Overview of Indiana Pathways for Aging
New Program Coming July 1, 2024: Indiana Pathways for Aging, or Pathways, is a statewide Medicaid managed long-term services and supports (MLTSS) program for state residents who are 60+ years old and Medicaid-eligible due to age, disability, or blindness. Via this program, Hoosiers, including those eligible for both Medicaid and Medicare (dual eligible) receive medical care, such as doctor appointments, hospitalization, laboratory work, and x-rays. Program participants can also receive nursing home care or home and community-based services (HCBS) in their home, the home of a loved one, an adult family care home, or an assisted living residence to prevent and delay the need for institutionalization (nursing home admission). HCBS might include personal care services, homemaker services, adult day care, home modifications, personal emergency response systems, and home delivered meals.
Benefits are received via a single Medicaid health plan provided by a managed care entity (MCE). A MCE is essentially a private healthcare company that has a network of care providers. It is through these providers that program participants receive services. There are three MCEs from which to choose a Pathways Medicaid health plan: Anthem, Humana, and United Healthcare. While program participants receive their Medicare benefits in the same manner as before, one’s Medicaid health plan can work with one’s Medicare health plan to coordinate care.
Indiana Pathways for Aging is a mandatory program for most eligible Hoosiers. Persons 60+ years old who are currently enrolled in IN Medicaid, including Hoosier Care Connect (HCC), the Aged & Disabled Waiver, and Nursing Home Medicaid, will automatically transition to Pathways when the program becomes live on July, 1 2024. An exception for automatic enrollment exists for persons who would enter Pathways on hospice or are part of a recognized tribe, such as Alaska Natives or American Indians. These persons can opt-out of the program.
There is some flexibility of providers for persons receiving home and community based services, as attendant care can be consumer-directed. Rather than receive this service via the MCE’s network of licensed care providers, a program participant can hire their own caregiver. While this includes adult children, nieces / nephews, grandchildren, and siblings, spouses cannot be hired. A financial management services agency handles the financial aspects of employment responsibilities, such as withholding tax and issuing payments.
Indiana Pathways for Aging is a 1915(b) Managed Care Delivery System Waiver that operates along with a 1915(c) Home and Community Based Services (HCBS) Waiver. The Pathways for Aging 1915(c) Waiver will provide the same HCBS that are currently offered via the Aged & Disabled Waiver. With 1915(c) Waivers, the federal government requires a state to limit the number of participant slots. This means a waitlist forms for HCBS when all the “slots” have been filled.
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For Service” or “Managed Care”. Under Fee-For Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.
Benefits of Pathways for Aging
Pathways covers care coordination (support for healthcare needs), physician appointments, laboratory work, x-rays, hospital care, surgical care, home health care, durable medical equipment, hospice care, therapies (i.e., physical, occupational), medications, vision, dental, mental health, and substance abuse treatment. Long-term care services and supports may include the following:
– Adult Day Care / Adult Day Services – daytime supervision and personal care assistance in a community-based group setting
– Adult Family Care / Community Home Share
– Assisted Living Services
– Attendant Care / Participant-Directed Attendant Care – assistance with daily living activities (i.e., bathing, dressing, toileting, eating, mobility)
– Caregiver Coaching and Behavior Management
– Community Transition – assistance with security deposit and utility set-up fees for persons moving from a nursing home to a private residence
– Home and Community Assistance – limited housecleaning, laundry, meal preparation, essential errands
– Home Modification Assessments / Home Modifications
– Meal Delivery
– Nursing Facility Care
– Nutritional Supplements
– Personal Emergency Response Systems
– Pest Control
– Respite Care – to relieve a primary caregiver
– Service Coordination – support for home and community based services needs
– Specialized Medical Equipment
– Structured Family Care – the program participant lives with a caregiver who provides supervision and assistance with daily living activities. Relatives, including a spouse, can be paid to provide care.
– Transportation (non-emergency, non-medical)
– Vehicle Modifications
MCEs also offer MCE-specific benefits, such as over-the counter pharmacy allowances, gift cards for groceries / household items, and gym memberships.
Pathways does not cover the cost of room and board in an Adult Family Care Home or Assisted Living Residence.
Eligibility Requirements for Indiana Pathways for Aging
Pathways is for IN residents who are 60+ years old and Medicaid-eligible on the basis of age, disability, or blindness. This includes Hoosiers who currently receive services and supports via the Aged and Disabled Waiver, nursing facility care, or enrolled in Hoosier Care Connect (HCC).
Financial Criteria: Income, Assets & Home Ownership
Income
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL). While this figure increases annually in January, IN Medicaid increases their income limit in March. Effective 3/1/24, the income limit for a single applicant is $1,255 / month. For a married couple, regardless of if one or both spouses are applicants, the income limit is $1,704 / month.
Persons who are applying for nursing home care or home and community based services are permitted a higher income. In 2024, the individual applicant income limit is $2,829 / month. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,829 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance.
There is a minimum income allowance, set at $2,465 / month (eff. 7/1/23 – 6/30/24), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which in 2024, is $3,854 / month. While this potentially allows a non-applicant spouse a higher income allowance, the exact amount one can receive is dependent on their shelter and utility costs. However, a Spousal Income Allowance can never push a non-applicant’s total monthly income over $3,854. This Monthly Maintenance Needs Allowance is intended to ensure the non-applicant spouse does not become impoverished.
Assets
In 2024, the asset limit is $2,000 for a single applicant. For married couples, regardless of if one or both spouses are applicants, the asset limit is $3,000.
When only one spouse is an applicant for nursing home care or home and community based services, the asset rules differ. While the assets of both the applicant and non-applicant spouse are still limited, the non-applicant is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance to prevent spousal impoverishment. The CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $154,140. If the non-applicant’s share of assets falls under $30,828, they can keep 100% of the assets, up to $30,828. This is in addition to the $2,000 the applicant spouse can retain.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of applying for nursing home care or home and community based services. This is because Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.
Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, Indiana Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has Intent to Return and their home equity interest is no greater than $713,000. Home equity is the current value of the home after subtracting any debt against it. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a child under 18 years old living in the home.
– The applicant has a disabled or blind child living in the home.
Learn more about the potential of Medicaid taking the home.
Medical Criteria: Functional Need
If an applicant does not require home and community based services nor nursing home care, there is no functional need criteria. For persons who require HCBS or nursing home care, a Nursing Facility Level of Care (NFLOC) is required. This generally means one requires help with a minimum of three Activities of Daily Living (ADLs), like bathing, dressing, mobility, eating, and toileting, or medically cannot take care of themself. A functional assessment is completed by one’s Area Agency on Aging (AAA) to determine if level of care need is met. In July 2025, the Level of Care Assessment Representative (LCAR) for Maximus Health Services Inc., the Pathways Enrollment Broker, will take over doing functional assessments. While persons with Alzheimer’s disease or a related dementia might meet the functional need for care, a diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Indiana Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons who require nursing home care or home and community based services have income over the limits, Miller Trusts, also called Qualified Income Trusts, can help. “Excess” income is deposited into the trust, no longer counting as income.
When persons have assets over the limits, there are many options. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts, although they violate the Look-Back Rule, are another option that protects assets from Medicaid’s asset limit. Still another option is to “spend down” countable assets, such as paying off debt, updating home plumbing and heating, and buying household furnishings.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in Indiana to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, some planning strategies not only help one meet Medicaid’s financial criteria, but also protect assets from the Medicaid Estate Recovery Program (MERP). Unfortunately, they often violate Medicaid’s 60-month Look-Back Rule. Therefore, they should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s).
How to Apply for Indiana Pathways for Aging
Before You Apply
Prior to applying for Indiana Pathways for Aging, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. A common reason applications are delayed is required documentation is missing or not submitted in a timely manner.
Application Process
To participate in Indiana Pathways for Aging, one must apply and be determined eligible for IN Medicaid. Persons can apply online, print and submit an Indiana Application for Health Coverage, or request an application be mailed. Persons can also contact a navigator to assist with the application process.
Current Medicaid recipients who are eligible for Pathways should have received an enrollment letter by mail in February or March 2024. Included was a chart comparing the three MCEs offering statewide health plans: Anthem, Humana, and UnitedHealthcare. To choose a health plan, or for assistance in choosing one, persons can call 877-284-9294 (87-PATHWAY-4) to reach the Indiana Pathways for Aging Helpline / Maximus (Pathways Enrollment Broker). Persons who do not select a plan before May 1, 2024, will have one selected for them. Program participants will receive a welcome packet in June 2024 from their MCE, and on July 1, 2024, the new health care plans begin.
Once Pathways begins July 1, 2024, new applicants 60+ years old who are determined Medicaid-eligible will be able to select a MCE and enroll in Pathways.
Learn more about Pathways. The Indiana Pathways for Aging Helpline / Pathways Enrollment Broker can also provide additional information at 87-PATHWAY-4.
The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy & Planning (OMPP) administers the Indiana Pathways for Aging Program. OMPP contracts with the managed care entities (MCEs).
Approval Process & Timing
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, as a waiting list may exist for home and community based services, approved applicants may spend many months waiting to receive these benefits.