadow of new federal restrictions. Provider tax revenue averages 18% of non-federal share of Medicaid nationally. — KFF FY 2025 Medicaid Budget Survey · Bipartisan Policy Center · Commonwealth Fund

Preprint submission to CMS

FSSA OMPP + CMS Region 5

Preprint reviewed by Region 5 + CMCS DSG

Preprint is the CMS document where SDP mechanics are vetted. ACR tier design must align with 2024 Access Rule demonstration requirements.

Public preprint redactions; CMS comments resolution log.

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CMS approval — HAF (Apr 28, 2026) + SDP (May 1, 2026)

CMS CMCS

Approval letters issued, retroactive provisions specified

HAF approved retroactive to July 1, 2025 — meaning rate-true-up cycle through MCEs takes additional time post-approval.

Approval letter conditions; MOEs (maintenance-of-effort) provisions.

CMS approved the revised Hospital Assessment Fee on April 28, 2026 (retroactive to July 1, 2025); the new State Directed Payment program approved May 1, 2026. — Indiana Capital Chronicle · IHA · Apr 28 / May 1, 2026

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Capitation rate adjustment to MCEs

FSSA OMPP rate-setting + Milliman (actuary)

MCE capitation rates re-cert with the new SDP folded in

SDP is paid through MCEs as a directed payment requirement — meaning capitation rates increase commensurately and MCE pass-through to hospitals is monitored.

Actuarial certification language; pass-through audit cadence.

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Texas has used SDPs heavily — pioneered ACR-based payment structures. Maryland operates an all-payer hospital rate-setting model (unique in the country). North Carolina integrates HealthyNC SDP with social-determinants metrics. Indiana's tiered ACR (158%/125%/100%) is a TX-style mechanism with NC-style equity tiering. — MACPAC · KFF

Tiered ACR ceiling enforcement (158% / 125% / 100%)

MCEs (operationally) + FSSA OMPP (policy)

Hospital contracts re-negotiated within ACR tier caps

Tiered ACR concentrates payment increases on rural and CAH facilities; caps consolidated, high-commercial-price systems. Operationally, MCEs must re-paper hospital contracts.

Per-hospital ACR positioning; consolidation/divestiture response from high-commercial systems.

Roob: 'This is the first time Medicaid has ever been used like this... a new covenant.' Tiered ACR directs more money toward lower-cost and rural providers; creates financial pressure on higher-priced consolidated systems. — Indiana Capital Chronicle · WBIW · May 15, 2026

Maryland operates the only all-payer hospital rate regulation system in the country since 1971 — every payer (Medicare, Medicaid, commercial, self-insured) pays the same rate for the same service at a given hospital. HSCRC sets rates under a 1814(b) SSA Medicare waiver. Since Nov 1, 2024 MD operates under the AHEAD Model (successor to Total Cost of Care). Texas pioneered ACR-based SDPs. Indiana's tiered ACR (158%/125%/100%) blends a TX-style payment mechanism with equity tiering. — CMS · MD HSCRC · Maryland Hospital Association · Healthcare Value Hub

Quarterly directed-payment reconciliation

FSSA + MCEs + Gainwell (claims) + IHA

Pass-through report to CMS; over/under reconciliation

Reconciliation requires clean encounter data — the same data quality issue that breaks rate setting elsewhere.

Reconciliation cycle time; encounter-error reject rate from MCEs to CoreMMIS.

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H.R. 1 SDP restrictions take effect (federal layer)

Congress + CMS

Federal restrictions narrow SDP eligibility post-Oct 2025

Indiana's SDP design is now bracketed by H.R. 1's further SDP restrictions on directed-payment scope and amount.

How H.R. 1 implementation rules will interpret tiered-ACR mechanisms.

Payment changes take effect January 1, 2026. HAF formula shifted from hospital patient days to total net patient revenue, maximizing the tax up to the 6% federal limit; county hospitals exempt via intergovernmental transfers. — Indiana Capital Chronicle · May 15, 2026

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The May 2026 hospital package is the most significant Medicaid rate restructuring Indiana has executed since the post-PHE unwinding. It threads three needles simultaneously: (1) shore up rural/CAH viability; (2) cap consolidated systems' Medicaid pricing power; (3) hold physicians at 100% of Medicare to protect access. The fiscal architecture works only if MCE pass-through is verifiable and encounter data clean. The H.R. 1 layer adds federal uncertainty: future SDP designs may be constrained.

Two active audit surfaces. ABA: $56M confirmed + $76.7M potentially improper (HHS OIG 2024). Attendant care: $200M sought from 5 largest providers (FSSA April 2026). Documentation gaps + EVV non-compliance the common surface.

Pattern detection / audit trigger

FSSA OMPP Office of Program Integrity + HHS OIG + CMS UPICs

Open audit case file

Pattern detection methods not publicly characterized (rules-based vs ML); referral mechanics between FSSA OPI, MFCU, and OIG opaque.

False positive rate on triggers; coordination of overlapping audits across agencies.

WISH-TV framed the Braun administration push as 'the free lunch is over' — broader effort to curtail Medicaid waste, fraud, and abuse including the attendant-care audit, ABA reforms, and the 340B change. — WISH-TV · Mar 2026

New York operates the Office of Medicaid Inspector General (OMIG) as a SEPARATE Inspector General office — distinct from the state Medicaid agency. OMIG conducted 266 pre-payment reviews in 2022, with sophisticated ML-driven pattern recognition and outlier analysis baked into the 2026 work plan. Indiana's FSSA OPI sits inside the program agency; the structural separation matters for independence and pre-payment capability. — NY OMIG · OMIG 2022 Annual Report · OMIG 2026 Work Plan

Records request to provider

Audit agency (OPI / OIG / UPIC / MFCU)

Provider produces records within statutory window

Document retention varies by provider class; small/medium providers often lack structured retention systems.

Records-production timeline median; refusal rate; partial-records rate.

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Medical record / EVV review

Audit team (often outsourced to clinical reviewers)

Findings documented at service-line and beneficiary level

Documentation gaps + EVV non-compliance are the common audit findings. ABA service notes often lack treatment-plan tie. Attendant care EVV records often lack co-located service location.

Per-service-line documentation defect rate; EVV-claim match rate.

FSSA audit reviewed claims 1/1/2022 – 3/31/2025 from Indiana's five largest attendant-care providers (Guardian Care, Healing Hands Personal Services, Help at Home, Tendercare Home Health, Team Select Home Care). Statistically valid random sampling of 625 claim lines. 'Nearly all reviewed claims had multiple issues, including missing criminal background checks, noncovered clinical tasks, insufficient documentation, misaligned authorizations, and other significant regulatory noncompliance.' Triggered by a $150M claim surge 2021 → 2022. — Indiana Capital Chronicle · WFYI · Fox 59 · WBIW · Apr 23–24, 2026

OIG audits typically cover 2-year review periods; Indiana's FSSA attendant-care audit covers 1/1/2022–3/31/2025 (a longer 3-year window). NY OMIG conducts 266+ pre-payment reviews annually per its 2022 Annual Report — pre-payment posture catches issues earlier than the retrospective audits dominant in Indiana. — HHS OIG · NY OMIG 2022 Annual Report

Statistical extrapolation

Audit statistician (HHS OIG uses RAT-STATS; UPICs vary)

Extrapolated overpayment amount derived from sample

Extrapolation methodology is the most-litigated step. ABA audit's $56M-confirmed/$78M-potentially-improper split is the extrapolation tail.

Sample-size adequacy challenges; extrapolation methodology in attendant care audit.

HHS OIG (Dec 2024) found Indiana made at least $56M in improper FFS Medicaid payments for ABA between January 2019 and December 2020, plus an additional $76.7M potentially improper. Findings: documentation, diagnostic evaluations, staff credentials, referrals. — HHS OIG · Dec 2024

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Findings letter / notice of overpayment

Audit agency

Provider response window opens (typically 60 days)

Findings letters trigger appeal rights; specifics of appeal path vary by audit type (OIG → HHS DAB; UPIC → MAC reconsideration; state → FSSA Hearings).

Per-audit-type appeal exhaustion rate; reversal rate at first appeal.

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Provider appeal & rebuttal

Provider + counsel; for state findings: FSSA Hearings ALJ

Reconsideration / hearing decision

Audit findings often survive provider contest because documentation gaps are evidentiary; less than 30% reversal nationally.

Indiana-specific reversal rate; per-service-line reversal rate.

Tendercare Home Health CEO Eric Deitchman publicly: 'I'm surprised we got listed publicly while we are working on our appeal. They said our care plans weren't up to par.' — Indiana Capital Chronicle · Apr 24, 2026

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Recoupment / settlement

FSSA OMPP / MFCU / CMS

Funds returned to state; federal share returned to CMS

Settlement vs litigation choice; settlement amount discount typically 20–40%.

Indiana settlement-vs-litigation policy; per-provider settlement amounts.

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Referral to MFCU if fraud suspected

FSSA OPI → AG MFCU (Whitmire)

Criminal investigation; exclusion proceedings

Referral mechanics: when does FSSA refer vs handle internally? MFCU declination criteria not public.

Referral volume; declination rate; exclusion outcomes.

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Governor's Working Group / legislative response

Governor's Office + General Assembly

Policy change (e.g., ABA usage cap; rate change)

Working Group recommendations (Nov 2025) on ABA usage cap and rate changes — translation into administrative or legislative action.

Implementation status of Working Group recommendations.

Governor's Medicaid Working Group (Nov 2025) recommended an ABA usage cap and rate changes. April 1, 2026 reforms went live: 4,000-hour lifetime cap with 15 hrs/week medical-necessity exception; 6% rate cut on max fee rates (except group); age-cap at 21 (EPSDT only); CASP accreditation required Oct 1, 2027. — Indiana Capital Chronicle · Hall Render · Behavioral Health Business · Nov 2025 – Apr 2026

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Systemic data / analytics build-out

FSSA OPI + future MFADS / pattern-detection capacity

Pattern detection improves; subsequent triggers fire faster

Indiana's current pattern-detection capability is largely retrospective and rules-based. ML/anomaly approaches would catch second-order patterns earlier.

Current MFADS capability map; ML/AI usage in pattern detection.

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NY OMIG's self-disclosure program lets providers proactively report and return overpayments within 60 days of identification, reducing the audit-recoup posture. Oklahoma has piloted FHIR-based pre-payment claim integrity. The shift is from retrospective recoup to prospective prevention. — NY OMIG · Oklahoma HCA

Two audits at $56M and $200M, in different service lines, with the same root surface (documentation + EVV), is a pattern. The pattern indicates that Indiana's claims-and-encounter data already contains the signal needed to predict the next audit — but the detection layer is downstream of the spending event. The integrity exposure is concentrated in a small number of large providers in a small number of service lines. Pre-payment integrity (claim edit + EVV validation at submit) catches earlier and cheaper than post-payment audit. The Working Group's ABA cap recommendation is a policy response; the operational response is a detection-and-prevention upgrade.

Indiana's first managed-LTSS program, in year 2. 11,296 waiver waitlist (714 invitations Feb 2026). $462M delayed NF payments (Feb–Apr 2026). HEA 1277 carves long-stay back to FFS, eff July 1, 2027.

Member identification & intake

DDARS (Mitchell) + Area Agencies on Aging (AAAs)

Intake screening → Level of Care determination

Intake throughput is the upstream bottleneck. 11,296 waitlist with 714 invitations in Feb 2026 reflects intake capacity, not slot capacity.

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

11,296 waiver waitlist with only 714 invitations issued in February 2026. The Arc of Indiana publicly tracks; ACLU of Indiana filed an HCBS waitlist class action in S.D. Indiana (2024, ADA/Olmstead). — The Arc of Indiana · ACLU of Indiana · 2024–2026

Arizona ALTCS (since 1989) is the oldest managed-LTSS program in the country and the operational maturity benchmark. Tennessee CHOICES and Kansas KanCare have similar contractor mixes to Indiana. Pennsylvania Community HealthChoices launched in 2018 and is the closest structural analogue — currently under court-ordered rebid (see H2.1). — OPEN MINDS · CHCS · MACPAC

Functional eligibility / Level of Care

DDARS assessor; standardized assessment tool

Eligibility decision → service plan

Assessment tool reliability across assessors; inter-rater agreement not publicly characterized.

Inter-rater reliability; reassessment cadence.

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Arizona ALTCS uses a single state-administered functional + financial eligibility assessment; Texas STAR+PLUS combines functional + intake in one bundled assessment. Indiana's separation between DDARS functional assessment and DFR financial assessment is the national majority pattern but creates handoff friction. — AZ AHCCCS · TX HHSC

Plan auto-assignment or selection (Anthem · Humana · UHC)

Maximus (enrollment broker)

Member assigned to one of three PathWays MCEs

Member education on plan choice; per-MCE network depth varies by region.

Per-MCE assignment distribution; member plan-switch rate.

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Care planning by MCE

PathWays MCE care manager

Plan of care issued; services authorized

Care plan quality and timeliness; care manager caseload sizes not public.

Per-MCE care manager caseload; care plan turnaround time.

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PA OLTL (Office of Long-Term Living) sits inside DHS and administers care planning separately from the MCEs — a different governance pattern from Indiana's DDARS + MCE shared model. PA reports care manager caseload metrics publicly. — PA DHS · OLTL

Service delivery (HCBS · attendant care · NF)

Provider (independent or agency)

Service rendered; encounter built

Attendant care providers are exactly the surface H4 (provider integrity) is concentrated on. Documentation + EVV.

Per-service-line encounter quality; provider EVV compliance rate.

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EVV capture (Sandata or open-vendor)

Provider EVV system → Sandata aggregator

EVV record posted to Sandata; matches against claim

EVV capture is real-time; reconciliation to claim is batch (typically nightly). Latency creates the gap audits exploit.

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

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Claim submission

Provider / clearinghouse

MCE adjudication (PathWays) or CoreMMIS (FFS waivers)

Sub-capitation by MCEs to delegated providers loses encounter visibility — a national pattern that applies in Indiana but is not publicly characterized.

Sub-capitation arrangements and their encounter-quality impact.

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NF payment cycle (quarterly, CMS-method)

FSSA OMPP + PathWays MCEs

Quarterly payment from MCE to NF

$462M in delayed NF payments (Feb–Apr 2026) reflects cycle time between state, CMS, and MCE on still-new contract structure.

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

$462M in NF payments delayed across 496 nursing homes; December and March payments missed heading into June. CMS hasn't approved Indiana's FY2026 methodology — state submitted June 2025, CMS still requesting data 9+ months later. H.R. 1 'added some wrinkles' to the calculation. Roob: 'I never would have pursued this program... it doesn't make sense for the population it serves.' — Indiana Capital Chronicle · WFYI · Skilled Nursing News · Apr 8, 2026 + Jun 10, 2025 testimony

Pennsylvania's mature CHC program (8 years in operation) does not have $462M-class quarterly NF payment delays — the methodology is well-established. The delays Indiana is experiencing are characteristic of a year-1–2 managed-LTSS program; PA's earlier years had analogous friction. The cycle time normalizes if the underlying methodology survives the H.R. 1 disruption. — PA DHS · OPEN MINDS

Encounter data submission MCE → CoreMMIS

PathWays MCEs

Encounter file ingestion to CoreMMIS analytics

Year 1–2 encounter data is structurally weak by national pattern. PathWays encounter quality publicly unaffirmed.

Encounter file reject rate; resubmission cycle time.

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Rate setting for next cycle

FSSA + Milliman (actuary)

Capitation rates re-cert against encounter data

If encounter quality is weak, rate setting is on shaky ground. The forecasting reform was triggered by exactly this risk.

Actuarial confidence interval on PathWays rates.

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HEA 1277 long-stay carve-out (effective July 1, 2027)

FSSA + General Assembly

Long-stay (>100 days) NF residents return to FFS

Carve-out is a legislative reaction to MCE-NF payment friction; operational implementation requires re-papering hospital and NF contracts on FFS basis.

Carve-out implementation plan; member transition mechanics.

HEA 1277 (authored by Rep. Brad Barrett, R-Richmond; sponsored by Sen. Mike Crider, R-Greenfield) signed by Gov. Braun March 12, 2026 — carves long-stay (>100 days) NF residents out of PathWays back to FFS effective July 1, 2027. Also imposes individual PathWays-waiver cost limit and requires FSSA to file a standalone assisted-living waiver application with CMS by September 1, 2026. — Indiana HCA · OPEN MINDS · Purdue Exponent · Mar 12, 2026

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PathWays' operational health concentrates on two seams: the intake throughput (waitlist) and the encounter-to-rate-setting loop. The $462M NF payment delay is a symptom; the underlying issue is cycle time between state, CMS, and MCE on a still-new contract structure. The HEA 1277 long-stay carve-out is a legislative reaction that doesn't fix the underlying mechanism — it just removes the most expensive population from the structure that's having trouble. Encounter data quality in years 1–2 is the single most important operational metric for the next rate-setting cycle.

Quarterly verification + 3-month lookback for ~560K HIP enrollees. Outreach window Jun 30 – Aug 31, 2026. 400 staffers (50 onboarded late April 2026). Implementation deadline Jan 1, 2027.

Federal rule clarification & state election

Congress · CMS · FSSA OMPP

Indiana elected quarterly + 3-month lookback (among most demanding)

Election locked in; federal rule details still emerging.

CMS clarifying guidance timing for implementation details.

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SEA 2 1115 amendment package

FSSA OMPP + CMS Region 5

1115 amendment under CMS review

Approval timing controls go-live. Past 1115 work-req approvals (Kentucky, Arkansas) faced litigation.

CMS approval timing; conditions of approval.

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H.R. 1 (Big Beautiful Bill, July 2025) closed the 1115 waiver path for work requirements — federal framework supersedes. Arkansas re-filed a work-req waiver in January 2025 anyway; Stewart v. Azar (KY HEALTH) and Gresham v. Azar (AR) set the prior CMS-approval litigation risk pattern. — Arkansas Advocate · KFF · CMS

Workflow design (IEDSS + DFR)

FSSA CIO Arrowood + DFR Beam

Rules engine update + caseworker process

80-hour/month threshold + 5 exemption categories + 3-month lookback × quarterly cadence = high-complexity rule set.

Rules engine release timeline; IV&V scope.

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Hiring 400 eligibility checkers

FSSA HR + DFR

Onboarding · training · production

50 onboarded by late April 2026; 350 more to onboard within ~10 weeks of outreach window opening.

Training curriculum completeness; per-cohort time-to-production.

FSSA hiring 400 employees to verify eligibility; 50 onboarded as of late April 2026. Effort began the prior month. — Indiana Capital Chronicle · Apr 29, 2026

Georgia Pathways spent more on administration than on health care, per a GAO report. Arkansas 2018 hired far fewer eligibility workers but produced 18,000 disenrollments in 7 months — the worker count isn't the binding constraint, the workflow design is. Indiana adding 400 staffers without restructuring the workflow risks the same outcome. — GAO · ProPublica · NEJM

Member outreach window Jun 30 – Aug 31, 2026

FSSA + MCEs + advocacy partners

Outbound mail + portal notification + MCE member services

Outreach is single-shot at members already in the renewal funnel. Outreach quality + comprehension drives the per-member compliance result.

Outreach plain-language compliance; comprehension testing.

Mandatory member outreach window June 30 – August 31, 2026. Federal implementation deadline January 1, 2027 with possible extensions through Dec 31, 2028. — FSSA · KFF tracker · 2026

Arkansas 2018: outreach campaign was insufficient — confusion + lack of awareness drove the 18,000-person coverage loss in 7 months. 97% of those who lost coverage were actually compliant or exempt. The takeaway for Indiana's outreach window: a single-shot mail campaign in summer 2026 reproduces the failure mode. — NEJM · Commonwealth Fund · Urban Institute

Member documents work activity OR claims exemption

Member; navigators; employer for verification

Documentation uploaded via fssabenefits.in.gov or DFR channel

This is where the same workflow that produced 78% procedural disenrollment now carries quarterly verification.

Documentation rate by activity type (wages vs school vs caregiver vs SUD).

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Quarterly compliance evaluation

IEDSS work-req module + 400 DFR staffers

Compliance result → continued / non-compliant / exempt

Volume math: ~560K HIP × 4 cycles = 2.24M evaluations/year, on top of annual renewals (~560K) and ex parte attempts (~560K).

Evaluation throughput per staffer; auto-evaluation share.

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Georgia Pathways is the only currently-operating state work-requirement program. Compliance verification is monthly via online portal — and the program is shifting to verification at application + annual renewal (de facto admitting the ongoing-reporting model doesn't work). 4,900 enrolled vs. 240K projected = 2% — a strong negative indicator for the policy theory itself. — GA DCH · WABE · ProPublica · GAO

Notice of non-compliance

IEDSS notice generator + DFR

USPS + portal; cure period before disenrollment

Notice clarity + cure-period mechanics drive the per-member disenrollment outcome.

Cure period rules; per-MCE outreach coordination during cure.

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Arkansas: of 18,000 people who lost coverage, 97% were compliant or exempt — the system removed them anyway because the reporting failure was procedural. Indiana's 78% procedural disenrollment rate during the unwinding is the same pattern. Notice clarity + cure-period mechanics determine whether the policy outcome matches the policy intent. — NEJM · Urban Institute

Disenrollment for non-compliance

IEDSS → CoreMMIS member master

X12 834 to MCE

Procedural-vs-substantive non-compliance breakdown is the critical metric — procedural failures aren't policy success.

Per-cycle procedural-vs-substantive split.

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Appeal pathway

FSSA Hearings ALJ + MCE internal

Internal MCE appeal → state fair hearing

Appeal capacity at scale; aid-pending mechanics.

Appeal volume forecast vs ALJ capacity.

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H.R. 1 quarterly verification on top of an unchanged renewal workflow produces the same operational risk that drove the 78% procedural disenrollment rate during the unwinding — at four times the cadence. The 400 staffers are needed, but they don't change the workflow's structural failure modes (document handling, notice comprehension, channel mismatch). Indiana elected the most demanding implementation parameters in the country (quarterly + 3-month lookback); the implementation will reveal whether that election is operationally sustainable. The Kentucky / Arkansas litigation history means CMS approval timing and conditions of approval are non-trivial path dependencies.

The political wound from 2023. $984M underestimated across FY24–25. Drove Steinmetz resignation (Dec 2024), Rusyniak departure (Jan 2025), and Mishler's Medicaid Oversight Committee.

Forecast methodology design

FSSA OMPP + Office of Management & Budget + actuary

December forecast feeds biennial budget cycle

Pre-2023 methodology relied on pre-pandemic utilization rates that didn't reflect post-PHE actual experience.

Current methodology revisions; assumption-testing cadence.

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Washington's MAEFW (Medical Assistance Expenditure Forecast Workgroup) reviews financial data, caseloads, FMAP, and step adjustments in a documented workgroup process — twice yearly (Feb + Oct). The methodology is published. Indiana's revised forecast methodology post-2023 miss is not. — WA OFM

Member volume projection

FSSA OMPP analytics + State Demographer

By-program enrollment projections feed the model

Volume projections during the unwinding (Apr 2023 – Apr 2024) were complicated by procedural disenrollments and re-enrollments.

Re-enrollment churn rate post-unwinding; net steady-state by program.

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PMPM cost projection

FSSA OMPP + Milliman (actuary)

Per-member-per-month cost trends by program

PMPM trends shifted post-PHE for chronic conditions, behavioral health, LTSS — and the model didn't catch the shift in 2023.

Sensitivity analysis publication.

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Washington publishes PMPM trend assumptions; Oklahoma invests heavily in encounter data quality as a rate-setting input. Indiana's actuary (Milliman) operates against post-2023 reformed forecasting but the published-methodology gap remains. — WA HCA · OK HCA

Monthly Medicaid financial reports (post-reform)

FSSA CFO Bowling

Monthly report to OMB, Senate Approps, House Ways & Means

Reports launched in 2024 give earlier signal but quality of underlying data drives quality of signal.

Report variance flags; threshold for budget alarm.

FSSA launched monthly Medicaid financial reports in 2024, in direct response to the 2023 forecasting miss. — FSSA · Indiana Capital Chronicle · 2024

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Variance analysis at month-close

FSSA CFO + OMB

Variance explanation to legislative oversight

Variance attribution: volume vs PMPM vs casemix vs ratesetting vs other.

Attribution methodology consistency.

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Senate Approps Medicaid Oversight Committee

Sen. Mishler (Chair) + LSA OFMA

Public testimony and oversight

Oversight cadence and information access; the political feedback loop.

Committee schedule; hearing transcripts availability.

Sen. Mishler (R-Mishawaka, Appropriations Chair) on the December 2025 forecast: now projecting positive annual Medicaid surplus rather than large deficit. Mishler created the Medicaid Oversight Committee after the 2023 miss; later authored a bill requiring FSSA to report data to the Committee and present annually on five-year look-back enforcement. — Indiana Senate Republicans · Inside INdiana Business · Dec 19, 2025

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Forecast revision at re-estimate

FSSA + OMB + actuary

Revised December forecast feeds next biennium

Revision must absorb H.R. 1, SEA 2, HEA 1277, EO 25-60 effects all at once for FY27–28.

How each policy instrument is being absorbed into the forecast assumptions.

FY2026 Medicaid forecast: HIP 2.0 enrollment forecast 707,851; HIP expenditures $6.4B; total Medicaid bill growth 9.4% to $4.8B (FY26), 6.9% to $5.2B (FY27). Earlier (Dec 2024): the forecast revision left top lawmakers 'scared' as the program ran $1B more expensive than projected. — Yahoo News · WFYI · Inside INdiana Business · Dec 2024 – Dec 2025

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The 2023 forecast miss was not bad math — it was bad data + bad assumptions. The corrective response (monthly reporting, oversight committee, leadership changes) addressed signal cadence and political feedback, but did not yet fundamentally restructure the data layer the forecast runs on. The next high-risk re-estimate is FY27–28, which absorbs H.R. 1, SEA 2, HEA 1277, EO 25-60, and the hospital SDP reform — all of which materially affect member volume, PMPM, and rate setting. Without a comparable depth of data-layer reform, the same risk class persists.

Federal court (Jun 27, 2024) vacated HHS 2020 reapproval of HIP 2.0. POWER accounts paused. Retroactive eligibility waiver vacated. NEMT waiver vacated. SEA 2 1115 amendment pending. The expansion vehicle for ~560K Hoosiers operates under constrained authority.

HIP 2.0 baseline (pre-Rose)

FSSA OMPP

1115 demonstration waiver

HIP architecture: premiums, POWER accounts, retroactive-eligibility waiver, NEMT waiver, Gateway-to-Work.

Pre-Rose policy intent retention.

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Rose v. Becerra ruling (Jun 27, 2024)

U.S. District Court

Vacates HHS 2020 reapproval

Court grounds: failure to consider coverage loss as a relevant factor under APA review.

Appeal status; subsequent federal court reactions.

Rose v. Becerra: U.S. District Court vacated HHS's 2020 reapproval of HIP 2.0 on June 27, 2024. The D.C. Circuit affirmed in March 2026 — HIP 2.0 remains operative except Indiana lacks authority to collect POWER premiums or to terminate HIP Plus coverage for non-payment. — U.S. District Court · D.C. Circuit · Indiana Justice Project · Jun 2024 + Mar 2026

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POWER accounts paused

FSSA OMPP

Member contributions ceased; cost-sharing logic suspended

POWER account is HIP's defining feature; pausing it changes the program's policy theory.

Whether POWER accounts return in some form post-amendment.

POWER account contributions have been paused since the 2024 ruling; CMS December 2023 letter had said premiums would stay in the program despite documented concerns about coverage losses, though Indiana had not implemented contributions for nearly four years at that point. — CMS · Indiana Justice Project · 2023–2024

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Retroactive eligibility waiver vacated

FSSA OMPP

Standard retroactive eligibility resumed

Operationally requires IEDSS rules + claim adjudication updates.

Rule-and-system update completion status.

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NEMT waiver vacated

FSSA OMPP + MCEs

Standard NEMT requirements apply to HIP

MCE contracts must accommodate NEMT obligation; MCE network capacity for NEMT.

MCE NEMT operational implementation cadence.

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SEA 2 work-req amendment package

FSSA OMPP + CMS Region 5

1115 amendment under review

Approval is on the timeline-critical path for H.R. 1 implementation.

Amendment language; approval conditions.

Federal H.R. 1 framework supersedes the 1115-waiver path for work requirements (work req cannot be waived via 1115). Indiana states may implement sooner through a state plan amendment. — KFF · CHCS · 2025–2026

Federal law (H.R. 1) explicitly removes the 1115-waiver route for work requirements — only state-plan amendments are available. Arkansas re-filed for a work-requirement waiver in January 2025; the pre-H.R. 1 litigation history (Stewart v. Azar invalidated KY HEALTH; Gresham v. Azar invalidated Arkansas) shapes CMS approval risk. — KFF · Arkansas Advocate · CMS

Architecture redesign for next procurement

FSSA + future MCEs

August 2026 RFP must reflect post-Rose architecture

RFP must specify HIP architecture without the vacated waivers; alternate cost-sharing mechanisms.

Whether post-Rose HIP design is settled going into RFP.

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Rose v. Becerra didn't end HIP; it constrained its authority. The vacated waivers (premiums-as-condition, retroactive eligibility, NEMT) were the policy features that distinguished HIP from straight ACA expansion. Without them, HIP is structurally closer to standard expansion than to the Daniels-era design. The SEA 2 1115 amendment for work requirements re-opens the question of how distinctively Indiana HIP will remain. The August 2026 RFP must specify a HIP architecture; if the 1115 amendment isn't yet approved, the RFP either bets on approval or designs around it.

Mandatory new SMC templates (APD · OAPD · AoA · Intake Form) for any procurement reaching CMS after July 1, 2026. Zero Indiana MES modules on the public CMS SMC repository. 90/10 DDI · 75/25 M&O federal match rides on certification.

Module identification & boundary design

FSSA CIO Arrowood + CMCS DSG

Module list aligned to CMS SMC framework

Current Indiana posture: monolithic CoreMMIS + IEDSS + Acentra + Sandata, not modular. Aug 2026 RFP must specify the modular partition.

Module list under consideration.

Ohio and Michigan have well-developed MES modular module libraries with multiple certified modules on the public CMS SMC repository. Tennessee and North Carolina are progressing on outcomes-based certification under SHO #25-003. Indiana's zero-module posture is a meaningful gap relative to these peers. — CMS SMC Repository · SHO #25-003

Outcomes & metrics definition

FSSA + CMS

Outcomes-based certification (OBC) — now folded into SMC under SHO #25-003

Outcomes must be defined upstream of the RFP. Vendors must be able to certify against them.

Indiana's outcome set; baseline measurement plans.

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APD/OAPD/AoA submissions on new templates

FSSA CIO + CMS Region 5 + CMCS DSG

Federal review against new templates

July 1, 2026 deadline. Submissions before that date can use old format; after must use new.

Indiana submission cadence vs deadline.

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Module build (vendor-led, under contract)

Vendor + FSSA CIO oversight

Build → test → readiness review

Modules certified BEFORE contract start get 75% M&O match from day one; later certification costs the state the difference.

Vendor commitment timing in RFP responses.

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CMS readiness review & certification visit

CMS CMCS + state demonstration

Certification decision

Certification visits are sequential; module-by-module process has a serialized timeline risk.

Certification visit calendar.

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Posting to CMS SMC public repository

CMS

Public record of certified modules

Zero Indiana entries currently; needs visible progression by mid-2027.

Repository update cadence.

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Enhanced FFP claim against certified modules

FSSA CFO + CMS

75% M&O claimed via CMS-64

Match math is the economics of every modernization decision; certification timing converts directly to dollars.

Per-module dollar impact projection.

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SMC certification is the federal funding leverage that determines the economics of every modernization decision. Indiana's zero-module posture on the public repository is a meaningful gap relative to peer states — and the August 2026 RFP is the inflection point. Modules specified loosely in the RFP can't be certified tightly later. Modules certified before contract start earn 75% match from day one; modules certified later cost the state the difference. The July 1, 2026 mandatory template deadline lands before RFP issuance, so RFP design must already be compliant.

Indiana's homegrown MCE exits HHW, HIP, and HCC on Jan 1, 2026. Members auto-assigned to Anthem · CareSource · MHS unless they make a different selection. Largest single MCE transition in Indiana managed care history.

MDwise exit announcement (Nov 13, 2025)

FSSA OMPP + MDwise

Public notification + member communication strategy

Member communication clarity is the operational binding constraint.

Per-member outreach receipt + comprehension rate.

FSSA decided MDwise would no longer be a Medicaid plan option after January 1, 2026, citing 'a comprehensive review of MDwise's performance and its ability to meet FSSA's standards for member services, provider support, and program accountability.' — FSSA · Indiana Capital Chronicle · The Arc of Indiana · Nov 13, 2025

Iowa 2017 — AmeriHealth Caritas exited mid-cycle, scrambling members into auto-reassignment. Indiana's MDwise exit (announced Nov 13, 2025, effective Jan 1, 2026) is the controlled-exit benchmark: 6+ weeks of open enrollment, 90-day post-cutover change window, 90-day authorization honor. The mid-cycle Iowa template is what controlled-exit prevents. — Managed Healthcare Executive · IA HHS

Member plan-selection window opens

Maximus (enrollment broker)

Member chooses Anthem · CareSource · MHS, or accepts auto-assignment

Plan choice burden on member; comprehension drives quality of choice.

% members who actively choose vs accept auto-assignment.

Open enrollment ran November 1 – December 24, 2025. Members had a 90-day window after January 1, 2026 to switch plans. — FSSA · Indiana Medicaid · Nov 2025 – Jan 2026

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Auto-assignment algorithm runs

FSSA OMPP rules + Maximus

Auto-assigned members allocated to remaining MCEs

Auto-assignment algorithm: family-keeping, provider continuity, geographic distribution, MCE market share.

Algorithm details (proprietary); equity outcomes by demographic.

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Member-record migration MDwise → new MCE

MDwise + receiving MCE + FSSA

Care plans, PAs in progress, claim history

Continuity-of-care during the migration: in-progress PAs, ongoing therapies, scheduled procedures.

Care-continuity protocol; PA honor period.

Receiving MCEs (Anthem, CareSource, MHS) required to honor existing authorizations a minimum of 90 days, or until PA expiration, or until approved units exhausted — whichever first. — FSSA · The Arc of Indiana · Nov 2025

Iowa 2016 (Amerigroup dropped mid-cycle, member confusion) and Illinois HealthChoice (~700K member transition) are the most-studied recent MCO transitions. Common lessons: minimum 90-day authorization honor period (Indiana matches this), explicit cross-MCE care manager assignment continuity, provider directory reconciliation as a separate workstream, equity tracking on auto-assignment outcomes. — MACPAC · SHVS

Provider re-contracting

Receiving MCEs + provider networks

Network agreements re-papered or maintained

Some MDwise-only providers may not be in the new MCEs' networks.

Provider network overlap analysis.

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Illinois HealthChoice (2018) required receiving health plans to offer a 90-day transition period for members new to the plan PLUS a 180-day out-of-network provider transition with FFS-rate payment. The PA-honor + provider-network templates Indiana is using on MDwise track to the IL national template; the Aug 2026 RFP should specify the same minima. — IL HFS · DSCC UIC

Cutover Jan 1, 2026

All parties

Live operations under new MCEs

Day-one risk: card issuance, formulary access, in-process services.

Day-one operational metrics.

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Post-cutover monitoring

FSSA OMPP + MCEs + advocacy partners

Issues triage; corrective action

Public issue tracking; member-facing escalation channels.

Issue volume; resolution time.

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Influence on August 2026 RFP

FSSA + bidders

MDwise transition becomes informational input to RFP design

Lessons-learned codification: what went well, what didn't, how it shapes the RFP's transition clauses.

MDwise post-mortem; documented lessons.

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MDwise's exit is the operational dry run for the August 2026 procurement transition. It's a smaller version of the same problem (member migration, provider re-contracting, care continuity, cutover) on a constrained timeline. The lessons from MDwise — what worked, what didn't — should be codified by mid-2026 because they inform the transition mechanics of the much larger 2027–2028 cutover for the new master contracts. A well-documented MDwise post-mortem is the single most useful artifact FSSA could produce in this window.

Application channel → IEDSS verification → eligibility decision → MCE assignment → CoreMMIS member master.

Application channel selected

Applicant; optional navigator (FQHC, certified counselor)

Channel-specific intake

Per-channel rate and quality varies. Paper applications take longest; portal fastest but excludes low-digital-literacy.

Per-channel response time distribution.

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North Carolina ePASS consolidates Medicaid + SNAP + TANF + Child Care + LIEAP into a single statewide application portal — flatter than Indiana's per-channel approach. California BenefitsCal does the same on the West Coast. The single-application model reduces redundant data entry and is the upstream lever for ex parte success. — NC DHHS · CA DHCS

Application intake

fssabenefits.in.gov (portal) · DFR call center · DFR county office · paper/mail

Application routed into IEDSS workflow

Paper and call-center channels add manual data entry steps that introduce error.

Per-channel data-entry error rate.

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Document upload (if non-self-attested data needed)

Applicant

IEDSS document store

EO 25-60 ended self-attestation, raising the volume of documents required at intake.

Post-EO 25-60 document volume change.

EO 25-60 (Apr 15, 2025) ended self-attestation. Where the Federal Data Hub / DWD has no record of an applicant's income, members must produce manual proof — increasing intake document volume. — Governor's Office · Apr 15, 2025

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Identity verification

IEDSS → Federal Data Services Hub (USCIS SAVE for non-citizens)

Verified / requires manual review

USCIS SAVE response variance; manual review queue.

USCIS-failure manual-review rate.

SB 1 (signed by Gov. Braun March 4, 2026) mandates rigorous verification of immigration status for all Medicaid and SNAP applicants; requires the office to report compliance information to the federal government. — Indiana Senate Republicans · WSBT · Mar 4, 2026

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Income verification

IEDSS → IRS + DWD wage data + Equifax/Work Number

Verified / requires manual proof

Self-employment, gig, and cash income not in DWD; require manual proof.

Share of applicants requiring manual income proof.

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Arizona and New Mexico use 'gross-up' verification logic against the Federal Data Hub to reduce manual income review — a small acceptable variance avoids requiring the member to produce proof. California BenefitsCal automates self-employment income via tax records. — AHIP · CA DHCS · CMS

MAGI categorization (kids, pregnant, parents, expansion)

IEDSS rules engine (Deloitte)

If MAGI fails → non-MAGI branch

MAGI cliffs and 5% disregard are precision points; small errors disqualify.

MAGI categorization reversal rate at appeal.

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Non-MAGI evaluation (ABD, LTSS, dual)

IEDSS + DDARS (LTSS) + functional eligibility assessment

Eligibility decision

LTSS path adds LOC assessment by DDARS — a separate workflow.

LTSS path completion time.

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Notice generation

IEDSS + DFR

USPS mail + portal notification if opted in

Notice readability; per-program variant.

Notice receipt and comprehension rate.

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Plan selection (MCE programs)

Maximus enrollment broker

Member selects Anthem · CareSource · MHS (or Humana/UHC for PathWays) or accepts auto-assignment

Choice quality varies; auto-assignment dominates in time-pressured cases.

Per-program active-choice rate.

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CoreMMIS member master update

IEDSS → CoreMMIS interface

Member record created/updated; X12 834 transactions to MCEs

Interface latency between IEDSS and CoreMMIS varies; member-card issuance delays.

IEDSS-CoreMMIS sync latency.

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The application flow's failure modes concentrate in two places: identity/income verification (steps 4–5) and plan selection (step 9). Identity/income verification failures send applicants into a manual-proof funnel that's the same funnel that breaks renewals. Plan selection failures produce members in plans with low-quality network match for their needs, which then drives later care-access friction.

Ex parte first → pre-populated form → member response → re-verification → result. Now layered with H.R. 1 quarterly + SB 1 quarterly + SEA 2 amendment.

Renewal trigger fires (annual or quarterly)

IEDSS scheduler

Member added to renewal queue

Multiple-schedule overlap on the same member.

Overlap rate.

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Ex parte attempt against existing data

IEDSS

Federal Data Hub + DWD wage + prior verification cache

National post-PHE ex parte rate ~41%; Indiana rate not public.

Indiana's ex parte rate.

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North Carolina: 99% ex parte success during the unwinding — final procedural disenrollment rate 12%. Maine had the only lower disenrollment rate. NC's automation uses SSA + IRS + state wage databases. Indiana's ex parte rate is not publicly published but national post-PHE rate is ~41%; the gap explains why Indiana ran 78% procedural disenrollment. — KFF · NC Medical Society

Pre-populated form (if ex parte fails)

IEDSS form module

USPS + portal

Mail-based renewal dominates; address staleness is a known driver of procedural disenrollment.

Address-staleness rate; mail-return rate.

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Member responds via 5 channels

Member; navigators

Response channels: online · phone · paper · in-person · navigator

Phone capacity at DFR call center; rural digital access for portal.

Per-channel response rate.

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Document submission

Member

IEDSS document store

This is the step that produced the 78% procedural disenrollment rate.

Per-document-type rejection rate.

Indiana's procedural disenrollment rate held at 78% as the unwinding concluded (Apr 2023 – Apr 2024) — the national average was 69%. Earlier in the unwinding the gap was wider: Indiana 85% vs national 75%. In response to early advocate feedback, Indiana's Medicaid outcomes dashboard now publishes a breakdown of procedural disenrollments. — KFF tracker · Indiana Capital Chronicle · May 2024

Arizona and New Mexico use 'gross-up' logic with the Federal Data Hub to reduce manual document review — instead of asking the member to prove income, the system accepts a small variance against the FDH data. California's CalSAWS consolidation enables 'no-touch' auto-renewals at scale. — AHIP · CMS · KFF

Caseworker reconciliation

DFR caseworker (one of 92 county offices)

Reconcile uploaded docs to IEDSS request

Per-county queue depth varies; new staffers being added to unchanged workflow.

Per-county queue depth.

400 new eligibility checkers being hired into the existing workflow; 50 onboarded by late April 2026. Document-reconciliation queue runs across the 92 county DFR offices. — Indiana Capital Chronicle · Apr 29, 2026

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H.R. 1 quarterly verification (HIP)

IEDSS work-req module + DFR

Compliance pass / fail / exemption

Volume math: 2.24M evaluations/year on top of annual renewals.

Auto-evaluation share.

H.R. 1 quarterly work-requirement verification (HIP only). Mandatory outreach window June 30 – August 31, 2026; implementation deadline January 1, 2027. — CMS · KFF tracker · 2026

Arkansas 2018 (18,000 coverage losses in 7 months; 97% of removed people compliant or exempt) and Georgia Pathways 2023–present (2% of projected enrollment) are the only operating data points. Both indicate the work-requirement reporting layer fails procedurally, not substantively. Indiana's quarterly cadence is more demanding than either AR or GA. — NEJM · ProPublica · GAO

SB 1 quarterly check + immigration disclosure (eff July 2026)

IEDSS + DFR

Additional verification cycle

Another schedule overlay; same workflow.

SB 1 operational implementation.

SB 1 (March 2026) also: removes 12-month eligibility period for HIP and requires semiannual renewal; changes general Medicaid renewal from 12 months to 6 months; modifies presumptive eligibility; SNAP candy/soft-drink purchase restriction. — Indiana Senate Republicans · WSBT · Paragon Health Institute · Mar 4, 2026

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Notice generation

IEDSS + DFR

Continued · disenrolled · pending

Notice plain-language compliance.

Notice comprehension rate.

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Disenrollment to CoreMMIS member master

IEDSS → CoreMMIS

X12 834 to MCEs

Procedural-vs-substantive disenrollment split not transparently published.

Per-program split.

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Iowa 2017's AmeriHealth Caritas exit auto-reassigned 215K members. Illinois HealthChoice 90-day transition template is the cleanest. Indiana's IEDSS→CoreMMIS handoff during a disenrollment event needs equivalent transparency. — Managed Healthcare Executive · IL HFS

Appeal pathway opens

FSSA Hearings ALJ

Aid pending if filed in time

Appeal capacity; aid-pending compliance.

Appeal volume.

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The renewal flow is where Indiana's biggest operational risks live, because it's the single workflow that now carries: annual renewals + H.R. 1 quarterly + SB 1 quarterly + EO 25-60 end-of-self-attestation + SEA 2 work-req checks. The 78% procedural disenrollment rate from the unwinding is the leading indicator of how much load this workflow can carry without further failure. Adding 400 staffers to the workflow without restructuring it is the most expensive way to discover the bottleneck is procedural, not capacity-related.

Apply → screen → ID assigned → MCE credential → revalidate every 5 years.

Apply via IHCP Provider Healthcare Portal

Provider

CoreMMIS provider enrollment module (Gainwell)

Portal usability for small providers; ownership-disclosure complexity for entity providers.

Application abandonment rate.

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Texas TMHP operates a single provider portal that funnels into all managed-care plans. Colorado and Arizona were early adopters of CMS PECOS integration patterns reducing duplicate disclosure burden. NCQA has a standardized credentialing framework states could adopt for cross-MCE reciprocity. — TX HHSC · TMHP · NCQA

NPI · taxonomy · license · ownership disclosure submitted

Provider

Verification against state license boards + CMS NPI registry

Ownership disclosure is the integrity hook; gaps in disclosure are pattern-detectable.

Disclosure-failure rate.

—

—

CMS risk-level screening (§455.450)

Gainwell + FSSA OPI

Limited / moderate (adds unannounced site visit) / high (adds fingerprint background for provider and 5%+ owners)

Site-visit completion rate for moderate-risk providers; fingerprint completion for high-risk.

Per-risk-level completion timeline.

—

—

Exclusion list checks

Gainwell + FSSA OPI

LEIE (monthly) · SAM.gov · Indiana exclusion list · §455.417 cross-state

§455.417 cross-state termination cascade — compliance not publicly characterized.

Cross-state termination handling rate.

Background-check gaps were among 'multiple issues' identified in the FSSA attendant-care audit findings — implicating the provider-screening pipeline (LEIE/SAM/state exclusion list/§455.450 risk levels). — FSSA audit findings · Indiana Capital Chronicle · Apr 23, 2026

—

Internal Medicaid provider ID assigned

Gainwell (CoreMMIS provider master)

Provider activated in claims system

Activation latency from application to first-claim-eligible date.

Activation latency.

—

Texas TMHP operates a single provider portal that funnels enrollment into all four STAR programs. Arizona AHCCCS has a single provider master across acute + LTSS programs. Indiana's CoreMMIS provider master + 5 separate MCE credentialing processes is the national majority pattern but the cost is provider directory accuracy. — TX TMHP · AZ AHCCCS

MCE credentialing (separate process per MCE)

Each of 5 participating MCEs

Provider added to MCE network

Credentialing duplication: same provider, 5 MCE credentialing processes.

Cross-MCE credentialing reciprocity efforts.

—

Few states have implemented cross-MCE credentialing reciprocity at scale, but New York's CAQH integration is the closest national model. NCQA's Credentialing Verification Organization standard is the reciprocity scaffold. Indiana's five separate MCE credentialing processes are the national norm — but the cost is provider directory accuracy. — NCQA · CAQH · NY DOH

Service delivery & claim submission begins

Provider

Into F4 (claims) or F5 (managed care)

First-claim error rate for newly enrolled providers.

First-90-day error rate.

—

—

Revalidation every 5 years (§455.414)

Provider + FSSA OPI + Gainwell

Refreshed disclosures + screening

Revalidation queue is where dormant or non-compliant providers can be identified.

Revalidation completion rate; per-cycle de-enrollment rate.

—

—

Provider enrollment is where Indiana's integrity exposure begins. The two recent audits (ABA, attendant care) suggest the screening + ownership-disclosure layer is where the leakage starts. Cross-state termination cascade (§455.417) compliance is the highest-leverage cleanup. MCE credentialing duplication is a member-experience friction that affects access; provider directory accuracy depends on it.

Verify eligibility → deliver service → submit 837 → CoreMMIS adjudicates → 835 remit → post-payment review.

Eligibility verified at point of service

Provider; portal or 270/271 EDI

Eligibility confirmation

Cached vs real-time eligibility; portal latency.

% providers using portal vs 270/271.

—

—

Service delivered; encounter/claim built

Provider + EHR/billing system

X12 837 generated

Documentation practices vary by provider class; audit surface (see H4).

Documentation-defect rate by service line.

—

—

Claim submitted via clearinghouse

Provider/clearinghouse (Availity · Optum · Waystar · Inovalon)

CoreMMIS claim ingestion

Per-clearinghouse error rates and reject patterns vary.

Direct-submission share vs clearinghouse share.

—

—

Front-end edits (CoreMMIS)

Gainwell

X12 999 + 277CA responses

Edit version control opaque; edit changes can shift rejections.

Edit rejection rate; edit change cadence.

—

Washington's ProviderOne MMIS modernization (2010–present) is a published case study in incremental MMIS replacement. California's xDR modernization replaced the legacy MMIS over multiple modular phases. Indiana's CoreMMIS (1991, 35-year lineage) is on the older end of the country. — WA HCA · CA DHCS · GAO-20-179

Adjudication

Gainwell + FSSA OMPP (fee schedule, PA cross-check, TPL/COB, eligibility)

Clean claims auto-adjudicate; failed-edit claims suspend

Suspended-claim queue is the manual workaround layer.

Suspension rate; resolution time.

—

Pre-payment clinical edits and EVV validation at submit are increasingly common — NM, SC, and NY OMIG-aligned states catch documentation issues earlier. Indiana's suspended-claim queue (the 13th-layer manual workaround) is the symptom of the post-payment posture. — NM HSD · SC DHHS · NY OMIG

Suspended-claim resolution

Gainwell + FSSA OMPP

Resolved / denied

Manual workload; provider follow-up workflow.

Suspended-claim queue depth.

—

—

Payment EFT + X12 835

Gainwell + state treasury

Provider remit

Prompt-pay compliance: 90% in 30 days, 99% in 90 days (42 CFR §447.45).

30-day vs 90-day compliance rate.

HEA 1474 set standards for how quickly an MCO must pay, deny, or suspend a claim — plus interest owed when deadlines are missed. Legislative response to PathWays provider claim-processing complaints. — WFYI · Indiana Public Media · Jun 2025 (Roob testimony) – 2026

Wisconsin and Pennsylvania publish prompt-pay performance against 42 CFR §447.45 (90% in 30 days, 99% in 90 days) on public dashboards. Indiana's HEA 1474 (2025) established MCO-side prompt-pay standards but the public-dashboard piece isn't yet implemented. — WI DHS · PA DHS · WFYI

Post-payment review

FSSA OMPP + UPIC + PERM contractor + MFCU

Recoupment / extrapolation / referral

This is the audit step. ABA + attendant care concentrated here.

Per-service-line audit rate; finding sustain rate.

Two active integrity audits sit at this step. ABA: $56M confirmed + $76.7M potentially improper (HHS OIG 2024). Attendant care: $200M sought from 5 largest providers (FSSA Apr 2026). FSSA said it is 'expanding oversight to more providers.' — HHS OIG · Indiana Capital Chronicle · Dec 2024 / Apr 2026

—

The FFS claim flow's weak points are at steps 4–6 (front-end edits, adjudication, suspended-claim resolution) and step 8 (post-payment review). Edits catch some errors at submit; the suspended-claim queue carries the rest into manual handling. Post-payment review (H4) is where the audit exposure surfaces. Pre-payment integrity logic (edit + EVV validation at submit) is the highest-leverage upgrade for both throughput and integrity.

Rate setting → capitation → MCE adjudicates → encounter submission → reconciliation → quality + network adequacy → contract performance.

Rate setting against encounter data

FSSA OMPP + Milliman (actuary)

Certified capitation rates

Rate setting quality depends on encounter quality. PathWays year-2 encounter quality is the highest-risk input.

Actuarial confidence interval per program.

—

Washington publishes actuarial methodology + sensitivity analysis. Oklahoma has invested heavily in encounter data quality as a rate-setting input. North Carolina ties capitation withholds to MCE outcomes (NC Tailored Plans). — WA HCA · OK HCA · NC DHHS

Capitation payment to MCEs (X12 820)

FSSA + state treasury

Monthly capitation flows to Anthem · CareSource · MHS · Humana · UHC

Capitation accuracy depends on member-master accuracy (IEDSS → CoreMMIS).

Capitation reconciliation cycle time.

PathWays NF capitation-cycle delays of $462M (Feb–Apr 2026) reflect end-to-end friction in this step — state → CMS → MCE on a still-new contract structure. — Indiana Capital Chronicle · Skilled Nursing News · Apr 8, 2026

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MCE adjudicates member claims

MCE claims systems (each MCE separately)

Payment to MCE-contracted providers

Per-MCE claim adjudication policy variance; same service, different MCE handling.

Per-MCE PA approval rates; denial rates.

—

—

Encounter data submission to CoreMMIS

MCEs → CoreMMIS encounter ingestion

Encounter file ingestion (often batch flat-file)

Encounter file reject rates; resubmission cycle. Sub-capitation to delegated providers loses encounter visibility.

Per-MCE encounter quality scores; sub-cap arrangements.

—

Sub-capitation arrangements are common nationally but rarely contractually visible to states. North Carolina requires sub-cap disclosure in its Tailored Plans contracts — the most transparent model. New York requires sub-cap arrangements be reported through encounter data with delegated-provider flags. — NC DHHS · NY DOH

Encounter reconciliation

FSSA + Gainwell

Reconciled encounter dataset for analytics + reporting

Reconciliation lag; data quality affects T-MSIS and forecasting.

Reconciliation cycle time; data-quality scoring.

—

Ohio is a national leader on T-MSIS data quality scores. Indiana's T-MSIS DQ scoreboard is not public; OH publishes its scorecard tracking. — OH DOM · CMS T-MSIS DQ

MCE quality reporting + network adequacy

MCEs + FSSA + NCQA accreditation

Quality metrics (HEDIS, CAHPS); network adequacy reports

Behavioral health network adequacy is the most-failed access category nationally; Indiana all-92-counties shortage areas amplifies it.

Per-MCE specialty network depth.

—

NC Standard Plan withhold program launched 2024 — capitation withholds tied to quality measure performance, with funds returned to MCEs based on annual cycle results. Tailored Plan withhold is planned but not yet implemented. NC publishes the methodology. Most states pay capitation flat and reconcile retroactively. — NC DHHS · NC Medicaid

Contract performance review

FSSA OMPP

Sanctions, withholds, corrective action plans

Performance-to-payment linkage — capitation withholds tied to encounter quality?

Per-MCE withhold history.

FSSA cited 'comprehensive review of MDwise's performance and its ability to meet FSSA's standards for member services, provider support, and program accountability' as the basis for the MDwise exit (Jan 1, 2026). — FSSA · Indiana Capital Chronicle · Nov 13, 2025

North Carolina Tailored Plans tie capitation withholds to encounter data quality + outcomes — the single highest-leverage MCE accountability mechanism in the country. Most states pay capitation flat and reconcile retroactively. — NC DHHS · MACPAC

Managed care operations' binding constraint is encounter data quality. Rate setting, forecasting, MCE accountability, and federal reporting all depend on it. Sub-capitation arrangements between MCEs and large delegated provider groups are a known national gap in encounter visibility; in Indiana it's not publicly characterized. Capitation withholds tied to encounter quality are the single highest-leverage contract mechanic.

FFS: Acentra Atrezzo. Managed care: each MCE. CMS-0057-F decision timeframes (Jan 2026) and FHIR PA API (Jan 2027).

Provider determines PA needed

Provider / EHR

PA request initiated

PA criteria knowledge varies by provider class.

PA-needed misidentification rate.

—

—

PA submission

Provider → Acentra Atrezzo (FFS) OR MCE portal (managed care)

PA enters review queue

Each MCE has its own portal; provider must navigate 5 different systems. CMS-0057-F FHIR PA API requires a unified standard.

PA submission error rate by destination.

CMS-0057-F operational provisions began January 1, 2026: 72-hour expedited and 7-day standard PA decisions for all impacted payers. — CMS-0057-F final rule · Jan 1, 2026

Oklahoma's FHIR Plan-Net pilot (Sep 2024 launch) is the early state implementation of CMS-0057-F's interoperability provisions. California's AB-3030 (the 'AI in PA' law) limits AI-driven denials. Indiana hasn't publicly committed to a FHIR readiness pathway for the August 2026 RFP. — OK HCA · CA Legislature · CMS-0057-F

Clinical review

Acentra clinical reviewers / MCE UM team

Approve / deny / request additional info

Review timeliness; clinical criteria source-of-truth.

Per-MCE review cycle time.

—

—

Decision notification

Acentra / MCE

Provider + member notified

CMS-0057-F sets decision timeframes from Jan 1, 2026.

Pre-vs-post CMS-0057-F decision timing.

By March 31, 2026 every impacted payer was required to publish CY2025 PA metrics (approval/denial rates, appeal outcomes, average decision timeframes) on its public-facing website. — CMS-0057-F final rule · Mar 31, 2026

CMS-0057-F required ALL impacted payers to publish CY2025 PA metrics on their public websites by March 31, 2026 — including approval/denial rates, appeal outcomes, average decision timeframes. Indiana MCEs should have these live; this is a check-and-publish moment, not a future deadline. — CMS-0057-F final rule

Denial → appeal pathway

MCE internal appeal first; then state fair hearing (F9)

Into F9

Appeal exercise rate; denial pattern by service line.

Per-MCE denial appeal rate.

—

Medicare's WISeR PA AI pilot launches January 2026 in six states (AZ, NJ, OH, OK, TX, WA), running through 2031. California's AB-3030 limits AI-driven denials. Indiana hasn't publicly engaged with the AI-in-PA frontier. — STAT · CMS · CA Legislature

Authorization issued; care proceeds

Provider

Service delivered under PA

PA-honored period for cross-MCE transitions (MDwise exit).

PA honor period during MCE transitions.

—

—

Claim submission with PA reference

Provider

Into F4/F5; PA cross-check at adjudication

PA-claim match logic; PA expiration handling.

PA-match failure rate at adjudication.

—

—

PA is the most-cited provider burden in Medicaid nationally and the same applies in Indiana. CMS-0057-F's January 2027 full FHIR PA API requirement is the major operational milestone — it forces standardization across MCE systems plus Acentra. Pre-FHIR, providers navigate 5 different MCE portals plus Atrezzo, multiplying friction. The MDwise transition creates a near-term PA-honor question.

Traditional Medicaid (FFS): OptumRx. HHW/HIP/HCC/PathWays: MCE PBM. MDRP rebate invoicing through Gainwell.

Prescription written

Prescriber

Pharmacy electronic transmission

PDL knowledge varies; off-PDL prescribing requires PA.

PDL adherence rate.

—

—

Pharmacy claim adjudication

OptumRx (FFS) OR MCE PBM (managed care)

Real-time claim approval / PA / denial

PA path adds friction; specialty drugs through medical benefit go to Acentra (FFS).

Specialty drug split between pharmacy and medical benefits.

FSSA proposed (Feb 2026) to end Medicaid reimbursement for drugs purchased through the 340B program, effective July 1, 2026. Savings estimate rose from $20M to ~$60M annually. FQHCs exempted May 1, 2026 after pushback; hospitals still affected. — Indiana Capital Chronicle · WISH-TV · 340B Report · Feb – May 2026

Two distinct national models: California Medi-Cal Rx (Jan 2022) and New York NYRx (April 2023) carved pharmacy fully OUT of managed care to a single state-administered FFS contractor (Magellan in CA). Outcomes uncertain — Medi-Cal Rx 'increased budget volatility and uncertainty,' initial savings projections 'not validated by actual data.' Ohio took a middle path: a single state-controlled PBM (Gainwell, since Oct 1, 2022) keeping managed care intact — $140M saved over 2 years, 1,200% boost in dispensing fees, 99% pharmacy network. Indiana's August 2026 RFP could specify either model. — CA DHCS · NY DOH · OH DOM · Ohio Capital Journal · LAO 5026

Member receives medication

Pharmacy

Dispensing event

Co-pay collection; member affordability.

Co-pay-related abandonment rate.

—

—

Pharmacy submits claim for payment

Pharmacy → PBM/Gainwell

Payment to pharmacy

Pharmacy reimbursement rates vary by program.

Per-program pharmacy rates.

—

California Medi-Cal Rx (Magellan-operated state FFS) added a 2026 requirement: prescribers must enroll in Medi-Cal FFS using NPI Type 1 (effective June 26, 2026); pharmacies must submit ICD-10 diagnosis codes on adjudications (effective fall 2026). NY NYRx and OH Single PBM operate without these requirements. Indiana's August 2026 RFP could specify any of these models. — CA DHCS · NY DOH · OH DOM

MDRP rebate invoicing

Gainwell (FFS) + MCEs (managed care) → manufacturer

Rebate collected and returned

Rebate accuracy depends on claim data quality; 340B claim flagging is critical.

340B duplicate-discount rate.

Roob: 'Indiana Medicaid relies heavily on drug rebate revenue to help fund the program, and when claims run through 340B, the state loses those rebates. These entities bill Medicaid far above their discounted acquisition cost.' Advocates: change will 'erode Indiana's safety net.' — Indiana Capital Chronicle · Axios Indianapolis · Mar – May 2026

California and New York keep 100% of federal pharmacy rebates by operating state-administered carve-outs. Ohio's single-PBM model also captures rebate scale while preserving managed care. Indiana's current carve-IN to MCEs splits rebate flows across the five MCE PBM arrangements. — CA DHCS · NY DOH · OH DOM

Specialty / oncology under medical benefit

Acentra (FFS) + MCEs (managed care)

Medical-benefit PA + claims path

Medical-benefit drug PA has different mechanics than pharmacy PA.

Volume of medical-benefit drug spend.

—

—

Pharmacy carve-in vs carve-out is the policy decision that drives every operational variable. Indiana's hybrid (managed care carved IN; Traditional carved OUT) is the national majority pattern. California (Medi-Cal Rx) and New York (NYRx) moved the opposite direction to capture rebate scale and eliminate PBM spread. Indiana has not made that move; the August 2026 RFP is the next decision window.

Functional eligibility → care plan → service delivery → EVV → claim → MCE adjudicates (PathWays) or CoreMMIS (FFS waivers).

Functional eligibility / Level of Care

DDARS assessor + AAA

Eligibility decision

Assessment tool reliability; inter-rater agreement.

Inter-rater reliability score.

—

Arizona ALTCS — the first statewide capitated managed-LTSS system (acute care 1982; LTSS expansion 1988) — uses a single integrated functional + financial assessment. Indiana's PathWays is in year 2; AZ has 40 years of operational maturity to draw from. — AZ AHCCCS · PubMed (Health Care Financing Review)

Care planning

MCE care manager (PathWays) OR DDARS (FFS waivers)

Plan of care + authorized services

Care plan quality and timeliness; per-MCE care manager caseload.

Per-MCE caseload; turnaround time.

—

—

Service delivery

HCBS provider · attendant care provider · nursing facility

Service rendered; encounter built

Attendant care providers are the H4 audit surface.

Per-service-line encounter quality.

—

—

EVV capture

Provider EVV system → Sandata aggregator

EVV record posted

Real-time capture; batch reconciliation to claim.

EVV-to-claim match rate.

Sandata is the Indiana EVV state aggregator, integrated with CoreMMIS via Gainwell. Open vendor model — alternates must export to the Sandata Aggregator. Provider-side training via Sandata Learn LMS. — in.gov/medicaid · Indiana Medicaid Provider · current

Sandata is the most-deployed state EVV aggregator (Indiana, TX, PA, others). Texas runs the most mature EVV reconciliation; Pennsylvania's CHC EVV ties to managed-LTSS contracts more directly. Real-time EVV-claim reconciliation (not batch) is the leadership benchmark — few states have implemented it. — Sandata · TX HHSC · PA DHS

Claim submission

Provider / clearinghouse

PathWays MCE adjudicates OR CoreMMIS for FFS waivers

Sub-capitation in PathWays may obscure delegated-provider claims.

Sub-cap arrangements in PathWays.

—

—

Payment

MCE OR CoreMMIS

EFT + 835

PathWays NF payment cycle delays (H5: $462M Feb–Apr 2026).

Per-NF payment-delay distribution.

$462M in delayed NF payments across 496 facilities (Feb–Apr 2026); Roob: 'I never would have pursued this program.' Program running $300M+ over budget. — Indiana Capital Chronicle · WFYI · Apr 8, 2026

Pennsylvania Community HealthChoices (since 2018) does NOT have $462M-class quarterly NF payment delays — the methodology is stable. Tennessee CHOICES NF payment cycle is also stable. The Indiana delay is a year-1–2 managed-LTSS friction pattern that should normalize unless H.R. 1 disrupts the methodology. — PA DHS · TN DHHS

Encounter to CoreMMIS / analytics

PathWays MCEs → CoreMMIS

Encounter ingestion (often batch flat-file)

Year 1–2 encounter quality structurally weak (H5).

PathWays encounter reject rate.

—

Pennsylvania Community HealthChoices (2018 launch) has documented encounter-data-quality benchmarks across 7+ years of operation. Arizona ALTCS has 38 years of operational maturity on encounter feedback loops. Indiana's PathWays is in year 2 — the encounter quality structural weakness is age-of-program, not vendor performance. — PA DHS · AZ AHCCCS

Rate setting feedback loop

FSSA + Milliman

Next-cycle rates

Encounter quality drives rate accuracy; weak encounter → weak rates → repeat.

Actuarial confidence interval.

—

HCBS waiver waitlists exist in 40 states (KFF 2024). Average wait is 40 months. The South has 3/4 of all waitlisted people — some wait 10+ years. Olmstead v. L.C. (1999) is the legal mechanism for ADA enforcement; Indiana's ACLU 2024 S.D. Indiana class action follows the pattern. — KFF · MACPAC · Olmstead v. L.C.

HEA 1277 long-stay carve-out (eff 7/1/2027)

FSSA + General Assembly

Long-stay (>100d) returns to FFS

Transition mechanics for long-stay members; provider re-contracting.

Transition plan details.

HEA 1277 (Rep. Brad Barrett, R-Richmond, author; Sen. Mike Crider, R-Greenfield, sponsor) signed March 12, 2026 — long-stay (>100 days) carve-out from PathWays effective July 1, 2027; FSSA must file standalone assisted-living waiver application with CMS by September 1, 2026. — Indiana HCA · OPEN MINDS · Mar 12, 2026

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LTSS / HCBS / EVV concentrates all of Indiana's hottest operational risks: encounter quality (PathWays year 2), provider integrity (attendant care audit, H4), payment cycle (NF $462M delays), and waitlist (intake throughput). EVV reconciliation is the single fork that determines audit defensibility, payment accuracy, and rate-setting quality.

Adverse notice → MCE internal appeal (managed care) → state fair hearing (ALJ) → judicial review.

Adverse action notice issued

MCE (managed care) or FSSA (FFS/eligibility)

60-day appeal window opens

Notice readability drives whether members exercise appeal rights.

Per-notice-type appeal exercise rate.

Of 9,608 Hoosiers terminated procedurally in March 2024, members had 90 days to appeal — possible to regain coverage if new documentation showed eligibility. Notice readability drives whether appeals are exercised. — Indiana Capital Chronicle · WFYI · 2024

—

Internal MCE appeal (managed care)

MCE appeals unit

Appeal decision; one level required per 42 CFR §438.402

Internal appeal is the procedural gate before fair hearing; reversal rates vary by MCE.

Per-MCE internal appeal reversal rate.

—

—

Aid pending request

Member (+ legal aid)

Services continue at state risk if filed timely (42 CFR §431.230)

Aid pending compliance is the single biggest member-protection mechanism; non-compliance is rare but costly.

Aid-pending compliance rate.

—

—

State fair hearing filing

Member or representative

Filed with FSSA Hearings

Filing literacy; representation rate at fair hearing.

Per-program filing rate; representation rate.

—

—

ALJ hearing

FSSA Hearings ALJ

Standard 90-day decision (§431.244(f)); expedited 3 working days

ALJ caseload; decision quality.

ALJ caseload; decision wait time.

—

New York operates an integrated external-appeals process tied to the state's overall managed care appeals; California's BHSO is the independent appeals analog. Most states (Indiana included) rely on FSSA Hearings ALJ for state fair hearings without integrated external review. — NY DOH · CA DHCS

Decision issued

ALJ

Affirmed / reversed

Reversal rate by program; per-issue type.

Per-program reversal rate.

—

—

Judicial review

State courts (Indiana Tax Court / Indiana Court of Appeals depending on issue)

Court review

Judicial review rate is small but the cases that reach it set precedent.

Judicial review filing rate.

—

—

The appeals flow's primary failure mode is non-exercise: members don't appeal because notices aren't clear or aid-pending mechanics aren't understood. Procedural disenrollment outcomes during the unwinding likely produced an under-appeal pattern (people walked away rather than fought). Capacity is the second concern: a major H.R. 1 disenrollment wave will load FSSA Hearings.

FSSA OPI front line → audit triggers → records review → extrapolation → recoupment → MFCU referral if fraud → federal layer (OIG · UPIC · PERM).

Pattern detection / audit trigger

FSSA OPI + HHS OIG + CMS UPICs

Open audit case file

Detection capability: rules-based vs ML.

False-positive rate.

Braun administration: 'the free lunch is over.' Pattern detection prompted the $200M attendant-care audit + ABA reforms + 340B change in a single 12-month window. — WISH-TV · Indiana Capital Chronicle · Mar 2026

New York OMIG (separate Inspector General office) is the structural separation peer. Texas OIG sits inside HHSC. California DHCS Audits & Investigations is a within-agency model. The structural choice affects investigation independence and pre-payment capability. — NY OMIG · TX HHSC · CA DHCS

Records request to provider

Audit agency

Records produced within statutory window

Document retention varies; small providers often lack structured retention.

Records-production timeline.

—

—

Medical record / EVV review

Clinical reviewers

Findings at service-line and beneficiary level

Documentation gaps + EVV non-compliance the common surface.

Per-service-line documentation defect rate.

—

—

Statistical extrapolation

Audit statistician

Extrapolated overpayment amount

Extrapolation methodology is the most-litigated step.

Sample-size adequacy challenges.

—

—

Findings letter / overpayment notice

Audit agency

Provider response window opens

Appeal path varies by audit type.

Per-audit-type appeal exhaustion rate.

—

—

Provider appeal & rebuttal

Provider + counsel

Reconsideration / hearing decision

<30% reversal nationally.

Indiana-specific reversal rate.

Tendercare CEO Eric Deitchman pushed back publicly: 'I'm surprised we got listed publicly while we are working on our appeal.' Provider appeal outcomes survive contest <30% of the time nationally. — Indiana Capital Chronicle · Apr 24, 2026

—

Recoupment / settlement

FSSA OMPP / MFCU / CMS

Funds returned

Settlement-vs-litigation choice.

Indiana policy.

—

—

MFCU referral if fraud suspected

FSSA OPI → AG MFCU

Criminal investigation; exclusion proceedings

Referral mechanics opaque.

Referral volume; declination rate.

FSSA said it is 'now expanding oversight to more providers' — signaling intent to scale audit posture without (yet) publicly addressing pre-payment vs post-payment architecture. — Indiana Capital Chronicle · Fox 59 · Apr 23, 2026

—

Systemic data / analytics build-out

FSSA OPI

Pattern detection improves; faster triggers

Current capability largely retrospective + rules-based.

ML/AI usage in pattern detection.

—

NY OMIG's 2026 work plan explicitly references 'sophisticated data analysis techniques and updated software resources' for ML-based pattern detection and outlier analysis. OK's pattern engine pilots are second-tier. Indiana's MFADS capability gap is publicly characterized; the build-out window aligns with the August 2026 RFP. — NY OMIG 2026 Work Plan · OK HCA

The integrity flow's defining feature in Indiana is its retrospective posture: detect, audit, recoup. Two large audits (ABA $56M, attendant care $200M) in different service lines with the same root cause (documentation + EVV) indicate the data layer already contains the signal needed for prospective detection — but the detection layer is downstream of the spending event. Pre-payment integrity catches earlier and cheaper.

T-MSIS monthly · CMS-64/-37/-21 quarterly · PERM cycle · FSSA monthly Medicaid financial reports (post-reform).

T-MSIS monthly data pull

FSSA data team

Claims · encounters · provider · TPL from CoreMMIS + eligibility from IEDSS

Data lineage: CoreMMIS + IEDSS as sources of truth; encounter quality limits T-MSIS quality.

T-MSIS data quality scores from CMS DQ assessments.

—

CMS released the 2025 MAC Scorecard in December 2025: an additional 4 states + 1 territory met T-MSIS quality targets under the Outcomes-Based Assessment framework versus the prior year. Indiana's standing isn't publicly disclosed in the scorecard analysis. Ohio is a published leader. — CMS · Mathematica · 2025 MAC Scorecard

T-MSIS submission to CMS

FSSA → CMS T-MSIS portal

Submission accepted / rejected with errors

Reject-and-resubmit cycle adds latency to downstream analytics.

Reject rate by file type.

—

—

CMS-64 quarterly expenditure report

FSSA CFO Bowling

MBES/CBES submission

Post-2023 reform: monthly Medicaid financial reports give earlier signal.

Variance flag thresholds.

FSSA launched monthly Medicaid financial reports in 2024 in response to the 2023 forecast miss. Sen. Mishler (Approps Chair) created the Medicaid Oversight Committee in the same window. — FSSA · Indiana Senate Republicans · 2024

Washington's Medical Assistance Expenditure Forecast Workgroup (MAEFW) produces a forecast twice yearly (February + October) and reviews financial data, caseloads, primary trends, FMAP, and step adjustments in a documented methodology. Colorado implemented similar reforms after a forecast miss. Indiana's monthly reports (launched 2024) are higher cadence but variance-attribution methodology isn't published. — WA OFM · WA HCA · CO DHCPF

CMS-37 quarterly forward projection

FSSA CFO + OMB

Budget projection for upcoming quarters

Projection quality depends on the forecast methodology (H7).

Per-program projection accuracy.

—

—

CMS-21 quarterly CHIP expenditures

FSSA CFO + CHIP program

MBES/CBES Title XXI submission

Title XXI is parallel infrastructure; reconciliation with Title XIX.

Cross-title reconciliation cycle.

—

—

FSSA monthly Medicaid financial reports

FSSA CFO + OMB + Senate Approps

Public reports to Senate Approps + House Ways & Means

Earlier signal, but signal quality depends on data quality upstream.

Variance thresholds; alarm criteria.

—

—

PERM cycle (every 3 years per state)

Indiana sample collection + PERM contractors

Results returned ~26 months later

Lag is the structural issue — actions today affect a measurement 2 years away.

Indiana's RY2024/RY2025 results when reported.

Indiana's pre-PHE PERM rate of 28.8% is the political baseline cited in EO 25-60; national Medicaid PERM rate (RY2025) is 6.10%. H.R. 1 sets an October 1, 2029 federal-share repayment trigger for states above 3%. — EO 25-60 · CMS PERM cycle · 2025–2026

PERM cycle is ~26 months sample-to-result. CMS publishes annual rate-year results for each state's eligibility, fee-for-service, and managed care components. Indiana's pre-PHE 28.8% baseline (cited in EO 25-60) is from RY2019; the current cycle covers Indiana again RY2025 — results not yet published. — CMS PERM Cycle · EO 25-60

PERM eligibility component (highest-leverage)

PERM contractor + FSSA OPI

Eligibility error rate component

Eligibility component drives national rate; Indiana's pre-PHE 28.8% is the political baseline.

Indiana's post-PHE eligibility component rate.

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Federal reporting flows are downstream-of-data-quality. T-MSIS, CMS-64, PERM — all only as good as the source data in CoreMMIS, IEDSS, and the MCE encounter pipelines. Post-2023 monthly reporting cadence is a signal-frequency reform; it doesn't change signal quality. The PERM cycle's 2-year lag is the structural reason eligibility documentation work must start early — H.R. 1's October 2029 trigger is set against measurements still being collected.