InsideSources

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.”

Over 100 Iowans attended the state’s final Medicaid Public Comment meeting of 2017, on December 5, 2017 at the Des Moines Public Library, venting their frustrations and criticisms with the state’s privatized Medicaid program, less than 30 days after AmeriHealth Caritas’ departure left only two managed care organizations (MCOs) in the market.

Lindsay Paulson, manager for member services area of the Iowa Medicaid program served as the event’s facilitator, which featured two hours of public comment. Alongside Paulson was a panel of state and healthcare officials including: Matt Highland, public information officer for the Iowa Department of Human Services (DHS), Maria Bentrott, policy adviser for the state, and Paige Pettit, a representative of UnitedHealthcare.

These officials did not respond to comments, as outlined in the policy of the meetings that have been held monthly since March of 2016. Patrons were told that if they had questions, they could speak with the panel after the conclusion of the meeting. These meetings were first established as a way to provide oversight for the managed care Iowa Healthlink Program. All feedback from the public is presented to the Medical Assistance Oversight Committee, which then makes policy recommendations to DHS.

Comments ranged from the personal to the procedural, with many declaring the move to privatization as a failure and a complete disregard for poor and disabled Iowans.

“I mean, what action have you taken from our comments that you take back to you little council board?” said Amanda Blackford, “I don’t get it. You know how many people in this room don’t get it? You know, because we’re not seeing change, there’s been no change, in fact it’s gotten worse and you took away our choice. And this is the problem that so many of us have to face day after day, this Medicaid debacle. It’s just been one fight after the other and it’s just been a constant battle and guess what? We’re tired out here. We’re sick and tired of our lives meaning less than day old freaking bread.”

Less than two weeks before the comment meeting, MCO AmeriHealth Caritas left the Iowa Medicaid program, leaving only two MCOs (UnitedHealthcare and Amerigroup) to handle nearly 215,000 displaced enrollees. Since AmeriHealth Caritas’ departure, Amerigroup has announced that it can take on no new members until it gathers the resources necessary to handle increased caseloads, leaving nearly 10,000 members who had chosen to enroll in Amerigroup, to be placed on the Iowa Medicaid Enterprise (IME) fee-for-service plan, which will be not be available for the remaining 213,000 Iowans who will have to enroll through UnitedHealthcare.

Here is a roundup of the various comments shared throughout the night:

Many spoke about problems they’ve had with the MCO program when it comes to providing care for disabled relatives. One of the many criticisms of the privatized system is that it doesn’t allow for relatives of enrollees to be caregivers, making it hard for the enrollees to have constant care, for those that require it.

• Communication: Many of the arguments against the MCOs boiled down to a lack of communication between doctors and service providers, the MCOs, and the enrollees. Many experienced a disruption in services when the provider wasn’t receiving payments from the MCO, and the enrollee was never notified of a service disruption until they went to receive care.
• EOBs: In relation to the lack of communication, many expressed that the MCOs, including UnitedHealthcare, were not sending explanation of benefits (EOBs) to enrollees, who were then not communicating with providers, resulting in service disruption. When enrollees then go to appeal a claim, only then are EOBs sent. In the appeals process, many experienced an MCO stating that EOBs not being sent isn’t an appealable issue, leaving enrollees with disruption of services.
• Case Management: One of the fears of switching to an MCO system, among patrons, was the fact that case management was taken from the state and handled by the companies. For many, this has led to the dissolving of care teams that families had spent years assembling. With MCOs providing their own case managers, many described the scenario as a conflict of interest, seeing as an MCO with its own case manager could not provide the entirety of services required to an enrollee. Some even experienced MCO case managers telling once classified disabled persons that they no longer qualify for care because their condition isn’t severe enough.
• Nursing Home Care: For those that still qualified for services, many MCO case managers assigned enrollees to nursing homes, when the cost for nursing home services was drastically higher than in-home care. Jennifer Donovan, of Iowa Legal Aid, said that the decision by MCO case managers to put some enrollees into nursing homes when they aren’t in need of nursing home care violates the Supreme Court decision in Olmstead v. L.C. (1999) and the Americans with Disabilities Act (ADA) by discriminating against people with mental disabilities.
• Healthcare Infrastructure: While there was much to be said about MCOs not paying for adequate care, several comments pointed out that Iowa doesn’t have the healthcare infrastructure to provide the care required across all counties (mental health services, in-home services, nursing home openings), and that better health networks are also a solution to the problem.

Two ranking Iowa State Senators have asked Iowa Governor Kim Reynolds to extend the sign-up period for over 200,000 Medicaid enrollees who have been reassigned to the Managed Care Organization (MCO) United Healthcare, following the AmeriHealth Caritas departure from Iowa’s privatized Medicaid system as of today, November 30.

Senator Amanda Ragan (D-District 27), a ranking member on the Health and Human Services Budget, and Senator Liz Mathis (D-District 34), ranking member on the Human Resources Committee, wrote a letter to Reynolds, explaining that the loss of AmeriHealth Caritas and the inability of MCO Amerigroup to take on new enrollees leaves too many Iowans without a choice.

“It is a fundamental, legal requirement to offer Medicaid beneficiaries a choice of managed care plans,” the letter says. “It is completely unfair to offer the fee-for-service system to only those members that were able to make a choice before November 16.”

Public Information Officer for Iowa Department of Human Services Matt Highland said that all remaining enrollees from AmeriHealth Caritas’ departure, who did not initially pick Amerigroup as their MCO, will be enrolled with United Healthcare.

A total of 10,121 enrollees who had chosen Amerigroup will be managed by the state’s fee-for-service program until Amerigroup can take on new enrollees. Highland said that this program is limited only to these specific enrollees, who can choose to opt out of the state’s program and join United Healthcare if they so choose.

“In the future members again will have a choice in MCOs and will be notified when that choice is available,” Highland said. “At this time, UnitedHealthcare is the only MCO available to new IA Health Link members.”

Ragan explained in an interview that she’s not sure the exact date that enrollees with AmeriHealth Caritas were given notice of the MCO’s departure, but that it occurred around late October, early November.

“They did not have much time to decide on this,” Ragan said. “So people that decided by the [November] 15 and went, they were treated differently than people who didn’t.”

Enrollees with AmeriHealth Caritas were instructed in their letter that they would have to choose a new MCO — either United Healthcare or Amerigroup — before November 16 to maintain continuous coverage. Iowa Department of Human Services posted to its website this past Monday that those who had signed up to be a part of Amerigroup would temporarily be a part of the Iowa Medicaid Enterprise (IME), which will manage their cases until Amerigroup can take on new enrollees. Reynolds said at a press conference this past Tuesday that approximately 9,000 Iowans will be overseen by the state.

“Due to the lack of timely notice, more than 200,000 Iowans are being assigned to United Healthcare, regardless of their preference,” the letter says. “In the name of fairness and choice, we are requesting that you grant an additional 30 days for former AmeriHealth members to choose either United or the fee-for-service system.”

Iowa’s current privatized system pays a capitation rate to MCOs per enrollee, effectively shifting the cost burden from the state to the MCOs. Under a fee-for-service model, run by the state, healthcare providers are paid based on the services they provide to the client.

Highland said that DHS does not anticipate any funding issues in taking on the enrollees as the state regularly serves “roughly 40,000 members” on a monthly basis.

“It’s been very difficult for people to work through this,” Ragan said in an interview. “There’s been no timely notice for people, it’s just been really super difficult.”

Ragan explained that the type and quantity of care between United Healthcare and fee-for-service will not be much different. The main difference is that some enrollees run the risk of having to switch doctors if they are not partnered with United Healthcare.

According to a press release from the Iowa Senate, “a 30-day extension would address the concerns of Iowans who did not have a choice of managed care organizations, which directly affects which doctors, hospitals and other health care providers they can see.”

The release also references a federal regulation that in a privatized Medicaid system, enrollees need to be able to choose their MCO. Last week, a DHS memo was circulating among the administration that it had received approval from CMS to suspend MCO choice, but amid reports that CMS had in fact not given approval, said that it never needed approval, in that it had the regulatory authority to temporarily suspend choice.

“An ‘approval’ from CMS to suspend choice is not necessary,” Highland said. “Iowa has not requested any additional waiver authority as part of this transition, but is in constant communication with CMS. Iowa Medicaid is proceeding forward in temporarily suspending choice for Medicaid beneficiaries.”

Highland said that states generally have the ability to manage their respective programs in situations such as the one Iowa is currently experiencing, within existing statutory and regulatory authorities.

As of press time, Ragan said that she had not received any response from Reynolds’ office.

“Yesterday, they said that everything’s great,” Ragan said. “That’s not what I’m hearing. Clearly they’re talking to different people than I am.”

Iowa Gov. Kim Reynolds told reporters Tuesday that her administration will stay the course in proceeding with the state’s privatized Medicaid management system, just days after Managed Care Organization (MCO) Amerigroup notified the Iowa Department of Human Services (DHS) that it cannot take on any more members.

On Monday, it was posted on DHS’s website that those who elected to join Amerigroup after AmeriHealth Caritas announced its exit from the privatized Medicaid system this past October — ahead of the formal termination of services on November 31 —would be automatically enrolled in the state’s Fee-For-Service (FFS) program, Iowa Medicaid Enterprise (IME). Amerigroup, which currently has 186,000 Medicaid enrollees, told DHS that it currently does not have the capacity to take on new enrollees in its current structure.

Reynolds said that “around 9,000 people” in FFS enrollment are temporary until Amerigroup can “ramp up” its resources to take on new enrollees. DHS did not return inquiries about the total number of enrollees who had selected Amerigroup as their MCO and will now temporarily receive FFS.

“We’re in the transition,” Reynolds said. “We signed contracts with two providers, [United Healthcare] is taking the majority of the participants in the interim, until Amerigroup can build up their capacity, which we have every belief that they can.”

The remainder of just one MCO means that enrollees only have one choice when it comes to picking providers, however. Under federal rules and regulations for privatized Medicaid systems, qualifying enrollees must have access to a choice of providers, unless a particular state receives approval from the Centers for Medicare and Medicaid Services (CMS). DHS came under fire late last week after a memo began circulating among administration and legislative officials stating that the state had “received approval” to temporarily suspend MCO choice. DHS has since clarified its memo in illustrating the department’s authorities and responsibilities under the circumstance, and what’s allowable under state law. DHS did not return inquiries about whether or not the state will take on more of the approximately 213,000 enrollees remaining after the AmeriHealth Caritas departure.

Enrollees’ Medicaid benefits will be managed differently — one being FFS under the state, and the other in capitation (paid per enrollee and the services rendered). Typically, under an FFS system, states will simply pay care providers per service rendered, which is what drove Iowa’s spending from $2.4 billion in 2004 to $4.9 in 2015. Reynolds told reporters that the average rate of increase for FFS was 10.7 percent. In a capitation system, the state contributes funds per enrollee to MCOs, who then finance the services, shifting more of the cost burden to the companies. DHS did not return inquiries about whether or not services under FFS or capitation will be equal in quantity and quality.

Since former Gov. Terry Brandstad (now President Trump’s ambassador to China) made the announcement that the state would transition the Medicaid program back in 2015, the program and its administrators have had it anything but easy.

The implementation process was several months behind schedule, finally being handed off to the three out-of-state MCOs AmeriHealth Caritas, Amerigroup, and United Healthcare, in April 2016. Back in August 2016, AmeriHealth Caritas and Amerigroup reported losses of $42.6 million and $66.7 million, respectively, in covering healthcare costs. After one year’s worth of service, the three MCOs collectively estimated a total loss of nearly $450 million. In October 2017, AmeriHealth Caritas announced it was leaving the system after state negotiations to increase compensation for the MCOs failed. The state did agree to a 3.3 percent capitation increase for Amerigroup and United Healthcare.

Still, the Reynolds administration will continue the course.

“This is not perfect,” Reynolds said. “I never said it was perfect, but I will put in the time and the effort to show that Iowans get the care that they deserve in a managed and coordinated and more modern delivery system. I’m not going back.”

As to when Iowans would see their choices again, Reynolds was blunt, saying, “They’re going to have a choice. We’re going to work with them.”

The state of Iowa does have a request for proposal out to accept new providers into the system, however, a new MCO wouldn’t be able to enter the system until 2019.