2016 ISSUE #4

Issue 4, 3/4/2016

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Legislators had only three short weeks between deadlines to get their priority bills through most of the legislative process. While there has been debate on many bills, there have been very few committee and subcommittee meetings. There seems to be a general lack of urgency at the Capitol, so expect that a lot of bills will not make next Friday's second and final "funnel deadline."  For those unfamiliar with this second legislative deadline, by Friday, March 11:

  • Senate Files must have been voted out of the Senate, assigned to a House committee, assigned to a subcommittee, approved by that subcommittee, and then finally approved by the full House committee.

  • House Files must have been voted out of the House, assigned to a Senate committee, assigned to a subcommittee, approved by that subcommittee, and then finally approved by the full Senate committee.

The only bills that do not have to get through this process by March 11 are those assigned to the Appropriations Committee, Ways & Means Committee, or Government Oversight Committee.  These bills are eligible for discussion at any time because they involve taxes, spending, and government agency accountability.

Beginning March 14, most committee work will be done and your legislators will spend most of their time in debate.  Remember that you can watch debate at any time (live or archived) here.  In addition, legislators will start to turn their attention and focus to state budgets, which often take weeks (sometimes months) to negotiate. Make sure you watch our Facebook page for updates on budget discussions and actions on priority bills!

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The news many of you have been waiting for came last week - the federal government (Centers for Medicare & Medicaid Services, or CMS) gave Iowa the go-ahead to make the move to managed care starting April 1, 2016.

  • Click here for the Governor's news release.
  • Click here to read a letter from Iowa Medicaid Director Mikki Stier here.
  • Click here for the letter from CMS.

There have been a lot of questions about dates.  A recent communication from Iowa Medicaid (now called Iowa Health Link) provided the following information:

  • Coverage through the managed care organization (MCO) you chose or are assigned to begins April 1, 2016.
  • Members can change MCOs for any reason until June 16, 2016.
  • Member can change MCOs after that for 'good cause' such as their provider hasn't joined the MCO network.
  • All existing authorizations go through June 30, 2106 (90 days).
  • MCOs must contract with any provider willing to take their rates through September 30, 2016 (six months) for physical and behavioral health, and through March 31, 2018 for long-term services and supports (2 years).

 If you have questions, contact Iowa Medicaid Member Services at 1-800-338-8366.

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Six Republicans joined 26 Democrats in approving a bill (SF 2213) that will make sure Iowa avoids many of the mistakes other states have made in rolling out their Medicaid managed care systems. The "Medicaid Managed Care Program Integrity and Oversight" bill will make sure the three private companies chosen to manage Iowa's $5 billion Medicaid system will be closely watched by state agencies and stakeholder-led committees.  Click here to see how your Senator voted.

As Senator Amanda Ragan of Mason City said at the beginning of debate on the bill, "The intent of this legislation is to safeguard the interests of Medicaid members, encourage the participation of Medicaid providers and protect Iowa taxpayers.”   The bill is in response to concerns lawmakers heard from constituents concerned about privatizing the state's Medicaid program that provides health and long-term care services to 560,000 Iowans. 

The bill does four 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.  The role of the legislative Health Policy Oversight Committee is expanded to include broader oversight powers, the membership of the Medical Assistance Advisory Council (MAAC) is expanded (as is their role, with the addition of five subcommittees to address various areas of oversight), and the Patient-Centered Health Advisory Council is pulled into the discussion to develop strategies to improve the health of Medicaid members.  In addition, the state's Long Term Care Ombudsman is given authority to act on behalf of all Medicaid members receiving or needing long-term services and supports, and is directed to help any Medicaid recipient navigate state agency bureaucracies. The bill provides protections so that other agencies or elected officials cannot influence or interfere with the duties of the Ombudsman.

  2. Makes sure there are resources to invest in improvements to the system by creating a Medicaid Reinvestment Fund.  Each of the three MCOs will be required to contribute $5 million ($15 million total) to the fund beginning July 1, 2016.  After that, 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. Maintains the autonomy of the children's health insurance (hawk-i) board, which is supposed to approve all changes to contracts that provide services in this program.  They were not consulted nor did they approve the change to managed care, so legislators felt it important to emphasize what is already in current law.  In addition, the bill adds occupational therapy as a covered service under the hawk-i program, and requires the hawk-i board approve any changes to the criteria used to authorize services to children.

  4. 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 do the following (and withholds an additional 2% of their payments that will only be paid to them if they meet all requirements):
  • Continue a Medicaid member's benefits during an appeal.
  • Continue same services, at same levels, with same conditions as before managed care.
  • Monitor and report service reductions, suspensions, and terminations.
  • 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 (not discriminate against them).
  • Allow a Medicaid member 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 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.
  • Continue to pay cost-based reimbursement to community mental health centers requesting it.
  • Work hard to include safety net providers (free clinics, rural health clinics, community health centers).
  • Make sure costs are not shifted to other non-Medicaid providers (like MH/DS regions).
  • Give all existing Medicaid providers the chance to be a part of their network (at rates in law).
  • Require MCOs to allow exceptions so that people can keep out-of-network (or out-of-state) providers.

During a press interview, Governor Branstad seemed to indicate the bill was not needed.  “The whole idea of managed care companies is indeed to provide oversight over the providers to see that we’re moving in that direction...How much of that duplication do we want and how much will it cost? Those are the kinds of things you have to balance in determining whether this is good public policy.”

The bill is not expected to be discussed in the House. Instead, Representatives hope to discuss parts of the bill during the budget negotiation process, and look for areas of common ground that will help make sure MCOs are accountable, they are achieving expected results, and that any problems are quickly addressed.

Do you see things in this bill that you like?  Are there things that you think are not necessary?  Are there things missing that the state should consider doing?  If you have ideas, contact your legislators now. 

  • Call your Representatives during the week at (515) 281-3221.
  • Call your Senators during the week at (515) 281-3371.
  • Your 2016 Guide to the Iowa Legislature will list home phone numbers and email addresses.
  • You can also email your legislators using our Grassroots Action Center here.

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If you missed the debate on the Medicaid Managed Care Program Integrity and Oversight (SF 2213), you might consider going back and watching it. While the debate was long, it was passionate and full of personal stories shared by legislators. Many of you have wondered if your contacts matter, and if your stories are being heard.  Legislators do commonly re-tell stories they have heard from constituents during debate, and the debate over managed care is a really good example of this.

Here are a few quotes from Senators during the debate:

"It is critically important for each of us to remember all of those constituents who talked to you, that have shared their concerns, to hold the people who are going to be dealing with this accountable."  Sen. Amanda Ragan (D-Cerro Gordo)

"This is the day for 560,000 Iowans. It's not about us, it's about them...One thing I know, it's important to listen." Senator David Johnson (R-Osceola)

"We've heard from the people. We've held listening posts and oversight meetings. Last week we heard heart-wrenching stories of children and adults and families who will be upside down in all of this for months if not years to come...We have a chance to hold the managed care organizations accountable to protect the Iowans who rely on us for help."  Senator Liz Mathis (D-Linn)

"Last year I had a group of people up here from Easter Seals and Candeo and I tried to take a little extra time and bring them on the floor.  And I was asked by many of those people about this managed care system.  I told them that I would not support this managed care system.  I currently believe and have confidence in the Department of Human Services to make sure those important services are provided to the most vulnerable people...I've been very clear when we've talked about mental health and the facilities we have shut down...We are all blessed in this room.  And I tell you what, if you ever had an experience such as what my wife and I have had in regards to mental health, it's a little different. It opens your eyes...I ask my colleagues to think about the people that are most dependent on this service."  Senator Brad Zaun (R-Polk)

"I live in the nightmare as a parent. I also now have an additional duty as a legislator, and I can assure you I have had others in this chamber, clerks, state troopers, have come to me and said thank you. Thank you for standing up for my kids that have autism. Thank you for standing up for my kids with intellectual disabilities." Senator Pam Jochum (D-Dubuque)

"I have a face that I want you to think about.  Alot of my constituents that have been contacting me throughout this experience..but I'll talk to you about the one I know the most about. He's my nephew.  When he was 19 he was in the wrong situation at the wrong time, and he was shot.  The bullet exploded in his spine, and he knew he was paralyzed from the neck down.  When I think of him in that situation, he was then just like he is now, very positive, a thinker, always trying to make things better. So he said to the emergency people... 'Calm down, I'm going to be okay, you guys just gotta do your job.'  And that's the way he's been ever since. You know the rest of us get excited, get worried...Now I look at this situation and I hear Tucker's voice.  You guys gotta calm down, and do you jobs.  Today we have a job to do."   Senator Rita Hart (D-Clilnton)

"Let's talk about how ready we are for this....I have a constituent from Council Bluffs.  She's choosing an MCO for her adult child, wondering specifically if Catholic Health Initiatives (Mercy hospital) had signed with each MCO. She asked me to check for her. (From his staff): I had a terrible time, went to the IME website and found web portals for each of the MCOs.  United's wouldn't let me in.  Said there was an error in development. AmeriHealth found CHI Mercy easy. AmeriGroup, many steps...it finally gave me a list of 69 providers, when I filtered for hospitals, no hospital.  I didn't feel confident that I had found accurate information, so I called the number for Medicaid. First time got cut off. Second time got a message about high call volume and a hang up.  Then got a message to call the 800 #.  First time I pushed one for English and got a dial tone.  Second time I pushed one for English and got the fast busy tone.  Then got through to someone, who told me to go to the website and check the portals for provider ists.  Then called a person at DHS who said she would call member services for me.  She called back after not getting a human either, since somebody was on vacation.  She said someone from provider services would call me. I then called a lobbyist who called Mercy Council Bluffs directly and found out they were only signing with AmeriHealth.  Does that sound to anybody in this room like they are ready? It doesn't sound like it to me...We have to stand up for the patients and the providers in this state."  Senator Mike Gronstal (D-Council Bluffs)

You can watch the debate from your computers, smart phones, and tablets here (fast forward the tape to 10:44 am). 

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More than 200 advocates with disabilities came to the Capitol on February 24 to participate in a rally against the state's decision to privatize its Medicaid managed care system.  At the same time, Senators hosted a listening post to give advocates another opportunity to discuss their concerns about the changes ahead.  One of those advocates was Barb Faber, who has been an infoNET reader for two decades. 

Barb spoke to an over-flowing room, one of dozens of people who boldly sat in front of legislators, cameras, and news reporters to tell their highly personal stories.

“I’ve been working since I was 16," Barb told the room. "And I’ve been working for Wells Fargo and the Independent Living Center since 1994.  I met a man who I married, and we were together for 17 years." 

At this point, Barb choked up.  "He was my care provider, he cared for me and everything around us."  Barb told how her soulmate died, and how everything changed for the woman who had been living successfully and independently for decades.  "My mom and dad couldn’t take care of me, so they put me in a nursing home, then a group home. Made it tough to continue to work."

Because Barb needs about 130 hours of support to maintain her independence, she is concerned that managed care will think she is better served in a group home or somewhere where it will make it tough for her to continue to work.  "I don’t have regular insurance since I qualify for Medicaid and Medicare, and my county will not pay for my 24-hour care," said Barb.  So what is it that she wants from legislators?  "To provide me with the service that you would want for your kids.  We need to make sure I’m not the only one out there going thorough this uncertainty."

Legislators were clearly moved by her story.  And you might think that this story ends there, but it does not.  Yes, legislators do remember those stories, and that's why we are like a broken record, reminding you to tell them! 

During debate on the Medicaid managed care oversight bill this week, Sen. David Johnson referenced Barb's emotional testimony.  

"I want to go back to the two hours of intense testimony down in room 116 when we had Iowans with disabilities traveling from all over the state," said Sen. Johnson. "I just want to put a face on this because we talk alot about the money.  It's a lot of money, but let's narrow it down to Barb and her high-tech wheelchair, who comes up to the microphone and tells us about the joy of getting married and the agony of her husband passing away.  And  her happiness that she got the training and kept her health up and got a job at Wells Fargo.  Amazing story.  She's there because the system worked for her."  

After talking about other advocate stories Sen. Johnson concluded, "it was just overwhelming."  Those advocate stories can be seen here

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No news is, well not really good news.  There has been no work publicly on the budgets for over a month now, and committee chairs say they are waiting to hear from the state's Revenue Estimating Conference to know if they will have good news (money is coming in as expected or better) or bad news (state revenues are slowing down and we have to lower budget targets).  That day is March 16, so do not expect to hear much about budgets until then.

One thing that we know will be a tough sell anyway is the $7 million needed to secure services in the regional Mental Health and Disability Services (MH/DS) system.  Over the last decade, the state has gone from making more than $200 million in investments in local services to $2 million last year and $0 in the budget recommendation for this year.  While MH/DS regions no longer have to pay for Medicaid services, they still do not have enough money to pay for the services they are currently expected to deliver. 

This year, the Polk County region is short $7 million to just maintain existing service levels. Next year, another handful of regions will experience similar problems, at least doubling the money needed to stabilize services.  The Iowa Association of Counties has come up with a solution that does not require one penny of state aid to move forward.

  • Allow each county in a MH/DS region to raise (from property taxes) up to $47.28 per person in that county. This is the current "per capita" amount regions are allowed to spend.

  • Up to 13 counties would be able to raise their taxes slightly to collect the money needed.  For example, in Polk County, raising property taxes to get up to the $47.28 level would mean that a person that owns a $100,000 home would pay just $17 more in taxes each year. The increase in taxes under this is expected to collect about $15 million statewide.

  • The 86 remaining counties would cut taxes or keep budgets level, resulting in at least (and very likely more) $22 million in property tax cuts statewide.

  • So the effect of this change is a reduction in property taxes statewide by at least $7 million (and very likely more).

  • No state funds (also tax dollars) would be needed.

  • The Department of Human Services would still be required to approve county budgets and service plans.

  • County supervisors, who are elected, would still have to answer to voters when deciding whether or not to raise property taxes.

You will hear more about this plan in the coming weeks.  Sen. Mark Segebart, a former Crawford County supervisor, knows the MH/DS system well and has introduced a bill to do just that.  Senate File 2236 was assigned to the Senate Ways and Means Committee (so it's safe from deadlines), and must first pass out of subcommittee.  Members of the subcommittee are Sen. Joe Bolkcom of Iowa City, Sen. Janet Petersen of Des Moines, and Sen. Jason Schultz of Schleswig.  More to come on this topic!

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There are a number of bills that are facing the funnel deadline next week.  You can see current status of all these bills anytime at http://www.infonetiowa.org/news/bill-tracker/.  Here is a quick review of where bills are at right now:

Bills That Have Already Cleared the March 11 Deadline:

  • HF2272 & SF2101 Supported Employment Reimbursement Rates (Senate & House Floors) - Directs Medicaid to increase supported employment provider Medicaid rates by 20% beginning January 1, 2016.

  • HF2334 & SF2188 Psychologist Prescription Authority (Senate & House Floors) - Allows prescription authority for doctorate-level psychologists that receive an additional two-year degree in psychopharmacology.

  • SF475 Home Modification Tax Credit (Senate Ways & Means Committee) - Allows a refundable $2,500 home modification income tax credit for homeowners with disabilities (or homeowners with family members that have disabilities living in the home) or individuals with progressive diseases that require home modification who earn no more than 250% of the federal poverty level.

  • SF509 ADA Compliance/Gas Stations (House Ways & Means Committee) - Requires gas stations to comply with the federal Americans with Disabilities Act.

  • SF2109 Supplemental Appropriation-Medicaid (Senate Floor) - Adds $80 million to the current year Medicaid budget.

  • SF2144 Mental Health Information Disclosure (House Floor) - Amends current law that prohibits disclosure of mental health information to allow disclosures for the purpose of patient care coordination.

  • SF2161 Children's Mental Health and Well-Being (Senate Floor) - Implements recommendations from the children’s mental health and well-being workgroup final report submitted to the Department of Human Services in December 2015.

  • SF2236 MH/DS County Levy (Senate Ways & Means Committee) - Sets a statewide standard property tax levy for mental health and disability services (MH/DS) for beginning July 1, 2017.

  • SR2006 Special Education Rules (Senate Floor) - Nullifies an administrative rule adopted by the Board of Educational Examiners that establishes a special education endorsement and specializations.

Bills That HAVE NOT Yet Cleared the March 11 Deadline:

  • HF510 MH/SA Transportation Contracts (Senate Human Resources Committee) - Allows a county or a MH/DS region to contract for the transportation of persons with substance abuse disorders or mental illness being committed either involuntarily or voluntarily.

  • HF2287 Commission for the Blind Membership (House Floor) - Increases the number of members on the Commission for the Blind from 3 to 5, and requires that at least one member be blind, one be appointed by the National Federation of the Blind of Iowa, and another be appointed by Iowa Council of the United Blind.

  • HF2366 Mental Health Advocate Duties (Senate Human Resources Committee) -  Makes changes to mental health advocate oversight by giving Judicial Branch authority to develop best practices and guidelines for advocate performance.

  • HF2384 Medical Cannabidiol Act (House Floor) - Amends the Medical Cannabidiol Act by expanding Iowa's existing law to allow use for epilepsy, MS, and terminal cancer and allowing the manufacture and sale of the product through two in-state dispensaries.

  • SF2125  Medicaid Managed Care Termination (House Human Resources Committee) - Requires the Department of Human Services terminate contracts with Managed Care Organizations.

  • SF2145 Speech Therapy (House Human Resources Committee) - Requires Medicaid managed care provide speech therapy benefits for children who have speech, language, and hearing disorders.

  • SF2197 Medical Assistance Advisory Council (House Human Resources Committee) - Adds the state long-term care ombudsman or the ombudsman’s designee to the membership of the medical assistance advisory council and the medical assistance advisory council executive committee.

  • SF2213 Medicaid Managed Care Oversight & Program Improvement (House Human Resources Committee) - Sets up structures to make sure there is good government oversight of the Medicaid managed care system, including enhancing the role of various advisory boards, appointment of an interagency program integrity work group, expansion of the role of the state's long-term care ombudsman, establishing a Medicaid Reinvestment Fund to pay to expand access and improve outcomes, and amending the Managed Care Organization (MCO) contracts to address concerns that have been raised.

  • SF2225 High School Sports Concussions (House Education Committee) - Requires the home team at certain high school sporting events to have a health care professional present and available to assess athletic injuries.

  • SF2244 Vehicle Registration Plates (House Transportation Committee) - Allows the authorized representative of an irrevocable trust to apply for special registration plates for vehicles on behalf of a person with a disability.

  • SF2254 Autism Coverage/Insurance Mandate (House Commerce Committee) - Requires insurance plans pay for the screening, diagnosis, and treatment of autism spectrum disorders. 

  • SF2260 Medicaid Provider Information Disclosure (House Human Resources Committee) - Requires the Department of Human Services contract with a third-party CPA firm to collect and verify information on each person with an ownership or controlling interest in a Medicaid-approved provider organization.

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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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