2016 ISSUE #7

After 110 days of fighting over budgets, water quality, medical marijuana, tax breaks for baseball fields, Medicaid managed care, fireworks, and fantasy sports, the Iowa Legislature finished up its work on Friday, April 29.  The legislative session was only supposed to last 100 days, but given the tight budget and tough issues discussed this year, ten days late is pretty good timing.

It was a bit touch-and-go there in the final days.  Democratic legislators couldn't work on Saturday (district conventions were held throughout the state).  House Republicans were to lose votes if they went another week; rumor was that if they didn't finish up on April 29, it would be a full two weeks before they would have the votes to pass any bills.  Top that with the Capitol parking lots being overrun with Garth Brooks fans who were told to park at the Capitol to avoid traffic jams downtown.  It was all a sign that it was time to get out of town.

This issue reviews where we landed on some of the big topics that were addressed this year: medical marijuana, autism services, regional mental health and disability services funding, Medicaid managed care oversight, and of course budgets.  Congrats to all of you that took action this year, no matter how small the act.  In the words of Garth Brooks, "There ain't nobody in this world that's gonna do it for you, so do what you gotta do."

Here's to those of you that did.

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Legalizing marijuana to treat medical conditions has gotten a lot of attention in the disability community.  Currently, Iowa law allows people with a severe form of epilepsy to use the oil that comes from medical cannabis to treat seizures, but they have no legal way of getting it. Advocates for the use of medical cannabis want to change Iowa law to expand the conditions that can qualify for use, and allow for the legal purchase of the oil (called cannabidiol) from authorized Iowa distributors. 

Advocates have presented the science behind the cannabidiol to several legislative committees, saying it has been used to successfully treat returning veterans with post-traumatic stress disorder, individuals with MS, and people who are in pain because of terminal cancer, ulcerative colitis, and other diseases.  Advocates held ralies, gave impassioned testimony, and pulled out all the stops to attempt to get legislation passed.  Ultimately all efforts failed, but advocates vow to return next year.

In the final week of session, Rep. Zach Nunn of Bondurant attempted to pass a compromise (amendment H-8290) that would have expanded who could use the cannabis oil, but still did not allow its purchase in Iowa.  While opportunities would exist to partner with other states who would produce the oil (Minnesota was mentioned), access was still a barrier.  In the end, that was one of the reasons that many supporters ended up opposing the legislation. It failed 31-63.

The day before session ended, Rep. Bob Kressig of Cedar Falls tried a little-used rule that would allow legislators to vote on a bill that had not yet passed out of committee. This "Hail Mary" effort to try to revive the issue in the final days of session failed 44-54.  

Many thought this was the year for expansion of Iowa's law, after a high-profile Republican sponsored legislation. Rep. Peter Cownie of West Des Moines ultimately didn't have the votes to pass the bill. The Iowa Senate passed a bill last year 26-19, and it's chief advocate Sen. Joe Bolkcom of Iowa City has vowed to continue this fight. You can see a list of how each legislator voted on these bills (House & Senate) here.

According to an Des Moines Register poll, 78% of Iowans support the use of cannabis for medical purposes.  Opponents say they are fearful of the quality of the product, since its purity is not regulated as other medicines, and suggest waiting until the FDA finishes its clinical trials and makes a decision on whether to allow it to be prescribed as any other medicine. Supporters say people who are suffering need help now.  You can weigh in on your thoughts by contacting your legislators this summer and letting them know what you think!

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Parents of children with autism have long advocated for legislation that requires insurance plans pay for the screening, diagnosis, and treatment of autism spectrum disorders, including applied behavioral analysis (ABA for short).  A bill that would have done this (Senate File 2254) failed to pass out of House Commerce Committee again this year. The bill did make it further than before, having passed with huge bipartisan support in the Senate (41-7).  You can see how your Senators voted here.

While this bill did not pass, signficant changes were made to a state program that was created in 2013 to help families whose insurance plans would not pay for these services. The state appropriated $2 million each year to the Autism Support Program to help families, but advocates say the program is too restrictive and too complicated to access.  In the Health/Human Services Budget Bill (House File 2460), the following changes were made to address these issues:

• Children under fourteen will now be eligible for program funds.  Currently the age limit is nine.

• Families with incomes up to 500% of the federal poverty level will be eligible for the program.  Current cap is 400%.
  
  
• Requires families with incomes at or above 200% of the federal poverty level to have pay for up to 15% of the costs. Currently that cost-share cap is 10%.
  
  
• Appropriates $2 million for this next fiscal year, but also states that any funds not yet spent in the current fiscal year can be retained.  So unspent program funds will remain, and can be used to fill needs.
  
  
• Requires the Department of Human Services to report on the number of people applying for the program, funding awarded, administrative costs, and recommendations for the program.

In addition, a portion of the funds is used to help provide grants to individuals getting certification in applied behavior analysis (ABA). This was done in increase the number of people providing ABA services in the state, because access wasn't just about coverage but also about provider availability.  The bill changes the program to allow grants to people who receive training in or out of state (currently only Iowa schools eligible).  Iowa residents still have priority in receiving grants.  The program is changed to require that those receiving grants agree to practice in Iowa for a period of time (up to four years), and agree to supervise others that are going through training during this time.

To access program funds, families still must show that they have been denied insurance coverage, and getting that documentation has been very difficult for some families.  The Department of Human Services and autism advocates plan to work on this to find a way administratively to ease this burden.

Requiring insurance coverage for this will be an issue again in the 2017 legislative session, so if this is important to you, make sure you talk to your legislators over the interim.

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The Legislature finished its work this year without passing a permanent fix for funding the state's regional mental health and disability services (MH/DS) system. Three years ago, the Legislature redesigned the way counties delivered non-Medicaid mental health and disability services.  In an effort to make services more uniform throughout the state and use tax dollars the most efficiently as possible, legislators required counties to operate as regions, set "core services" that all regions were to deliver, and outlined cost-saving "additional core services" that were expected to be developed over time. 

During the redesign, the state agreed to allow all counties within a region to spend up to $47.28 per person.  That was called the "per capita expediture limit."  It basically equalized the amount of money each region would spend per person on services.  About half of Iowa's 99 counties lowered their taxes to the $47.28 limit.  The counties that could not raise their taxes to the $47.28 limit were to receive state dollars to make up the difference. So if you were in a county whose property tax rates were frozen at $40 per capita, the state promised to give you $7.28 per residentt to make up the difference. 

That happened the first year, when legislators appropriated $30 million.  The second year (last year), legislators decided only one county needed money ($2 million was given to Polk County).  This year, two counties were given money Polk ($2.5 million) and Scott ($500,000).  Polk County estimates its shortfall to be $7.1 million, and Scott County says it needs $1.6 million.

The Iowa State Association of Counties (ISAC) had proposed a fix that would have allowed all counties to raise property taxes up to $47.28 per person.  No state funding would be needed, locally-elected county supervisors would make decisions on property taxes, and the state would continue to approve county/regional plans for services.  That bill (Senate File 2318) was sponsored by Sen. Mark Segebart, a former Crawford County Supervisor. While that bill passed out of the Senate Ways & Means Committee with both Republican and Democrat supporters, it was never debated.

Legislators did pass House File 2456, which held property taxes for MH/DS services down at the $47.28 level for another year.  As you might recall, 45 counties reduced taxes to that $47.28 level in redesign.  Without this extension, those counties could have raised property taxes higher than that level (although all said they would not). The only group supporting this bill was Farm Bureau; it did nothing to permanently fix the problems in the funding of the regional system.

Legislators have promised to act on a permanent and sustainable funding system early next legislative session, but many advocates are skeptical and say they've heard that promise before.  This year, legislators asked the Iowa Farm Bureau (the only opponent of the fix proposed by the counties) and the Department of Human Services to help come up with a solution that meets the need while making sure proper controls are put on property taxes. 

There was a big group of supporters of the ISAC proposal this year: Brain Injury Alliance of Iowa, Child & Famliy Policy Center, Easter Seals Iowa,  Epilepsy Foundation, Eyerly Ball Community Mental Health Center, Iowa Annual Conference of the United Methodist Church, Iowa Association of Area Agencies on Aging, Iowa Association of Community Providers, Iowa Behavioral Health Association, Iowa Coalition Against Sexual Assault, Iowa County Attorneys Association, Iowa Developmental Disabilities Council, Iowa Hospital Association, Iowa Police Chief Association, Iowa Primary Care Association, Iowa Psychological Association, Iowa State Police Officers Council, Iowa State Reserve Law Officers Association, Iowa State Sheriffs & Deputies Association, League of Women Voters of Iowa, National Association of Social Workers (Iowa Chapter), National Multiple Scelrosis Society (Upper Midwest Chapter), Orchard Place, United Way of Central Iowa, Veterans' National Recovery Center, and Visiting Nurse Services of Iowa.

For those of you that care about this issue, make sure you talk to your legislators this summer to remind them of their promise.  Ask them how they are coming with a permanent solution, and ask them to keep you in the loop as progress is made!

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One issue clearly dominated discussion at the Capitol this year - Medicaid managed care.  Legislators were deeply divided on on this issue, but all agreed good government oversight was needed to make sure the Medicaid system continues to meet the needs of the Iowans it serves, and that managed care organizations (MCOs) are held accountable.  Legislators were finally able to agree on three things:

• Legislators needed to have good information so they can decide if future changes are needed to the system.
• Stakeholders needed to have meaningful input so problems are addressed quickly, and successes are highlighted.
• Strong government oversight is needed to protect the $1.3 billion in state tax dollars being spent on Medicaid annually.

Legislators put this Medicaid managed care oversight compromise into the Health/Human Services Budget (House File 2460):

        First, stakeholders will have many opportunities to have their voices heard.

• The Council on Human Services, Medical Assistance Advisory Council (MAAC), and hawk-I Board are required to submit any minutes to meetings where managed care is discussed to the Legislature for review.
  
  
• DHS is to compile the input and recommendations from stakeholders and Medicaid members attending public meetings being held around the state monthly (these meetings started in March - check here for others).
  
  
• Requires these monthly stakeholder meetings to continue through December 2017 (but the meetings will change to bimonthly on March 2017).  DHS is to encourage MCO attendance at the meetings.
  
  
• Expands the MAAC to include a public member as co-chair, and adds 10 members of the public to the council (including consumer group representatives, family members, and Medicaid members).  Also adds the long-term care ombudsman as a non-voting member, and a hawk-i board member as a voting member.

• Continues the 10-member Legislative Health Policy Oversight Committee and revises its scope to require them to meet at least twice outside of the legislative session to continue oversight for Medicaid managed care, ensure effective and efficient administration of the program, address stakeholder concersn, monitor program costs and expenditures, and make recommendations.

• Requires Council on Human Services, MAAC, hawk-I Board, MH/DS Commission, and Office of Long-Term Care Ombudsman all regularly review and report on their Medicaid managed care duties (and submit an executive summary annually on November 15).
  
  
• The hawk-I Board is to monitor the capacity of MCOs to appropriately meet the needs of kids.

        Second, Medicaid members will be guaranteed certain rights legislatively.

• Benefits must continue during an appeal if requested (but the MCO can recover costs for those services if the appeal is not successful; the MCO is required to let the person know upfront if that is a possibility).  Providers are allowed to appeal on behalf of a Medicaid member.
  
  
• Occupational therapy is added as a required service for the children's health insurance program (hawk-I).
  
  
• MCOs must attempt to negotiate single-case agreements with a member's out-of-network (or out-of-state) provider to provide continuity of care.  If a provider of a medically necessary service is not available within the MCO network, the MCO must (at the request of the Medicaid member) attempt to negotiate a single-case agreement with an out-of-network provider, even if the Medicaid member does not currently have a relationship with them.

        Third, legislators will be given data on a quarterly basis to make sure consumers are protected, outcomes are
        achieved, and program integrity is maintained.  This information will be available to the public and posted on a public
        website, and the Health/Human Services Budget Subcommittee is required to devote at least one meeting during the
        legislative session to a review of these reports.  The information that will be reported in three sections:

• Consumer Protection: Legislators wanted to find a way to track whether members continue to have access to services, and compare how MCOs were doing with each other. This information includes: member enrollment/disenrollment; member grievances/appeals; member call center performance; prior authorization denials/modifications; provider network access (gaps in provider coverage); care coordination and case management (ratio of members to care coordinators/case managers, and average number of contacts made with members during reporting period); level of care and functional assessments; population-specific reports for children, adults, special needs, behavioral health, elderly; and number of individuals served on HCBS waivers by waiver type and changes to waiting lists.
  
  
• Outcome Achievement: Legislators want to make sure MCOs are meeting the objectives of improving the quality of care and achieving outcomes for Medicaid members.  Some of the types of data to be collected include claim processing (% paid, denied, disputed, ten most common reasons for denials, timelineness); payment of claims; member health outcomes (including quality measures in behavioral health, children's health, prenatal and birth outcomes, chronic condition management, adult preventive care, value index score performance); consumer satisfaction surveys; and utlization information (ER visits, readmisions).
  
  
• Program Integrity: A significant amount of data will be included to make sure the proper controls are put in place to prevent, detect, and eliminate fraud, waste and abuse.  All MCOs had to submit a program integrity plan as a part of their contract with the state, so this portion of the report will help make sure MCOs are following that plan, and see if some plans are more effective than others in this area.

Medicaid managed care will continue to be an issue for legislators, and many are planning to hold their own input sessions.  Watch our calendar for new meetings on Medicaid managed care here.  Make sure you continue to let your legislators know how the transition is going for you - and make sure you share your success stories as well as problems you encounter.   The only way legislators can create a system that works is to know what is working, as well as what is not working.

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The budget the Legislature just passed this session is for fiscal year 2017, which begins on July 1, 2016 and pays for services and programs through June 30, 2017.  The following items were included in the budgets passed by the Legislature this year, but the Governor has not yet signed them.  The Governor can “line-item veto” budgets, which means he can veto some appropriations, while signing others into law.  The Governor has until May 29 to decide to sign or veto bills. You can read more about each budget in our Bill Tracker here.

• $15.1 million (1%) increase for Medicaid - total funding is $1.32 billion.  This includes a cut of $16.8 million to DHS for undefined “process improvement savings.” Legislators were unable to find out what these "process improvements" were, but DHS is prohibited from implementing cost-saving changes that would align Medicaid reimbursement for physicians with Medicare rates, and changes for people eligible for both Medicare and Medicaid (dual eligibles).  DHS is required to report to legislators any cost containment strategies and “process improvements” made.
  
  
• $67 million was added to the current year's Medicaid budget (fiscal year 2016), and DHS was allowed to move unspent money around to make up for the remaining $15 million shortfall.

• $100,000 increase for an additional long-term care ombudsman to provide assistance and advocacy to persons receiving Medicaid waiver services.
  
  
• $150,000 increase for the Department of Public Health's brain injury program for brain injury resource facilitator services and brain injury service provider recruitment and training (total $1.04 million).
  
  
• $86,000 increase to the Children at Home program for expansion to new service areas (the Family Support Subsidy is reduced by $4,650 as the program continues to phase out and transition to the Children at Home program).
  
  
• $1 million to increase HCBS provider rates by 1%, and $1 million to increase home health agency rates by 1%.
  
  
• $200,000 for a new contract with the College of Direct Support to provide internet-based training for mental health and disability services providers.
  
  
• $2 million to reduce HCBS waiver waiting lists.  DHS is required to report on the impact of changes in the HCBS waiver supported employment and prevocational services (report due 12/15/16).
  
  
• $500,000 for Eastern Iowa Mental Health Region (Scott County) & $2.5 million for Polk County Mental Health Region. DHS is required to report on the progress of MH/DS redesign, including identifying any challenges facing redesign; governance, management, and administration; best practices, including evidence-based practices; availability of, access to, and provision of initial core services and additional core services to and for required core service populations and additional core service populations; and the financial stability and fiscal viability of the redesign.
  
  
• $300,000 for the development of children's mental health crisis services, and establishment of "learning labs" to review emerging collaborative efforts that improve the well-being of children with complex needs and their families.  The bill also creates the Children's Health & Well-Being Advisory Council within the Department of Human Services to continue the work of the same-named work group.
  
  
• $100,000 new appropriation to Department of Public Health to to develop recommendations for a broader, more systematic and strategic workforce initiative, which may include a comprehensive study of workforce program needs and the establishment of an advisory workgroup (due 12/15/16).

As noted in other articles, the budget:

• Continues $2 million in funding for the Autism Support Program, retains any funds unspent at close of fiscal year, and makes changes to program eligibility (click here for more details).

• Adds strong consumer protections and government oversight of the Medicaid managed care system (click here for details).

Most other areas of the budget remained the same as the current year - vocational rehabilitation, Entrepreneurs with Disabilities program, Newsline for the Blind, independent living center grants, and farmers with disabilities program.  Instead of cutting whole programs, the Administration & Regulation Budget (Senate File 2314) opted to cut all agencies by .5% - including the Office on the Status of Persons with Disabilities and Office of Deaf Services in the Department of Human Rights. 

It is important to note that, contrary to what you may have read in news reports recently, the Legislature did not include an increase for supported employment in the budget passed this year.  As you might recall, last year the Legislature appropriated (and the Governor signed) a $750,000 increase for supported employment providers, but forgot to include the language that stated how that money was to be used.  While it was included in budget document descriptions, it was not specifically outlined in law, and therefore was not implemented. 

On a final note - the Legislature passed a new budget process for next year, requiring all state agencies to include supporting data and explanations when they submit budget requests to the Department of Management, and the Department of Management is then required to consult with the non-partisan Legislative Services Agency so information about each budget request is available to legislators.  That likely means all programs and funding requests will receive closer review.

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It's hard to believe it's already May. Soon it will be Memorial Day, and June will be here before you know it.  We just wanted to remind everyone that there is a Primary Election scheduled for Tuesday, June 7, 2016.  Eight state legislators are facing primary opponents:

• Rep. Mary Gaskill (D-Ottumwa)
• Rep. Stan Gustafson (R-Cumming)
• Rep. Jake Highfill (R-Johnston)
• Rep. Dan Kelley (D-Newton)
• Rep. Jarad Klein (R-Keota)
• Rep. Kevin Koester (R-Ankeny)
• Rep. Brian Meyer (D-Des Moines)
• Rep. Jo Oldson (D-Des Moines)

There are also primary races in other areas, including primaries to select the Democrats running against US Senator Chuck Grassley, US Representative Rod Blum, and US Representative David Young (and David Young himself has a primary). There is also a hotly contested Republican primary between US Representative Steve King and State Senator Rick Bertrand, and Democratic primary for State Senator Dick Dearden's seat - his daughter Pam Dearden Conner faces off against labor lawyer Nate Boulton. 

As you can see, there are a lot of primary challenges out there, and every vote will count.  Primaries typically have lower voter turnout than general elections, so vote counts can be close.  Here's some information you'll want to know about the June 7 Primary Election:

• Candidate lists are available here.
  
  
• You have until Friday, May 27 to pre-register to vote. You can check to make sure you are registered to vote here. You can register to vote on primary election day, but you will need to bring with you proof of identity and proof of residency.  Click here for more information about same-day voter registration.
  
  
• You can now request an absentee ballot be mailed to you, or vote early in person at your county auditor's office.  You can request an absentee ballot until 5 pm on Friday, June 3 (but don't wait that long, as there isn't much time to get it mailed to you, and have it back in the office in time to be counted).
  
  
• You can find lots of information online at the Secretary of State's website here, or you can contact your local county auditor for more information.
  
  
• The polls will be open from 7 am to 9 pm on Tuesday, June 7, 2016.  As a reminder, you must be a registered Republican to vote in the Republican primary, and a registered Democrat to vote in the Democratic primary.  You can change your party choice at the polls, and change it back after if you want.  But you must be registered with the party to vote in the primary.

There will be a lot of opportunities between now and the General Election in November to meet the candidates for elected office.  Take advantage of campaign events or debates; introduce yourself to the candidates and ask them for their positions on the issues important to you.  If you are not happy with the way things are - get involved and help change them. 

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Do you want to make a difference in the lives of Iowans with disabilities? Consider joining the Iowa Developmental Disabilities (DD) Council! 

The DD Council is in need of individuals with developmental disabilities and family members to serve as members. You can find out more information and download an application at the DD Council’s website, http://iddcouncil.idaction.org/about/application/. Appointments to the Council are made by the Governor’s office each June so apply soon!

If you have any questions, please contact the DD Council office at (800) 452-1936.

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During the legislative session, you receive newsletters every other week.  Now that the session is over, we will return to our every other month schedule.  However, you will receive one more newsletter after the Governor has taken action on bills, and we have results from the June 7th primary election.  Be sure to watch Facebook and website for updates between issues!

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Keep track of bills that may impact the lives of individuals with disabilities in our Bill Tracker.  Bills listed as "active" have passed and are waiting for the Governor to take action.  By law, the Governor has 30 days from the end of session to sign bills (May 29).  Bills listed as "inactive" didn't make it and will not become law.

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Now that the legislative session is over, there will be fewer public forums and town hall meetings with legislators.  However, we will continue to track these opportunties, as well as meetings to discuss Medicaid managed care and other opportunities for public input.  These are excellent opportunities for your voice to be heard. Click here to find a public forum, town hall meeting or other event near you.

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