Federal Medicaid reconciliation law. PERM 3% repayment trigger (Oct 1, 2029). Work-requirement framework. State implementation by Jan 1, 2027.

Indiana's day-to-day federal counterpart. Waiver amendments, APD reviews, policy clarifications.

Center for Medicaid & CHIP Services + Data and Systems Group. Owns SMC certification, MES funding, 1115 waivers. New SMC templates mandatory Jul 1, 2026.

Federal audit jurisdiction. 2024 ABA audit found $56M confirmed improper, $76.7M potentially improper.

Rose v. Becerra (Jun 27, 2024) vacated HIP 2.0 reapproval — premiums, retroactive eligibility waiver, NEMT waiver. POWER accounts paused.

EO 25-60 "Make Indiana Healthy Again" (Apr 15, 2025). Convened Medicaid Working Group (Nov 2025). Inherited the 2023 forecast miss as the political baseline.

Ends self-attested eligibility. Enforces hospital performance standards for presumptive eligibility. Orders interagency data matching.

Convened Nov 2025. Recommended ABA usage cap and rate changes. Policy follow-up to HHS OIG audit.

Sec. Lisa Hershman. Owns December Medicaid Forecast. Drives the biennium budget rhythm. Post-2023 forecasting reform.

Author of SEA 2 (HIP work requirements). Established Medicaid Oversight Committee after 2023 forecast miss. Owns the spending signal.

Sen. Charbonneau (Health & Provider Svcs); Rep. Barrett MD (House Public Health); Rep. Thompson (Ways & Means); Sen. Yoder (Senate Min. Leader).

SEA 2 (HIP work req · 2025) · SB 1 (welfare fraud · Feb 2026) · HEA 1277 (PathWays long-stay carve-out · Mar 2026) · Hospital reform package (May 2026).

SBOA · Paul Joyce CPA (State Examiner). LSA OFMA (fiscal notes). IOIG · Jared Prentice (appointed Jan 31, 2025).

Medicaid Fraud Control Unit. Director Matthew Whitmire. Prosecutes provider fraud cases; coordinates with FSSA OPI and HHS OIG.

Unified Program Integrity Contractors. Federal post-payment review layer. Coordinate with MFCU on referrals.

Reappointed Jan 13, 2025. Original architect of HIP under Daniels. Interim OMPP Director. "Inherited a mess."

Office of Medicaid Policy and Planning. Program design, MCE contracts, waiver authority, day-to-day operations. Cora Steinmetz resigned Dec 2024.

Family Resources. Eligibility operations across 92 counties. Hiring 400 eligibility checkers (50 onboarded late April 2026) for H.R. 1 compliance.

Disability, Aging & Rehabilitative Services. Consolidated Aging + DDRS. Owns 1915(c) waivers and PathWays oversight on the state side.

Mental Health & Addiction. CCBHC demonstration (joined June 2024). All 92 counties designated MH workforce shortage areas.

Technology owner for FSSA programs. The "rails" pillar. Inside actor on the August 2026 procurement architecture.

Operates post-2023 forecasting-reform monthly Medicaid financial reports. CMS-64 / CMS-37 / CMS-21 owner.

Legal. Hearings/ALJ infrastructure. Provider audit defense. Coordinates with AG on MFCU referrals.

State CIO since Mar 31, 2025. Consolidating IT across agencies including FSSA infra. Hybrid cloud direction (AWS + Azure GovCloud).

Workforce Development (wage/tax data into IEDSS). State Dept. of Health (vital records). Ins. Comm. Lambert (parallel commercial market).

Indiana Eligibility Determination Services System. Pilot Apr 29, 2019. Citizen front-end fssabenefits.in.gov. Carries Medicaid, CHIP, SNAP, TANF eligibility for all 92 counties.

Claims engine since 1991 (HP → DXC → Gainwell). Adjudicates FFS claims, processes MCE capitation/encounters, hosts provider master. IHCP portal at portal.indianamedicaid.com.

Two citizen/provider front ends. Application uploads, claim status, eligibility verification, prior auth submissions.

IRS · SSA · USCIS SAVE · Equifax/Work Number. The verification spine that IEDSS calls on every application and renewal.

FFS / Traditional pharmacy. PDL, FFS PAs, FFS pharmacy claims. Carved IN to MCEs for HHW / HIP / HCC / PathWays. MDRP rebate invoicing through Gainwell.

FFS prior authorization / UM since Jul 1, 2023 (replaced Kepro/CNSI). Medical, BH, pharmacy-under-medical, Right Choices, TBI waiver. CMS-0057-F deadline Jan 1, 2026.

Electronic Visit Verification state aggregator. Open vendor model — alternates (HHAeXchange and others) must export to Sandata.

Holds Indiana's enrollment broker contract since 2007. HHW, HIP, HCC, PathWays plan-selection counseling and call center.

Hybrid: Bloomington DR (on-prem) + AWS GovCloud + Azure GovCloud. Stated direction: Azure migration. MARS-E / IRS Pub 1075 baselines.

Monthly T-MSIS pull from CoreMMIS + IEDSS. Quarterly CMS-64 / CMS-37 / CMS-21. PERM sample collection. Indiana's pre-PHE PERM rate: 28.8% (cited in EO 25-60).

Children, pregnant women, low-income families. MCEs: Anthem · CareSource · MHS (Centene). Largest of the four programs.

ACA expansion adults · ~560,000 enrollees. POWER accounts paused per Rose v. Becerra. SEA 2 work-req amendment pending with CMS.

ABD / SSI non-dual adults. MCEs: Anthem · CareSource · MHS. Smallest of the managed care lines.

Adults 60+ in managed LTSS · ~120K lives · launched Jul 1, 2024. MCEs: Anthem · Humana · UnitedHealthcare. HEA 1277 long-stay carve-out eff Jul 1, 2027.

Health & Wellness · TBI · Community Integration & Habilitation (CIH) · Family Supports. The Arc waitlist ~30 months for I/DD. ACLU class action (S.D. Ind., 2024).

Indiana's homegrown MCE. Largest single MCE transition in Indiana managed care history; members auto-assigned to Anthem / CareSource / MHS unless they choose.

All four programs in a single RFP. Contracts start Jan 1, 2029. Must clear: new SMC templates (Jul 1, 2026), CMS-0057-F readiness, post-Rose HIP architecture, H.R. 1 ops.

Indiana Hospital Association. May 2026 SDP overhaul: $1.866B distributable; tiered ACR — 158% rural/CAH, 125% high-commercial. CMS approved Apr 28 / May 1, 2026.

Indiana Primary Health Care Assn. Federally Qualified Health Centers. Certified application counselors; safety-net access; PPS payment.

Indiana Health Care Association. PathWays managed-LTSS payment cycle delays Feb–Apr 2026 ($462M flagged). HEA 1277 carves long-stay back to FFS (eff Jul 1, 2027). New NF rates eff Jan 1, 2025.

Two active integrity surfaces. ABA: $56M confirmed + $76.7M potentially improper (HHS OIG, 2024). Attendant care: $200M sought from 5 largest providers (FSSA, April 2026).

2026 physician fee schedule = 100% of 2025 Medicare (the access floor). MDRP pharmacy invoicing through Gainwell. Behavioral health under DMHA + MCE integration.

Channels: online (fssabenefits.in.gov), phone (DFR call center), paper, in-person at county DFR, navigator-assisted (FQHC, certified counselors). Integrated app: Medicaid + SNAP + TANF.

The Arc of Indiana (Kim Dodson; waitlist tracker) · Citizens Action Coalition (Cover Indiana) · AARP Indiana (caregivers, dual-eligibles) · ACLU of Indiana (HCBS class action 2024) · Indiana Disability Rights · Voices for Independence.

FSSA Hearings (ALJ-presided fair hearings). State court review. S.D. Indiana — venue for the ACLU 2024 HCBS waitlist class action (ADA / Olmstead).

Ex parte renewal first; pre-populated form if ex parte fails. Now layered with H.R. 1 quarterly verification + SB 1 quarterly checks + SEA 2 work-req amendment. Same workflow, new load.

Internal MCE appeal (≤60 days; 1 level required per 42 CFR §438.402). Aid pending if filed timely (§431.230). State fair hearing — ALJ. Standard 90-day decision, expedited 3 working days.

Channel: online · phone · paper · in-person at county DFR · navigator (FQHC)

Intake to IEDSS workflow; document upload

IEDSS calls Federal Data Hub (IRS · SSA · USCIS · Equifax) + DWD wage/tax

IEDSS rules engine: MAGI categories first, then non-MAGI

Approval / denial notice (90-day appeal window starts)

Maximus enrollment broker — MCE plan selection or auto-assign

CoreMMIS member master; X12 834 transactions to MCEs

Ex parte renewal attempt using existing data

If ex parte fails — IEDSS sends pre-populated form

Member responds via fssabenefits.in.gov / DFR / paper / navigator

Verification re-runs against Federal Data Hub + DWD

Plus: H.R. 1 quarterly work-req verification (HIP, 3-mo lookback)

Plus: SB 1 quarterly checks · SEA 2 1115 amendment (pending)

Result: continued · disenrolled · appeal pathway

Apply via IHCP Provider Portal (CoreMMIS)

NPI · taxonomy · license · ownership disclosure

Screening: CMS risk level (limited / moderate / high)

LEIE monthly · SAM.gov · Indiana exclusion list checks

Internal Medicaid provider ID assigned

MCE credentialing (separate for each of 5 participating MCEs)

Revalidation every 5 years per §455.414

Eligibility verified at point of service (270/271)

Service delivered; encounter / claim built

Provider submits X12 837 via clearinghouse (Availity · Optum · Waystar · Inovalon)

CoreMMIS front-end edits (999 / 277CA)

Adjudication: fee schedule · PA cross-check · TPL/COB · eligibility

Clean claims auto-adjudicate; failed-edit claims suspend for review

Payment EFT + X12 835 remittance

Post-payment review: PERM · MIC · UPIC · MFCU

OMPP rate setting against encounter data

Capitation payment to MCEs (820)

MCE adjudicates member claims

MCE submits encounter data to CoreMMIS

Encounter reconciliation (often batch flat-file)

MCE quality reporting · network adequacy

Contract performance review · sanctions if needed

FFS: Acentra Atrezzo portal (since Jul 1, 2023)

Covers medical · BH · pharmacy-under-medical · Right Choices · TBI

Managed care: each MCE runs its own UM

CMS-0057-F new decision timeframes (Jan 1, 2026)

Full FHIR PA API requirement (Jan 1, 2027)

Denials trigger MCE internal appeal → state fair hearing

Traditional Medicaid (FFS): OptumRx — PDL, FFS PAs, pharmacy claims

HHW / HIP / HCC / PathWays: MCE PBM (carved IN)

MDRP rebate invoicing through Gainwell (CoreMMIS)

340B claim flagging; duplicate-discount avoidance

Specialty / oncology under medical benefit via Acentra (FFS)

Functional eligibility / Level of Care (DDARS)

Care planning · service authorization

Service delivery by HCBS provider · attendant care · NF

EVV capture (Sandata or open-vendor alternate exporting to Sandata)

Claim submitted; matched against EVV record

PathWays MCE (Anthem · Humana · UHC) for adults 60+

Other waivers FFS (H&W · TBI · CIH · Family Supports)

Adverse action notice triggers 60-day appeal window

Managed care: MCE internal appeal first (42 CFR §438.402)

Aid pending if filed within 10 days / by effective date

State fair hearing — FSSA Hearings · ALJ

Standard 90-day decision · expedited 3 working days

Judicial review available in state court

FSSA OMPP Office of Program Integrity (front line)

Audit triggers: claim pattern · tip · risk score · UPIC referral

Field audit · medical record review · extrapolation

Recoupment / overpayment notice · provider appeal rights

Suspected fraud → AG MFCU referral (Whitmire)

Federal layer: HHS OIG · CMS UPICs

PERM cycle (~26 months sample → result)

Monthly T-MSIS pull (claims · encounters · provider · TPL + eligibility)

Quarterly CMS-64 (expenditures) via MBES/CBES

Quarterly CMS-37 (forward budget projection) — OMB coordination

Quarterly CMS-21 (CHIP expenditures, Title XXI)

FSSA monthly Medicaid financial reports (since 2024)

PERM cycle — sample · medical-record review · result ~26 months later

Eligibility documentation surface

EO 25-60 (end self-attestation) · H.R. 1 quarterly verification · SB 1 quarterly checks · 400 new eligibility checkers (50 onboarded by late April 2026).

Indiana's pre-PHE PERM rate (28.8%, cited in EO 25-60) and the 78% procedural disenrollment rate from the unwinding sit on the same workflow that now carries H.R. 1.

The August 2026 master procurement

RFP issuance Aug 2026 → contract start Jan 1, 2029. ~$68B over the contract life. All four programs in one RFP.

Must clear new SMC templates (Jul 1, 2026), CMS-0057-F, post-Rose HIP, and H.R. 1. Largest single Medicaid procurement in U.S. state history.

Hospital reform + State Directed Payment

Hospital Assessment Fee revised — CMS approved Apr 28, 2026 (retroactive Jul 1, 2025). New SDP program approved May 1, 2026: $1.866B distributable. Tiered ACR 158% / 125% / 100%.

Indiana's first major post-PHE hospital rate restructuring. Lives in the shadow of H.R. 1's further SDP restrictions.

Provider integrity audits

HHS OIG ABA audit (2024): $56M confirmed + $76.7M potentially improper. FSSA attendant-care audit (April 2026): $200M sought from 5 providers. Governor's Working Group recommended ABA cap (Nov 2025).

Concentrated in a small number of large providers in a small number of service lines. Documentation gaps + EVV non-compliance the common surface.

PathWays operational quality

11,296 waiver waitlist (only 714 invitations Feb 2026). $462M delayed NF payments Feb–Apr 2026. HEA 1277 carves long-stay (>100 days) out of PathWays back to FFS eff Jul 1, 2027.

Second year of Indiana's first managed-LTSS program. Encounter data quality structurally weak in years 1–2; next-cycle rate setting rides on it.

H.R. 1 work-requirement rollout

Mandatory member outreach window Jun 30 – Aug 31, 2026. Quarterly compliance verification (one of two states electing quarterly). 3-month lookback (max). 400 staffers being hired.

Implementation deadline Jan 1, 2027. Layered on top of the same workflow that produced the 78% procedural disenrollment rate.

Forecasting reform

Post-2023 forecast miss ($984M underestimated across FY24–25). FSSA monthly Medicaid financial reports launched 2024. Senate Approps Medicaid Oversight Committee established by Mishler.

The political wound from 2023. Steinmetz resignation (Dec 2024) and Rusyniak departure (Jan 2025) traced back to it.

Rose v. Becerra · HIP architecture

Federal court (Jun 27, 2024) vacated HHS 2020 reapproval. POWER accounts paused. NEMT waiver vacated. Retroactive eligibility waiver vacated. SEA 2 1115 amendment pending.

Indiana's signature expansion vehicle (~560K lives) operates under a constrained waiver. The next procurement must design for this new architecture.

SMC certification + CMS modular templates

Mandatory use of new SMC templates (APD, OAPD, AoA, Intake Form) for any procurement reaching CMS after Jul 1, 2026. Zero Indiana MES modules confirmed on the public SMC repository.

90/10 DDI + 75/25 M&O federal match rides on certification. Modules certified before contract start earn enhanced M&O from day one of operations.

MDwise exit (1/1/2026)

Indiana's homegrown MCE exits HHW, HIP, and HCC on Jan 1, 2026. Members auto-assigned to Anthem, CareSource, or MHS unless they make a different selection.

The largest single MCE transition in Indiana managed care history; sets the operational baseline going into the Aug 2026 RFP.