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

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

3. History of the transition

4. 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: FY % = +$45.6M in Federal Funds
Declining FMAP (-4.81% FY14-FY16)
Intentional Underfunding
Growing Enrollment

5. 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

6. 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

7. 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

8. 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.

9. Program overview

10. 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

11. Program Standards

12. 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.

13. 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

14. 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.

15. 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) *

16. 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

17. 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.

18. Advocating for patient care

19. 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.”

20. 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.

21. 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.

22. 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

23. 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

24. 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

25. 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.

26. 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

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

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

29. 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)

30. Key Contacts

31. Key Contacts IME Member Services (800) 338-8366
IME Provider Services
(800)
Managed Care Ombudsman
(866)
Amerigroup
Member Services: (800)
Provider Services: (800)
AmeriHealth Caritas
Member Services: (855)
Provider Services: (844)
UnitedHealthcare
Member Services: (800)
Provider Services: (888)
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

32. Questions?
Dennis Tibben
(515)

33. 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) , us at or find us online at
Closing slide.