Lawmakers want transparency in Medicaid waiver denials

The tool is used to determine when a person is eligible for family supports and community integration and habilitation waivers, which allow disabled Hoosiers to remain in their homes.

FSSA officials contend the new assessments are needed because they believe too many waivers were being approved, but Democrats on the Medicaid Advisory Committee questioned the accuracy of the assessments when the committee met Tuesday.

“If I’m confused about the process, I can imagine our Hoosiers who are going through this process are overwhelmed,” said Rep. Chris Campbell, D-West Lafayette, a committee member.

Indiana isn’t the only state using the new tool. Legal Aid of Nebraska, joined by other groups, filed a lawsuit in May against the Nebraska Department of Health and Human Services, challenging the state’s use of the assessment system, which uses an algorithm to cut Medicaid home-care services for many individuals with intellectual and developmental disabilities.

FSSA approved more than 99% of disability waivers before the rollout of interRAI, but internal estimates suggest the appropriate approval rate is closer to 90%, according to spokesperson Marcus Barlow.

Barlow said eligibility remains the same, but criteria is now being more accurately enforced.

“Where there is smoke, there is sometimes fire,” FSSA Secretary Mitch Roob said Tuesday. “Sometimes that smoke turns out to be fog. An assessment tool that has approved over 99% of determinations and redeterminations should be questioned, let alone reviewed.”

Some have suggested that the new tool uses artificial intelligence but state leaders say humans make the final decision.

He continued, “We need consistency and objectivity in this process. This tool, developed by researchers and practitioners from around the world, is a way to move us closer to these ends.”

In a letter to Roob last week, Rep. Robin Shackleford asked the agency to pause waiver denials, conduct an independent audit of the assessment tools and provide families with complete, unreacted copies of their assessment evaluations and other documentation.

The waiver denials were first reported by WTHR.

“It is impossible to look at these numbers and conclude anything other than that the state is using rigid, flawed assessment tools as a sledgehammer to make up for FSSA’s budget shortfalls at the expense of Hoosier families,” Shackleford said in a statement.

“A three-day lookback window, binary yes-or-no questions, and opaque scoring algorithms cannot replace the realities of what a person with complex needs experiences every single day,” she said. “Furthermore, forcing families to beg for basic documentation of their own child’s assessment just to navigate an intimidating appeals process violates fundamental principles of fairness and transparency.”

Hoosiers can appeal FSSA’s decision within 33 days of their notice of determination. Barlow said members do not lose services during the appeals process.

“We need to be taken seriously as (medicaid advisory committee) members,” Campbell said. “That our concerns are important and need to be answered and not dismissed. We can’t just continue to use the word fraud to justify their actions when the mention of names being purged was taken as offense.”

SUBSCRIBE: GET THE MORNING HEADLINES DELIVERED TO YOUR INBOX.