Section 405IAC10-6-1. Medically frail screening

   (a) A member shall be reviewed for medically frail status at any of the following times:

(1) During the verification period if such member's responses on the application questionnaire indicate the potential existence of a medically frail condition.

(2) At any time during the benefit period if documentation demonstrates that the member may have a medically frail condition.

(3) At any time if documentation demonstrates that the member may no longer have a medically frail condition.

(4) At any time upon member request.

(5) For a medically frail member, at least annually by the insurer for continued medically frail eligibility.

  (b) The division shall forward an applicant's responses to the health screening questions obtained in accordance with 405 IAC 10-3-1(c) to an insurer for verification of medically frail status if the division determines:

(1) the applicant is eligible under the plan; and

(2) the applicant's responses indicate the possible existence of a medically frail condition.

  (c) During calendar year 2015, beginning upon the date an individual identified as potentially medically frail in accordance with subsection (b) becomes a member, the insurer shall have a period of sixty (60) days to verify the member's medically frail status. For purposes of this section, this period is referred to as the verification period. Beginning in calendar year 2016, and for each subsequent year of the plan, the verification period shall be thirty (30) days.

  (d) A member identified as potentially medically frail in accordance with subsection (b) shall receive HIP State Plan benefits during the verification period and shall be enrolled in either HIP State Plan Plus or HIP State Plan Basic in accordance with 405 IAC 10-4-3.

  (e) In order to verify a member's medically frail condition, the insurer shall consider one (1) or more of the following using a process approved by the office:

(1) The member's responses to the application questionnaire.

(2) The member's initial health screen.

(3) The member's health assessment.

(4) The member's medical records.

(5) The member's present or historical medical claims data.

(6) Any other information relevant to the member's health condition.

  (f) If the insurer determines that a member is not medically frail or the insurer is unable to verify the member's medically frail status during the verification period, the member shall be transferred to either:

(1) HIP Plus if the member was enrolled in HIP State Plan Plus during the verification period; or

(2) HIP Basic if the member was enrolled in HIP State Plan Basic during the verification period.

  (g) An individual wishing to appeal an insurer's determination under this section shall first appeal to the insurer making the determination in accordance with 405 IAC 10-5-2. If, on appeal to the insurer, the insurer finds that the member is not medically frail, the member may appeal the finding to the state in accordance with 405 IAC 10-5-1.

  (h) The office may review the placement of a member who has been determined to be medically frail to determine whether the member meets the medically frail definition under 405 IAC 10-2-1(29) by considering any of the following:

(1) The member's responses to the application questionnaire.

(2) The member's medical records.

(3) Communication with or other outreach to the insurer, the member, or the member's provider or providers.

(4) The member's past claims history, if available and accessible.

(5) Other processes, as determined by the office.

  (i) If, under subsection (h), the office determines that a member is not medically frail, the member shall no longer receive HIP State Plan benefits and shall be transferred to:

(1) HIP Plus if the member is currently enrolled in HIP State Plan Plus; or

(2) HIP Basic if the member is currently enrolled in HIP State Plan Basic.

An individual determined not medically frail under this subsection may appeal the determination directly to the state in accordance with 405 IAC 10-5-1. (Office of the Secretary of Family and Social Services; 405 IAC 10-6-1; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA)