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Legislature Approves Plan to Expand Access to Health Care

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One of the most difficult issues for Iowa lawmakers this year was tied to the very political "Affordable Care Act" (also known as "ObamaCare").  The federal Affordable Care Act (ACA) allowed states to expand their Medicaid programs to cover any person earning up to 138% of the federal poverty level. That's an annual income of $15,856 for a single person, or $32,500 for a family of four.  Before the ACA, a person had to fall into a specific category in order to receive Medicaid services, such as having a disability, having a child in the home, being pregnant, or being over age 65.

Typically, the Federal government pays for about 60% of the costs of Medicaid.  States that chose to expand Medicaid would receive an "enhanced Medicaid match" - with the Federal government picking up 100% of the costs for the first three years, then slowly lowering that match until it becomes a permanent at 90% in 2020 and beyond.  So Iowa would never have to pick up more than 10% of the costs of this expansion.

Prior to the start of session, Governor Terry Branstad rejected the idea of expanding Medicaid, saying it is too costly a program, does nothing to improve the health status of those in it, and the Federal government can't be trusted to live up to its funding commitment..  Most of the Republicans in the Iowa Legislature agreed, and liked the Governor's alternative plan (Healthy Iowa Plan) that would cover people with a combined approach to expand Medicaid services to some, and cover others with private health insurance plans. The plan would have been paid for with the traditional mix of state and federal dollars (40% state, 60% federal), including $40 million in county mental health and disability services property taxes.

In the end, the Legislature agreed to create a "Iowa Health and Wellness Plan" that used the Senate Democrats' financing plan (100% federal match) and used the Governor's health incentives and combined private insurance-Medicaid approach. The final agreement passed by the Legislature:

  • Creates the Iowa Health and Wellness Plan to provide health coverage for individuals with incomes up to 138% of the federal poverty level.     

    • Individuals with incomes up to 100% of the federal poverty level will receive services through Medicaid with a benefits package modeled after the state employees' health plan.  You can see the differences between those plans here.    

    • Individuals between 101-138% of the federal poverty level will be covered by a private insurance plan on the state's "insurance exchange" (although we do not know if people will choose between plans, or one will be chosen for them).  Their plans are paid for by the program if certain conditions are met.
  • People earning more than 50% of the federal poverty level will be charged monthly premiums, which are waived the first year.  So the coverage is "free" in this first year. 
    • If a person earning more than 50% of the federal poverty level completes the required preventive health services during that first year, premiums are waived for another year.  That continues as long as the person completes these prevention requirements annually. 

    • If a person does not meet the prevention requirements, they will have to pay monthly premiums to keep their coverage, but these are limited by the federal government (premiums and other cost-sharing requirements can't be more than 2% of a person's annual income). Preventive services include things like annual physicals, smoking cessation, diet counseling, mammograms, regular exercise, etc. (but a person isn't required to do all of these things - what is required will be outlined in DHS rules later this year).
  • Allows people to choose their doctor (called a "medical home") - the provider network includes all Medicaid providers and any providers that are a part of an approved Accountable Care Organization. 

    • If a person does not choose their medical home, DHS will assign them to one.  This "medical home" becomes the person's care coordinator, focusing on "whole person" health.  They are required to provide care coordination that provides links to community and social supports that help a person maintain a healthy lifestyle.  

    • Gives members a choice of providers within the network, but allows DHS or an Accountable Care Organization to limit that choice if a person is over-using the system, or the person's health condition would be better managed by another provider.
  •  Enrollment for the plans begins in October, but coverage will not begin until January 1, 2014.  

The Iowa Health and Wellness Plan passed the Iowa Legislature with bipartisan support - 80-17 in the Iowa House and 26-24 in the Iowa Senate (you can see how your legislator voted here). The plan requires a waiver from the Federal government because it is not a straight "Medicaid expansion" (which would have simply extended our current Medicaid program to people earning up to 138% of the federal poverty level).  The Iowa plan does a few things that trigger a waiver:

  1. Charges premiums.  Medicaid does not typically allow premiums to be charged (co-pays are allowed, but not premiums). Even though these are waived in the first year, a person must comply with certain wellness activities which are not yet identified in order to be waived in subsequent years.  Some organizations say this could cause disruption in coverage for some people, which means their access to health care will be limited.  Others say this is an important part of encouraging personal responsibility.

  2. Splits the coverage between Medicaid and private insurance plans.  Those earning up to 100% of the federal poverty level become eligible for a more limited Medicaid plan (one that matches the state employee benefits package).  It is unclear at this point as to whether these plans will have full mental health and substance abuse parity and include transportation (the existing state employee health benefit plan does not, but federal law requires such coverage).  Those earning between 101-138% of the federal poverty level get their coverage from a private insurance plan and their benefits may or may not be equal to those in the first group.  it is also unclear as to whether this group will get a choice in providers on the Insurance Exchange, or if that choice will be made for them.

  3. Allows Medicaid to assign providers to some.  The Iowa Medicaid Enterprise is allowed to limit a person's choice in health care provider if they are over-using the system, or another provider would improve heatlh outcomes for that person.  Accountable Care Organizations are allowed to do the same, with Medicaid approval, for people enrolled in their programs.

States (like Iowa) that are requesting a waiver from certain Medicaid rules are required to hold hearings to allow public comment on the plan.  Four meetings have been scheduled, but the plan needs to be revised to reflect legislative action.  You can read more about the plan, and updates to the public meeting schedules here.

If you would like to know more about the plan or comment on it, you can do so in three ways:

  1. ATTEND A PUBLIC HEARING.

    June 3, 2013 at 9:00 am (DES MOINES)
    River Place - Room 1, 2309 Euclid Avenue

    June 3, 2013 at 1:00 pm (SIOUX CITY)
    Wilbur Aalfs (Main) Library - Gleeson Room. 529 Pierce Street

    June 3, 2013 at 1:30 pm (DAVENPORT)
    Scott County Administration Building, 1st Floor Board Room (inside building lobby), 600 West Fourth Street

    June 4, 2013 at 1:00 pm (CEDAR RAPIDS)
    Dummermuth Intergenerational Center, Four Oaks Bridge - The Great Room, 2100 First Avenue NE

  2. SEND IN WRITTEN COMMENTS OR QUESTIONS (due January 17).
    Deanna Jones
    Department of Human Services/Iowa Medicaid Enterprise
    100 Army Post Road
    Des Moines, Iowa 50315

  3. EMAIL YOUR COMMENTS OR QUESTIONS (due by June 17).
    dhsimehealthyiowaplan@dhs.state.ia.us

This is really the first step in the waiver request process.  States are to create these opportunities for public input, and use these comments to improve their waiver application. States must show how they addressed the issues raised by the public in their application to the Centers for Medicare & Medicaid (CMS).  Once the state submits its waiver application, the public will have another opportuniity to submit comments for CMS consideration. 

The Federal government has taken both rounds of public comments very seriously when deciding whether to approve or deny these ACA-related waivers.  They can approve a plan entirely, reject a plan entirely, or approve parts of the plan.  So, for instance, if they object to the premiums, they can approve the plan, but tell the state that it is not allowed to charge premiums. The state would have to come back next legislative session to fix it, but it wouldn't affect the plan going into affect January 1, 2014.  Similarly, if they decide transportation must be a covered service, they can accept the Iowa plan contingent upon that service being included.

___________________________________________________________________________________________________
TIPS TO REMEMBER WHEN OFFERING PUBLIC COMMENT:

  • Remember your comments are public record, and can be viewed by the public and the press.
  • Consider sending your comments to your legislators and the Governor.   
  • Tell a personal story to emphasize your points, if you are comfortable doing so publicly.
  • Suggest changes if you are concerned about something that is in the plan.
  • You can find more information on the plan here. For background, you can find more here.