Quality and Outcomes Reporting

The FSSA Office of Medicaid Policy and Planning conducts continuous quality improvement projects and contract oversight throughout the year. This webpage contains high level descriptions of key quality improvement processes and links to various resources to help interested parties see how Indiana's Medicaid program is performing.

Managed Care

OMPP contracts with six health insurance companies to deliver healthcare to more than a million Medicaid members. These companies are Anthem, CareSource, Managed Health Services, UnitedHealthcare and Humana. Indiana has four managed care programs: the Healthy Indiana Plan, Hoosier Healthwise, Hoosier Care Connect and Indiana PathWays for Aging.

Contracts

OMPP uses a base contract for each managed care program with a consistent scope of work by program unless otherwise noted. Contracts are typically awarded from a competitive procurement and are for a base period of four years with two optional years (consistent with IC 12-15-30-4). Amendments (denoted as "AM") are needed from time to time to adjust rates for actuarial soundness, modify scope of work language, or update requirements. Managed Care Entity contracts must be approved by the Centers for Medicare and Medicaid Services to ensure federal requirements are met and rates are actuarially sound. Below is a table of all the current CMS-approved contracts in effect for managed care entities. All non-confidential, fully approved contracts are publicly available at the Indiana Transparency Portal , as required by Executive Order 05-07.

The following documents are legal forms and cannot be altered. If you need assistance reviewing the content, please refer to https://www.in.gov/fssa/contact-us/.

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Capitation Rates

Risk-based managed care is an arrangement under which a health plan assumes responsibility for providing covered healthcare services for each member assigned to that health plan. In return for provision of these services, the health plan is paid a monthly capitation payment for each assigned member. The capitation payment that the health plan receives can vary based on the covered member’s age, gender, benefit plan and health status.

Capitation rates are established annually based on program claims experience in accordance with Actuarial Standards of Practice, CMS regulations, and other requirements.

Operational and Program Oversight

OMPP monitors MCE compliance with contractual requirements. MCEs submit reports to OMPP on a monthly and quarterly basis, which are reviewed by staff for compliance with the hundreds of service level agreements. OMPP also conducts a monthly on-site meeting at each of the MCEs' offices to discuss focus areas and see demonstrations of MCE processes. Synopses of the MCE quarterly performance will be posted here.

Indiana PathWays for Aging Claims Adjudication

External quality reviews

Each state that operates a managed care program and contracts with managed care entities must retain an External Quality Review Organization to annually analyze the effectiveness of the state's managed care program and MCE performance (per 42 CFR 438.350). OMPP has contracted with Burns & Associates to conduct the annual External Quality Review. Annual EQR reports are listed below.

OMPP has contracted with Qsource to conduct the annual External Quality Review.  Annual EQR reports are listed below.

Hoosier Healthwise / Healthy Indiana Plan / Hoosier Care Connect

• 2025 external quality review
• 2024 external quality review
• 2023 external quality review
• 2022 external quality review
• 2020 external quality review

Indiana PathWays for Aging

• 2025 external quality review

Quality strategy plans

Each year, OMPP prospectively identifies priorities for improving the delivery of healthcare to Medicaid members and improving operations. This plan, known as the Indiana Health Coverage Programs quality strategy plan, is required in accordance with 42 CFR 438.340. Although specifically required for managed care programs, OMPP has recently begun to incorporate traditional Medicaid and other non-managed care programs.

The quality strategy plan includes an overall framework for continuous quality improvement that utilizes several quality committees related to key agency priorities (e.g, neonatal quality subcommittee, health services utilization management subcommittee, etc.). Representation on these committees includes state agencies (e.g., Indiana State Department of Health), MCE staff, and other industry experts. The QSP framework also includes MCE-led quality improvement projects that promote innovation and health outcomes improvement. These QIPs are submitted to OMPP and reviewed for performance.

• 2025 IHCP quality strategy plan
• 2024 IHCP quality strategy plan
• 2022 IHCP quality strategy plan
• 2021 IHCP quality strategy plan
• 2020 IHCP quality strategy plan

National Committee for Quality Assurance accreditation

State statute (IC 12-15-12-21) and contract requires all managed care entities to be (or become within one year of operation) NCQA-accredited. NCQA is an independent, non-profit organization that is considered an industry benchmark for continuous quality and outcomes improvement. The NCQA health plan accreditation process is rigorous and involves on-site visits, survey instruments, and reviews. NCQA publishes accredited health plan performance results based on clinical quality, member satisfaction, and NCQA accreditation survey results.

NCQA also issues health plan report cards that provide more detail based on the health plan's combined HEDIS^®, CAHPS^® and NCQA Accreditation Standards scores. NCQA evaluates health plans on the quality of care patients receive, how happy patients are with their care, and health plans' efforts to keep improving. The NCQA health plan report cards can be found here.

Healthcare Effectiveness Data and Information Set

HEDIS^® is an industry standard for measuring performance and year-over-year trend. NCQA, which administers HEDIS^®, collects audited results from health plans for their respective populations. HEDIS^® includes more than 90 measures across six domains of care: effectiveness of care; access/availability of care; experience of care; utilization and risk adjusted utilization; health plan descriptive information; and, measures collected using electronic clinical data systems. For more information about MCE HEDIS scores, click here.

Children's Health Insurance Program annual reports

As part of the Federal Balanced Budget Act of 1997, Congress created the Children's Health Insurance Program to help encourage the states to provide health insurance to uninsured children. CHIP is a part of Hoosier Healthwise, Indiana's health coverage program for children and some pregnant women with low incomes. If you are interested in signing up or learning more information about Hoosier Healthwise, please click here. An annual report describing program activities is due to the legislature by April 1 of each year (IC 12-17.6-2-12). Additional information about the program may be found at CMS' CHIP website.

• CHIP annual report (April 2024)
• CHIP annual report (April 2023)
• CHIP annual report (April 2022)
• CHIP annual report (April 2021)
• CHIP annual report (April 2020)
• CHIP annual report (April 2019)
• CHIP annual report (April 2018)
• CHIP annual report (April 2017)
• CHIP annual report (April 2016)
• CHIP annual report (April 2015)
• CHIP annual report (April 2014)
• CHIP annual report (April 2013)
• CHIP annual report (April 2012)
• CHIP annual report (April 2011)
• CHIP annual report (April 2010)

Related sites

CMS scorecard for Indiana

Indiana management performance hub

Indiana Health Coverage Programs provider reference materials

Indiana Health Coverage Programs quick reference guide (phone numbers, URLs, and other information)

U.S. DHHS Agency for Healthcare Research and Quality's national healthcare quality and disparities reports: Indiana snapshot

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