Iowa Medicaid Update: One Year of Medicaid Modernization Dennis Tibben Director of Government Affairs UICCOM Refresher Course for the Family Physician April 19, 2017

Overview History of the Transition IA Health Link Program Overview Program Standards Advocating for Patient Care Year One Data Key Contacts

History of the transition

History of the Transition Recent Medicaid Budget Shortfalls Factors FY14 Estimated -167,000,000 FY15 Estimated -148,000,000 FY16 Estimated -$206,000,000 FMAP Comparison: FY17 +1.21% = +$45.6M in Federal Funds Declining FMAP (-4.81% FY14-FY16) Intentional Underfunding Growing Enrollment

History of the Transition FY17 (Q1 Report): 606,154 total in Managed Care Includes Traditional, 7 HCBS Waivers, IHWP & hawk-i Population Approx. 6% of Medicaid Patients still on FFS *Excludes Family Planning Waiver Source: Council on Human Services Budget Submission for State Fiscal Year 2018 and 2019

History of the Transition Growing Program Costs Growing Program Costs Driven Primarily by Traditional Medicaid, but Increasingly IHWP as Well as 100% FMP declines Source: Council on Human Services Budget Submission for State Fiscal Year 2018 and 2019

History of the Transition Avg. Per Capita Costs: $9,675 in FY16 Wide Variability: $2,952 Avg. Per Capita Children; $23,300 Avg. Per Capita Elderly & Disabled 5% of patients with Chronic Conditions = 48% of Acute Care Costs Source: Council on Human Services Budget Submission for State Fiscal Year 2018 and 2019

History of the Transition State’s Goals February 2016 Governor Announced move to managed care. Has the authority to do so without legislative approval. CMS twice delayed implementation because the state was not ready. Program went live April 1, 2016.

Program overview

IA Health Link Program Overview Iowa’s Medicaid Managed Care Program = IA Health Link Three statewide Managed Care Organizations (MCOs) Virtually all Medicaid Patients Affected All traditional Medicaid beneficiaries Iowa Health and Wellness Plan beneficiaries Hawk-i beneficiaries IDPH substance abuse patients Approximately 606,000 patients impacted Excluded Populations PACE, American Indian, Health Insurance Premium Payment Program, Medically Needy, Undocumented Individuals FFS Coverage continues to exist for these patients

Program Standards

Patient Access Patients auto-attributed evenly among MCOs; claims history not factored into attribution algorithm. Individuals given 90 days to select a different MCO before being locked in for a year. Patients can change at any point for “good cause.” Patients asked to select primary care provider; will be assigned to one if they do not select. MCOs may impose additional requirements for Out-of-Network Providers. Currently in Year 2 Open Enrollment for First Wave IME Member Services are the patient’s enrollment broker; able to offer conflict-free assistance. MCOs requiring prior authorizations for all services provided by an out-of-network provider. Some MCOs also requiring referral from in-network provider.

Network Adequacy Primary Care Specialty Care Access within 30 minutes or 30 miles Appointments available within: 4-6 weeks for routine care 48 hours for persistent symptoms 1 day for urgent conditions Specialty Care Access within 60 minutes or 60 miles of at least 75% of non-dual eligible members’ homes Access within 90 minutes or 90 miles of all non-dual eligible members’ homes 30 days for routine care Not to exceed 1 day for urgent conditions

Provider Credentialing 90% of credentialing must be completed within 30 days. 100% of credentialing must be completed within 45 days. Uniform credentialing application now accepted by all three MCOs. State working toward centralized credentialing system. Credentialing issues continue.

Covered Benefits Physical health care in inpatient and outpatient settings, behavioral health care, transportation, etc. Facility-based services such as Nursing Facilities, Intermediate Care for Persons with Intellectual Disabilities, Psychiatric Medical Institution for Children, Mental Health Institutes, and State Resource Centers Home and Community-Based Services (HCBS) waiver services Dental services “carved out” If it was a covered benefit under FFS, the MCOs must cover it. MCOs not required to cover services at the same scope as FFS (e.g., caps on units of therapy covered) *

Prior Authorization MCOs MUST: Honor existing prior authorizations for minimum of 30 days Provide for the continuation of medically necessary services regardless of prior authorization or referral requirements throughout the contract Pharmacy Determinations required within 24 hours. If PA is required in an emergency situation, the MCO must cover at least a 72-hour supply of the drug. Non-Pharmacy Determinations required within 7 days. Requirement can be expedited to within 3 days if deemed necessary by the provider or the MCO. After April 2017, existing prior authorizations honored for 30 days after patient assigned to new MCO. Prior auth is an area of extensive problems. If in doubt, DO NOT simply submit a prior auth. Consult provider manuals and call provider services. Prior Auths Deemed Approved After These Limits

Provider Payments MCOs MUST: Pay in-network providers at rates equal to or higher than the current Medicaid fee-for-service schedule for the duration of their contracts with the state. Pay for telehealth services at rates that are equivalent to in-person rates when provided in accordance with generally accepted health care practices. Process 90% of clean claims within 14 days; 100% within 90 days. Out-of-network providers will be paid at 90% of in-network rates. In-network claims must be filed with the MCO within 180 days of the date of service; out-of-network claims within 365 days. Claims processing continues to be a significant issue. MCOs paying incorrect rates across the board; slowly working to fix issues.

Advocating for patient care

Advocating for Patient Care Grievance “An expression of dissatisfaction about any matter other than an ‘action.’” Appeal “A request for review of an action; a clear expression by the member or the member’s authorized representative, following a decision made by the MCO, that the member wants the decision to be reviewed and reconsidered.”

Copyright © 2014 Iowa Medical Society. All Rights Reserved. IME has developed a number of flowcharts to help explain processes. MCOs Required to have Grievance and Appeals Process with Uniform Caps on Length (90 Days Grievance and 45 Days Appeals (3 Days Urgent)) MCO Grievance and Appeals Processes Differ Providers can file grievances and appeals on the member’s behalf with written consent. Can Escalate MCO Decisions to State Hair Hearing Appeals Process (Must do Within 90 Days of Decision) Must Exhaust the MCO Process First Copyright © 2014 Iowa Medical Society. All Rights Reserved.

Copyright © 2014 Iowa Medical Society. All Rights Reserved. Must be submitted within 365 days of claims disposition Each MCO has a different process. Amerigroup requires a mailed appeal. Copyright © 2014 Iowa Medical Society. All Rights Reserved.

Advocating for Patient Care Managed Care Ombudsman Charged with Assisting Select Populations LTSS Members in Health Care Facilities, Assisted Living, Elder Group Homes HCBS Waiver Members: HIV/AIDS, Brain Injury, Elderly, Health & Disability, Children’s Mental Health, ID, Physical Disability. Assistance Available Member Enrollment Complaints, Grievances, Appeals Individual Case Management

Year One Data State issues quarterly managed care reports. Fy17 Q1 (July-Sept) was published at the end of November. Some Positive Developments Several Areas For Improvement Year One Data

History of the Transition Year One Data Program Costs Source of Savings Capitated State Payments MCOs Sustaining Significant Losses Reduced/Delayed Provider Payments Reduced/Delayed Care Good News is Program Costs to the State Have Declined Projected $102M Annual Cost Reduction to the State (Even with $33M State Supplemental (+ $94.5M federal) in October 2016) Appear to be on Track: FY16,Q4 (-$22M); FY17,Q1 (-$29M) MCOs Still Estimated to Lose $450M in Year One – $150M Amerigroup; $200M AmeriHealth; $100M United Bad News For Iowans is Source of Program Savings

History of the Transition Year One Data Amerigroup: 30% Denied or Suspended AmeriHealth: 28% Denied or Suspended UnitedHealthcare: 35% Denied or Suspended Significant Increase from FFS Amerigroup did not correctly report suspended claims in April, May, and June of 2016.

Initial Performance Data Year One Data Good news: More Medicaid Patients Receiving HRAs State Requirement Previously Only IHWP Now Requirement for All Patients Anecdotal Evidence of Improved Focus on Prevention & Managing Chronic Conditions Remember %% of chronic patients = 48% of program costs

History of the Transition Year One Data Value Added Services are not Available Statewide

Initial Performance Data Year One Data Initial Performance Data Network Adequacy Network Adequacy as a Percentage of Historical Utilization

Initial Performance Data Year One Data Metric FY16 Q4 FY17 Q1 Grievances 145 224 42 133 39 79 Appeals 14 370 52 216 50 100 State Fair Hearings -- 120 69 Prior Auths Within 7 Days 68% 95% 99% 100% Members in VBP 0% 17% 3.4% 6% 2% Medical Loss Ratio 123.30% 109.92% 102.45% 114.05% 104.38% 111.88% Again, a grievance is an expression of dissatisfaction. 100% of prior auths to be processed within 7 days. Accuracy of Payment Not Tracked Yet; State Acknowledges Still a Problem 40% of patient population to be in a value based purchasing arrangement by 2018. MLR must exceed 88%; MCOs expected to lose money during the first years of the contract. MCOs didn’t expect to lose this much ($450M)

Key Contacts

Key Contacts IME Member Services (800) 338-8366 IMEMemberServices@dhs.state.ia.us http://dhs.iowa.gov/iahealthlink IME Provider Services (800) 338-7909 IMEProviderServices@dhs.state.ia.us Managed Care Ombudsman (866) 236-1430 ManagedCareOmbudsman@iowa.gov www.iowaaging.gov Amerigroup Member Services: (800) 600-4441 Provider Services: (800) 454-3730 AmeriHealth Caritas Member Services: (855) 332-2440 Provider Services: (844) 411-0579 UnitedHealthcare Member Services: (800) 464-9484 Provider Services: (888) 650-3462 Tips Call Center Performance & Reliability is Improving Always Start With MCO Rep When That Doesn’t Work, Contact IME Centers (& Ombudsman if Appropriate) – MCO Liaisons Can Force Action Contact IMS; We Have Escalated Contacts & Identify Problem Trends Utilize Grievance & Appeals Process; Help Patients to do the Same – State Closely Monitoring to Identify Trends

Questions? Dennis Tibben (515) 421-4779 dtibben@iowamedical.org

Established in 1850, the Iowa Medical Society (IMS) is a statewide professional association representing more than 6,400 Iowa physicians, residents and medical students. IMS exists to assure the highest quality health care in Iowa through our role as physician and patient advocate. Call us at (800) 747-3070, email us at info@iowamedical.org or find us online at www.iowamedical.org. Closing slide.