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
• FY14 Estimated -167,000,000
• FY15 Estimated -148,000,000
• FY16 Estimated -$206,000,000
• Factors
• Declining FMAP (-4.81% FY14-FY16)
• Intentional Underfunding
• Growing Enrollment
History of the Transition
*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
Source: Council on Human Services Budget Submission for State Fiscal Year 2018 and 2019
History of the Transition
Source: Council on Human Services Budget Submission for State Fiscal Year 2018 and 2019
History of the Transition
State’s Goals
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
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.
Network Adequacy
• Primary 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
• Appointments available within:
• 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.
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
Determinations required within 24 hours.
Pharmacy
If PA is required in an emergency situation, the MCO must cover
at least a 72-hour supply of the drug.
Determinations required within 7 days.
NonPharmacy
Requirement can be expedited to within 3 days if deemed
necessary by the provider or the MCO.
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.
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.
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
History
ofOne
the Transition
Year
Data
Program Costs
Source of Savings
• Capitated State Payments
• MCOs Sustaining Significant Losses
• Reduced/Delayed Provider Payments
• Reduced/Delayed Care
History
ofOne
the Transition
Year
Data
Amerigroup did not correctly
report suspended claims in April,
May, and June of 2016.
InitialYear
Performance
One Data Data
History
ofOne
the Transition
Year
Data
One Data Data
InitialYear
Performance
Network Adequacy
One Data Data
InitialYear
Performance
Metric
FY16
Q4
FY17
Q1
FY16
Q4
FY17
Q1
FY16
Q4
FY17
Q1
Grievances
145
224
42
133
39
79
Appeals
14
370
52
216
50
100
State Fair
Hearings
--
120
--
42
--
69
Prior Auths
Within 7 Days
68%
95%
95%
99%
100%
100%
Members in
VBP
0%
17%
3.4%
6%
0%
2%
Medical Loss
Ratio
123.30%
109.92%
102.45%
114.05%
104.38%
111.88%
KEY CONTACTS
Key Contacts
IME Member Services
(800) 338-8366
[email protected]
http://dhs.iowa.gov/iahealthlink
IME Provider Services
(800) 338-7909
[email protected]
http://dhs.iowa.gov/iahealthlink
Managed Care Ombudsman
(866) 236-1430
[email protected]
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
Questions?
Dennis Tibben
(515) 421-4779
[email protected]
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) 7473070, email us at [email protected] or find us online at
www.iowamedical.org.