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2015 ISSUE #10

Issue 10, August 25, 2015

Articles in This Issue:


FOUR COMPANIES PICKED TO MANAGE IOWA MEDICAID

Many of you have been waiting to hear how our state plans to move its Medicaid system to managed care, and the companies that will be chosen to help us do it.  Last week, the Iowa Department of Human Services (DHS) made the announcement.  The State of Iowa has selected four companies to manage Medicaid supports and services beginning January 1, 2016.  The companies selected are:

  • Amerigroup Iowa, Inc.
  • AmeriHealth Caritas Iowa, Inc.
  • UnitedHealthcare Plan of the River Valley, Inc.
  • WellCare of Iowa, Inc.

These four companies were selected from a field of eleven applicants, including the state's existing behavioral health managed care contractor (Magellan).  Magellan, along with the only company offering insurance on the Health Insurance Exchange (Coventry) were not chosen.  The state decided to modernize its Medicaid system at the beginning of this year, with the goals of:

  • Improving quality and access through better coordinated care.
  • Focusing on accountability and outcomes.
  • Making the Medicaid budget more predictable and sustainable.
“This patient-centered approach will mean that Medicaid members get the right care, at the right time, and in the right setting,” said DHS Director Chuck Palmer. “That will lead to a healthier Medicaid population, and that’s good news for members and Iowa taxpayers who make this program possible. These companies have demonstrated that they can manage Iowans’ care so they’ll be connected with the services they need to help them lead healthier lives,”

DHS is now calling this new (managed care) approach IA Health Link. DHS plans to launch a targeted communications campaign with Medicaid members, stakeholder organizations, providers, and other interested audiences about this new approach.  So when you see this logo, you know its the new Medicaid system.

“We’ll keep Iowans informed about their choices and how this patient-centered approach can help improve the overall health of the member,” said Palmer. “Through the IA Health Link program, we’ll improve the coordination of care for Iowans who receive health care assistance and provide greater predictability in Medicaid spending for all Iowa taxpayers.”
  • Information about the IA Health Link/Medicaid Modernization initiative, including fact sheets, presentations and FAQs can be found here.
  • You can find a fact shee on the transition to this new system here.
  • You can see how the companies submitting bids scored, see review team comments, and a list of each company's strengths/weaknesses here.

DHS has told us that they will be posting information frequently on their Modernization website (http://dhs.iowa.gov/ime/about/initiatives/MedicaidModernization) and has asked that those interested or affected by this change keep their eyes on this website for announcements.  Make sure you bookmark our website for breaking news and follow us on Facebook to stay updated.

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MEDICAID MANAGED CARE: See How Companies Scored

A team of four reviewers (all DHS employees) scored each of the 11 companies that submitted bids to manage Iowa's Medicaid system.  Companies were able to get a total of 100 points - the four companies with the highest scores would be awarded the contract.  You can see the final scorecard here.

Here is how each company ranked, with their score:

  • Amerigroup - 78
  • United - 77.25
  • WellCare - 68.75
  • Amerihealth - 63.25
  • Iowa Total Care (Centene) - 60.25
  • Aetna (Coventry) - 56.5
  • Magellan - 51.75
  • Molina - 41.25
  • Medica - 40.75
  • Meridian - 35
  • The eleventh company - Gateway - did not submit a bid.

While Iowa has chosen to award the contract to the four bolded companies, those that were not successful had five days to appeal the decision.  That appeal process can take time, and it should be noted that the state's current mental health managed care contractor (Magellan) won its contract on appeal, after the state originally selected Value Options.  So while the Department of Human Services has made its choice - it will not be final until all appeals are finalized, and contracts are signed.

The evaluation committee made a list of each company's strengths and weaknesses.  You can find the complete list here.  Here are a few of those strengths and weaknesses for the four companies chosen:

  • Amerigroup Iowa
    Strengths: 5.2 million members in 19 states; strong successful implementation experience; good pharmacy management plan; comprehensive approach to behavioral health, long-term supports and services (LTSS), and person-centered planning; high LTSS member satisfaction (greater than 90%); recognition of the importance of social services like housing, employment, and transportation; LTSS incentive programs including nursing facility transition incentives; good electronic access to after-hours care, web-based physician consultants as an alternative for members needing non-emergent care, 24/7 behavioral health consultation, and expanding telehealth; proposing enhanced services to fill the rural gap; goal of using habilitation to achieve outcomes in child welfare, juvenile justice, and education; partnership with Wellmark BlueCross BlueShield in developing relationships with existing providers.

    Weaknesses: Network development focus on physical health; low percentage of members in other states have serious mental illness (SMI) or intellectual and developmental disabilities (IDD).
  • UnitedHealthcare Plan of the River Valley, Inc.
    Strengths: 5.1 million members in 23 states; established network in Iowa; recognize social services are part of members’ needs, including employment; good LTSS experience including success in moving individuals from nursing facilities into the community; discuss providing in-lieu of services for facility transition and diversion; waiver waitlist experience; comprehensive behavioral health approach including 24/7 crisis line; stated support for serving individuals in the most integrated setting; strategies for provider recruitment and work plans that include LTSS, behavioral health, and rural access; solid member and provider satisfaction results; strong demonstrated results of care coordination in other programs.

    Weaknesses: LTSS experience is primarily with elderly; two instances in which they failed terms as part of contract negotiations.
  • Wellcare Health Plans, Inc.
    Strengths: 2.3 million members in 9 states; 8 offices in Iowa - headquarter in Des Moines with 2 regional offices and 5 locations using a welcome room concept with walk-in member services; thoughtful approach to member services; member services help line available 30 days prior to go-live; preferred partnership with UnityPoint including care coordination strategy; strong successful implementation experience; demonstrated an awareness of Iowa-specific health issues and proposed solutions; has begun coordination with regions and other community-based organizations; demonstrated understanding of integrating physical and behavioral health; facility transition success in other states; propose rural solutions including telemedicine and mobile health; incentives for reduction of facilities and hospital use; provide special assistance for LTSS and members that cannot be reached by telephone; community liaisons will be staffed by Ticket to Work and Welfare to Work individuals as much as possible

    Weaknesses: 70% of member services staff located out of state; utilization management and prior authorization strategy lacked comprehensive detail for behavioral health and long term care.

  • AmeriHealth Caritas Iowa, Inc.
    Strengths: Experience in 16 states and DC; headquarters and 3 community wellness centers in Iowa that provide in-person member services;Let Us Know Program for providers to identify need for non-medical services; 24/7 provider assistance line; good description of overall approach to behavioral health services; Iowa specific research regarding LTSS; demonstrates understanding of current community care model; identifies Iowa specific issues and working with stakeholders to resolution; focus on comprehensive LTSS network; multiple opportunities for members, providers, and stakeholders to provide input and advice; address rural strategy including telemedicine and mobile services; care plans are designed for member accessibility and success; good alignment with Healthiest State Initiative and regional mental health/disability services system.

    Weaknesses: Limited description of interface with other state agencies; LTSS primarily emphasizes services for elderly; frequency of level of care reassessment in care coordination; nurse call line may require member call back for resolution; no interim key personnel named and no details on how they intend to fill positions.

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MEDICAID MANAGED CARE: Three Part Series

Many of you may receive information directly from the ASK Resource Center, but for those of you that do not, we are reprinting a three-part series they have done focusing on the state's transition to Medicaid managed care.  The ASK Resource Center released this excellent and informative series of newsletters in an effort to educate the public, share information and resources, and help provide an understanding of the emerging issues related to the proposed changes to managed care.

  • PART ONE - The first newsletter of this three-part series explains managed care, addresses the emerging issues related to the proposed changes to Medicaid, and provides a timeline of important dates involved in Iowa's move toward managed care. Click here to read Part One.

  • PART TWO - The second publication in the series explains the process Iowa DHS is required to follow in order to initiate and implement the proposed changes to Medicaid. Part two also touches on how these changes will affect consumers and their families throughout the state. Click here to read Part Two.

  • PART THREE - The third and final newsletter in the series focuses on how consumers, families, and communities will be impacted by the proposed changes to Medicaid, and different ways the public can voice their concern, provide feedback and suggestions, and advocate for themselves or others as the state transitions to managed care.  Click here to read Part Three.

You can read more about the Ask Resource Center here.

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MEDICAID MANAGED CARE: Public Comment on Waivers

In order to modernize Iowa's Medicaid system and transition to managed care, the State must ask the federal government to allow changes to the state's Home and Community Based Services (HCBS) waivers.  Before the Department of Human Services (DHS) can make this request, it must first give the public time to comment on the proposed changes.

DHS started this process back in July, when several waiver changes were proposed. That comment period expired on Monday, August 24. DHS is now proposing changes to the final four HCBS waivers:

. Impacted waivers now include the two final 1915(c) HCBS waiver amendments which are linked below:
·         §1915(b) High Quality Healthcare Initiative Waiver (New Waiver)
·         §1915(c) HCBS Intellectual Disabilities Waiver (Amendment)
·         §1915(c) HCBS Children’s Mental Health Waiver (Amendment)
·         §1915(c) HCBS Elderly Waiver (Amendment)
·         §1115 Iowa Wellness Plan Demonstration Waiver (Amendment)
·         §1115 Family Planning Demonstration Waiver (Amendment)
·         §1915(c) HCBS Health and Disability Waiver (Amendment)- Released on August 14, 2015
·         §1915(c) HCBS Physical Disability Waiver (Amendment)- Released on August 14, 2015
·         §1915(c) HCBS Brain Injury Waiver (Amendment)- Released on August 21, 2015
·         §1915(c) HCBS AIDS/HIV Waiver (Amendment)- Released on August 21, 2015
 
Comments will be accepted for 35 days following the notice of the waiver amendments.

  • Comments on the Health and Disability and Physical Disability waivers must be received by Friday, September 18.
  • Comments on the Brain Injury and AIDS/HIV waivers must be received by Friday, September 25.
  • Written comments may be addressed to Rick Riley, Department of Human Services, Iowa Medicaid Enterprise, 100 Army Post Road, Des Moines, IA 50315.  Comments may also be emailed to the attention of: DHS, High Quality Healthcare Initiative at ModernizationWaiverComment@dhs.state.ia.us.

Waiver documents can be found in the Federal Waiver Documents section of the Medicaid Modernization web page.

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SUPPORTED EMPLOYMENT CHANGES PROPOSED

The Iowa Department of Human Services filed administrative rules to implement the Employment Services Redesign Plan on August 19.  This plan was developed by a workgroup in 2013, and implementation of that plan is just now starting to move forward.  These rules are not yet final - this is the first step in the rulemaking process (the "notice" of rules). 

  • Review the proposed rule changes here,
  • Read the 2013 Plan here.
  • Find out more about how DHS is increasing employment opportunities for people with disabilities here.

 The proposed rule changes noticed on August 19 change employment service definitions as required by the federal Centers for Medicaid and Medicare Services (CMS). The rules also change provider qualifications, scope of services, duration, limitation and reimbursement methodologies for the Home- and Community-Based Services (HCBS) prevocational and supported employment services within the Habilitation services program and the Intellectual Disability (ID) and Brain Injury (BI) waivers.

The rules also:

  • Increase Individual Supported Employment rates by 20% and establish rates for Career Exploration (which is a new activity under Prevocational). 

  • Decrease Enclave/Group Supported Employment and Prevocational rates to offset the increase listed above (thus making this rule change cost-neutral).  Enclave goes down from an average of $6.66/person (groups of 6 or 8 typically) to $5.32/person.  Prevocational goes down from an average of $12/hour to $9.91/hour (about a 20% cut).
The public may submit written comments on these changes until September 8, 2015.  Comments should be sent to: Harry Rossander, Bureau of Policy Coordination, Department of Human Services, Hoover State Office Building, Fifth Floor, 1305 East Walnut Street, Des Moines, Iowa 50319-0114. Comments can also be faxed to (515)281-4980 or e-mailed to policyanalysis@dhs.state.ia.us.

If you have concerns about these changes or would like to voice your support for them, you have several ways to take action:

  1. Email, fax, or mail your comments to DHS.

  2. Ask DHS to hold a public hearing on the rules. You can do that by sending DHS a request signed by 25 people (or an organization representing 25 people).  If you make this request, you will want to be prepared to have people attend the public hearing and speak.  DHS must then hold a hearing no less than 20 days before the final rules are adopted.

  3. Contact the legislators on the Administrative Rules Review Committee.  It does not matter if these legislators represent your district - they know that their role on this committee is to make sure rules are lawful and the people that have a stake in the rules are heard.  You can find a list of these people here and you can contact them here.

  4. Contact your State Representative and State Senator and let them know what you think.  You can ask them to contact their colleagues on the Administrative Rules Review Committee (ARRC) - you are basically asking your legislators to lobby the ARRC on your behalf.  You can contact your legislators here.

  5. Contact the Governor and ask his Administrative Rules Coordinator to take action on the proposed rules.  You can contact the Governor here..

______________________________________________________________________________

ABOUT THE RULEMAKING PROCESS

Administrative rules are written to explain how legislation will be implemented and enforced. The Legislature will pass a bill telling a state agency to do something, and the state agency must write rules saying how they will do it.  The rulemaking process requires agencies to give the public notice of the rules they are proposing, and legislators sitting on the Administrative Rules Review Committee have a chance to stop rules they feel went too far or didn't meet the intent of the law.  It's a last check and balance, to make sure agencies aren't ignoring the law or going beyond what the law allows. 
 
The entire rulemaking process takes a minimum of 108 days - and usually takes six months.  Legislators can allow for quicker rulemaking action if they give a state agency "emergency rulemaking authority" (and there are a few other situations where emergency rulemaking is allowed).  Here is a quick review of the administrative rulemaking process:
  • Step One: Notice of Rules - State agencies give the public notice of new rules or changes to existing rules.  Notices are found in the Iowa Administrative Bulletin, which comes out every two weeks. By law, agencies must give the notice at least 35 days before the rule is finalized, and the public must be given at least 20 days to submit written comments. While agencies frequently schedule public hearings on rules to give people a chance to speak, it is not required.   If requested by 25 people or more, or a group representing 25 or more people, the agency must hold a public hearing on a proposed rule. It is important to note that ANYONE can comment on rules that have been noticed.   Iowa law actually requires that an agency "“consider fully all written and oral submissions.”   While agencies are to give public comments full and fair consideration, it does not mean they have to make changes to the rules.  A state agency does not have to tell you why they did or did not make changes, but anyone can request that the state agency provide “a concise statement of the principal reasons for and against the rule it adopted, incorporating therein the reasons for overruling considerations urged against the rule."

  • Step Two: Adoption of Rules. The state agency must adopt the rules in their final format within 180 days, or withdraw the rules and start over.  A proposed rule is not effective until three things occur: 1) the agency adopts the rule in final form; 2) the adopted rule is filed with the Administrative Rules Coordinator; and 3) the adopted rule is published again in the Iowa Administrative Bulletin at least 35 days before it becomes effective.  The Administrative Rules Review Committee
Both the Governor and the Legislature review agency rulemaking on an ongoing basis. The Legislature’s Administrative Rules Review Committee (ARRC) meets monthly to review all proposed and “final” rules that are currently in process (including both steps 1 & 2). The public is welcome to attend these meetings and may make presentations or provide comment on noticed or final rules. The Governor’s Administrative Rules Coordinator also sits on the committee as an ex-officio non voting member.
 
Both the Governor and the Administrative Rules Review Committee can “object” to any rule. In effect an “objection” is a written opinion that either the Governor or the Committee finds a rule to be unlawful. If the rule is later challenged in court, the objection requires the agency to come forward an d to prove the validity of its rule. The Governor can stop any proposed rule up to 70 days after it has become effective. The committee can also choose to delay the effective date of a proposed rule pending additional  review by the Legislature itself.  This is called a "session delay."   When the Legislature comes back into session, it may take action to stop an administrative rule (through a joint resolution passed by both the House and Senate).  For more information:
  • Click here for information on the Administrative Rules Review Committee.
  • Click here for more on the rulemaking process.
  • Click here for the Iowa Administrative Bulletin.

 

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BILL DRAFTER MISTAKE LEADS TO CONFUSION ON SUPPORTED EMPLOYMENT INCREASE

At the end of session, we reported that the Legislature had added $750,000 to the Medicaid budget to pay for an increase in supported employment provider rates. Since that time, the Department of Human Services has decided to use those funds to support the Medicaid program, and not increase supported employment rates.  This situation is causing a lot of confusion among our readers, so we wanted to explain why this is happening, and what you can do about it.

  • Legislators increased the Medicaid budget by $750,000 to pay for a 20% increase in supported employment provider rates.  The additional money for this was added to the budget, and was listed on page 4 of the budget agreement spreadsheets and on page 37 of the final budget document, which states: "An increase of $750,000 to increase supported employment rates by 20.00% beginning January 1, 2016."

  • Unfortunately, in their rush to get the final budget bill done (staff had less than 24 hours to prepare it for final passage), bill drafters left out language that directed DHS to use these funds to increase supported employment rates.  So the money was added, and the intent was clear in the budget supportive documents, but the actual directive to use the money for the increase in provider rates was accidentally omitted.   While it is clear to most that the Legislature intended for these funds to be used for supported employment provider rate increases, DHS has decided to use these funds to support the overall Medicaid budget, which continues to operate at a deficit (that is, they don't have enough money to meet current needs, let alone pay for a provider rate increase). You can read DHS' complete response here.  The two co-chairs of the Health/Human Services Budget Subcommittee - Rep. Dave Heaton (a House Republican) and Sen. Amanda Ragan (a Senate Democrat) - have written a letter to DHS Director Chuck Palmer stating that it was their intent for these funds to be used to increase supported employment provider rates. You can read that letter here.

This is a very tricky situation.  It is a fact that the Legislature gave DHS the $750,000 and intended it to be used to increase supported employment provider rates.  It is a fact that they left out language telling DHS they had to spend the money that way.  It is also a fact that had the language been included, the Governor could have vetoed it.  We are not saying that he would have vetoed it - but not having that language in the bill took away the Governor's ability to choose whether to sign it into law or veto it.  If the Governor had vetoed it, it would have had the same result.  

If you are upset about this situation - contact your legislators and let them know.  They can call DHS or the Governor's Office on your behalf, and they can work hard to get this rate increase in the next year's budget when they return to the Capitol for the 2016 legislative session.  You can contact your legislators and the Governor easily (you don't even need to know their name) using our Grassroots Action Center.  Just click here to get started.

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HOUSE REPUBLICANS SELECT FIRST FEMALE SPEAKER OF THE HOUSE

Earlier this month, State Representative Kraig Paulsen of Hiawatha announced he would step down as Speaker of the House.  This is the highest leadership position in the Iowa House of Representatives, a post that has never been held by a woman.  That changed on Thursday (August 21) when House Republicans selected State Representative Linda Upmeyer of Garner as their new Speaker.  Rep. Upmeyer, who was the House Majority Leader, is not only the first female Speaker of the House, but is also the first to have a parent who also served in that position.  Upmeyer's father Del Stromer served as Speaker of the House in the early 1980s. 

Speaker Upmeyer attended and spoke to advocates attending Advocating for Change Day at the State Capitol in 2013.  The Speaker of the House is in charge of the House of Representatives, and is the lead negotiator for the House.  The Speaker decides which issues will be front and center each session and speaks for the House Republicans.

State Representative Chris Hagenow of Des Moines was elected House Majority Leader, the position Upmeyer left to become Speaker.  The House Majority Leader decides which bills will come up (or not come up) for debate each day, and is in charge of assigning bills to committee. 

State Representative Joel Fry of Osceola will become the new Majority Whip, a position that is as it sounds, the person who makes sure House Republican votes are there to pass priority issues.  Of course, leaders no longer use whips to make sure people vote the right way.  Rep. Fry has been very involved in the regionalization of the Mental Health and Disability Services system, has helped negotiate the Health/Human Services budget and is very involved in and familiar with Medicaid services and the long term care system.  In other words, he knows the issues many of you care about.

Finally, freshman legislator Representative Zach Nunn of Altoona was elected Assistant Majority Leader. Rep. Nunn was first elected in 2014, after having served our country in the military as a Major in the US Air Force.  He was deployed three times during his service, and served on the National Security Council.  Rep. Mat Windschitl of MIssouri Valley will continue to serve as Speaker Pro Tempore, and Representatives Lee Hein of Monticello, Jarad Klein of Keota, and Walt Rogers of Cedar Falls will continue to serve as Assistant Majority Leaders.

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INTERIM STUDY COMMITTEES APPROVED

The Legislative Council has approved three interim committees that will meet between now and the end of the year to review three issues that lawmakers thought needed more study.  They will make recommendations to the Legislature for consideration in the 2016 legislative session.  These committees will:

  • Evaluate the effectiveness of Iowa's reycling system, including bottle deposit laws and handling fees.
  • Look at school finance inequities.
  • Study the need for a non-smoking casino in Cedar Rapids.

In addition there will be a committee established in the near future to oversee the transition Medicaid to a managed care system.  You can find out more about these committees and when they will meet at https://www.legis.iowa.gov/committees.  While information about them is not yet posted here, it will be available soon so check back in a few weeks.

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MAKE YOUR MARK 2015!

ID Action is excited to host its second Make Your Mark! Self-Advocacy Conference October 7-9, 2015 at the Coralville Marriott in Coralville, Iowa. Register by September 16 to take advantage of several discounted offers.

The Conference will offer a series of sessions to help Iowans with disabilities become more active in their state and local communities by building their leadership, storytelling and advocacy skills. Here is a preview of a few session (visit www.advocacyuniversity.org for a full listing of sessions and descriptions):

  • Maureen Korte "Storytelling 101": Maureen Korte is a professional storyteller who will take you through the steps of writing your story (or someone else's) and explain how to use it to advocate for yourself and others. Maureen will teach you about the use of descriptive phrases, the development of plot and the emotional connections in stories. She will also teach you how to deliver a story in the most effective manner in order to make people want to listen.

  • Peter Leidy "Back By Popular Demand!" - This year we will bring back Peter Leidy. Peter has been learning from people with disabilities since 1983. He is a consultant, facilitator, listener, learner, improviser and speaker who focuses on personalized supports and community membership for people with disabilities. He also writes and sings songs about human services and those who find themselves connected to it. Learn more about Peter on his website (www.peterleidy.com) or watch his entertaining videos on his YouTube channel. Peter will discuss what it truly means to make your mark and how to unlock your creativity to get results and have fun through innovation and improvisation.

Attendees from last year’s conference shared what they learned and why attending the conference was beneficial to their lives. To hear from past attendees, visit www.idaction.org.

Early Bird Discount: Register by September 16, 2015, to receive $20 off the regular rate for individuals with a disability and direct care providers/family members attending with an individual with a disability. If you are a professional, you will receive $25 off the regular rate.

Group Discount: The ID Action conference is intended to bring Iowans with disabilities together to learn and grow as advocates. If you register with a group of five or more, you can take advantage of the group discount and receive your registration fees at a discounted rate. The mission of this conference is to assist participants towards engaging and organizing your community. This is your opportunity to work together to attend the ID Action Self-Advocacy Conference

Find out more information about the ID Action Self-Advocacy Conference and register at www.advocacyuniversity.org.

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FORUMS: They Aren't Just for Session!

That's right, legislators and other elected officials hold town hall meetings and public forums during the summer and fall months too!  Make sure you keep an eye on our Calendar to see when there are meetings in your area. The Governor, legislators, and our US Senators and Representatives all hold meetings during the "interim" months when our state legislature is not in session, and during breaks when Congress is not in session.  These are great opportunities to get to know your elected officials and ask questions about the issues you care about - find out more here

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