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It's tough for even the most experienced legislators to read through a 31-page Medicaid bill, let alone those of us that never went to law school.  We wanted to give you some highlights of the bill, so you know what's in it, and can decide whether its a good bill or one that needs more work.  The bill does three basic things:

  1. Makes sure there is good government oversight of the Medicaid managed care system, and strong stakeholder involvement.  This includes requirements to collect and analyze data to make sure the state is getting the results it expects, creation of an interagency work group to make sure state agencies are working together, and expanding the role of various state councils to make sure stakeholder input is received and addressed. Some of the ways this is done:

    • A new inter-agency Program Integrity Workgroup to make sure state agencies are working together and not duplicating efforts.  Includes the Insurance Commissioner, State Auditor, Attorney General, Office of Long-Term Care Ombudsman, Medicaid Director & Medicaid Bureau Chiefs, and the Department of Inspections & Appeals' Medicaid Fraud Unit.  This workgroup recognizes that many state agencies work with Medicaid populations, and have roles in both the new and old Medicaid system; this makes sure they are all communicating and working together.

    • The State Office of the Long-Term Care Ombudsman is given more responsibility for oversight of the managed care system, authorizing them to see MCO eligibility determination decisions as well as lists of people whose service levels have changed or have been dropped from plans, all in an effort to help them perform their function as an independent citizen aid for individuals recceiving Medicaid services under managed care.  These changes also allow the ombudsman to draw down federal money to help pay for this expanded role.

    • The existing Patient-Centered Health Advisory Council is also tasked with more responsibility to collect and analyze data, and make recommendations tha will improve health outcomes of Medicaid members. This Council, which is housed in the Iowa Department of Public Health and came about during health care reform, will look at funding available to support prevention and wellness, look at Iowa's health workforce needs and recommend strategies to address shortages, and look for opportunties to integrate or coordinate various service delivery systems (such as public health agencies, aging and disability services agencies, MH/DS regions, child welfare and social services regions). 

    • The 43-member Medical Assistance Advisory Council will meet more frequently, the Office of the Long-Term Care Ombudsman is added to the council (and its executive committee), and four subcommittees are created.  Stakeholder Safeguards Subcommittee (to guarantee ongoing stakeholder engagement and feedback on issues); Long-Term Services and Supports Subcommittee (to develop outcomes for long-term care services and supports, address issues related to HCBS waiver waiting lists, ensure HCBS services are delivered consistent with Olmstead principles and focused on a sustainable person-centered approach); Transparency, Data, and Program Evaluation Subcommittee (makes sure the right data is collected, analyzed, and action taken as needed); and the Program Integrity Subcommittee (make sure Medicaid has the resources necessary to properly oversee managed care). 

    • MCO rates and administrative fees are limited.  Under this bill, the capitation rates paid to MCOs (the amount of money they get for each Medicaid member) cannot be increased by more than 3% annually, and no more than 5% every two years.  Those increases are only allowed if the Legislature approves them.  Also under the bill, MCOs must spend at least 88% of its funds on services and quality improvement. They are limited to 12% administrative fees. 

  2. Makes sure there are resources to invest in improvements to the system by creating a Medicaid Reinvestment Fund.  Money from overpayments to MCOs, savings achieved by moving people from institutions into community settings, incentive funds that MCOs couldn't collect, and other savings are deposited into this fund.  Legislators will have the final decision on how to use this money, but it can be used to help increase provider rates, provide HCBS as needed to rebalance the system, reduce the HCBS waiver waiting list, fund systems that will protect the interest of Medicaid members and maintain an adequate provider network, pay for the services of the long-term care ombudsman, address workforce needs, and support innovation in public health agencies, aging and disability resource centers, MH/DS regions, social services, and child welfare providers.

  3. Amends the Managed Care Organization (MCO) contracts to protect consumers, preserve provider networks, make sure the unique needs of children are addressed, and assure MCO accountability.  By far this is the most controversial piece of the bill, forcing all MCOs to sign contract amendments that would require them to:
    • Continue a Medicaid member's benefits during an appeal.
    • Continue same services, at same levels, with same conditions as were authorized before managed care.
    • Monitor and report reductions, suspensions, and terminations in services to Medicaid members.
    • Report on HCBS waiver waiting list changes.
    • Treat people with chronic conditions or long-term supports and services the same as other populations when it comes to service authorizations (i.e. not discriminate against them).
    • Allow a Medicaid member to choose to keep their existing case manager beyond the six-month transition.
    • Guarantee all care coordination and case management are delivered by appropriately trained professionals in a conflict-free manner.
    • Maintain existing provider-member relationships for at least one year.
    • Provide access to dental coverage.
    • Account for decisions made (no automatic or arbitrary denials of service).
    • Maintain lists of complaints and appeals, which will be made public (not details - just raw numbers).
    • Survey members for satisfaction.
    • Address needs of children and maintain child health panels to make sure policies reflect this.
    • Cover early intervention and prevention strategies for children.
    • Provide special incentives for innovative and evidence-based preventive strategies for kids.
    • Include coverage for children that reflects what is in state law, and is no more restrictive.
    • Monitor the quality of children's services, including the provision of EPSDT benefits.
    • Make sure savings achieved through Medicaid managed care does not come at the expense of further reductions to provider rates.
    • Reimburse providers at reasonable rates that are consistent with what is in Iowa law (no lower).
    • Keep rates the same for the entire contract period.
    • Use the same process as all MCOs (drug lists, prior authorization, utilization management).
    • Give providers up to 365 days to submit claims.
    • Pay hospitals at rates required in law, and pay critical access hospitals for 100% of their costs.
    • Work hard to include safety net providers (free clinics, rural health clinics, community health centers, etc).
    • Make sure costs are not shifted to other non-Medicaid providers (MH/DS regions, aging and disability resource centers, child welfare providers, pulbic health agencies, etc). 
    • Give all existing Medicaid providers the chance to be a part of their network (at rates in law).

The subcommittee assigned to this bill is: Sen. Amanda Ragan, Sen. Liz Mathis, Sen. Joe Bolkcom, Sen. Mark Segebart, and Sen. David Johnson.  You can see the entire committee here.