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HEALTHY AND WELL KIDS IN IOWA (HAWK-I)

BOARD MEETING

MINUTES

April 17, 2000

 

BOARD MEMBERS:

Eldon Huston, Chair

Terri Vaughan, Vice-Chair

Dave Krutzfeldt

Nancy Mounts

Ted Stilwill (absent)

Stephen Gleason, D.O. (absent)

Mary Weaver (for Stephen Gleason)

Susie Poulton

LEGISLATIVE BOARD MEMBERS:

Senator Johnie Hammond (absent)

Senator Mary Kramer (absent)

Representative Brad Hansen (absent)

Representative Robert Osterhaus (absent)

DEPARTMENT OF HUMAN SERVICES:

Dennis Headlee

Anita Smith

Anna Ruggle

Shellie Goldman

Deb Van Den Berghe

ATTORNEY GENERAL'S OFFICE:

Marne Woods

GUESTS: AFFILIATION

Diane Briest New HAWK-I Board Member effective 5/1/00

Kehla Garrett John Deere Health

Sonni Vierling Iowa Department of Public Health - Covering Kids

Frann Otte Wellmark

Michelle Coon Visiting Nurse Services

Bill Brand Iowa Dept. Human Rights - Community Action Agencies

Lloyd VanderKwaak Special Health Care Needs Subcommittee

Mary O'Brien Visiting Nurse Services

Pat Hildebrand HAWK-I Clinical Advisory Committee

Pat Moreland Iowa Dietetic Association

Jim Donoghue Broadlawns

Paul Stanfield Human Needs

Barbara Fox-Goldizen Eligibility Services, Inc.

Dr. David Alexander Blank Children's Hospital

WELCOME AND INTRODUCTIONS:

The Healthy and Well Kids in Iowa (HAWK-I) Board met on Monday, April 17, 2000, in the Oak Room at the Botanical Center, 909 East River Drive, Des Moines, Iowa. Eldon Huston, Chair, called the meeting to order at 12:35 p.m.

Mr. Huston noted that a quorum was present as well as staff from the Department of Human Services. Anita Smith took the roll call.

Ms. Smith introduced Dennis Headlee, Iowa's new Medicaid Director. Mr. Headlee is currently serving as the Administrator for the Division of Medical Services, Iowa Department of Human Services. Mr. Headlee's areas of responsibility include management of the Bureau of Eligibility Services, Bureau of Health Care Purchasing and Quality Management, and the Bureau of Contract Management and Reimbursement.

Mr. Headlee told the Board his background has been primarily on the provider side. He has served as chief executive officer and chief financial officer for hospital systems and networks and has a managed care background. Mr. Headlee shared the Department's vision, indicating the agency is moving towards changing their delivery of services to ensure service access, that as many Iowans as possible are served, and doing so in a quality way. When the Department either contracts for services or delivers services, they will do so with an eye on obtaining results for the dollars and efforts the agency has invested.

Mr. Huston announced that newly appointed Board member Diane Briest was in the audience. Ms. Briest will be more formally introduced at the May Board meeting.

The remainder of the introductions of staff and guests were made.

ANNOUNCEMENTS:

Mr. Huston informed the guests that there would be an opportunity for public comment later in the agenda and if someone would like to address the Board, they should notify him.

APPROVAL OF THE MARCH 20, 2000, MEETING MINUTES

Dave Krutzfeldt made a motion to approve the March 20, 2000, minutes as written. The motion was seconded by Nancy Mounts. Unanimous approval was made by Eldon Huston, Nancy Mounts, Mary Weaver, Susie Poulton, Terri Vaughan, and David Krutzfeldt.

CORRESPONDENCE:

Ms. Smith provided a synopsis of the correspondence that was provided to the Board.

The first was correspondence with Pamela Brocker, Sponsorship Director for the Iowa State Fair Blue Ribbon Foundation. Wellmark arranged this sponsorship for HAWK-I to have a presence at the State Fair for a nominal fee of $4,000. The sponsorship contract provides an exhibit table in the immediate area of the Wellmark Blue Cross Blue Shield exhibit space near the Riley Stage and "Gator the Clown" will walk around promoting HAWK-I. Ms. Smith explained that since legislation requires the Board to approve all contracts, the Board would have to approve this contract before the Department could sign off on it. Ms. Smith mentioned that contracts like this and the one with the Marriott to hold the "Still Searching for Austin" conference, come to the Department; sometimes with very short time frames. Ms. Smith asked the Board if they wanted to approve all such contracts or whether the Department could be authorized to approve smaller contracts without formal Board approval.

Discussion followed. Mr. Krutzfeldt suggested that the Board give the Department authority to approve contracts under a certain dollar amount on behalf of the Board. Nancy Mounts made a motion to give the Department of Human Services prior authority to execute any administrative contracts under $10,000. All provider contracts would still come before the Board. The motion was seconded by Terri Vaughan. Unanimous approval was made by Eldon Huston, Nancy Mounts, Mary Weaver, Susie Poulton, Terri Vaughan, and David Krutzfeldt.

Marne Woods suggested the Department give the Board a courtesy copy after these contracts are executed. Ms. Vaughan indicated these contracts could be an agenda item at Board meetings.

Susie Poulton made a motion to approve the contract with the Iowa State Fair Blue Ribbon Foundation. Motion was seconded by David Krutzfeldt. Unanimous approval was made by Eldon Huston, Nancy Mounts, Mary Weaver, Susie Poulton, Terri Vaughan, and David Krutzfeldt.

The second item of correspondence was a letter from Frann Otte of Wellmark. Ms. Otte shared the summary document from a March 16th HAWK-I focus group. Ms. Smith noted that most participants identified their physician or clinic as their first introduction to HAWK-I and recommended the continuous supply of applications and information to all health care providers. Participants all agreed that HAWK-I enrollment is easy and hassle free, and the application form is easy to understand and complete. Under "Barriers to Signing Up" it was noted that a few didn't sign up initially because the program sounded too good to be true. Participants found no stigmas attached to signing up for HAWK-I and characterized their experience with Medicaid as degrading, tense, and very cumbersome. It was even suggested that HAWK-I needs a new slogan, "the no hassle insurance". There was some discussion by the focus group participants about the lack of dentists accepting new patients or HAWK-I insurance and the desire for orthodontia coverage.

Participants repeatedly asked that a product similar to HAWK-I be developed to meet the uninsured parents needs. Participants were asked if there was anything they would change about HAWK-I and none recommended any changes at this time. Those with minimal experience would like to be asked again in one year.

Ms. Otte indicated 8 people participated in the focus group and were all from Polk County.

Ms. Mounts stated she felt very good about the results of this focus group, however, she had several concerns. One concern is the length of time for approval and were people notified in the time parameters of the contract? Ms. Mounts stated her other concern is with the comments about Title XIX and the way people were dealt with.

Ms. Smith asked Ms. Otte if the names of the focus group were available so they could be contacted with follow-up questions. Ms. Otte indicated the names were available.

Ms. Mounts noted the comments about physician participation and suggested more could be done to let physicians know that the compensation and paperwork for HAWK-I is different from Medicaid.

The next item under correspondence were the notes from the HAWK-I Outreach discussion Ms. Smith and Ms. Van Den Berghe attended on March 20. This meeting had been arranged by Peter W. Roberts, President of Wellmark, in an effort to assist with outreach activities. Mr. Huston read the remarks of one of the participants representing physicians who indicated that "physicians are not interested in HAWK-I, they see it as Medicaid and full of red tape, poor reimbursement, and a hassle. Something needs to excite the physicians." Mr. Huston noted that the Iowa Medical Society is trying very hard to encourage their doctors to participate so he was somewhat surprised at these comments.

Ms. Van Den Berghe indicated that thanks to the help of Mr. Roberts, the providers are doing several things to assist with outreach and will continue to do more. The providers are adding to the "Still Searching for Austin Conference", but getting physicians to attend the conference is difficult. The providers are addressing the issue by utilizing their communication systems, such as newsletters and other communication tools, to increase provider education. They will also be focusing on the dental convention in Des Moines in May and the upcoming osteopathic convention.

CHILDREN WITH SPECIAL HEALTH CARE NEEDS ADVISORY COMMITTEE UPDATE:

Ms. Poulton indicated the main concern she wanted to bring to the Board is the Advisory Committee is asking for a little more direction. They have an initial report and are trying to gather information about the population to see if their needs are being served. The Advisory Committee is asking that a planning subgroup be developed, with board members included in the subgroup.

Lloyd VanderKwaak , a member of the Children with Special Health Care Needs Advisory Committee, addressed the Board. Mr. VanderKwaak stated that the HAWK-I Board adopted a definition of a child with special health care needs. It would be very helpful if the statistical sheets included the category of "special needs" on a county-by-county basis. The Committee would like to know how many enrollees meet the definition of "special health care needs" in order to get a feel for how large this population is.

Shellie Goldman, Department of Human Services, indicated she has been working with MAXIMUS on encounter data. Ms. Goldman stated she felt they need to look at not only the definition of special health care needs from an encounter data perspective, they have to be able to define in some way what diagnoses are reflective of a special health care needs population. Even though "special health care needs" has been defined, how will those populations be defined and at what point a diagnosis if there are several incidents? Outcome measurements need to be developed which would indicate how many children are receiving multiple services from subspecialists. Ms. Goldman indicated she would like the Advisory Committee to look at these issues so she can get a better understanding of how to pursue these measurements.

Ms. Poulton stated that Ms. Goldman had raised some good issues. Right now the Committee doesn't feel they have the necessary data and need to find out who the special needs children are and if their needs are being served. Between working with MAXIMUS and performing a functional survey, this population should be able to be identified.

Ms. Poulton made a motion to create a joint committee, to include representatives from the Board, to identify and define what needs to be done to identify these special needs children.

The motion was seconded by Ms. Vaughan. Unanimous approval was made by Eldon Huston, Nancy Mounts, Mary Weaver, Susie Poulton, Terri Vaughan, and David Krutzfeldt.

Mr. Huston appointed Susie Poulton to represent the Board and indicated another Board member will be assigned after the two new Board members begin their duties.

Mr. VanderKwaak stated that Dr. Jeff Lobas had two concerns he wanted mentioned to the Board. The first was care coordination in relation to the Deloitte & Touche report. Dr. Lobas wants to make sure the subcommittee has a chance to comment on the care coordination issue and associated costs, and establishing medical home for special needs kids. The other concern was nutritional services and the issue of how do we reimburse the cost of nutrition and nutritional substances for children, whether it is dealt with as a prescription versus essential substance. Mr. VanderKwaak stated that however it is categorized, he feels essential substances for special needs children, as prescribed by the physician, is something that should be paid for through HAWK-I

Mr. Krutzfeldt asked if essential substances are currently covered by traditional health insurance plans. Mr. VanderKwaak said yes.

Mr. Huston indicated that nutrition is an area that will be discussed later.

ADMINISTRATOR'S REPORT:

Enrollment and Statistics:

Ms. Smith announced that the HAWK-I Program reported its second largest increase in enrollments in March, 2000 with 607 children added to the program. Both the Medicaid expansion and HAWK-I continue to increase.

Ms. Weaver asked if the goals for Medicaid expansion and HAWK-I could be added to the Combination Medicaid Expansion and HAWK-I Program graph. Ms. Smith indicated staff would do so.

Ms. Smith informed the Board that March applications are still up, but Ms. Smith expressed her concern about the large number of referrals to Medicaid, which are well over 50 percent and have been since February 28. For the week of March 20th, 76 percent of the HAWK-I applications were referred to Medicaid and there has been a complaint about the length of time it is taking for HAWK-I applications to be approved. Currently, the reports from ESI show there are over 2,000 applications pending that have been referred to Medicaid. With only four income maintenance workers at ESI to establish Medicaid eligibility, this is of great concern.

Mr. Krutzfeldt asked if we had any statistics as to how many of the referrals to Medicaid are correctly referred. Mr. Krutzfeldt was concerned that applications were being inappropriately handled.

Mr. Huston felt that perhaps outreach efforts for HAWK-I are reaching people who could have applied for Medicaid and did not realize it.

Ms. Mounts is concerned that without adequate staffing to review the applications, it will increase the number of complaints that the HAWK-I program is cumbersome, not responsive, et cetera.

The Board inquired as to the turn around time required for Medicaid and is the State currently in compliance with the law. Also, are HAWK-I funds financing anyone that comes onto Medicaid this way? Ms. Smith indicated that under federal law the State has up to 30 days to process a Medicaid application and she would have to check to see if the State is currently meeting that requirement. HAWK-I funds would only finance those that fall into the expansion category.

Ms. Smith indicated she would find out about the processing time and report back to the Board. Ms. Smith said that the process is more efficient now with the four income maintenance workers co-located with ESI instead of having the applications spread out over the 99 counties. However, the four workers are getting so many applications, it is of concern whether they can continue to process this amount. Under the new contract with MAXIMUS, space for ten workers will be provided.

Ms. Vaughan asked if additional staff could be temporarily reassigned to process applications, or if applications could be distributed to the field to reduce the backlog.

Ms. Vaughan made a motion to have Ms. Smith look into this issue and to report back to the Board as soon as possible on how this issue will be addressed. The motion was seconded by Mary Weaver. Unanimous approval was made by Eldon Huston, Nancy Mounts, Mary Weaver, Susie Poulton, Terri Vaughan, and David Krutzfeldt.

Dennis Headlee indicated he will be attending a meeting on April 19th with staff who are responsible for coordinating activities between the central office and the field. He will address the processing time and income maintenance work load at that meeting.

Ms. Smith then referred the Board to the Applicant Status Summary Report. Current HAWK-I enrollment is 5,934; pending Medicaid referrals are 2,661; and pending HAWK-I applications are 296. The top five reasons for denial are still the same. The "HAWK-I Disenroll Reason by County" report shows that during March, 61 children lost eligibility: 27 because they became eligible for Medicaid; 22 because they had other insurance; and 1 was for failure to pay a premium. Each month the reason for disenrollments differ, showing no trend.

The "How You Heard of Us" report shows that as of March 31, 166 applications have been received as a direct result of a mailing to families that were previously denied because they were over income, but who might now qualify. The March report also shows that some applicants heard about the program through work, so it appears as if some employers are starting to make referrals to the program.

The "Follow Up on Renewal Applications" report indicates the return rate appears to be improving. An annual review form is sent to enrollees to be recertified. Initially, there was just a 30 to 50 percent return rate. Ms. Smith stated she anticipates a continued increase in the return rate due to the new MAXIMUS contract. A preprinted review form will now be sent, so the applicant will only need to make necessary corrections and enter current income verification information.

A question from last month's Board meeting was about ethnicity and how the numbers approved for HAWK-I compare with the demographics and population of the State. Anna Ruggle reported the following percentages, based on the 1990 census.

 

% of Iowa's

Population

% Enrolled

in HAWK-I

African Americans

1.7

3.9

Asian American

.9

.9

American Indian

.3

.5

Hispanic

1.2

.6

Ms. Smith stated that based on those statistics, for all ethnic populations other than Hispanic, we are equal to or exceeding the percentage of population in the state. For Hispanics we are significantly lower.

The last statistical report discussed was the "Medicaid and HAWK-I Progress Monitoring Report". Ms. Smith noted that some counties are really doing well in obtaining their goal: Clark 48%; Montgomery 54%; Ringgold 61%; and Wayne 48%. For the most part, almost all counties are at 25 to 40 percent of their enrollment goal. Ms. Smith asked the Board to keep in mind the counties did not want to use the 75 percent take up rate, they wanted their goal to be 100 percent, so they are probably closer to a realistic goal than the numbers reflect. These numbers are based on a 100 percent enrollment rate.

Mr. Huston asked if the outreach workers find it easier to locate eligible enrollees in the least populated counties? Ms. Smith indicated that the economic base of the county has a lot to do with the enrollment. Also, there may be more employers in the larger counties who offer health insurance coverage.

Budget:

Ms. Smith informed the Board that interest earned to date from the HAWK-I trust fund is $86,506; which is being used to offset administrative costs. Expenditures are at $2.9 million and were projected at $5.9 million. However, the Department is still in the process of correcting some HAWK-I claims that were paid out of the wrong cost center.

The tobacco legislation includes language for expansion of HAWK-I to 200 percent of the federal poverty level as well as a Medicaid expansion for infants up to 200 percent.

Ms. Smith then reported on the status of FY 2000 CHIP funds. The HAWK-I trust fund had a $2.6 million carryover from FY 99. As long as this year's projected expenditures of $5.9 million are not exceeded, there will be an additional $4.3 million. The appropriations bill states that carry over funds from the trust fund (estimated at $6 million) must be used to fund next year's budget, which will leave a balance of $974,680. Between the HAWK-I expansion (projected at $669,783) and the Medicaid expansion for infants (projected at $126,848), there should be sufficient funding to go to 200 percent for both the Medicaid expansion and HAWK-I, even though no additional dollars were appropriated.

Legislative Update

Ms. Smith told the Board that the Department of Human Services' appropriations bill passed both houses, however, an amendment was added in the House which requires the Department to seek a waiver from HCFA to allow families a choice between Medicaid and HAWK-I. The Department has recommended the language be struck because the language did not provide for any resources. Seeking a waiver from HCFA and implementing a waiver of this magnitude would require significant resources. Ms. Smith explained that before a waiver is approved, parameters would have to be developed, there has to be a control group, a study group, funding, a way to measure success, and a demonstration of cost neutrality. After a waiver is approved, which may take as long as 18 to 24 months, a 3 to 5-year pilot is usually required.

The "tobacco bill" is currently on the House appropriations calendar.

The HAWK-I "clean-up" bill was approved for the first funnel February 16, but appears to be dead for the year. This was a non-controversial technical corrections bill, but there may have been some amendments added that made it controversial.

The Department Human Rights' appropriations bill contains provisions for $100,000 to do HAWK-I outreach. The bill was passed by the Senate on March 23rd. The House passed it on April 13th with an amendment that the HAWK-I Board must approve the use of the funds. The bill is currently awaiting further action by the Senate.

Bill Brand, Department of Human Rights, indicated the $100,000 is earmarked from the gamblers treatment fund, not out of HAWK-I funds, and would go to community action agencies.

Ms. Smith stated that the grassroots community projects are already putting together plans for next year so she would like to know if the Board foresees any changes from what is currently being done. Mr. Huston said what they are doing now seems to be working so he foresees no changes.

Ms. Woods voiced her concern about the $100,000 appropriation to Human Rights, should it pass, because the HAWK-I legislation states that any contracts for HAWK-I have to be approved by the Board. Additionally, all funds appropriated for the HAWK-I program must be deposited into the HAWK-I trust fund.

Transition to MAXIMUS:

Ms. Smith announced that Barbara Fox-Goldizen, currently with ESI, has been hired by MAXIMUS to continue as their project director here in Iowa.

Anna Ruggle informed the Board that MAXIMUS has signed a rental agreement for a location in West Des Moines. Staff has met with MAXIMUS numerous times, have met with the health plans numerous times, and things are moving along well. MAXIMUS is currently working on their policy and procedures manual, revising their letters, and other implementation tasks. The Board was provided with a list of these tasks with targeted completion dates. MAXIMIUS will officially take over on Friday, May 26th. Ms. Smith indicated that everything has been worked out with ESI as to when they will stop processing applications and when files, telephones, and the like will be transferred to MAXIMUS.

Shellie Goldman stated that MAXIMUS has worked with a lot of government agencies and is very up-to-date on standardization requirements and new HIPAA guidelines. MAXIMUS has recommended starting the transition to HIPAA guidelines. The new guidelines will eventually require health plans to standardize through encounter data and outcome measurements. Outcome eligibility encounter data has been developed with a lot of new edits to ensure the information, such as diagnosis codes and procedure codes, match up. Ms. Goldman stated a good provider file exists that has been discussed with the health plans. Checks and balances regarding physician coding have been set up as well as a lot of rejection codes. Ms. Goldman stated that unfortunately when the encounter data was under the ESI contract, the edit check had not been set up. Once the standardized format is established, the health plans have agreed to go back to when they started with the program and enter that information into the correct buckets so no information will be lost. As progression is made, additional fields will be added based on whatever HIPAA requirements are. Outcomes that were set in the original state plan, such as immunizations, well child care, asthma, and ER visits, will be at the top of the list. Ms. Goldman indicated the need to work with the Quality, Clinical Advisory, and Special Health Needs Committees to determine what special reports to pull from this data.

Ms. Smith noted that the health plans are working very cooperatively with the Department, MAXIMUS, and ESI.

Mr. Huston asked if there were any new health plans on the horizon. Ms. Smith indicated an inquiry had been received from Secure Care and additional information was sent to them, but she's heard nothing further. Ms. Smith indicated she will contact Secure Care and follow up.

Ms. Goldman outlined the contents of the annual report to HCFA that was submitted March 31. The report covers Medicaid expansion, as well as HAWK-I, for the time period July 1, 1998, to September 30, 1999. The National Academy for State Health Policy worked with HCFA and Congress to come up with a framework for all states to use that would cover questions Congress might have as well as the requirements for the HCFA report. The Academy will prepare a compilation of all the state plans.

Outreach Update:

Outreach Coordinator Deb Van Den Berghe provided the Board with a synopsis of outreach activities during the past month, as well as upcoming activities. Among those activities, Ms. Van Den Berghe and Ms. Goldman have conducted training for a Polk County area program, "HAWK-I Takes Flight", which is specifically targeted to reach minority populations. Ms. Van Den Berghe also attended a Global Information Systems program in Atlanta, Georgia, which will help staff identify the HAWK-I program market.

Over 17,000 brochures for the "Still Searching for Austin" conference were distributed and requests for approximately 1,000 more have been received. Conference staff is preparing for 700 attendees, registration is unknown as this time, but over 400 attended last year's conference. Three areas will be recognized for their outreach activities and winners will receive a customized congratulatory letter from Vice-President Gore. Mr. Huston has agreed to be the master of ceremonies at the conference.

Work on the FY 2001 contracts has begun. Intent is to have the funding to the outreach coordinators and fiscal agents before September. This year there will be a second cycle so if counties do not request the funding initially, there will be another opportunity. Ms. Van Den Berghe is working to develop a communication tool to provide monthly updates on policy changes, legislative changes, questions, or any other key issues.

Ms. Poulton asked for a reminder on how the distribution of outreach funds worked. Ms. Smith explained that $300,000 was designated to go to the communities. The allotment to each county was based on a formula of total child population and children in poverty population. The community develops their outreach plan, submits it to the Department of Human Services' regional administrator for approval, and forwards to Ms. Smith's staff. Once the contract is received, funding is issued within three days. Funds not expended by the end of the fiscal year have to be returned to the HAWK-I trust fund.

Ms. Van Den Berghe then commented on grassroots efforts and indicated the Board should be seeing good results from these efforts in the upcoming months. Also, last month the Board requested information regarding the 20 percent disregard exclusion mailing and how follow-up was being conducted. Ms. Van Den Berghe indicated that some of the counties have prepared releases of information so they can follow through and act as agents for individuals applying for or enrolled in HAWK-I. They are still in the process of fine tuning follow-up activities.

May Board Meeting:

The May Board meeting is currently scheduled for Monday, May 15th, at 12:30 in the Botanical Center. Due to the "Still Searching for Austin" conference being held on Wednesday, May 17th, the Board decided to move the May Board meeting to Tuesday, May 16th at the Des Moines Marriott from 4:00 to 6:00 p.m.

PUBLIC COMMENT:

Mr. Huston indicated that no one had requested an opportunity to address the Board.

RECOGNITION OF DEPARTING BOARD MEMBERS:

Mr. Huston recognized David Krutzfeldt and Nancy Mounts for their membership on the HAWK-I Board. Mr. Huston stated that getting a new program off the ground is difficult and he couldn't think of two people who contributed more in getting the program up and running. Good progress was made on a very important program and both Mr. Krutzfeldt and Ms. Mounts should feel good about their role. Certificates of appreciation were awarded to both.

Ms. Mounts stated that she had gained a new appreciation for the Department of Human Services and its staff. This has been a huge undertaking with limited resources, and it's been a wonderful opportunity for her.

Mr. Krutzfeldt agreed with Ms. Mounts' statements. Mr. Krutzfeldt stated that he was aware of the possibility of various conflicts that could arise in a program such as this so success could be measured not only with accomplishments, but with what kind of things did not happen. Mr. Krutzfeldt complimented the chairmanship and leadership among the Board.

CLINICAL ADVISORY COMMITTEE RECOMMENDATIONS:

Mr. Huston stated that unfortunately the additional information requested from the actuaries has not come back. The Board had earlier indicated they needed to talk again with the Advisory Committee, talk to the providers, then come back with more specific guidelines and recommendations. Mr. Huston asked with that process, can a more priority-based recommendation be put together as to what the Clinical Advisory Committee feels is the most important benefit.

Dr. Alexander stated it would be hard for that Committee to come to a consensus. However, based on data, the biggest need appears to be mental health, which is also the most expensive. The recommended changes in dental coverage probably would not cost anything. Dr. Alexander stated that the Committee had concerns with the actuary's first response that care coordination would cost as much or more for the HAWK-I population as for the Medicaid population.

Mr. Huston stated that decisions would need to be made in May and June in order to make a timely request for additional funding from the legislature next session

Ms. Poulton indicated she would like to discuss some of the suggestions and asked Dr. Alexander how he would see the care coordination.

Dr. Alexander stated the Committee felt that the same agencies who provide care coordination for the Medicaid population could be contracted with to provide these services. The Committee spent a lot of time to better understand the difference between care coordination and case management. Case management is for cases with complex illnesses to ensure that the right hand knows what the left hand is doing. Care coordination means that people are optimally using the services they are entitled to. This includes making sure people know they have a primary care provider, make an appointment, and ensure they have a way to get to that appointment. The Committee didn't feel that transportation issues are going to be as severe with this population as they are with Medicaid population. The Committee is concerned that the HAWK-I population is a population that has learned to do without, they have learned to get by without using services, the majority have not gotten preventive health care, and the Committee wants to make sure they are using these things optimally.

Pat Hildebrand, who is a member of the HAWK-I Clinical Advisory Committee, addressed the Board. Ms. Hildebrand stated that she is one of the contacts for care coordination and what Dr. Alexander is saying is correct. This is a different population who is not use to the insurance system, they're not use to preventive care. An education process is needed to explain what insurance means, and assistance is needed in selecting a provider. Ms. Hildebrand gave the example that some families do not have a good grasp of English and have selected primary care providers who are not located in their area, or one family did not pay their premiums because they didn't go to the doctor that month.

Ms. Vaughan stated she thinks care coordination is an area worth getting more information about and the Board needs to be careful not to make the assumption that the Medicaid population and the HAWK-I population have the same needs in terms of care coordination. Ms. Vaughan asked if there was going to be another HAWK-I focus group or if someone could structure a focus group that is a random sample of HAWK-I members. This group could be polled as to what kinds of problems they are having using the services.

Ms. Smith stated that under the new MAXIMUS contract, MAXIMUS will call the family, walk with them through the provider choices, and find a primary care physician that is located near them. This process will reduce costs because all the provider booklets will not have to be mailed out. The process previously had been once they are determined eligible, ESI notifies the plan, the plan contacts the family, and the family selects a primary care physician. Hopefully, some of the issues will not happen in the future with the new process.

Mr. Huston asked Dr. Alexander with care coordination does the recipient initiate the contact with the care coordinator or does the care coordinator initiate the contact with the recipient?

Dr. Alexander indicated that in most circumstances it is the care coordinator who will initiate the contact. The Committee didn't feel this would be an issue for the majority of the population insured under HAWK-I, but there will be families who will have to have help to learn how to use the system. There could be an initial contact now, make sure they have a dentist and get a check-up every year, tell them they need to go for a health maintenance visit every year, and provide follow-up at some point.

Mr. Huston asked how care coordination currently works with a Medicaid client. Ms. Hildebrand indicated that every new Medicaid enrollee gets a telephone call. A family may call a care coordinator and indicate they are having trouble with transportation and have a child who is very ill, things like that.

Ms. Poulton asked if it is known what percent of families on Medicaid have actually utilized care coordination. Ms. Smith indicated they can get that data.

Ms. Weaver stated that anticipatory guidance should be provided to enrollees. Guidance that could prevent future claims. Ms. Weaver felt it is more than just getting families set up initially with their health care provider, but to have someone who will go back and touch base with the family and see how they are doing. For example, remind families that their child will soon be cutting teeth and how to be prepared for the event, or to remind parents to put poisons out of the reach of the children.

Ms. Poulton cautioned the need to be careful with this population because these are families who have not utilized the system for whatever reason. Ms. Poulton stated if someone contacts the family, it has to be done in such a way it will benefit the family, not offend them, and not be viewed as intrusive.

Dr. Alexander stated it was his hope that for most families care coordination would consist of an initial call and maybe a follow-up to make sure they have hooked into the system.

Ms. Smith asked Pat Hildebrand about their care coordination activities with the Medicaid population as they relate to transportation. Do they simply arrange for transportation or does care coordination also pay the cost of transportation? Also, how does the Committee envision that component working under HAWK-I?

Ms. Hildebrand stated the activity would focus more on what transportation options are available to the family rather than providing transportation, which is why it is important that this be done on a local level.

Ms. Weaver stated that the care coordinator also ensures the appointment is kept and that follow-up occurs after the appointment to ask what occurred or if there are any questions.

Ms. Hildebrand indicated that what she hears from hospitals and health providers is that what is costing the health care system money is the population using the emergency room as their primary care provider. Providing education saves the system a lot of dollars and helps the family.

Ms. Mounts stated that the primary issue with dentists is when the patient does not show up for appointments, so this type of care coordination would play into that. Ms. Mounts then gave the example in her area when a parent cannot get away from work to take their child to the dentist, if the parent signs a waiver, an outreach worker can take the child to the dentist at no cost to anyone.

Dr. Alexander stated the Committee felt the biggest issue regarding the dental plan is not really related to provider reimbursement, but that maximum benefits are not the same across the plans.

Mr. Huston asked Dr. Alexander to discuss mental health since that is the area the Committee feels is most needed.

Dr. Alexander stated that from health assessment surveys which were sent out over the course of the last year, mental health was the most common health concern sited among this population of families. Additionally, providers across the state feel the biggest need is for mental health services for these children.

Ms. Mounts stated that from an educator's perspective, mental health services would be valuable because so many children have huge issues now and no way to get help.

Dr. Alexander felt the biggest concerns are that the plans don't necessarily cover all the diagnosis for which children need treatment, and the plans don't necessarily cover all the different venues in which children receive care. Dr. Alexander stated the plans cover in-patient care, but they do not cover the full spectrum of care between fully-paid hospitalization, which very few children need, to purely outpatient care. There are a lot of things in between, for example, partial hospitalization or day treatment, and the coverage in those areas is spotty. Dr. Alexander said those are much more cost effective ways to provide care than in-patient care and probably better.

Ms. Vaughan referred to a letter addressed to Dr. Alexander from Scott Shafer and Kermit Dahlen recommending carving out behavioral health care for HAWK-I. Ms. Vaughan wanted to know if that is a recommendation of the Clinical Advisory Committee.

Dr. Alexander stated that the Committee did not take a position on how the Board should accomplish the goals, but there is an insurance plan in the state that cares for children on Medicaid and that approach would work for this population also. The Committee put that forward as one strategy, but did not make implementation recommendations because that is not their role.

Ms. Vaughan commented that the letter expresses concerns about the continuum of care, the Wellmark plan only provides for two modalities, not a comprehensive continuum, and wondered if this information has been shared with the plans.

Mr. Huston acknowledged that is one of the reasons he felt the Board should meet with the plans. Mr. Huston stated this is the point when the philosophical conversations begin again. The Board's role to start with was to provide a health insurance contract for this population, now there is desire to go beyond what is a standard contract, but how is that accomplished? Is it accomplished by having the HMO's and others expand their contract and the State pays for it, or does the Board do a separate program, different from the health insurance contract, and finance it that way.

Dr. Alexander stated another way to spin this is that the legislative mandate that created HAWK-I was to provide an insurance program. Many of the members of the Advisory Committee were involved in writing the legislation and hoped the impact would improve health rather than just provide insurance. Dr. Alexander stated you can provide insurance coverage and not improve anybody's health.

Mr. Huston stated that he felt that is the dilemma facing the Board. He stated part of the constant debate is whether HAWK-I should be expanded and made similar to the Medicaid program for kids for up to 200 percent of poverty. Mr. Huston said that is a legitimate avenue to take, but that is not what the legislation says; the legislation says a health insurance contract. The Board can recommend changes to the legislature.

Mr. Krutzfeldt stated it was his understanding of the legislation that the Board is to provide a benchmark insurance product available to kids. The Board did that, but now is saying they are not sure the benchmark is right.

Dr. Alexander informed the Board that when those in the health care field talk about "benchmark practices" that is not something to hold up as "best practices." Dr Alexander feels the benchmark in terms of the best coverage for kids is Medicaid. Medicaid provides more coverage than what the vast majority of kids need and has the broadest range of coverage for kids.

Ms. Smith indicated that when she met with the Clinical Advisory Committee they also expressed interest in a meeting with representatives of their Committee and Board members to develop some strategic direction for this upcoming year. Ms. Smith also asked for a status report on the mental health parity legislation.

Ms. Vaughan said she believed mental health parity had cleared the House, but was still under consideration in the Senate. If the legislation passes, it will have to be looked at. Although the HAWK-I program is not really a private sector program, Ms. Vaughan feels the Board should comply with the provisions that the private sector will be subject to.

Ms. Smith clarified the term "benchmark equivalent" for the Board. Federal legislation says that the State must have a plan that is "at least a benchmark equivalent", it does not say the state has to use the "benchmark equivalent" as the benefit plan. It is to the State's advantage to choose a lower benchmark in order to have a better chance of getting federal approval for the plan. Otherwise, if the benchmark is set too high, it is harder to meet the requirement. It is better to have a lower benchmark and then make the program as rich as you want.

Mr. Huston stated that one of the Advisory Committee's recommendations had to do with medically necessary nutrition services and asked how much of that is now provided under the benchmark.

Dr. Alexander indicated he did not believe any of it is covered. For example, if a child was diagnosed with cystic fibrosis and part of their management is nutritional counseling, that is not a covered service.

Wellmark representative Fran Otte indicated that nutrition counseling provided by a dietician or pediatrician was allowed under their plan. Also diabetic counseling is allowed for diabetics.

Ms. Hildebrand stated what the Committee is talking about is anything that is provided by WIC, for example, children with high serum lead are not covered. WIC covers up to age 5 and up to 185 percent of the federal poverty level.

Ms. Poulton felt clarification is necessary with the plans regarding PKU because the formula costs 2 to 8 thousand dollars per year. Ms. Poulton stated this is definitely a service that should be provided to these families.

Ms. Goldman stated that this is an example of where the normal child is different from a special health care needs child. Is a special health care needs package needed for those children to provide care coordination, case management, and nutritional services, that would not be necessary for the normal child covered under HAWK-I?

Mr. Huston stated that the Board's charge from the legislation was to create a private health insurance program for kids under HAWK-I and that has been done. Mr. Huston felt that if the Board wants to add services, it would be easier to do that outside of the insurance contract because to get different carriers to accommodate an individual contract would be very difficult.

Dr. Alexander stated the easiest approach would be to take a very liberal definition of "special health care needs" and put those kids on Medicaid. There are a lot of children who are covered by Medicaid because of their family income who don't need all the benefits under Medicaid and could be very adequately covered by a "benchmark plan" provided under HAWK-I.

Ms. Vaughan asked if creating a separate program created a budget issue. Ms. Smith stated if there is a separate contract with an insurance plan to provide, for example, dental benefits, then associated costs come out of benefits rather than administrative costs. However, if the contract is with a group of dentists to provide direct services, then the funding would come out of administrative costs. Therefore, if the plan is enhanced to provide those services to everyone, then it can be charged to "benefits". If "special needs" can be defined so that only certain parts of the population are eligible for enhanced benefits without providing the benefits to everyone, there may be some latitude there.

Ms. Vaughan stated that it has become clear to her during these discussions that the Board does not have a good enough understanding of what the plans cover and what kinds of expansion could occur. Ms. Vaughan suggested a discussion with the plans.

Mr. Huston stated that he agreed it was necessary to have a discussion with the plans on whether they do or do not cover these kinds of services, or would they be able to cover these kinds of services. Mr. Huston suggested that when the information is received from Deloitte & Touche, representatives of the Board, DHS staff, and Clinical Advisory Committee meet with representatives of the plans to go over the information and clarify points.

The Department agreed to conduct a telephone survey of HAWK-I participants before the next meeting to ask if they would use the additional benefits being recommended.

Once the material is received from Deloitte & Touche, Ms. Smith will arrange the meeting. Representing the Board will be Eldon Huston, Susie Poulton, and Terri Vaughan, or her representative.

NEW BUSINESS:

Election of New Chair:

Terri Vaughan made a motion to nominate Eldon Huston for Board Chair for the next year. The motion was seconded by David Krutzfeldt. Unanimous approval was made by Eldon Huston, Nancy Mounts, Mary Weaver, Susie Poulton, Terri Vaughan, and David Krutzfeldt.

The next meeting is scheduled for Tuesday, May 16, 2000, at 4:00 at the Des Moines Marriott.

The meeting was adjourned at 3:50 p.m.