MAAC MEETING MATERIALS EXECUTIVE COMMITTEE MEETING November 16, 2017 1. Agenda of Meeting for November 16, 2017 2. Meeting Minutes of the October 10, 2017 - MAAC Executive Committee Meeting 3. Action Items 4. Full Council Recommendations for Consideration by the Executive Committee 5. IA Health Link Public Comment Meeting Minutes o Q1 SFY18: Bettendorf, IA – August 29, 2017 o Q2 SFY18: Dubuque, IA – October 11, 2017 6. IA Health Link Recommendations Letter – Q4 SFY17 o Kris Richey Letter o Nishna Production, Inc. (NPI) Letter o Tom Scholz Letter
Transcript
MAAC MEETING MATERIALS EXECUTIVE COMMITTEE MEETING November 16, 2017
1. Agenda of Meeting for November 16, 2017 2. Meeting Minutes of the October 10, 2017 - MAAC Executive Committee Meeting 3. Action Items 4. Full Council Recommendations for Consideration by the Executive Committee 5. IA Health Link Public Comment Meeting Minutes
o Q1 SFY18: Bettendorf, IA – August 29, 2017 o Q2 SFY18: Dubuque, IA – October 11, 2017
6. IA Health Link Recommendations Letter – Q4 SFY17 o Kris Richey Letter o Nishna Production, Inc. (NPI) Letter o Tom Scholz Letter
November 3, 2017
Executive Committee Meeting
Thursday, November 16, 2017 Time: 3:00 p.m. – 4:30 p.m. Hoover State Office Building
First Floor SE Meeting Room, Sides 1-2 1305 E. Walnut St.
Des Moines, IA Dial: 1-866-685-1580 Code: 515-725-1031#
AGENDA
3:00 Introduction and roll call – Gerd Clabaugh
3:02 Approval of October 10, 2017 Executive Committee minutes – Gerd Clabaugh
3:05 Q1 SFY18 Recommendations Discussion – Gerd Clabaugh o IA Health Link Public Comment Meeting – Bettendorf – August 29, 2017 o Tom Scholz Letter: Preventive and Developmental Services for Children Receiving
Medicaid o Nishna Production, Inc. (NPI) Letter o Kris Richey Letter o Review of MAAC Full Council Discussions
3:30 Department and MCOs on Secret Shopper Methodologies and Metrics – Liz Matney o DHS o MCO
Kate Gainer (Shannon Rudolph) – present Sean Bagniewski -
Lori Allen – present Luisito Cabrera - present
Richard Crouch – present Alisha Timmerman - present
Julie Fugenschuh – present Lisa Cook - present
Jodi Tomlonovic – present
Introduction Gerd called the meeting to order and performed the roll call. Executive Committee attendance is as reflected above and quorum met. Approval of the Executive Committee Meeting Minutes of September 12, 2017 Minutes of the Executive Committee meeting on September 12, 2017 was approved. Discussion and Actions on Recommendations Gerd reviewed the draft Q4 SFY17 letter of recommendations and the Executive Committee voted and approved the letter of recommendations with the acknowledged revisions. Action Items:
• MCOs to present on the service planning process between the member’s Interdisciplinary Team (IDT) and Utilization Management (UM) team to ensure conflict-free case management.
• The Department and MCOs to present on secret shopper methodologies and metrics. Medicaid Director’s Update Mikki reviewed all outstanding items in the Action Items document. Mikki reviewed recommended cost containment measures that were presented to the DHS Council. Liz Matney addressed the Items below.
a.) National benchmark on Program Integrity fraud rate data with home health providers
Liz provided an overview of the top provider types with the highest instances of fraud, waste, and abuse, conviction rates, and recouped fund amounts as reported by the Medicaid Fraud
Executive Committee Summary of Meeting Minutes
October 10, 2017
October 12, 2017
Control Units (MFCU). In SFY17, the top five provider types with the highest amount of fraud, waste, and abuse allegations at the IME were personal care providers, hospitals, mental health providers, and home health agencies. Nationally, in SFY16, the provider type with the highest number of convictions for fraud, waste, and abuse were personal cares providers. Nationally, in SFY16, the top 4 provider types with the highest amount of recoupments were Home Health, personal cares, transportation, and Durable Medical Equipment (DME). Iowa’s fraud, waste and abuse is in align with national standards.
b.) MCOs as secondary payer: Coordination between Medicare and Medicaid for dual
eligible members in the waiver programs Liz stated that most waiver services are not covered by Medicare and therefore billed directly to Medicaid. For covered Medicare services, there is a crossover and all MCOs have agreements with Medicare where the crossover calculation occurs automatically. In the instance of a crossover claim, the provider bills Medicare first and then Medicare sends the data to the MCOs to remit any balance that they may be responsible for. Liz explained the Medicare Advantage program and stated that providers must submit their initial claims to the Medicare Advantage plan then when the provider receives the remit back, the provider submits the claim and the EOB to the MCO for any additional charges the MCO is responsible.
c.) Managed Care Division review of managed care quality performance measures –
Healthcare Effectiveness Data and Information Set (HEDIS) and Health Services Advisory Group (HSAG) Lisa Cook handed out and reviewed a document with HEDIS data for April 1, 2016 through December 31, 2016 with measures such as the percent of expected prenatal visits completed, timeliness of prenatal and postpartum care, and follow-up after hospitalization for mental illness.
d.) Retroactive Eligibility Waiver Update
Mikki stated there were no updates from CMS at this time and the Executive Committee will be informed when information became available.
e.) Review of Quarterly Report (Q4 SFY17)
Liz gave a high level overview of the report and Mikki outlined the oversight committees that will be reviewing the report.
Action Items:
• Managed Care Division to provide first 12 months of HEDIS data when it becomes available and provide a list of what data is being tracked in the HEDIS measures.
Future Agenda Item:
• Liz to Review the Quarterly Report (Q4 SFY17) at the November 7, 2017 Full Council meeting and November 16, 2017, Executive Committee meeting.
Next Steps: November MAAC Full Council Agenda Future Agenda Items:
• Review of the Q4 SFY17 Recommendation Letter. • Review of Q1 SFY18 IA Health Link Public Comment session notes: Bettendorf. • Presentation from the Long Term Care Ombudsman’s Office regarding the “How to be your
own best advocate” document. • The Department to present on provider re-enrollment. • Rules and waivers review of outstanding items. • Electronic Visit Verification (EVV).
Open Discussion Cindy Baddeloo requested additional information regarding fingerprinting and the provider national criminal background check. Future Agenda Item:
• Richard Crouch’s letter that was shared with the Executive Committee members was to be discussed at the November 16, 2017, Executive Committee meeting.
Adjourn 4:45 P.M.
October 12, 2017
Full Council Recommendations for Consideration by the Executive Committee
1. Understand the process at IME and monitor Level of Care is appropriate
2. Ensure availability of providers and standard rates in the mental health community subacute area
3. Monitor issues that may arise involving the LTSS transition process to UnitedHealthcare
4. Review issues with pediatric speech and hearing specialists for hawk-i with UnitedHealthcare
5. Advocacy and care needs of families in the area of care coordination for children with developmental delays (Tom Scholz letter)
6. Review the LTSS population transition in the next quarter and create a plan to ensure a seamless transition of LTSS population to UnitedHealthcare
7. Review the situations of LTC persons that have been in nursing homes
8. Review outstanding state plan amendments affected by the transition to UnitedHealthcare
9. Understand how IME will monitor efficient transfer of information from AmeriHealth to UnitedHealthcare in light of the size of the population being transitioned
10. Understand conflict-free case management within managed care
11. Understand the impact of potentially removing the LTSS population from managed care
12. Establish a better process for communication regarding transfer of information between the state, the MCOs, and case management agencies to assist members to prevent gaps in services
13. Establish clear definition of the term ‘oversight” and identify roles that are involved in oversight
Iowa Department of Human ServicesMedical Assistance Advisory Council (MAAC)
Outstanding Items from the Executive Committee Meeting of October 10, 2017
Date Added Action Item Who is Responsible for Follow-Up
Status (Outstanding / Complete / In Process / To Be Scheduled)
11/4/2016 Update on the new CMS managed care rules and whether changes are necessary to be in compliance.
Medicaid Director Ongoing
2/23/2017 To have presentations regarding Integrated Health Homes and the Health Homes project. UPDATE on March 14, 2017: Deb Johnson and Joyce Vance are to be invited to a future Executive Committee meeting to continue the discussion on Chronic and Integrated Health Homes
Medicaid Director A follow-up presentation will take place at future Executive Committee meeting.
3/14/2017 Matt Highland and representatives from the three MCOs are to present information regarding mobile applications at a future Executive Committee meeting; after July 2017
Medicaid Director In Process
8/8/2017 Managed Care Division to provide a review of managed care quality performance measures - HEDIS and HSAG UPDATE on October 10, 2017: Managed Care Division to provide 12 months of HEDIS data when it becomes available and provide a list of what data is being tracked in the HEDIS measures.
Medicaid Director - Managed Care Division
To be discussed at future Executive Committee meeting
8/8/2017 Have future discussion on the role of care coordinators and case managers responsible for waivers. Which set of activities is making the greatest impact on improving outcomes? UPDATE on October 10, 2017: MCOs to present on the service planning process between the member's Interdisciplinary Team (IDT) and Utilization Management (UM)team to ensure conflict-free case management.
EC Members and Medicaid Director and Managed Care
Organizations
A follow-up presentation will take place at future Executive Committee meeting.
8/8/2017 Consider a discussion relating to the federal discussions on block granting Medicaid dollars, and how the state is positioned relative to this possible outcome.
EC Members and Medicaid Director
Ongoing
10/10/2017 The Department and MCOs to present on secret shopper methodologies and metrics.
Medicaid Director and Managed Care Organizations
To be discussed at future Executive Committee meeting.
Action Page 1
Iowa Department of Human ServicesMedical Assistance Advisory Council (MAAC)
Outstanding Recommendations from the Executive Committee Meeting ‐ October 10, 2017
Date Added Action Item Iowa Department of Human Services
Status (Outstanding / Complete / In Process / To Be Scheduled)
10/12/2017
Public Comment Recommendation: Ensure clear and consistent guidelines and protocols are published to guide decisions around prior authorization both within the Managed Care Organizations and the durable medical equipment (DME) providers. Ensure that the published guidelines are share with DME providers.
Medicaid Director
10/12/2017
Public Comment Recommendation: Ensure that training on these prior authorization guidelines is provided to internal Manage Care Organization staff in order to ensure a consistent application in the decision‐making process.
Medicaid Director
10/12/2017
Public Comment Recommendation: Ensure that Managed Care Organizations are communicating clearly and in a timely manner with providers, including ensuring that denial communication in the pre‐authorization process clearly delineates reasons for denial so that providers can address those denials as well as learn improved processes for the future.
Medicaid Director
10/12/2017Public Comment Recommendation: Ensure that durable medical equipment providers are notified in a timely way when changes to fee schedules occur.
Medicaid Director
10/12/2017
Public Comment Recommendation: Ensure the MCOs are using case managers effectively and efficiently to assist clients in navigating access to services. The Executive Committee requests information from Medicaid staff to better understand how conflict‐free case management operates in the Iowa program, including interactions in care planning between utilization management and interdisciplinary teams.
Medicaid Director
10/12/2017Public Comment Recommendation: The department is to develop a new methodology to track consistency of prior authorization determination within each MCO.
Medicaid Director
10/12/2017
Public Comment Recommendation: Include the accuracy and consistancy of information provided by the MCO customer service representatives to both providers and members in the Managed Care Quarterly Report.
Medicaid Director
10/12/2017Public Comment Recommendation: Include secret shopper results to the managed‐care quarterly report.
Medicaid Director
Recommendations Page 2
Iowa Department of Human ServicesMedical Assistance Advisory Council (MAAC)
Completed Items from the Executive Committee Meeting ‐ October 10, 2017
Date Added Item Responsible Party Status (Outstanding / Complete / In Process / To Be Scheduled)
1/19/2017 Public Comment Recommendation: The Department Develop a new methodology to track consistency or prior authorization determinations within each MCO.
Medical Assistance Advisory Council (MAAC)
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: The Department to enforce and communicate to the MCOs the cap after which a PA request is deemed approved (seven days) if a determination has not been made. The MCOs are then to communicate the determination to providers.
Outstanding Items from the Executive Committee Meeting of
July 11, 2017
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Encourage the MCOs to develop consistent service groups or crosswalk standards for PAs to allow for instances where approval is obtained for a specific service or products. Recommend that each of the MCOs develop an exemption process based on medical necessity.
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Require MCOs to provide a plain language explanation to Iowa Medicaid members and providers for PA denials.
Medicaid DirectorCompleted - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: The Department to determine the differences in credentialing requirements between the MCOs and develop a comparison grid of what additional measures beyond the IME's universal credentialing is required by each MCO.
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Require the MCOs explain the rationale for additional credentialing requirements beyond what is contractually required by the IME.
Medicaid DirectorCompleted - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Determine the percentage of clean claims payments that are paid on time and accurately based upon the established rate floors to track the accuracy of provider payments.
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Regarding clearinghouse to clearinghouse issues: Request that the MCOs provide data related to the initial denail rates from their clearinghousees and include this data in the Managed Care Quarterly Report.
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Include the accuracy and consistency of information provided by the MCO Customer Service Representatives to both providers and members in the Managed Care Quarterly Report.
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Include secret shopper results to the Managed Care Quarterly Report.
Medicaid Director Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Request that the MCOs report information regarding outreach efforts to increase access to care in areas identified in the MCOs' GeoAccess Reports as limited access areas.
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Request that MCOs present on results of outreach efforts in order to determine outstanding issues that the MAAC may be able to address.
Medicaid DirectorCompleted - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
Completed Page 3
Iowa Department of Human ServicesMedical Assistance Advisory Council (MAAC)
Completed Items from the Executive Committee Meeting ‐ October 10, 2017
Date Added Item Responsible Party Status (Outstanding / Complete / In Process / To Be Scheduled)
1/19/2017 Public Comment Recommendation: Request summaries of the MCOs' Consumer Advisory Panels and Clinical Advisory Panels. Request that MCOs make a periodic formal presentation to the MAAC regarding the timely data and feedback obtained from their required advisory panels.
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Encourage the development of a standardized process across the MCOs to create consistent member material to inform members on what services are provided by each MCO, the process for denying services, and what resources will be given to review available services
Medicaid Director
Completed - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Require MCOs to provide a plain language explanation to Iowa Medicaid members on all MCO denials.
Medicaid DirectorCompleted - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Public Comment Recommendation: Require that all MCO provider manuals be clearly posted in an easily accessible format and location on the MCOs' websites and available in hardcopy.
Medicaid DirectorCompleted - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
1/19/2017 Explanation and definition of plain language standards Medicaid Director Completed - Discussed in March 14, 2017 Executive Committee meeting.
2/14/2017 Executive Committee to meet with Iowa Medicaid Communications Specialist to discuss reconfiguration of the Iowa Medicaid website for ease of navigation for members/consumers.
Medicaid Director Completed - Discussed in March 14, 2017 Executive Committee meeting.
2/14/2017 Request that the MCOs assist in advertisement of the IA Health Link Public Comment meetings
Medicaid Director Completed - Confirmed by the State at March 14, 2017 Executive Committee meeting that MCOs were assisting by way of newsletters, the clinical advisory and the community advisory committees.
2/23/2017 Update on the new CMS managed care rules and whether changes are necessary to be in compliance. UPDATE on February 23, 2017: Matt Highland to present information and progress on new standardization of member content and format in publications at the March 14, 2017, Executive Committee meeting. Within presentation, Matt will also discuss how standardization will impact the grievance and appeals process.
Medicaid Director Completed - Matt Highland presented on the communications standardization of managed care regulations in March 14, 2017 Executive Committee meeting.
2/23/2017 General Recommendation: Enforce regulation that Managed Care Organizations (MCOs) follow established state Preferred Drug List (PDL), as required within their contracts.
Medicaid DirectorCompleted - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
2/23/2017 General Recommendation: Encourage the MCOs provide data regarding medication denial rates for MAAC Executive Committee to monitor for future recommendations.
Medicaid DirectorCompleted - Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.
2/23/2017 General Recommendation: Extend the allotted 30 day nursing facility stay for HCBS waiver recipients to 120 days.
Medicaid Director In rules process for change.
2/23/2017 Secondary Payer: * Clarify MCOs as a secondary payer. * To have presentation on the coordination between Medicaid and Medicare for dual eligible members in the waiver programs.
Medicaid Director Completed - Discussed at October 10, 2017 Executive Committee meeting.
Completed Page 4
Iowa Department of Human ServicesMedical Assistance Advisory Council (MAAC)
Completed Items from the Executive Committee Meeting ‐ October 10, 2017
Date Added Item Responsible Party Status (Outstanding / Complete / In Process / To Be Scheduled)
3/14/2017 Matt Highland to give an update regarding Communications Standardization for Managed Care Regulations at a future Executive Committee meeting.
Medicaid Director Completed
4/11/2017 Gather previous quarterly report data regarding the top five reasons for grievances and appeals for comparison to assist in determination if there are systemic trends in the information. The Department is to determine if a quarter by quarter comparison chart regarding this topic should be included in future quarterly reports.
Medicaid Director Completed - Discussed at August 24, 2017, Executive Committee meeting.
4/11/2017 Determine average aggregate cost per member per day for special needs members in ICF/ID. UPDATE July 11, 2017: Additionally, break down by: * Community-based ICF/ID providers * State resource centers * Out-of-state placement
Medicaid Director Completed - Discussed at August 24, 2017, Executive Committee meeting.
4/11/2017 Examine out-of-state placement for members in facilities to determine the impact on members as well as program. * Border Issues * Medical Conditions * Ages * Other factors leading to out-of-state placement
EC Members and Medicaid Director
Completed - Discussed at August 24, 2017, Executive Committee meeting.
6/15/2017 Identify trends involving payment issues: * The largest issues * Where issues are most prevalent and if this trend changes over time * Where issues continue to reside * If the same issues affect different provider types * The proportion of issues that occur with the MCOs versus with provider organizations * The top reasons why payment issues persist * Identify if the top reasons for payment issues change over time
EC Members and Medicaid Director
Completed - Discussed at August 24, 2017, Executive Committee meeting.
7/11/2017 Provide data on grievance and appeals - at the State Fair Hearing: * How many cases are ruled in favor of an MCO * How many never go through the entire appeals process * How many issues are resolved at the MCO level and never go to the level of the State Fair Hearing.
Medicaid Director Completed - Discussed at August 24, 2017, Executive Committee meeting.
7/11/2017 Updates on the EVV stakeholder workgroup meetings. Medicaid Director Completed ‐ Discussed at September 12, 2017, Executive Committee meeting.
7/11/2017 Research national benchmark on Program Integrity fraud rate data with home health providers.
Medicaid Director Completed - discussed at October 10, 2017 Executive Committee meeting
8/8/2017 Review the process involving transfer of member information from one MCO to another MCO when a member chooses to change their MCO
EC Members and Medicaid Director
Completed - Discussed at September 12, 2017, Executive Committee meeting.
11/4/2016 Provide information on status of individuals who are institutionalized in a hospital or facility for beyond 30 days and had been on waiver services although when transitioning out of institution to lose their waiver services.
Medicaid Director Completed - 1/19/2017:HCBS Recommendations Workgroup created for members who transition out of an instituion beyond the alloted 30 days.
11/4/2016 One-pager as preamble to Administrative Rules outlining changes that have been made to the document and submitted to the DHS Council
Medicaid Director Completed - In rules process.
Completed Page 5
Iowa Department of Human ServicesMedical Assistance Advisory Council (MAAC)
Completed Items from the Executive Committee Meeting ‐ October 10, 2017
Date Added Item Responsible Party Status (Outstanding / Complete / In Process / To Be Scheduled)
11/4/2016 Calendar to be developed regarding when reports are to be due and process timeline for when data is to be reviewed and recommendations made. Information to be added to the workplan.
Medicaid Director Completed - To be handed out at 1/19/17 EC meeting.
5/19/2016 One pager regarding the role of MAAC that members can use with the organizations in which they are representing and stakeholders
Medicaid Director Completed - Sent via email to EC members on 1/23/17.
11/4/2016 Request that the Attorney General's office attend a future meeting for orientation and the expectations for the EC members in addition to governance training and new sunshine advisory.
Medicaid Director Completed - Attended February 14, 2017, Full Council meeting.
Completed Page 6
Iowa Department of Human Services: August 2017 1
Bettendorf IA Health Link Public Comment Meeting
Tuesday, August 29, 2017 Time: 5 p.m. – 7 p.m.
Scott Community College Student Life Center 500 Belmont Road
Bettendorf, IA 52722
Meeting Comments and Questions IME/DHS Staff MCO Representatives MAAC Representatives
Lindsay Paulson - present Amerigroup Iowa, Inc. - present Dennis Tibben - present
Sean Bagniewski - present AmeriHealth Caritas Iowa, Inc. - present
Natalie Ginty - present
Matt Highland - present UnitedHealthcare Plan of the River Valley, Inc. - present
Sarah Belmer - present
Peter Crane - present
Comments Services Parents, advocates, and providers have expressed their concerns regarding how a member is able to obtain services they need. One provider stated that the Managed Care Organizations (MCOs) are prescribing medications rather than approving services. It was stated that members were being required to try medications before services would be approved. A parent conveyed his frustration about how his 38 year old mentally disabled and deaf son was denied an interpreter by the MCO. Durable Medical Equipment For the past four months a pediatric physical therapist has had a difficulty with obtaining approval for a wheelchair for a severely disabled 18 month old child. The MCO for that child has only worked with the member’s primary care provider for additional information rather than the pediatric physical therapist who was working directly with the child and submitting the paperwork.
Prior Authorizations A provider is requesting to have a set format for how and what information needs to be submitted in order for services and DME to be approved without having to go back and forth with the MCOs.
Case Management There is an issue with the MCOs using in-house case management because the person/entity determining the members hours and services are also making a profit when
Iowa Department of Human Services: August 2017 2
services are reduced. A parent stated they are also no longer able to sit down with the member’s team to discuss options and make a decision for the member like they were able to prior to the privatization; case managers were making decisions on behalf of the member. MCO Oversight State Representative Cindy Winckler informed the Public Comment Meeting recipients that the MCOs have taken the legislature oversight out of the system. Prior to implementation, legislators had the opportunity to provide input at meetings but now the meetings are not happening and despite trying to place more oversight in legislation, they do not have enough votes to do so. Representative Winckler stated the legislature was frustrated that they have been taken out of the process and that the Executive branch was the one who chose to privatize Medicaid. A parent also agreed that the lack in MCO oversite was unsettling. Home- and Community-Based Services (HCBS) Waiver A mother expressed concerns regarding low capitation rates and that her son was not receiving the HCBS Waiver services that he needed due to limited funding. The mother stated that the MCOs were receiving a maximum of $4,488 per HCBS Waiver member residing in a facility. Independent Support Brokers (ISB) and parents caring for members who are on a waiver are experiencing difficulties with effective communication. Prior to the privatization, any changes to the member’s Consumer Choice Options (CCO) budgets were electronically updated in the system for the ISB to view. Now the ISBs are no longer being informed when there has been a change to a member’s budget and case workers were not informing the ISBs. It was affirmed that facilities were being shut down due to the floor rates and that the people who needed HCBS services were not able to obtain the services that they needed. Consumer Directed Attendant Care (CDAC) CDAC providers are paid at a very low rate and members are requesting a higher rate to retain their CDAC providers although the MCOs are rejecting their requests. Questions
1. Are the MCOs required to be accredited?
2. When members and providers call the Iowa Medicaid Enterprise and the Managed
Care Organizations call centers, they are receiving different answers. What is being
done to train staff appropriately?
3. With demands of the Americans with Disabilities Act, why would a member be denied
an interpreter?
4. Is there a process that providers must follow to receive approval for prior
authorizations for DME/Services?
Iowa Department of Human Services: August 2017 3
5. Are they going to level out the reimbursement rates for the MCOs to be more
standardized (capitation rates)?
6. What happens to those of us who have kids with an exception to policy who go over
the daily rate? How are the MCOs going to address situations where the funding is
dropped to the floor rates set by the state?
7. How cost efficient is this to have SIS assessments done every 3-5 years?
8. What are the benefits from doing SIS assessments?
9. Why are SIS assessments required?
10. Is the shift to managed care because the state could not handle the costs?
Iowa Department of Human Services: October 2017 1
Dubuque IA Health Link Public Comment Meeting
Wednesday, October 11, 2017 Time: 5 p.m. – 7 p.m. Grand River Center
Meeting Room 6 500 Bell St.
Dubuque, IA 52001
Meeting Comments and Questions IME/DHS Staff MCO Representatives MAAC Representatives
Lindsay Paulson - present Amerigroup Iowa, Inc. - present Dennis Tibben - present
Sean Bagniewski - present AmeriHealth Caritas Iowa, Inc. - present
Sue Whitty - present
Alisha Timmerman - present UnitedHealthcare Plan of the River Valley, Inc. - present
Peter Crane - present
Comments Services and Provider Network
Following implementation, a member was required to obtain a new Primary Care Physician (PCP). When the member recently began treatment with her new provider, the provider assisted in locating new specialists although the member’s new provider network would require the member to travel distances further than 50 miles from her home for services. The member was told that one of the specialists was within the member’s MCO provider network and accepting new patients although when the member contacted the provider to schedule an appointment, the provider stated that they were not accepting new patients.
A different mother stated that her daughter had suffered a traumatic brain injury and was in a coma for seven months. The member began habilitation services following her release from the hospital although at the beginning of this year, the member was placed in a residential group home; this did not provide the proper treatment for the member’s condition. The member’s MCO re-evaluated the member’s needs and the MCO allowed an Exception to Policy (ETP) for the member to live alone with staff. In February 2017, the member and member’s guardian were notified that the member’s MCO would be reducing the member’s funding for services by 43% and the family was then required to pay the remainder for 24 hour staff. Two of the member’s staff discontinued services due to uncertainty of job security. With the reduction of funding and limited staff, the family was providing the remaining necessary services for the member. The member’s family contacted nursing homes in the member’s area but they had waiting lists and/or stated that they were not able to provide the level of care necessary for the member. The member’s father stated that the family was on a fixed income and that this has created hardship for the family.
Iowa Department of Human Services: October 2017 2
It was stated that a member had been successful when receiving respite care although the program discontinued.
A father stated that his son’s providers were ending their contracts with the MCOs and/or no longer serving Medicaid members and that he was concerned about the well-being of his son.
A provider at a Community Health Center stated that there were problems with the number of providers accepting a particular MCO as members were having to change their MCOs and wait for services until their MCO change would take effect. There are also issues with MCO choice cut-off dates and MCO changes taking 4-6 weeks to process while members go without services during that time. The provider stated that they would like to change the choice-cut-off dates to something less than 4-6 weeks. There had to be more providers and clinicians available in Dubuque who are contracted with all MCOs. Members were having to travel longer distances for doctor appointments although were not eligible for Non-Emergent Medical Transportation (NEMT) services therefore were unable to go to appointments.
Members were being required to complete a Health Risk Assessment (HRA) with the IME, MCO, and then complete an Oral Health Self-Assessment; this process is time consuming for both members and providers.
In regards to mental health, it takes up to 30-45 days for a Medicaid application to process although members receiving mental health services require assistance sooner for access to services.
A provider stated that the MCOs do not understand the Iowa Administrative Code (IAC) and that services are being denied that under Fee-for-Service were always approved. The MCOs are implementing standards for Behavioral Health Intervention Services (BEHIS) services that are not required per the IAC. The provider indicated that a member of her staff will spend many hours authorizing services for children that are on the Children’s Mental Health (CMH) Waiver as the MCH HCBS Waiver portal requires extensive amounts of time.
A mother received a letter from AmeriHealth Caritas Iowa, Inc. stating that the member would no longer have diabetic foot care. The mother called the IME and was told that the MCO could determine which services the member received and the IME would no longer make these determinations. The mother called the Rapid Response Team and was told to contact Governor Branstad. She was told that the services have to be medically necessary although the member was eligible for the services prior to implementation. Her son no longer has foot care and he does not have disposable income.
A mother stated that there had been a reduction in the number of medical shoes available to the member per year. Prior to implementation, the member received 2 pairs of shoes per year and now the member is only able to receive one pair of shoes per year because each shoe is counted separately.
Iowa Department of Human Services: October 2017 3
Prior Authorizations
An oncologist stated that he recently had two patients who required medication for cancer and it took over two weeks for prior approval of the medications. The provider stated that this has happened on several other occasions and that will no longer be working with the MCO.
Case Management A parent stated that MCO Case Managers are frustrating to deal with as they are not knowledgeable and admit that they are not aware of policies and/or procedures. Home- and Community-Based Services (HCBS) Waiver
A parent of a member on the Intellectual Disability (ID) Waiver stated that their son was currently receiving and living off of Social Security Income (SSI) due to the limited availability of prevocational programs. It was affirmed that Waiver services should be carved out of the IA Health Link managed care program. Additionally, there were too many assessments and they occurred far too frequently; Supports Intensity Scale (SIS) Assessment, Level of Care Assessment, and Case Management Risk Assessment. The parent spoke with the Ombudsman and requested why the member was not waived from the SIS assessment although did not find resolution.
A provider affirmed that there was not enough funding available for necessary services and that their organization was recently notified that 30% of HCBS providers in Iowa will take significant pay cuts.
A mother stated that she had started a community-based home with Hills & Dales where her son and 3 other adult Medicaid members were transitioned from institutions. The behaviors of all 4 of the adults had improved in the new setting although now, due to SIS Assessment and Level of Care, the members’ services were being reduced. Due to the reduction of her son’s services, the member’s mother would now be required to take care of the member and due to the member’s behavioral issues; the mother would now be in a dangerous situation. Alternately, the member may also be placed in an out-of-state facility given the nature of the member’s level of care needs.
A father of a son on the Intellectual Disability Waiver said that he was concerned about HCBS providers and what will happen to the services if providers continue to no longer serve Medicaid members. His son is currently employed in an integrated setting within the community although he may be losing employment services.
A mother indicated that the day prior her daughter was told that she would no longer be able to work at her current job due to cut-backs and subsidies. She stated that her daughter had tried vocational rehab although her daughter had been more successful with her current position.
Consumer Choices Option (CCO)
There have been rumors of Consumer Choices Option (CCO) being forced out and this has caused stress on family members and the member’s employees. CCO does not have a provider network to address issues.
Iowa Department of Human Services: October 2017 4
A parent stated that CCO employees were not being paid a livable wage due to costs associated with being a provider and their need to get private medical insurance. MCO case managers do not seem to understand how funding works between Veridian and members which has caused major delays in services and employee paychecks. The amount of time spent traveling, the cost of gas, scheduling fact-to-face meetings, and ensuring signatures on timesheets has become a burden on Independent Support Brokers (ISBs). Guardians and members are agitated that they must schedule a time each month to sign one piece of paper. Most ISBs have other jobs although they are having to take calls from Veridian and the members’ case managers during the day, while at their other place of employment, due to timesheet and paperwork issues. The MCOs are also not interpreting Iowa regulations correctly and include CCO in some of the traditional service regulations.
A CCO provider indicated that individuals received better care with CCO because the members hire their own staff which allows them to be more independent than if the member were with an agency. The provider stated that they had a meeting with the State and MCOs where it was identified that CCO services were saving the State money although the MCOs were instead forcing members to go to nursing homes or utilize alternate services that cost more money.
Another mother identified that her son uses CCO because of the quality of care it provides. The member had tried three different agencies in the Dubuque area although they were not the proper fit for the member and were not being accountable. The mother and son had asked the last agency specific information regarding the billing and services provided although they did not provide the requested information. The mother asked who paid for her son’s services and they stated, “Medicare, that’s not your problem.” Additionally, she stated that the rates continued to fluctuate which created uncertainty in service provisions.
Consumer Directed Attendant Care (CDAC) CDAC providers are paid at a very low rate and members are requesting a higher rate to retain their CDAC providers although the MCOs are rejecting their requests. Communications, Oversight, and General Comments This meeting was poorly advertised. Most people are unaware of upcoming meetings as they do not look at the IME website for upcoming meetings. Many members also may not be able to afford transportation to get to meetings. In regards to assistance with concerns or issues, members are not aware of who to contact for assistance. A parent requested better transparency from the State and MCOs to have additional information regarding how funds were being used. It was stated that the State needs to find a way to get rid of privatization. Medical Assistance Advisory Council (MAAC) member Sue Whitty stated that the MAAC had taken the input from meetings into consideration and made 19 recommendations to Director Foxhoven although one was taken into consideration while the other 18 received notice of denial; the MAAC will continue to make recommendations. It was also stated that staff were having to spend too much time working on MCO issues and it was taking time away from members. A provider stated that every month they are given lists of members and are being asked to reconcile the lists which requires the providers to check the accuracy of the MCOs
Iowa Department of Human Services: October 2017 5
work. A provider was concerned that members were required to take HRAs online and some members or member representatives do not have access to the internet or only have internet on their phone. Senator Pam Jochum stated that she has not seen improvement in the program following implementation and her daughter is not receiving the services that she needs such as day habilitation and Supported Community Living (SCL) services. Senator Jochum’ s daughter is currently receiving 3 hours of SCL because local providers cannot hire anyone as they cannot offer a competitive wage. Senator Jochum, Representative Chuck Isenhart, and Representative Shannon Lundgren informed the Public Comment Meeting participants that the legislature was frustrated that they have been taken out of the process and that the Executive branch has chosen to privatize Medicaid. The Senator and Representatives advised their constituents that they are encouraged to participate in changing the program by contacting their Senators, Representatives, and the Governor to voice concerns so that they are better able to see where modifications need to be made when considering future changes. Reimbursement A mother stated that her daughter had 10 providers prior to implementation although, due to providers not being reimbursed for services rendered, her daughter will have 5 providers beginning November 1, 2017. Tiered Rates A provider and a member stated that they had not yet received information regarding tiered rates. Billing, Claims, and Credentialing A provider had contracts with all MCOs. In August, claims for inpatient stays were denied by one of the MCOs although Case managers at the provider’s hospital verified that the proper criteria had been met prior to submission and following the denials. A Case Manager supervisor called the MCO regarding this issue and a representative from the MCO stated that if you have a patient with a one night stay, they were going to deny the claim and then the MCO would have to go through a Peer-to-Peer review and a longer process. Provider is also experiencing denials for Durable Medical Equipment as the MCO has stated that the hospital is not in-network and not credentialed with the MCO. The provider has provided evidence of network status although the claims continue to be denied. Additionally, the provider is not being paid at least 100% of the Medicaid fee schedule and one of the MCOs is paying based off of the Medicare fee schedule. The provider currently has 31 outstanding payment issues with one of the MCOs that have not yet been resolved. Non-Emergent Medical Transportation Providers are not available in Dubuque and members were having to travel further distances to get to appointments. Members eligible for NEMT were having difficulty with NEMT brokers as the brokers were not picking the members up and members were then missing their appointments. Members who missed appointments were at risk of their provider no longer seeing them due to missed appointments.
Iowa Department of Human Services: October 2017 6
Questions
1. Are CCO services being forced out?
2. What kind of training has been provided to the MCOs regarding CCO?
3. What kind of training has been provided to MCO case managers?
4. Where can CCO Independent Support Brokers (ISBs), members and family address issues with the MCOs directly?
5. Do the MCO understand CCO does not follow many of the traditional service relations
and that services are consumer driven?
6. Do the MCOs understand Pay Rates for CCO employers are higher than traditional services because CCO employees do not receive benefits of any kind?
7. Why have Supported Community Living (SCL) and Respite transportation funds been
eliminated although work transportation has not?
8. Initiating CCO services and processing background checks can take between 4 to 6 weeks for approval which is creating a delay in services and lack of employees for assistance. What is being done to improve this?
9. When will CCO budget forms be updated?
a. Can it be adjusted to reflect the new ISB pay rate? b. Can the form have an area added for who the Medicaid provider is? c. Can the form have an area added for Case Manager name and contact
information? d. Can the form be adjusted to show the member’s waiver? e. Can a comments area be added for special notes?
10. Why do some Case Managers require new budgets be submitted every 3 months, regardless of whether or not there have been changes to rates?
11. Can rules be changed so that ISBs do not need to turn in timesheets and have a set pay rate of $30 a month?
12. Can waiver services be placed under the state as they had been prior to
implementation?
13. CCO services are much less expensive than traditional agency services; why are the MCOs reducing CCO services?
Iowa Department of Human Services: October 2017 7
14. Can the MCOs and State have a CCO only training, or at least a Dubuque area
meeting, to address questions from members, their families, and employees?
15. Is there a way to get a summary of what was presented in the meeting and then receive a response from leadership to the concerns raised?
16. Does the MAAC have the authority to address these concerns or bring them forward to
leadership to ensure they are addressed?
17. There is too much paperwork required to obtain services. Why can’t they cut back on some of the paperwork and make the processes less difficult; revert to previous processes and requirements?
18. Who is responsible for making these determinations regarding budget? The MAAC,
legislators, etc.?
19. Does the governor get information from these meetings?
20. Why have we not had a meeting in Dubuque since May of 2016?
21. Why did the State make this change? What was wrong with the way that Medicaid was previously run?
22. A provider affirmed that there was not enough funding available for necessary services and that their organization was recently notified that 30% of HCBS providers in Iowa will take significant pay cuts. Where is the money going?
23. In March 2019, HCBS setting rules are going into effect. How are we going to pull this
off?
24. What is difficult to assess is the cost of staff time. What amount of funding is to be used for staff time; taking time to speak with members/representatives/providers? How much extra money is this costing the State?
25. What are the MCOs doing with the money and what are they doing with the money from all of the unpaid claims?
26. Can anything be done to change these policies?
27. What are you doing to learn managed care?
Iowa Department of Human Services: October 2017 8
Formal Written Comments
Name: Rosalie Jahn Organization: Nurse – Mercy Medical Center – Mental Health/Substance Abuse Comments / Questions: 1. Why was there a change in retroactive eligibility insurance coverage for hospitalizations of
patients who let their coverage lapse? Specifically for acutely mentally ill patients this is a consistent problem due to the nature of their illness and lack of supports that they don’t meet the requirements to keep their insurance active. Then, they end up being hospitalized and have a huge bill they can’t pay. Could there be some type of waiver or provision on this policy for this highly vulnerable population?
2. It is not a secret that we are in the middle of an opioid crisis. People are dying and your current policies are contributing to that. a. Prior Authorization to cover Suboxone is not timely; up to 10 days to wait for these
patients to get approval. b. Dose Limits. Coverage is for only up to 16 mg/day. There are a number of patients that
require more. c. Denials of coverage because of the dose regimen. Typically, 16 mg is supplied in (2) 8
mg sublingual films; these are not supposed to be cut. The doctor may prescribe 12 mg a.m., 4 mg p.m. or 4 doses of 4 mg throughout the day for better coverage. The Suboxone coverage is denied because the way the dose is written. This makes no sense and looks like the insurance company knows more about how to prescribe this than the doctor.
Iowa Department of Human Services: October 2017 9
Formal Written Comments
Name: Bill Stumpf Organization: Parent of Kyle Stumpf Comments / Questions: I thought things were somewhat stable in terms of Kyle’s medical providers and now it seems that another one of Kyle’s providers is discontinuing its contract with his MCO. Specifically, what is being done to bring them back in? I am also concerned about Kyle’s HCBS providers and if they will continue to be able to provide services. The only thing that keeps things going well is because Kyle is dual eligible. He works in the community. If he loses his HCBS providers he will be at risk of losing his integrated employment. With the HCBS Settings Rule going into effect in March of 2019, how will the levels of service be able to keep up with the true spirit of HCBS services?
Iowa Department of Human Services: October 2017 10
General Comments: Dental Wellness Plan and FFS Dental
There are currently no available dental providers in Dubuque.
Members in the Dental Wellness Plan were tentatively assigned to dental carriers and there are a limited number of dental providers accepting Medicaid members. Members were often required to change their dental carrier although it could take up to 4-6 weeks for the change to process which resulted in a lapse in care.
On Tue, Sep 12, 2017 at 11:31 AM, Kris Richey <[email protected]> wrote:
Last Thursday 9-7, I placed a called to the State Ombudsman office regarding a concerning trend we are seeing in the Integrated Health Home arena with one MCO, AmeriGroup, after yet again, another denial and creation of a gap in service. This gap potentially will land a very needy person in a homeless shelter as there is no other place for them to go after the member's mental health hospitalization and funding for the member was denied at the requested tier level. Yesterday I was directed to share my concerns with the Medicaid Advisory Committee.
The trend we are seeing at the Integrated Health Home (IHH) is specific to the LTSS members who are receiving Habilitation services. This started back in August of 2016 when the IHH’s first learned that Amerigroup would no longer backdate authorizations creating gaps in services for our most chronically mentally ill members along with having multiple physical health needs. These are members, who often times, have received 24 hr services for years in the community. Amerigroup came out early on with a rigid stance on not back dating authorizations shifting the cost for services to providers and in some cases Regions if they had a policy to fund for gaps in services when prior authorizations expired. In July 2017 it has worsened due to a process at Amerigroup called Physician Review. Since July 1st we have had five cases denied of members living in 24 hr sites, on prior authorization for services. During the months of July and August we were given the option to negotiate a lower tier and in some cases we did this in desperation to keep some type of funding in place for our members. Starting in September they are going directly to physician review and we are seeing the spike in denials for funding putting our members at risk for more costly services.
For reference, IHH Care Coordinators are responsible forsubmitting funding requests (prior authorization renewals) forHabilitation Waiver services. The Medicaid member’s services are decided by the interdisciplinary team which typically includes, IHH Care Coordinator, member, provider of services, guardian, court advocate, or any other informal or formal support. These are people who know and care about their members. The team meets at LEAST annually to discuss services and needs, but can meet more often, if needs change due to improvement of symptoms or decline in health. Documentation is reviewed and sent in as requested or when needed to show justification forservices. Prior to managed care most authorizations were approved for a two to three month time period and authorized through Magellan. However, with AmeriGroup specifically, we are only getting services approved for anywhere from a few weeks to monthly increments with authorization dates that vary throughout the month. This creates an enormous amount of tracking, and time put into paperwork rather than spending thetime needed with our members to try to be proactive and prevent emergencies or crisis to keep costs down.
As a result of these staggered dates IHH’s have struggled ensuring prior authorizations are submitted in a timely manner. In our agency we have two staff members tracking the end dates weekly on a spreadsheet along with the Care Coordinators. This is an administrative costs and takes away from our time to be out in thecommunity serving all of our members. Amerigroup has a rule that we can only request an authorization two weeks prior to theend date. When we submit the request and Amerigroup doesn’t agree with the request they now send those cases to physician
review. The IHH’s are not receiving consitant notification of this. When I have inquired about the rationale for this with Amerigroup, the response was they have too many to process to give us notice. This is the same rationele given for having varried authroiztion dates throughout the month. IHH’s are then notified of denial via phone. At that time we can begin the appeal process which we have been told takes 30-45 days to process. These denials are occurring at the end or after the former prior authorization has expired creating a gap in services for themember. The IHH’s are finding out about these denials via a phone call so there is nothing in writing until the IHH initiates theappeal request. This is creating a crisis for our most high needs and vulnerable members as the provider and IHH are frantically trying to justify and appeal these denials to prevent homelessness, emergency room visits, decline of member, and trying to keep providers in our area providing services, but they are getting burned. In some cases we have been able to agree to a lower tier or whatever Amerigroup is telling us to decrease to at least obtain some payment for service to provider, but often times the team is not in agreement to this drop in tier level. It doesn’t feel right at all having Amerigroup dictate the needed service formember, especially when the member, Care Coordinator, provider and interdisciplinary team members don’t agree to this reduction
*I would like to know how many cases that are sent to physician review are being overturned in order to allow member to keep their same level of service they have been receiving. When I have asked AmeriGroup this question, they have not answered. To thebest of my knowledge, the majority of these cases are yet again being denied.
Amerigroup’s stance is that they will not back date any prior authorization (request for services), unlike the other 2 MCO’s have more flexible policies because they are aware of the harm and issues it can cause by not backdating EVER (i.e. GAP IN FUNDING/SERVICES). At this time, we haven’t had a provider quit providing service say in a 24 hour site, but last week were very close to a provider having to end services due to Amerigroup’s decision to deny services at specific level for 24 hr care. If IHH is denied a tier level, then we are NOT allowed to request that Tier or a higher tier for 30 days from the date of the original request. If we agree to a lower tier level, AG has been extending that lower tier authorization for several months and we are NOT allowed to request a change until that authorization on file expires, this to me does NOT seem like it is in the best interests of the members, but shifting the cost of providing services to the provider, in some cases the Regions and the member who has very limited resources. When provider complain to Amerigroup about thedenials they are told the IHH isn't sending in enough documentation, bascially placing the blame on the IHH.
Equally concerning is what is going to happen to these members when, NOT IF but when, providers stop providing services. Providers cannot be expected to continue services for members in high tier levels during appeal process without guarantee of payment. I have requested support from Amerigroup in where to transfer these members whose services they are continually reducing as their physician reviewers determine they aren’t needing that level of care. Please share with us providers who are willing to serve members living in a 24 hour site and only receive payment for a portion of the day. In addition, this is not the preventative health each of the MCO's have testified as the way the will reduce services at the state capitol. Instead of gaining better outcomes for our members in fact we are seeing the exact opposite. They are instead receiving higher costly services
such as an increase in hospitalizations, ER visits, involvement of law enforcement, magistrates, county attorney’s and Regions which is something we had been trying to reduce with the start of the IHH’s.
I have requested that Amerigroup that they give us and providers at least 5 days to deal with a denial or reduction in services. There is no way to effectively serve our members when we are given no notice or time to transition and find new provider, or informal supports etc. We have also been told by Amerigroup that if they receive the same information on funding requests about our members that they will be denied, however, I’d like to note that a lot of our members have significant mental health issues that don't always improve or go away or change that drastically to update monthly.
I would like to finish by mentioning that the other 2 MCO’s are much easier to work with in regards to authorizations. We aren’t getting as pushed like we are with Amerigroup to reduce or deny services effective the date of the phone call or in some cases earlier. We at least still have somewhat of a say in the processes of deciding on services for the members we manage. I can safely say that if the Amerigroup members who have experienced reductions/denials, had another MCO, we would at least be able to converse with MCO staff to negotiate and plan services rather than being dictated and formulate a transition plan that will allow us a month, not the same day of denial to put alternative services in place. I am sending this to the MAAC after multiple meetings with Amerigroup have left us with no flexibility or opportunity to advocate on behalf of these most challenging members that are served throughout the IHH’s across the state. This is not just occurring with our IHH it is an issue statewide.
I serve a very rural area (like most of the state), where we have no Children Mental Health providers in two of the counties we serve. Members, who need those services, lose their waiver spot due to no providers in our area. This is more than a disservice to these citizens, and I am trying to prevent the same issue with Habilitation providers as well. This gap in service creation with Amerigroup has to be resolved as we are approaching another crisis for these most needy members.
Kris Richey Crossroads IHH Director 1003 Cottonwood, Creston IA 50801-1012
Optimizing Preventive and Developmental Health Services for Children Receiving Medicaid
As a member of the MAAC, I am writing to share the following recommendations. The purpose of these
recommendations is to optimize the use of preventive and developmental health services directed to children
receiving Medicaid, through ensuring that programs administered through the Department of Public Health
receive Medicaid financial coverage. This includes care coordination and gap-filling direct health care service
associated with Iowa’s Title V and 1st Five programs. The care coordination services provided to EPSDT enrolled
children by the Department of Public Health assists in enrollment and establishing and making use of medical
and dental homes. Prior to the transition to managed care, Iowa included these Title V and 1st Five services in
the administrative services budget.
The requirements to continue these services were not explicit contractual provisions within the managed care
contracts developed for Medicaid, and the data show that very few children are assigned a care coordinator by
any of the MCOs. Prior to the implementation of managed care, over 31,000 children received care coordination
from local Title V agencies.i According to the latest performance data report, only 4,012 children were assigned
a health care coordinator during the third quarter of SFY2017. This report also reveals that over the past 4
quarters (one year) only 9,127 children were assigned a health care coordinator—less than one third the
number of children who were receiving care coordination prior to the transition. During the third quarter of
SFY2017, less than 2 percent of children were assigned a health care coordinator—0.38 percent of children at
UnitedHealthcare, 2 percent of children at AmeriGroup, and 3 percent of children at AmeriHealth. ii In
comparison, prior to managed care nearly 11 percent of children received care coordination through Title V
agencies.iii
Recommendations:
The Departments shall work with managed care companies to ensure funding under Medicaid for Title V and 1st
Five for care coordination (and related services).
The Department shall work with providers of services under First Five to explore additional ways to secure
Medicaid financing, through administrative or direct service claiming, to further ensure that all medically
necessary preventive and developmental health services are covered under Medicaid.
The Department shall work with providers of services under First Five, the State Innovation in Medicaid (SIM)
grant, and managed care companies to develop additional research and demonstration projects to support the
development of health metrics for children related to social as well as bio-medical determinants of health that
can be incorporated into a value-based system Medicaid financing system. These recommendations will help
ensure that children receiving services through Title V and 1st Five programs have ready access to Medicaid care
coordination services, leading to better health outcomes and greater cost-savings.iv,v
Respectfully,
Tom Scholz, MD
i In FFY2015 (Oct. 1, 2014-Sept. 30, 2015) - 31,562 children received care coordination services
iiManaged Care Organization Report: SFY 2017, Quarter 3 (January - March) Performance Data
https://dhs.iowa.gov/sites/default/files/Q3SFY17_ManagedCare_QrtlyPerformance.pdf iii Medicaid/CHIP child enrollment September 2015: 295,057 https://goo.gl/MrWE6v
iv CMS Quality Strategy 2016 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy.pdf v Collins S, Piper KB “Kip”, Owens G. The Opportunity for Health Plans to Improve Quality and Reduce Costs by Embracing
Primary Care Medical Homes. American Health & Drug Benefits. 2013;6(1):30-38. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031704/
