2015 INFONET #3

Issue 3, 2/20/2015

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The pace is picking up at the Capitol as your elected officials close in on their first deadline, called a "funnel."  Committees need to get bills assigned to them out before the March 6 "funnel" deadline; those that do not get voted out before the deadline will see no further action this year.  Over the next two weeks, subcommittees will scramble to get bills ready for committee action, and committees are bracing for marathon meetings.  Most of the action will happen next week - you can see the subcommittee and committee schedules for each day here.

Luckily this year the number of highly controversial, politically charged bills is pretty small.   But there was one bill that emerged this week that caused a stir.  Yesterday the House Ways and Means Committee took up the controversial bill to increase the state's gas tax.  At the last minute, two House Republicans refused to support the bill, and House Democrats refused to help get the votes needed. In a move that has not been used for decades, the Speaker of the House removed the two Republicans from the committee, and replaced them with himself and another gas tax supporter.  The bill finally came out 13-12.  High drama for day 40 of the 110-day legislative session.

Looking ahead beyond the funnel, the Revenue Estimating Conference will review the state's revenues for the year, and make estimates on March 19.  These estimates let legislators know how much money the state is likely to collect in taxes this year.  Legislative leaders in both House and Senate are waiting to set budget targets until that date, so they know how much they can spend this year. 

As we reported earlier, the state's budget forecast looked bleak.  The previous estimates showed only about $200 million in new money to spend, and all of that has been promised.  The state needs $200 million more to fill the gap in Medicaid (and that is after $50 million in "savings" from a managed care contract that will go into effect mid fiscal year), $200 million to replace property taxes because of the business and industrial tax cuts made last year, and $150 million to fund schools with 1.25% increase (with Senate Democrats wanting to up that to 4%). 

Legislators will continue working on policy issues for now, but once the estimates are out, the focus will start to switch to budget.  So it's a good time to get warmed up, and start talking to your local legislators about the issues you care about.  Remember, you can easily email your state legislators using our Grassroots Action Center. You don't even need to know their names or email addresses - the system will find them for you.  So check it out here.

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The Health and Human Services Budget Subcommittee will make decisions about the future of the regional mental health and disability (MH/DS) services system this year.  The Governor has recommended $0 for the system; regions had planned to get about $30 million from the state to support non-Medicaid services.  The Department of Human Services has a plan to provide about half that amount using federal funds from the Social Services Block Grant ($11.7 million) and Community Mental Health Center Block Grant ($2.3 million), but some of those funds were already being used for services.  The budget subcommittee has said they will begin meeting in mid-March to address the funding of the system, and decide:

  • How much each region needs (region budget - local property taxes collected = amount of state funds needed)
  • Where the money will come from
  • How to fund the system long-term (permanent funding)

Rep. Dave Heaton of Mt. Pleasant and Rep. Lisa Heddens of Ames do not give up easy.  While the two may not agree on politics (one is a Republican, the other a Democrat), they do agree on the need to modernize Iowa's mental health advocate law.  The judicial work group of the mental health and disability services redesign recommended changes; legislators passed those changes three years ago, but the Governor vetoed it.  Rep. Heaton and Rep. Heddens tried again last year, but the effort fell short.  They are back at it this year, and it looks like they may have finally struck a deal that the Governor will sign.  A subcommittee passed House File 91 this week, making Iowa's mental health advocates county employees while creating protections so they remain independent (and able to represent the best interests of a person with mental illness being committed).  The bill will go before the entire House Human Resources Committee next week.

 Discussions continue on the prioritization of people on home and community based services (HCBS) waiver waiting lists.The Department of Human Services requested a bill - House Study Bill 82 - to allow them to set rules prioritizing people on waiting list according to level of need.  Advocates expressed concern about the bill, saying they would like to see more detail about how the prioritization would be done, and asking that legislators require stakeholder involvement in those decisions.  Legislators were willing to do that, but with the inclusion of waiver services in the Medicaid managed care plan, legislators may decide to wait and see first how things progress with managed care. 

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On Monday, Iowa released the much-awaited Medicaid Managed Care RFP. This "Request for Proposals" asks managed care organizations (MCOs) to outline how they would run the state's Medicaid program, including long term care supports and services, and waiver-covered services.  The state is calling this the "Iowa High Quality Health Care Initiative."  It is hard to summarize a 300-page document, but we wanted to give you the basics:

  • WILL THERE BE CHOICES IN PLANS?  Yes. The state will award contracts to 2-4 managed care organizations. Right now, there are many that have been present at the Capitol this year (including Magellan, Meridian, Centene, WellPoint, Molina, United, Coventry).  Individuals currently receiving services will be assigned to a plan, and will have 90 days to change plans.  For newly enrolled people, they will be given the choice of plans when they enroll.  People will be given additional options to switch plans, particularly if providers within the network do not offer the services the person needs, their provider drops out of the plan, or the person moves to a new area and does not have the same service options available there.

  • WHO WILL BE INCLUDED?   Almost all populations are included - tradtional Medicaid, Iowa Health and Wellness Plan, and children's health insurance (hawk-I).  This includes dual eligibles, users of long-term supports and services in both nursing home and in home and community based (HCBS) settings, and foster care populations. It includes the children's mental health waiver and habilitation program.  That is about 550,000 Iownans.  It does not include undocumented immigrants receiving temporary services, voluntary enrollments in the Program of All-Inclusive Care for the Elderly (PACE), and individuals covered by the Health Insurance Premium Payment (HIPP) program .  The state will continue to manage these populations separately.  Native American populations will have the choice to voluntarily enroll in managed care.

  • WHAT SERVICES ARE REQUIRED IN THE PLAN?  Managed care organizations would be required to offer all the services currently covered.  A list of those services is outlined in the "Scope of Work" starting on page 32. Managed care organizations must:

    • Develop strategies to integrate the delivery of long term care, physical health, and behavioral health.  They are also required to estabilsh an Integrated Health Home (IHH) network, and if a person is not enrolled in an IHH, show how the person's care will be delivered in an integrated manner. 

    • Establish a person-centered service planning process that is led by the person receiving Medicaid services whenever possible. 

    • Develop service models that are consistent with the Olmsted Decision, comply with the federal Mental Health Parity and Addition Equity Act, and are recovery-oriented and "welcome and engage members in their personal recovery efforts."
  • WHAT PROVIDERS WILL BE IN THE NETWORK?  That is not known, since the managed care organizations will negotiate with providers.  Managed care contractors will have to show that they have not only enough providers throughout the state, but also that those providers have the capacity to serve the population assigned to them.  That is important because sometimes a provider will sign up and say they'll take one or two people. So on paper it may look like there are a lot of providers, but in reality there are not enough "slots" to serve the people needing services.   Few other things to note:

    • Managed care organizations are required to contract with federally qualified health center and rural health clinics, and make a good faith effort to contract with family planning clinics and maternal child health clinics.  They must also show how they will use the Area Agencies on Aging (which operate the Aging and Disability Resource Centers called "LifeLong Links"). 

    • Managed care organizations must contract with both nursing facilities and home and community based service providers, and other providers of long-term care services and supports. They will also be charged with overseeing the Consumer Choice Options (CCO) and Consumer Directed Attendant Care (CDAC) programs, to ensure proper use of funds.

    • Managed care organizations are required to demonstrate how they plan to develop capacity in community-based residential alternatives, so that a person can find a facility within 60 miles of their home.  Note that this is a goal - they are not expected to have this capacity on day one of the contract.

    • Provider rates will be negotiated by the managed care organization, but some provider rates are set by law (such as federally qualified health center and rural health clinics receiving cost-based reimbursement). Provider rates for Medicaid are required by law to be "actuarially sound," which means they do not overpay or underpay significantly (although some providers may argue that the rates are indeed a signficant underpayment already). 

    • Managed care organizations must guarantee that there is continuity of care in this transition. In addition, managed care organizations cannot force a person to switch providers, even if they are not in the plan's network, in the first 90 days of the contract (and they may extend that period to help with a smooth transition).  Managed care organizations cannot move people out of their nursing facility, intermediate care facility for people with intellectual disabilities (ICF/ID), habilitation program, or waiver community-basee residential alternative unless 1) the person asks for this transfer; 2) the person agrees to the transfer; or 3) the provider does not contract with the managed care plan.  That last condition is a big one, and you will not know the answer to who is in the networks of each plan until later this summer (but before assignments are made). 

    • The RFP states that long term services and supports may not be reduced, modified, or terminated without an updated needs assessment.  In the first year of the plan, managed care organizations are required to allow residential placements to continue for up to one year, even if the provider is not in the network.  They are then to "facilitate a seamless transition to new services and/or providers." 

    • When it comes to long term services and supports, managed care organizations are required to "maximize community placement and participation."  The RFP states that the managed care organization shall "consider individual member choice and community-based alternatives within available resources."  The state designates the tools to be used to determine level of need (InterRAI for the AIDS/HIV, elderly, brain injury, health/disaiblity, and physical disability waivers; Supports Intensity Scale for intellectual disability waiver). 

    • Waiting lists are allowed for waiver services; the managed care organization is required to notify the person at the time of application that there is a waiting list, and let them know they may choose facility-based services until a slot opens, and the managed care organization is required to provide non-waiver supports and services as needed while on waiting list.

    • The RFP also requires community-based case management, and includes targeted case management.  There are requirements that case management be conflict-free (so the managed care organization that is paying for the service does not also provide the case management service unless it can prove the two functions are "administratively separated").

  • WILL PLANS HAVE TO BE STATEWIDE?  Yes.  Some states have allowed managed care organizations to pick a region or a county, but Iowa did not do this.  Managed care organizations must agree to serve the entire population (they can't just pick kids, or just pick long-term care), and cover the entire state.

  • WHAT IS THE TIMELINE?  The timeline is very aggressive; the state plans to award the contract by July 31 and have federal approval and the plans ready to launch by January 1, 2016.  Most experts say this timeline is not very realistic, given delays at the federal level and the amout of time it will take for a company to get agreements with providers signed, staff hired and trained, and information out to people being served.  Here is the timeline:

  • HOW MUCH MONEY ARE WE TALKING ABOUT?  The state's entire Medicaid budget is a little more than $4 billion, but that includes both federal and state dollars.  We do not know how much the state currently spends to administer the program, but we do know that the RFP states that managed care organizations must spend at least 85% of the money given to them on services and supports.  That means no more than 15% can be spent on administration.  The state also plans to keep 2% of those administration funds, and will only give them to the managed care organization if they achieve certain quality outcomes.  Managed care experts say this is a "best practice" that will make sure the focus of the managed care contract is not just about saving money, but also about access and outcomes.  By comparison, Magellan's current behavioral health managed care contract with the state is limited to 88%, so they can retain 12% for administrative costs.

  • WILL WE GET A CHANCE TO SAY ANYTHING ABOUT THIS?  Yes!  There are going to be several opportunities for you to ask questions, get additional information, and make comments about the state's plan to move to managed care, as well as the RFP itself.  Even after the RFP is awarded, the state must get federal approval, and that requires a public comment period.  Here are some of the ways you can get involved:

    • You can ask questions or make comments by email: MedicaidModernization@dhs.state.ia.us.  The questions and the answers will be public, as required by state contracting rules.

    • You can learn more and ask questions (or make comments) at a community meeting held by DHS to discuss the RFP, answer questions, and hear people's thoughts. 

      • Tuesday, March 3 (11:00 am-12:30 pm) - Cedar Rapids, Kirkwood Community College Ballrooms B & C, 7725 Kirkwood Blvd. S.W.; to call into meeting, dial 1-866-685-1580 (participant code: 542.870.0217)

      • Friday, March 6 (10:00 am-11:30 am) - Des Moines, Polk County River Place Room 1-1A, 2309 Euclid Des Moines; to call into meeting, dial 1-866-685-1580 (participant code: 542.870.0217)

      • Monday, March 9 (12:30 - 2:00 pm) - Davenport, Davenport Public Library, Fairmount St. Branch, 3000 N. Fairmount St. No conference call available.

      • Monday, March 16 (12:30 - 2:00 pm) - Council Bluffs, Iowa Western Community College, Auditorium 2700 College Rd; to call into meeting, dial 1-866-685-1580 (participant code 542.870.0217).

      A special meeting of the Medical Assistance Advisory Council (MAAC) will also be held on Feb. 27. Information related to MAAC can be found here.

    • Contact your legislators, and let them know your thoughts and questions.  Chances are, they've heard from others who have the same questions.  Many legislators have been asking some of these questions already, so make sure you let them know what you think, so they can help you get the answers you need.  Click here to contact your legislators.

    • Finally, there will be another round of public input when the state asks for federal approval to do this.  Federal law requires a 30-day comment period, and we know that the federal governemnt considers these comments when they review plans to change how Medicaid is administered.  They can force the state to make changes if they hear from enough people.

There is an excellent summary of the state's RFP done by Health Management Associates here.  You can view all of the RFP documents here. We will continue to post information in our Policy Tools , so check there frequently.  Also watch for updates on Facebook!


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The Health and Human Services Budget Subcommittee heard from national experts on managed care last week - Laura Tobler from the National Council on State Legislatures and Dr. Art Jones from Health Management Associates.  They were asked to highlight what other states have done with managed care, so legislators could learn what to do (and what not to do) as they make this transition.  It should be noted, legislators have very little say over this change.  The Governor's office can do this without legislative authority, so legislators are trying to figure out their role in this transition.  You can see the presentation materials from the speakers at the links below:

Laura Tobler of the National Council on State Legislatures said that managed care has been around a long time, with 39 states having some type of managed care arrangement.  "Managed care is very much the way services are delivered in Medicaid," said Tobler.   The biggest trend in managed care now is in the addition of more populations, most significantly the long term services and supports area.  In 2004, only 8 states included long term care in their managed care plans. By 2012, that numbered had doubled to 16.  As of last year (2014), the number of states moving these services to managed care was 26. If Iowa's plan moves forward, it would be added to this list.
Dr. Art Jones of Health Management Associates said states always set "savings" as their first goal when moving to managed care, but cautioned lawmakers to put equal emphasis on access, quality, innovation, and practice transformation.  "Some of the most innovative changes are happening in Medicaid managed care," said Dr. Jones.  "But part of the (legislative) oversight is making sure that focus is maintained."   
Dr. Jones said that states should focus on three objectives: savings, access, and quality.   Dr. Jones said that provider rates cannot be squeezed much more.  He cited a Robert Wood Johnson Foundation study from 2012, which found only modest savings in Medicaid managed care. The study showed there were several reasons why its difficult to expect big savings in managed care:

  • Medicaid rates are already too low to start with (you've already squeezed out the savings)
  • It's unlawful to impose patient cost-sharing or increase patient incentives
  • It's not permissible to indiscriminately cut rates (CMS must find them actuarially sound).
  • You can't cut state administration entirely, because you still have to provide oversight.
  • Not much population savings except in long term care services and supports.

 Dr. Jones said legislators and the state need to make sure they are continually asking "what is this doing to our delivery system in Iowa?" Overall advice for the state:

  • Invest and develop capacity to manage care.
  • Do not be a passive purchaser - you need to manage your managed care.
  • Involve stakeholders in implementation process, and in an ongoing and meaningful way.
  • Legislative oversight crucial to making sure MCOs are responsible, responsive, and achieve the results expected.
  • Clearly define your expectations up front.
  • Have a readiness plan, and decide what you will do if organizations are not ready to go live.
  • Make sure you have a solid member enrollment process that gives people choice.
  • Make sure contractors have a good grievance process in place.
  • Have financial consequences for member discrimination, selective marketing, or failure to meet expectations.
  • Have good quality metrics that go beyond prevention.
  • Make sure your rates are actuarially sound, and make sure your baseline costs are realistic.
  • Care coordination should be at practice level, not internal to the MCO (call center).

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When a person is unable to safely make decisions for him/herself, a guardian can be chosen to make decisions for that person.  Sometimes a guardian makes decisions about who is allowed to visit the person.  That's what has Senator Rob Hogg of Cedar Rapids concerned.  Sen. Hogg said he has heard from people in his district that the law needs to be clearer, so the person has a say in who visits them.  For example, a sister was made the guardian of her younger brother.  She didn't like the older brother, and would not let him visit, even though the younger brother was at the end of his life and wanted to see him.  Sen. Hogg wants to make sure that there is a better balance to make sure the person's wishes are taken into consideration.

Senate Study Bill 1162 does this by stating that if a person wishes to have a visitor, the guardian is not able to restrict that visit. The Guardian can set reasonable time limits or decide on the place for those visits, and can also go to court to show good cause why the visit would not be in the best interest of their ward (the legal term for the person who has the guardian).  A three-person subcommittee met on this bill on February 12, and decided to amend it to make sure the process for doing this was clear.  The subcommittee - Sen. Rob Hogg, Sen. Wally Horn (also of Cedar Rapids) and Sen. Tom Shipley of Nodaway - will meet again to consider the amendment and decide whether to move it to the full Senate Judicary Committee before the March 6 deadline.  If the bill does not get out of Judiciary Committee before then, it will no longer be eligible for debate (it dies for the year).

If this is something that you care about, contact the members of the subcommittee and Senate Judiciary Committee and let them know what you think.  You can see a list here.

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Have you ever wondered what issues your State Senator and State Representative are working on while they are at the Captiol?  The answers are just a few clicks away.  Just follow these steps to find the bills your legislators sponsored and the amendments requested:

  1. To find bills sponsored by your legislator, go to www.legis.iowa.gov/legislation/findLegislation/findBillBySponsorOrManager?ga=86
    Select your legislator from the "sponsor" box.  There are separate boxes for Senate and House.

  2. To see amendments sponsored by your legislators, go to /www.legis.iowa.gov/legislation/findLegislation/findAmendmentBySponsor?ga=86.  Again, select your legislator from the dropdown box next to "Senator' or "Representative".

If you do not know who your legislator is - just put your address in here.

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Not only is it easy to find the bills your legislators sponsored this year, it's also easy to see all of the bills that are in a committee.  While we track bills in our Bill Tracker that we think will interest you, we know that our readers care about many issues.  Some of you are hunters, and may want to know if changes are being made to hunting licenses.  Others are interested in taxes, and want to see changes in that area.  Maybe others want to make sure our veterans get the respect they deserve, and want to see what legislators are doing in that area. 

It's easy to see the full list of bills that are assigned to any given committee - whether its the Natural Resources Committee (for hunting issues), Ways and Means Committee (for tax issues), or Veterans Affairs Committee (for veterans issues).  Just follow these steps:

  1. Clck on this link: https://www.legis.iowa.gov/committees.
  2. Click on the committee.
  3. In the bottom right corner, you'll see "Legislation." Click on the "Bills in Committee" link.
  4. A list of bills in that committee will show up. These bills have to get out of committee before March 6, or they are dead for the year (unless you are looking at the Appropriations or Ways & Means Committee - bills in these committees are exempt from the deadline).

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Legislators read hundreds of bills each year, but only about 12% end up becoming law.  Even fewer of those have an impact on the lives of people with disabilities, their family members, their communities, and their service providers. 

  • Keep track of bills that may impact the lives of individuals with disabilities in our Bill Tracker.   We update this list daily, sometimes several times a day. 

  • You can look at all the bills introduced to date here.

  • You can look at the bills assigned to each committee here (just select the committee of interest, then click on the "Bills in Committee" link at the bottom right side of the page).

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Most legislators hold public forums and town hall meetings when they are back in their districts on Fridays and Saturdays. These are 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.

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