Legislative news – 11/14/2015; Managed Care Organizations for Medicaid
The State of Medicaid Managed Care
The confusion and uncertainty surrounding Iowa’s move toward full managed care for the state’s medical assistance program is shared by nearly all providers. Recently, the federal Center for Medicare offered some insight into what steps Iowa must show to ensure federal approval of their plan including:
1. The four Managed Care Organization (MCO) contracts with the state have been signed and fully executed.
2. Each MCO has contracted with and credentialed at least 50% of the current fee-for-service (FFS) providers in the following categories:
Primary care, adult and pediatric
OB/GYN
Five most common adult and pediatric specialty providers
Hospital
Pharmacy
LTSS providers
Behavioral Health, adult and pediatric (based on Magellan’s directory instead of FFS for this provider type)
3. Each MCO has hired at least 50% of its projected staff (emphasis on customer service call center staff).
4. The state can provide a complete set of member materials to be included in enrollment packet mailings.
5. Iowa’s Medicaid member enrollment broker (Maximus) has demonstrated readiness to serve beneficiaries.
6. The state provides CMS with a copy of its initial internal readiness review results that shows that the MCOs’ activities and plans are likely to achieve a January 1 implementation date and the review does not contain any serious red flags.
7. Iowa has a fully established ombudsman for patients receiving LTSS services.
8. The state provides CMS with call center statistics related to member calls following the initial IA Health Link introductory letter that was sent in September.
It remains to be seen if the state will either meet these conditions or if the federal government will deny the waiver for the new Iowa program.
Member Enrollment – Patients
According to Iowa Medicaid Services, current patients are currently being informed of the transition and to which provider they are assigned. The assignment to one of the four companies is being handled randomly. The assignment process will equally divide the patients between the four MCOs regardless of claims history or existing provider relationships. Family members with the same last name will, to the extent possible, be assigned to the same MCO. However, this will not guarantee that family members with different last names will receive the same treatment.
Patients will have an opportunity to change their MCO assignment once they receive written notification. Patients may select a different MCO up to December 17 before the system goes “live” on January 1, 2016. After the system is “live”, patients will have a 90-day window, until March 18, 2016, to switch MCOs for any reason. After that point, the only change that can be made is for “good cause” which is defined as:
• The member’s provider is not enrolled with that MCO and this would negatively impact the member’s health outcomes.
• The member needs related services to be provided at the same time and not all related services are available in that MCO network.
• There is a change in eligibility.
Provider Enrollment
According to Iowa Medicaid Enterprise, the process for contracting with providers is moving forward smoothly but they have failed to provide actual data as to the number of providers currently under contract for the upcoming year. All four MCOs will be required to cover services provided by all current Medicaid providers regardless of the contract status of a provider. This transition period lasts for six months for physical and behavioral health providers. Providers can continue to see their patients until June 30, 2016 even if they are not under contract with the patient’s MCO.
The question of reimbursement is more uncertain. During the initial discussions of the process and legislative discussions, it was understood that during this transition period, providers would receive full reimbursement. However, the state has now changed that position. If a provider is not under contract with their patient’s MCO by January 1, 2016, the reimbursement rate is reduced by 10%, mirroring the out-of network reimbursement rate. This is causing considerable controversy and is largely seen as a “hammer” to force providers to sign contracts more quickly.
Here are the weblinks for the four MCO provider manuals as approved by IME:
• Amerigroup Iowa, Inc.
• AmeriHealth Caritas Iowa, Inc.
• UnitedHealthcare Plan of the River Valley, Inc.
• WellCare of Iowa, Inc.
DHS has indicated that they have adopted a single, centralized form for credentialing with the four companies and IME (which is still required to be a Medicaid provider). This reduces the administrative and regulatory burden on providers who wish to be credentialed with multiple MCOs. If you have already completed the individual credentialing form, you are not required to resubmit based on this policy change.
For more information about the provider enrollment process and the transition to managed care, IME has developed this website: https://dhs.iowa.gov/ime/about/initiatives/MedicaidModernization
Legislative Oversight
The legislature established the Health Policy Oversight Committee to provide guidance and a forum for providers, patients and others about the transition to managed care. This committee, comprised of legislators, is open to the public and includes a timeframe for making public comment. You can also submit written comments to the committee. Their next meeting is December 7 starting at 10:00 a.m. in Room 116 of the Capitol. Members of the committee can be found at this link: https://www.legis.iowa.gov/committees/committee?ga=86&groupID=24165.
The initial meeting of the committee highlighted the partisan divide that is occurring as the state moves toward finalizing this transition. It remains to be seen what, if anything, the committee can influence within the transition process. The first set of administrative rules to implement the transition will be presented to the Administrative Rules Review Committee on December 8. The rules review committee is comprised of legislators from both chambers and is the oversight body for all proposed rules.
Submitted by:
Emily Piper | [email protected]
Piper Consulting Services
P.O. Box 12011 | Des Moines, Iowa 50312-2011
Phone: 515-202-7772 | Fax: 866-869-2842