Iowa’s Managed Care privatized Medicaid System was dealt another blow earlier this month when UnitedHealthcare notified Integrated Home-Health (IHH) service providers that the Managed Care Organization (MCO) would no longer be covering the service’s claims, no matter the provider.

At the Health Policy Oversight Committee meeting on Monday, December 18, UnitedHealthcare responded to Iowa House of Representatives and Senate inquiries regarding its decision to stop paying claims for IHH services. According to testimonies, UnitedHealthcare made the announcement on December 7, 2017, via phone call to IHH providers, stating that IHH services will no longer be covered by the MCO, and that the MCO would only pay claims up to December 1, 2017.

CEO of UnitedHealthcare Community Plan of Iowa Kim Foltz told Iowa senators and representatives that as the goal of having a managed care model was to have value-based programs that are “sustainable” and that Medicaid dollars are responsibly managed, that IHH services are more fee-for-service, which is what managed care is to move away from. Additionally, the way IHH services are coded, Foltz told legislators that the services are viewed as “administrative.”

“That’s the basis,” Foltz said. “We are driving to value based arrangements and moving that care. IHH are fee-for-service, and it’s a fee-for-service rate. When we think of this delivery model, we are moving to an Accountable Care Organization (ACO) model where there is a savings opportunity.”

An ACO model involves the cooperative and voluntary work done by hospitals, doctors, and other provider networks to administer a multitude of care to a patient. Foltz said that in such a model, which UnitedHealthcare is working to establish, value is “driven” into the program to coordinate the best use of services.

Foltz admitted that something could have been done differently during its notification process for IHH, and said these were one of the “bumpy” areas that could be expected in switching to a managed care system.

“In retrospect and understanding the questions, we could have done something outside of our standard notification process,” Foltz said. “This is one area we admitted there could be bumps in process.”

Foltz did say the UnitedHealthcare would continue paying claims for IHH that are part of duplicate coverage (a patient with Medicaid and Medicare eligibility) through January 31, and that a formal, written announcement, was still being approved by the Iowa Department of Human Services, and could possibly be sent out to providers by the end of the year.

According to a letter submitted to the committee by Executive Director Kathy Johnson of the Abbe Mental Health Center (an affiliate of UnityPoint Health), the original request for proposal for MCOs in 2011 applied for IHH grants, and that she described the move as well needed.

Currently, UnitedHealthcare is the only MCO that’s said it would deny claims for IHH.

However, UnitedHealthcare wasn’t the only organization under scrutiny from legislators during the meeting. DHS Director Jerry Foxhoven, Deputy Director Mikki Stier, and Medicaid Director Michael Randol all faced legislator inquiries about the managed care program, and what the state can anticipate in the coming months.

One other predominant concern between all parties, including UnitedHealthcare, as well as Amerigroup, was the fact that according to the Managed Care Ombudsman Quarterly Report, 1,819 of 4,187 contacts to the ombudsman (from October of 2016 to September of 2017) were regarding services being reduced, denied, or terminated.

Both Foltz and Plan President of Amerigroup Cynthia MacDonald were asked whether or not the MCOs were denying, reducing, or terminating services of members through misevaluating them on their Supports Intensity Scale (SIS) assessments, which dictates the severity of a health problem and the care needed.

Both Foltz and MacDonald denied that SIS assessments were being wrongly conducted, and that even if a SIS result had changed, the state serves as a check to the MCO, and must approve of the change itself.

When asked if such changes were occurring, Steir said that if a member believed their assessment results weren’t accurate, that they could request and should be granted a re-evaluation. Steir said that a SIS score is currently not listed as appealable when it comes to grievances between an MCO and members.

Foltz said that the claim that a majority of calls are about denied, reduced, or terminated services, was “inaccurate representation.”