2016 ISSUE #2

Issue 2, 2/6/2016

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Snow and the Iowa Caucuses cut the legislative work week short, but that didn't stop the flood of new bills that were introduced this week. Since our last issue of infoNET, more than 275 bills have been introduced, dealing with everything from legalizing fireworks to ending Medicaid managed care to stopping Iowa's universities from interacting with Stanford University (because their band made fun of Iowa at the Rose Bowl game).  While the last bill was what we call a "message bill" - not one that is serious - there were many very serious bills filed this week. 

The Senate Democrats continue to try to stop the Governor's Medicaid managed care plan, introducing a bill that would return to a state-managed Medicaid system and another that would increase oversight of the privately-managed system and address many of the concerns they heard from people around the state.  While these bills both send messages to the Governor's office about the Senate's unhappiness with the way the managed care plan was rolled out, there are some areas where the House and Senate might reach agreement. 

Our next articles will go into more detail about what these bills do.  We know that many of you are concerned about this change and what it means to your services now and in the future.  We know some of you are excited about new opportunties that might be offered under managed care, especially when it comes to living independently in your communities.  That's why we want to let you know what's in the bills, and what you can do to express your thoughts to your legislators.  ID Action does not take a stand on issues - but we know this is an emotional and confusing issue to many of you.  As we often say, advocacy isn't just about sitting up and taking notice.  It's about getting up and taking action.  So take a few minutes out of your day to let your legislators know what you think about any of the issues covered - it's your right, and it's your responsibility.

Were you successful?  Share your story with us and other advocates by emailing us at infonet@idaction.org.

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The Iowa Senate released two bills this week to tackle concerns they heard from Iowans about the transition to Medicaid managed care. 

One in five Iowans depends on Medicaid for vital health care services, including the elderly, people with disabilities and mental health concerns, children and moms. - See more at: http://www.senate.iowa.gov/democrats/iowans-nervous-about-medicaid-privatization/#sthash.PycxHUJD.dpuf
One in five Iowans depends on Medicaid for vital health care services, including the elderly, people with disabilities and mental health concerns, children and moms. - See more at: http://www.senate.iowa.gov/democrats/iowans-nervous-about-medicaid-privatization/#sthash.PycxHUJD.dpuf

The first bill is Senate Study Bill 3081, and it stops the move to Medicaid managed care. Contracts with all three managed care organizations (MCOs) would end immediately.  Iowa Medicaid is asked to take back management of the system, and focus on developing patient-centered care.  The issues that will make this difficult - the state has lost its mental health managed care contractor (Magellan), has ended its contract with Wellmark to manage the children's health insurance progam (hawk-i), and has ended contrats with the companies that have helped run Medicaid for decades. So - does the state have the capacity now to take back the management of the system? And if so, does it have the money to do it? 

The second bill (Senate File 2107) assumes managed care is here to stay and instead focuses on making sure there is proper oversight of the new system, adequate opportunities for meaningful stakeholder involvement, good data collection to make sure that the state is getting the results it expects, and requires contract changes to make sure providers and members are treated fairly, get information they need to make good decisions, have protected rates, and are not subjected to unnecessary red tape.  Now whether the bill achieves that or simply micromanages the system to the point of breaking is something that will be debated. 

On Monday (February 8) the Senate Human Resources Committee will host two meetings to discuss the first option (stopping managed care).  First the three-person subcommittee will meet to discuss, and then the full Senate Human Resources Committee will debate and vote on the bill.  Both meetings will be live-streamed so you can watch them from your tablet, smartphone, or computer. 

Subcommittee members are President of the Senate Pam Jochum, Sen. Mary Jo Wilhelm, and Sen. David Johnson.  You can see who is on the full committee here.  Meetings on the second bill will be announced later in the week, so watch our breaking news section of the website, or follow us on Facebook.

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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.

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Legislators were not happy this year when they learned that the Department of Human Services had not increased Medicaid supported employment provider rates by 20% on January 1 - they passed a bill last year that increased the rates, found the $750,000 to do that, and the Governor signed it into law.  Both House and Senate Human Resources Committees passed bills unanimously this week to demand rates be increased as planned.  Senate File 2101 is now ready for full Senate debate; House File 2121 was sent to the House Appropriations Committee for a final look (and assigned to Representatives Heaton, Heddens, and Rizer).  Both bills are safe from the first deadline.

There is a lot of confusion about the services managed care organizations (MCOs) will offer to children who had previously been on the state's Wellmark-managed hawk-i children's health insurance program. Legislators have been contacted by parents who say their children will not be able to qualify for Medicaid-funded speech therapy, because MCO manuals say their children must have had a stroke to qualify (typically a requirement that only applies ot adults).  That has prompted Sen. Amanda Ragan to file a bill (SF 2049) that would require coverage for speech therapy services for kids.  That bill is assigned to a subcommittee of Senators Jochum, Wilhelm, and Costello. 

In response to concerns, Medicaid Director Mikki Stier plans to provide legislators with a comparison chart of the plans for children's services (called a "cross walk") in hopes that clears up some of the confusion. We will post that document once it is available.  In the meantime, a parent recently spent time pulling out all the language from the MCO member manuals related to these services, so legislators could see why there is confusion. That information is here

Finally, the Children's Mental Health and Well-Being Work Group has come up with a set of recommendations to create a coordinated, statewide integrated mental health system for children in this state.   In December they issued their final report, which you can read hereSenate Study Bill 3109 implements the recommendations of that workgroup:

  • Appropriates $300,000 for planning grants to develop chlldren's mental health crisis services.

  • Requires DHS to study and collect data on emerging, collaborative efforts to address the well-being of children.  DHS is to select 3-5 "learning labs" to see how these approaches can benefit children with complex needs and their families throughout the state.

  • Directs DHS to work with the MH/DS Commission, Department of Public Health, and the Mental Health Planning Council to develop additional recommendations for the creation of a children's mental health crisis service system, and development of a children's mental health education and awareness campaign,

  • Appointment of a permanent Children's Mental Health and Well-Being Advisory Committee in the Department of Human Services to continue to provide guidance in this area.

 This bill is currently assigned to a three-person subcommittee (Senators Mathis, Ragan, Segebart).

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This coming week we hope to get a report on the status of the ABLE Act, legislation passed last year that allows individuals with disabilites to set up special savings accounts without affecting eligibility for services. Rules were just finalized at the federal level, so we do expect to see some work started on the state level soon.  State Treasurer Mike Fitzgerald was tasked with administering the program, much like he administers Iowa's College Savings Plans. He will be presenting to the Administration and Regulation Committee on Tuesday (Feb. 10) so we hope to have more to report in our next issue.

The week of February 8 will be a busy one, as legislators get ready for the first legislative deadline, called a "funnel."  By Friday, February 19, all bills need to be reported out of their first committee. So a bill that starts in the House needs to be voted out of a House committee, and a bill that starts in the Senate needs to be voted out of a Senate committee.  Bills left in committee after this date are dead; bills that survive get to move on in the process. So by the time we send you another newsletter, we will know which bills made the funnel, and which ones did not.

Now is the time to advocate for the bills you care about. 

Click here to see a list of bills of interest.
Click here to find the names of your State Senator and State Representative.
Call your State Senator during the week at (515) 281-3371.
Call your State Representative during the week at (515) 281-3221.

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In March 2014,  the federal Centers for Medicare & Medicaid Services (CMS) issued new definitions of settings in which it is okay for states to pay for Medicaid Home and Community-Based Services (HCBS).  The purpose of these changes is to make sure individuals receive Medicaid HCBS in settings that are integrated and support full access to the greater community.
The Iowa Medicaid Enterprise (IME) has been working with CMS to develop a statewide transition plan to assure that all HCBS settings will be in compliance with the new regulations by March 17, 2019.  The state will submit a revised plan to CMS  on April 1, 2016. CMS requires that the plan be available for review and comment before it is sent in for final approval.  IME is looking for feedback on the revised plan.  You can read and comment on the plan from February 1, 2016 – March 2, 2016:  https://dhs.iowa.gov/ime/about/initiatives/HCBS/TransitionPlans.

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On a sad note, former Senator Tom Hancock passed away suddenly just after midnight last Sunday from an apparent heart attack.  Always a public servant , Sen. Hancock spent 31 years working for the US Postal Service, was Chief of the Epworth Volunteer Fire Department for 16 years, was past President of the Iowa Firefighters Association and Dubuque County EMS Association, spent 13 years in the Iowa Senate (2005-13), and has been a Dubuque County Supervisor since 2014.   Many of his former colleagues in the Iowa Senate took off early on Thursday to attend his funeral.

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Keep track of bills that may impact the lives of individuals with disabilities in our Bill Tracker.  Status is updated daily.

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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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