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House members place transparency requirements on FSSA following Medicaid snafu

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House members place transparency requirements on FSSA following Medicaid snafu

Feb 28, 2024 | 7:00 am ET
By Whitney Downard
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House members place transparency requirements on FSSA following Medicaid snafu
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FSSA will have enhanced transparency requirements following a House committee amendment that preceded lengthy discussion on attendant care. (Leslie Bonilla Muñiz/Indiana Capital Chronicle)

A bill dealing with state fiscal matters attracted a bevy of amendments in the House Ways and Means Committee Tuesday, ranging from a tax exemption for feminine hygiene products to enhanced reporting on Medicaid spending.

The Republican supermajority additionally beat back several Democratic amendments on attendant care, a program used by over 1,600 families with disabled children that will be curtailed following a $1 billion Medicaid shortfall. 

The bulk of Tuesday’s discussion revolved around the Family and Social Services Administration’s oversight of attendant care. As costs surged under the program, which had no hourly caps nor federal approval, the agency decided to transition those families to Structured Family Caregiving and make up some of $1 billion deficit. Families decried the move, which would transition them from an hourly rate to a lower per diem.

Committee Chair Rep. Jeff Thompson said work was ongoing and discussed possible second reading amendments addressing attendant care.

“I don’t want to make any promises. I think there will be a motion on second reading but for me to say, ‘This will be in,’ or ‘This will not be in’ — I can’t do that,” Thompson, R-Lizton, said. “But I’m trying to find a spot to land with the Senate in discussions.”

Second reading amendments must be adopted by Thursday, the deadline for such maneuvers, when a bill is heard before the entire House Chamber.

Medicaid oversight

Thompson introduced an amendment that would place additional reporting requirements on the Family and Social Services Administration (FSSA), the agency responsible for administering Medicaid.

House members place transparency requirements on FSSA following Medicaid snafu
Indiana Medicaid Director Cora Steinmetz, with FSSA Secretary Dan Rusyniak, responds to lawmaker questions on a $713 million shortfall in Medicaid funding, at a State Budget Committee meeting on Tuesday, Dec. 19, 2023. (Leslie Bonilla Muñiz/Indiana Capital Chronicle)

FSSA must make two reports to the State Budget Committee annually, one in either April or May — depending on whether it’s a budget-writing year or not — and another in December, under the proposal. The agency’s secretary, currently Dr. Dan Rusyniak, must present a “detailed plan for monitoring expenses” under Medicaid, including managed care and waiver programs, improving transparency on Medicaid expenditures and how they will share Medicaid data with legislators along with traditional forecasts.

Lastly, the agency presentation must include an analysis of the feasibility of a Medicaid dashboard that includes monthly reports on expenditures and enrollments.

“We know, obviously, there were some surprises that occurred last summer,” said Thompson. “… In my view, it’s a transparency amendment.”

While the amendment had the full support of the committee, enrollment and the growth of expenses continued to be a concern for legislators — foreshadowing difficult conversations when lawmakers convene next year for a budget-writing session.

“It’s not just a forecast issue, it’s a policy issue where we may agree or disagree. But that’s the broader issue to me,” said Rep. Jack Jordan, R-Bremen. “I like the transparency in the forecast but we have a policy issue that I’m assuming we’ll deal with and wrestle with maybe not this session but next session.”

Attendant Care under the microscope

An amendment offered by Indianapolis Rep. Greg Porter, a Democrat, sparked vigorous debate about attendant care, which will still be used by elderly and adult Hoosiers. Porter pushed for a one-year pause in the transition of 1,622 pediatric beneficiaries from attendant care to Structured Family Caregiving — a move that Thompson said “part of (him) likes” but he worried about the state’s compliance with the federal waiver. 

“The other thing is — we have to change the structure. And how that should be changed, that we can debate about,” Thompson said. “But the costs right now and what’s happening in terms of excessive costs that some of the providers, in my opinion, are receiving — that has to be addressed.”

House members place transparency requirements on FSSA following Medicaid snafu
Rep. Ed DeLaney, D-Indianapolis, asks about a $713 million shortfall in Medicaid funding at a State Budget Committee meeting on Tuesday, Dec. 19, 2023. (Leslie Bonilla Muñiz/Indiana Capital Chronicle)

In particular, Thompson said there were some cases where payments exceeded those sent to nursing homes, traditionally the most expensive form of intensive care. 

“I’m not saying that’s all bad, maybe it’s a good thing,” Thompson said. “But there is, in some cases, a lot of money being paid and the service that’s needed isn’t that great … I’m not so sure the dollars are being put in the right spot.”

Indianapolis Democrat Rep. Ed DeLaney introduced a separate amendment targeting monies to intermediaries, or providers, noting that FSSA said last week it didn’t have transparency on funds paid to families. The agency said it paid providers $34.36 per hour, anticipating that families would get 60% and providers would keep the rest for administrative fees. Instead, families have indicated that they receive roughly $15 per hour, or 44% of the funds.

“What I’ve learned, to my utter amazement, is that FSSA does not know if they send $150 bucks to a home for attendant care (FSSA) does not know what percentage actually goes to the family and what percentage goes to the intermediary,” DeLaney said. “I find that stunning.”

DeLaney’s amendment would have included other programs administered by FSSA. While attendant care has received most of the attention, FSSA has enacted several changes in response to the Medicaid shortfall, including a pause on indexing reimbursement rates and halting a practice of automatically approving certain claims.

DeLaney opted to withdraw his amendment, with the intention of reintroducing the language on the floor, while Porter’s failed on a party-line vote.

Federal compliance, families in limbo

Being out of compliance with federal guidelines could be costly for the state should the federal government penalize Indiana for spending Medicaid dollars — of which roughly two-thirds is paid by the federal government — on an unapproved program. While using attendant care dollars to pay families of disabled children is an acceptable use, Indiana is not approved for it.

Rep. Ed Clere, R-New Albany, flagged concerns about adopting Porter’s amendment, in particular, which would have extended the unapproved program for another year.

House members place transparency requirements on FSSA following Medicaid snafu
Rep. Ed Clere, R-New Albany, speaks in committee on Tuesday, Jan. 23, 2024. (Leslie Bonilla Muñiz/Indiana Capital Chronicle)

“If we were to adopt this amendment, I think it could actually dig our Medicaid hole even deeper and endanger other vulnerable Hoosiers who may see their services reduced because we would have to come up with this money,” Clere said. “I think it could lead to other unpredictable and unfortunate cuts in Medicaid.”

But Indianapolis’ Democrat Reps. Cherrish Pryor and DeLaney pointed to the families, who would transition to Structured Family Caregiving by July 1 of this year. 

“I’m bothered by the notion that we don’t quite know what’s going to happen to them,” DeLaney said.

Clere said that his discussions with stakeholders had convinced him that “many, if not most” families currently receiving payments under the attendant care system “will be served better under Structured Family Caregiving.”

“My concern is there is a segment of families for which Structured Family Caregiving may not be adequate. And those are the folks we risk leaving behind if we don’t do something here in the legislature before sine die,” Clere said, using the legislative term for the adjourning session. 

He noted that the state doesn’t have enough providers to cover the needs of families, especially in rural areas. 

The committee cleared the underlying bill, now with several amendments, to the House Chamber unanimously. Even if the measure passes the House, senators must also accept the changes before it can move to the governor’s desk to be signed into law.