2015 INFONET #1
Issue 1, 1/24/2015
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Articles in This Issue:
- SESSION BEGINS
- MEDICAID MANAGED CARE PLAN SURFACES
- MANAGED CARE GUIDING PRINCIPLES
- CAPITOL DAY GRANTS AVAILABLE
- PUBLIC FORUMS LIST
- BILL TRACKER
The 2015 legislative session began on Monday, January 12 with the swearing in of 21 new legislators and 128 returning legislators. At this time, one seat remains open (House District 23). If you live in Fremont, Mills, or most of Montgomery County, this is your House District! The special election has been set for February 10. Here are a few things you need to know if you live in that district:
- No Democrat has announced in this very heavily Republican district.
- The Republican candidate is David Sieck, a Mills County farmer and past Iowa Corngrowers Association President.
- People in this district can vote at the polls from 7 am to 9 pm on Tuesday, Feburary 10.
- You must be registered to vote by Friday, January 30 (or you will have to follow same day voter regislatration instructions).
- Absentee ballots cannot be requested after Friday, Feburary 6 (and they must be returned with a postmarked on or before Feb. 9).
- For more information about this race, go to: http://sos.iowa.gov/elections/voterinformation/sh23special.html.
Also last week, the Governor laid out his priorities for the year in his "Condition of the State" speech. Top on his list for the year - making Iowa a bully-free state. For the last several years, the Governor has been unsuccessful in his attempts to help our schools end bullying. Students with disabilities are 2-3 times more likely to be bullied. In fact, one study shows that 60% of students with disabilities reported being bullied regularly, compared to 25% of all students.
The Governor also released his budget last week, but all increases in the budget are to fufill promises already made to schools and local governments (property tax cuts), and pay for part of the shortfall in Medicaid (much of it caused by loss in federal funds due to a formula change in the Medicaid program). The state's Medicaid progam is facing some signficant budget problems. First, Medicaid is short $68 million for the current fiscal year. The Governor does not recommend funding for this, so legislators want to know what the impact of that decision will be on people receiving (and waiting for) Medicaid services. In addition, the Governor underfunds Medicaid for next year by $200 million and closes two of the state's mental health institutes (Mt. Pleasant and Clarinda).
In addition, the Governor is recommending no funding for MH/DS regions – a cut of $30.6 million. He is also scooping the $10 million “offset” repayment for Medicaid (these funds were part of the savings to regions because of the Iowa Health and Wellness Plan picked up costs previously paid by regions). Iowa law currently directs the Legislature to reinvest those "offset" funds into the regional services system. So regions will need to pay for non-Medicaid services to Iowans with disabilities using only their local tax levies (which are capped) and fund balances (extra money they have in the bank).
One reason the Governor may have for cutting services - a few regions have a lot of money sitting in the bank, some counties are lowering their local property tax levies, and some regions have enough money in the bank to cash-flow their programs for months without state money. Regions say it took a long time to move from a 99-county system to a regional system, it took a long time to find providers and staff to provide new core services, and state funding is unpredictable.
Regions say it's like buying a house. You need to save for a down payment, so it may look like you have a lot of money in the bank. If you were not sure you'll have a job in a year, you will probably wait to buy the house until you know that you will have a steady paycheck to help pay your monthly house payment. That's what regions say they are doing - they saved money to bring new core services online, but they are worried about hiring staff and beginning the service if they aren't sure the money will be there in a year to keep the doors to that new service open.
We will be talking about this throughout the session, and will go into more detail in upcoming newsletters. If funding for MH/DS regional services concerns you, here are a few ideas:
- First, do not get upset. This is just the first step in a long discussion about funding.
- Second, take that concern and turn it into action!
MEDICAID MANAGED CARE PLAN SURFACES
Iowa's Medicaid budget is facing a crisis. First, the federal match rate changed so Iowa will get fewer federal dollars. An additional $56 million in state dollars is needed to make up for this loss. The cost of services goes up each year, and the number of people served continues to grow. Another $36 million is needed for this. In all, the Governor's budget leaves Medicaid about $200 million short.
Buried in the Governor's budget are two words - cost containment. The Governor says his "cost containment" initiatives will save Medicaid $70 million. Chuck Palmer, Director of the Iowa Department of Human Services, shed some light on those two words at budget hearings this week. Director Palmer admitted that $50 million of that "cost containment" savings will come from moving all or most of the state's Medicaid program to managed care. Director Palmer stated that DHS was developing a "Request for Proposals" that would be out sometime in March. That RFP would outline the state's plan for Medicaid managed care, and ask private companies for proposals to manage this care.
In a managed care plan, the state pays a company (or companies) a set amount of money to manage the care of the people assigned to them. New models of managed care save money by focusing on getting people healthy, or stabilizing people in their own homes instead of hospitals and institutions. According to CMS, 70% of the people receiving Medicaid services nationally are in managed care. You can look at how other state managed care plans look here.
Legislators asked Director Palmer which services and populations would be impacted by this move; he did not answer, saying state laws about contracting would not let him be specific. We know that the words "managed care" can be very frightening, particularly since this is on the fast track (January 2016 is the target start date). We will take a lot of time this year to talk about managed care and its impact on services.
Since we do not have a lot of facts at this point, we wanted to give you some ideas on what you can do now. Now is a good time to talk to your legislators or call/email the Governor, and let them know your thoughts. If you are not sure what questions to ask, consider the following:
- How will this change affect my services?
- What will happen to the state's Home and Community Based Services waivers if we make this change?
- Will my waiver services be affected?
- Will managed care reduce waiver waiting lists, or will it increase wait times?
- How can the state save money AND improve access and quality?
- What happens to consumer-directed care options under managed care?
- Who will make sure services are not disrupted as we make this change?
- Will I have a choice in health plans?
- What happens if a managed care company decides to stop providing services?
- Can I keep my current service provider, or will I have to switch?
- Will I be able to live where I do now, or will I be forced to move?
- Will there be an opportunity for the public to make comments about this?
- What's the rush? Can't we take our time and do this right?
There are lots of ways to talk about this with your legislators and the Governor.
MANAGED CARE GUIDING PRINCIPLES
The National Council on Disability has developed a checklist of ten items they consider "Guiding Principles" that can be used to evaluate a state's managed care plan proposals. Any plan put forth by the state should meet and exceed the expectations in these "Guiding Principles." You can see the full explanation of these principles here.
- COMMUNITY LIVING
The managed care plan must show how it will help individuals with disabilities live full, healthy, inclusive lives in the community. There must be a focus on both health care and long term supports that will enable individuals with disabilities to live as independently as possible. It is essential that those covered by the managed care plan receive medical and non-medical supports that promote health and wellness, and improve their ability to live independetly in fully integrated community settings rather than institutions and congregate care facilities.
- PERSONAL CONTROL
Managed care systems must be designed to support and implement person-centered practices, consumer choice, and consumer direction. People with disabilities must be able to control their own lives and choose the services and supports that are consistent with their personal goals. To do this, plans must offer a flexible array of high quality, personalized services and supports, and there must be providers available to deliver these services and supports. Managed care plans must offer enrollees with disabilities the option of overseeing their own direct services and supports, and provide training they will need to effectively self-direct their services.
Iowans with disabilities must receive the supports needed to get and keep jobs. For working-age adults with disabilities, employment is an essential path to independence and community integration. Employment at prevailing wages not only enhances an individual's sense of self worth and economic well-being, but often results in reductions (sometimes very big reductions) in service costs and support needs. Managed care plans should increase opportunities for employment by providing the necessary supports both in and out of the workplace, and eliminating disincentives to maintaining a job.
- SUPPORT FOR FAMILY CAREGIVERS
Families should get the help they need to effectively support their family members with disabilities. Given funding shortages and direct careworker workforce shortages, family caregivers roles will continue to expand in the coming years. Family members must recieve the information, counseling, training, and support they need to carry out these important responsibilities. State policies should permit family caregivers to be paid for providing services.
- STAKEHOLDER INVOLVEMENT
States must involve individuals with disabilties, family members, support agency representatives, and advocates in designing, implementing, and monitoring Medicaid managed care services to make sure they are effective and outcomes are achieved. Active, open, and continuous dialogue with all stakeholders is the best way to make sure the system meets the needs of individuals with disabilities. The involvement of these stakeholders should not end when the Medicaid managed care plan is approved. Instead, stakeholders should actively participate in the monitoring and implementation of the plan, and provide feedback on system performance and modifications needed at regular intervals.
- CROSS-DISABILITY, LIFE-SPAN FOCUS
The system must be able to address the diverse needs of all plan enrollees, including children and adults with physical disabilities, intellectual and developmental disabilities, traumatic brain injuries, mental illnesses, and substance use disorders. The types of services and supports needed vary from person to person. The needs of an 85 year old widow with Alzheimer's Disease are very different than the needs of a teenager with autism. Both may require specialized medical services and prescription medications in combination with ongoing personal assistance, but the competencies of the team providing that care is very different. A one-size-fits-all approach will not work.
- READINESS ASSESSMENT & PHASE-IN SCHEDULE
States should make sure they are ready and not rush into managed care agreements that involve health services and long-term supports for individuals with disabilities. Existing disability services systems are complex. Creating a managed care service delivery system capable of addressing the diverse health and long-term care needs of individuals with disabilities is no easy task, and lack of planning can have disasterous consequences. If the state's goal is to administer Medicaid-funded health services and long-term supports under a single managed care umbrella, state officials must work with stakeholders to assess how things are now, identify gaps in services, and plan accordingly. The goal of this assessment is to identify changes needed to existing facilities, programs, services, and administrative policies/practices before the managed care transition begins.
- PROVIDER NETWORKS
The managed care organization's provider networks must include providers that offer health care, behavioral health, and long-term supports, and must include a balance of institutional, home, and community based providers. Each network should have enough providers to allow choice. Service providers must have the capacity and expertise to address the needs of each population included in the managed care plan, and must be available in both rural and urban areas. Individuals with disabilities must have a voice in the selection of their provider. The state should require managed care plans to allow individuals with disabilities access to services outside the network if it is necessary for that person to receive all the services they need.
- TRANSITIONING TO COMMUNITY-BASED SERVICES
Managed care plans must include providers of home and community based services and supports, as well as institutional program, and this requirement should be built into the contracts. Because of the US Supreme Court's Olmstead ruling, states must show how their Medicaid plans effectively transition eligible individuals with disabilities from long-term care institutions to home and community based settings. Iowa's managed care plan waiver should strongly demonstrate compliance with the Olmstead ruling.
- COMPETENCY & EXPERTISE
State Medicaid officials should draw upon the knowledge, expertise, and skills of their colleagues serving in other state agencies (including vocational rehabilitation, education, housing, transportation). In other words, Medicaid directors should not design their plans without input from other states agencies involved in providing support to persons with disabilities.
- OPERATIONAL RESPONSIBILITY & OVERSIGHT
State managed care plans should be supervised by a qualified state official that is looking out for the public interest. Managed care should not be seen as a way for state agencies and lawmakers to shift responsibility to a private company (and away from them). State policymakers need to make sure there are enough state workers to properly oversee the managed care system and hold contractors accountable for their performance. It is very important for contracts to include clear performance standards, operating guidelines, data reporting requirements, and outcome expectations. A state-of-the-art information management system is essential to effectively administering a managed care system.
- CONTINUOUS INNOVATION
States should actively promote innovation in long-term services and supports for people with disabiliites. Building a strong, resilient community-based infrastructure to support individuals with disabiltiies is essential to creating a sustainable health care delivery system. This should include encouraging public-private partnerships; promoting better use of natural and community resources; broadening definitions of services and supports in order to achieve outcomes; and improving use of other government services that will help in reaching goals.
- MAINTENANCE OF EFFORT & REINVESTING SAVINGS
States must not be allowed to cut back on services when moving to a managed care plan, and savings should be used to provide services to unserved or underserved individuals with disabilities. States should require any savings from less reliance on high-cost institutional care, unnecessary hospital admissions, and improved service delivery be used in this way. In Iowa, that could include addressing long waiting lists and expanding services to other types of disabilities (such as all types of developmental disabilities).
- COORDINATION OF SERVICES & SUPPORTS
A well-balanced service system coordinates the service delivery of primary and specialty health services with long-term care services and supports. The state should require managed care organizations to assign a health care coordinator with special knowledge and experience in assisting individuals with disabilities. If the state chooses to administer health services separately from long-term care servcies, managed care agreements should spell out the collaborative steps each system will take to ensure that the health care and long-term services and support needs of the individual are in sync.
- ASSISTIVE TECHNOLOGY & DURABLE MEDICAL EQUIPMENT
Managed care plans must give individuals with disabilities access to the durable medical equipment and assistive technology they need to function independently and live in the least restrictive setting. Covered services must include professional assesssments of the need for the equipment, as well as set-up, maintenance, and user training.
- QUALITY MANAGEMENT
The state's quality managment system must protect vulnerable individuals, while measuring how effective services are in helping an individual achieve their goals. The state's quality management system must monitor strategies that make sure services are person-centered and appropriate, and make sure that quality measures are being reviewed continuously.
- CIVIL RIGHTS COMPLIANCE
All health services and supports must be provided in settings that meet ADA requirements. Individuals with disabilties must have ready access to all services and sites where Medicaid services are provided. These sites must be in full compliance with the Americans with Disabilities Act, including physical, cognitive, and sensory accessibility standards.
- CONTINUITY OF MEDICAL CARE
People should be allowed to keep ther doctors and other health care providers, as long as those providers are willing to accept the Medicaid managed care plan's rules and payment schedules. This is sometimes called "any willing provider." People should be allowed to choose a new primary care doctor at any time. Continuity of care is important, but so is the patient-doctor relationship. People enrolled in a managed care plan should be allowed to keep current providers, switch providers when they are unhappy, and change managed care plans periodically.
- DUE PROCESS
People with disabilities shoud be fully informed of their rights and obligations under managed care plans, including steps necessary to access services. States should develop and implement an aggressive education and outreach strategy to make sure people know what is expected of them, and how services and supports are accessed. The state should work with community-based organizations to spread the word.
Medicaid managed care plans should have a transparent appeals process, clearly communicating how a person can resolve complaints and disputes. Appeals should comply with all existing Medicaid requirements, except in the case of plans serving dual eligibles when Medicare protections are stronger.
CAPITOL DAY GRANTS AVAILABLE
Coming to the Capitol to see your legislators can be fun, educational, and very productive! This year, ID Action is again offering to help local groups visit the Capitol and meet with their legislators during the 2015 legislative session. For more information call 866-432-2846 or go to http://www.idaction.org/get-involved/capitol-days/. Local Capitol Day grants cannot be used to attend Advocating for Change Day, which is scheduled for Wednesday, April 22, 2015.
PUBLIC FORUMS LIST
Most legislators hold public forums and town hall meetings when they are back in their districts on Fridays and Saturdays. These are ways they keep in touch with their constituents. Some of them (like Council Bluffs) are so well-attended, they have been moved to larger venues. Others are small, with only a few people attending. Some are very informal, while others require you to submit your questions in writing at the beginning. The one thing they have in common is they are all excellent opportunities for you to meet your legislators, learn from them, and educate them on your priorities. Click here to find a forum near you.
We track any bills that may have an impact on the lives of people with disabilities, their family members, their communities, and their service providers. You can always find a full list of these bills and their current status in our Bill Tracker. We update this list daily, sometimes several times a day. So bookmark our Bill Tracker, watch for issues that interest you, and take action on those issues using our online Grassroots Advocacy Center!
The following bills were introduced in the first two weeks of the legislative session. You can look at all the bills introduced to date here.
- HSB39 - Governor's Anti-Bullying Bill - Requires all school districts provide training on how to investigate bullying incidents in schools. School districts are only required to provide this training to at least one employee per year. The Department of Education is required to establish a student mentoring pilot program with best practices for bullying and violence prevention among middle and high school students. The bill also expands the definition of bullying to include social media and social networking websites, and broadens the definitions of bullying; and harassment to capture more incidents. School anti-harassment and anti-bullying policies would need to require prompt notification of parents/guardians of all students involved in a reported incident (exceptions to the notification policy are made if the target of the bullying believes notification would subject the child to rejection, abuse or neglect related to actual or perceived sexual orientation, gender identity, or gender expression). The bill outlines certain conditions in which school officials can be granted authority to investigate and enforce school discipline even if the alleged incidents occurred off school grounds/ outside of school functions. The bill also allows kids that are bullied to change schools (open enrollment) and immediately participate in sports (right now there is a 90-day waiting period before an open enrolled child can play sports). The bill appropriates $150,000 for the next fiscal year (FY16) for training programs and $50,000 for the student mentoring pilot program. Companion bill is SSB 1044. (Status: House Education Committee)
- SF3 - Drivers' Education/Rights of Persons with Disabilities - Requires that approved drivers education classes include classroom instruction on the rights, privileges, and penalties of parking for persons with disabilities. (Status: Senate Transportation Committee)
- SF22 - Service Dog Abuse - Makes it a crime to abuse a service dog - up to $6,250 in fines and up to two years in jail. Service dog abuse includes owning/having a dog that attacks a service dog (but this does not include incidents that occur when a person owns both dogs or if the service dog was not under control of its owner/handler or if the service dog is behaving aggressively. (Status: Senate Judiciary Committee)
- SSB1082 – Accessible Parking/Penalties for Improper Use – Changes the penalties for improper use of an accessible parking permit (called in law “persons with disabilities parking permit”). Under current law, this is a simple misdemeanor and is subject to a $200 fine. This bill allows a city to bypass this and charge and collect a $100 fine. (Status: Senate Judiciary Committee)