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HEALTHY AND WELL KIDS IN IOWA (HAWK-I)

BOARD MEETING

MINUTES

August 28, 2000

 

BOARD MEMBERS:

Eldon Huston, Chair

Terri Vaughan, Vice-Chair (absent)

Susan Voss (for Terri Vaughan)

Stephen Gleason, D.O. (absent)

Mary Weaver (for Stephen Gleason)

Ted Stilwill (absent)

Brenda Oas (for Ted Stilwill)

Susie Poulton (absent)

Diane Briest

Barry Cleaveland

 

LEGISLATIVE BOARD MEMBERS:

Senator Johnie Hammond

Senator Kenneth Veenstra

Representative Brad Hansen

Representative Robert Osterhaus

DEPARTMENT OF HUMAN SERVICES:

Anita Smith

Dennis Headlee

Anna Ruggle

Deb Van Den Berghe

ATTORNEY GENERAL'S OFFICE:

Marne Woods

GUESTS: AFFILIATION

Carla Beneke Iowa Department of Public Health – Covering Kids

Jennifer Dreibelbis Iowa Community Action Association

Stacey Cyphert University of Iowa Hospitals & Clinics

Barbara Fox-Goldizen MAXIMUS

Drew Hoffman MAXIMUS

Gary DeLuca MAXIMUS

Kristine Klauer John Deere Health

Cindy Groene John Deere Health

Bill Brand Iowa Dept. Human Rights - Community Action Agencies

Deb Anderson Legislative Fiscal Bureau

Sonni Vierling Iowa Department of Public Health – Covering Kids

Ed Conlow House Democratic Staff

Jim Donoghue Broadlawns Medical Center

Paul Stanfield IUP

Anne Kinzel Iowa Department of Public Health

Dr. Jeff Lobas Child Health Specialty Clinics

Leila Carlson National Association of Social Workers

Denise Hill Iowa Medical Society–Covering Kids Now Task Force

Tawanna Morris Polk County HAWK-I Outreach

Edward Schor, MD Iowa Department of Public Health

WELCOME AND INTRODUCTIONS:

The Healthy and Well Kids in Iowa (HAWK-I) Board met on Monday, August 28, 2000, in the Oak Room, Des Moines Botanical Center, 909 E. River Drive, Des Moines, Iowa. Eldon Huston, Chair, called the meeting to order at 12:35 p.m.

Anita Smith took the roll call, a quorum was present. Audience members introduced themselves. 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 JULY 17, 2000, MEETING MINUTES

Barry Cleaveland made a motion to approve the July 17, 2000, minutes as written. Mary Weaver seconded the motion. Unanimous approval was made by Eldon Huston, Mary Weaver, Brenda Oas, Diane Briest, and Barry Cleaveland.

CORRESPONDENCE:

Anita Smith discussed various items of correspondence beginning with a July 18, 2000, letter from Ms. Smith to Paul Carter, President of Iowa Health Solutions. Ms. Smith’s letter stated that the Board and the Department are interested in knowing what steps, if any, Iowa Health Solutions plans on taking with the results of their member satisfaction survey. No response has been received to that letter. Ms. Smith did receive a response to her July 12, 2000, letter to Iowa Health Solutions inquiring about the handling of dental and mental health services in counties where the provider panel has been determined inadequate. Ms. Smith’s letter sought clarification on which counties have been identified and how enrollees are informed of the services. Iowa Health Solutions identified five counties in which they have contracted providers, but not within the standards of 30 minutes/30 miles. Seven counties were identified as lacking an adequate mental health/substance abuse provider panel. Iowa Health Solutions provided copies of letters they send to enrollees informing them that they do have open access, that they can go to providers who are not necessarily contracted providers to receive these services, and that Iowa Health Solutions will honor these claims.

Ms. Smith stated she received a call from Larry Carl of the Iowa Chiropractic Society regarding John Deere’s coverage of chiropractors under the HAWK-I plan. As a result, Ms. Smith sent a letter to Cynthia Groene, John Deere Health Plan, on August 1st. A response was received just prior to today’s Board meeting. The response will be reviewed and made available to the Board before their September 18th meeting.

Ms. Smith shared a report entitled, "States Experiment with CHIP Outreach Methods". Ms. Smith explained that prior to CHIP there was no outreach in Medicaid so states are really struggling to find good outreach models. The report addresses some of the problems states have been having, as well as some of the "thinking outside the box" kinds of efforts. Of the estimated 11 million children nationally there are 2 million enrolled (18 percent), so there continues to be emphasis on outreach. Iowa’s enrollment is better than the national average at 28 percent.

Ms. Smith also shared a July 13, 2000, letter from HCFA to the Tribal leaders outlining some of the discussions that have taken place between HCFA and the Tribal governments. HCFA is currently considering some of these issues, the most significant being that the Tribal governments are requesting direct administration of Medicaid and CHIP for their populations.

Susan Voss, designee of Board member Terri Vaughan, arrived at the meeting at this time.

The next item Ms. Smith discussed was a report from the Center for Immigration Studies. Ms. Smith stated there has been a lot of talk about how the uninsured numbers keep growing despite all the efforts to provide coverage to the uninsured. According to this report, immigrants are more than twice as likely to be uninsured as native households and are accounting for as many as 59 percent (2.7 million) in the growth of the uninsured population. Ms. Smith said the Department has been getting a lot of calls about how to serve these people. The immigration issue affects legal immigrants who have been here less than 5 years as well. Ms. Smith said the Department is looking for ways to serve these children and have met with Latino Affairs and other organizations to find a way to serve these children through Title 5 or providing better education on how to use insurance.

Mr. Huston asked if there are outreach workers in locations where there are a large number of immigrants to try to educate the families. Ms. Smith said there have been discussions about contacting some of the clinics to see if an outreach worker can actually sit in their waiting room to talk to people about HAWK-I and Medicaid or if they have insurance, to educate them on using it. There are some Drake University students who might be interested in working on this project.

Also included in the correspondence were several newspaper articles. Ms. Smith said that the number of articles that are appearing in newspapers regarding this program are phenomenal. There is a lot of interest and the articles generate lots of questions.

Ms. Smith drew the Board’s attention to two articles concerning the Health Insurance Portability and Accountability Act (HIPAA). Ms. Smith said that Shellie Goldman has attended several meetings which discussed HIPAA and the possible impact on the health plans and the ultimate impact it may have on the HAWK-I program. Ms. Smith asked that the Board members review this information for discussion at the September Board meeting.

The final piece of correspondence that Ms. Smith shared with the Board was a recently issued report from Covering Kids. The report states that six out of ten parents whose children qualify don’t believe their kids are eligible. Ms. Smith indicated this is another hurdle to overcome with outreach efforts to educate people about who can actually qualify for the program.

ADMINISTRATOR'S REPORT:

Budget:

Ms. Smith informed the Board that State Fiscal Year 2000 expenditures are below projections and this was primarily due to the fact that enrollments have been below projections. $1.6 million in state funding was budgeted for HAWK-I premiums and just over $1 million has been spent. However, a claim voucher was just submitted for $1.1 million to pay health plans for retroactive eligibility which has occurred due to the transition to MAXIMUS. Some of that $1.1 million will fall into June so expenditures for FY 00 will be increased. Outreach expenditures applied to the HAWK-I budget were $38,495. However, this does not reflect the $300,000 in delinking money being used for outreach. Interest from the HAWK-I trust fund is $205,401.

Representative Osterhaus asked Ms. Smith to elaborate on what makes up the HAWK-I administration budget. Ms. Smith said that budget is for staff salaries as well as the third party administrator. There are two factors for the administration costs for the fiscal year. HCFA allowed Iowa to carry over the amount that exceeded the 10 percent limit in the start-up year. Therefore, the year started with a $400,000 carryover. The administration budget also had the additional cost due to changing contractors and having to pay out more to the original contractor during the transition.

Senator Hammond asked if the budget is caught up on all of the previous year costs in administration. Ms. Smith stated she believed so and also believes that Iowa can defer what is exceeded in the 10 percent administrative costs again this year. This deferment means 100 percent state dollars will not have to be used.

Transition to MAXIMUS and Enrollment & Statistics:

Gary DeLuca and Barbara Fox-Goldizen of MAXIMUS spoke to the Board about the transition period and presented the Board with the statistical reports from June and July.

Mr. DeLuca told the Board that the transition from the previous contractor to MAXIMUS was not an easy transition. MAXIMUS experienced many difficulties with the data received from the previous contractor. Some of the problems experienced with the data were interpretation and lack of business rules and how the previous contractor interpreted the data they provided. Mr. DeLuca said his staff spent many hours on these reports because MAXIMUS did not want to provide data that was not accurate. MAXIMUS will continue to refine the data as much as possible. MAXIMUS will continue to monitor the data and make changes so that the data going into the system will be accurate and will result in accurate reports.

Ms. Fox-Goldizen shared a summary page with the Board showing an overview of applications received each month and total enrollment. Total enrollment was 5,282 as of the end of June, 2000 and 5,911 as of the end of July, 2000. Ms. Smith noted that these figures would show a decline in the number from what was reported for the end of May, 2000; which was 6,881. The reason for the difference is that duplicate cases were found in the system and also the way the reports were being created. What was being reported to the Department previously was "ever" enrolled as opposed to "currently" enrolled.

Representative Hansen entered the meeting at this time.

Mr. DeLuca said when they first looked at the data they were concerned the data was being interpreted incorrectly and spent many hours trying to link cases together. One thing they found was that there were duplicate cases, some of which were renewals that had received another case number. The health plan files were matched against MAXIMUS files and MAXIMUS will continue to work with the plans to ensure the enrollment files match.

Senator Hammond asked how many duplicate cases there were and Mr. DeLuca said he really couldn’t say for sure. There were probably more cases that were inactive due to losing eligibility. Senator Hammond asked if there was a possibility that plans were being paid twice for some of the cases and has that been pursued and reimbursement requested? Ms. Smith said if there were duplicate payments those are being cleaned up on the capitation reports. Mr. DeLuca stated their next step is to look at the retro-disenrollment and see if there were cases that have been paid that should not have been paid. Mr. DeLuca stated he doesn’t believe the number of payments on duplicates is that great and the main problem is that the case was counted twice even though one of the cases was closed. Mr. DeLuca informed the Board that MAXIMUS is using a system that has one case number for each enrollee and that number will be the only number used by that individual.

Ms. Weaver asked what kind of quality assurance is in place to ensure the integrity of the new system. Ms. Smith said many quality assurances have been built into the contract with MAXIMUS. The numbers have to match so reports can be related to each other. Additionally, documentation is required as to how the numbers were arrived at.

Mr. DeLuca told the Board that MAXIMUS has their own quality assurance reports to make sure they don’t have a problem with the numbers not tying together. During this transition they have focused on making sure that the cases in the database are, in fact, cases that should be eligible, enrolled, and are working with the plans to make sure everyone is where they belong. Right now they are 90 percent over the hurdle, but still have a way to go. Once that is complete the focus will be on the capitation report that ties out with the enrollment file that goes to the plans at the end of the month. They send daily files to the plans as well as a monthly file that ties into every one that is to be enrolled. Mr. DeLuca said that quality is one thing they are really stressing in their projects.

Ms. Fox-Goldizen asked the Board members to review the reports and let her know of any suggestions so that changes or adjustments can be made. Ms. Smith said that several reports will be invaluable such as the demographic reports. There is a HAWK-I applicant demographic summary as well as an enrollee demographic summary. These are broken down by county and show monthly counts as well as year-to-date counts and will help identify populations. This report is also available by zip code. These reports will not be printed out each month but will be available from the website for authorized individuals such as outreach workers and central office staff.

Mr. DeLuca said that once the reports are acceptable they will put them on the website. Representative Hansen stated that as long as Ms. Smith is satisfied with the reports and the Board can continue to make adjustments and modifications he thought the reports could be put on the website. It was the consensus of the Board that the reports are acceptable and can be placed on the website.

Ms. Weaver asked about the Department moving towards a uniform application for Medicaid and HAWK-I. Mr. Headlee stated his staff is working on a simplified application so the application would cover both HAWK-I and the Title XIX application. The Title XIX application is also tied to the economic assistance, FIP, and food stamp application processes as well. The Legislature mandated several years ago that there be an application which incorporated all the data fields and requirements for all of those programs to be included within the Medicaid application. Some 300 data fields are required to be reported for the economic assistance and food stamp programs, as are similar requirements for Title XIX and HAWK-I. As a result, staff is coming up against a number of barriers with the application information.

OUTREACH UPDATE:

Bill Brand provided a brief update on the outreach pilot project. A total of 10 applications were received and those were reviewed and scored by the grant review team. Four community action agencies were awarded amounts ranging from $25,000 to $40,000. The four agencies are:

Two factors were used in making the selections. One factor was the focus on building community partnerships and developing linkages in the communities with appropriate providers to make sure they really reach people. Applications that were strongly focused on working with schools, public health, medical providers, and private sector interests such as chambers of commerce and businesses were ones that were selected. The other factor was the focus on face-to-face contact with people. These agencies also meet the criteria as far has having an urban area focus (Dubuque), rural areas with all four agencies, and Mid-America is focused on outreach strategies for non-English speaking populations. The next step will be working with the agencies on their reporting requirements. Mr. Brand stated he will be working with the Iowa Department of Management to develop specific measurement criteria.

Ms. Van Den Berghe told the Board that is hard to identify audiences in the program. The grassroots effort used by the outreach coordinators is a process of orientation, community development, plan development to their specific area, brochure distribution, poster distribution, and similar activities. When a new coordinator comes on board they solicit schools, faith-based organizations, and medical facilities in the community to make sure they have a broad wash of brochures and visibility. Then they begin their community networking. This includes community training, events, presentations to chambers, duplicating successes, and follow-up. Ms. Van Den Berghe said that it takes 6 to 8 months with a full time coordinator for one county to get started. Therefore, she believes Iowa is right on track with how outreach should be going and how it is going. Out of a total of 55 counties or clusters of counties, 51 report having at least a volunteer.

Ms. Weaver asked about situations of someone who applies for HAWK-I, they are not eligible because they are Medicaid eligible, and the lengthy period of time before they hear they are eligible or not. Ms. Weaver asked if Ms. Van Den Berghe was hearing these stories and what, if anything, is being done with the outreach component to curtail those stories. Ms. Van Den Berghe responded that these issues are being addressed through training as part of the grassroots efforts.

Ms. Smith added that a formal process is being put in place to address these situations. They will be called into central office where staff can then research the issue to try to pinpoint where the problems are occurring. Staff is working with MAXIMUS on developing "cheat sheets" for workers so applications aren’t referred to Medicaid if they really shouldn’t be. The elimination of monthly reporting and going to prospective budgeting for Medicaid will also help. Income will be looked at the same for the same period of time. Ms. Smith said that the co-located workers have been going out of their way not to deny people and longer periods of time have been allowed to submit information. The workers are trying to be more customer-friendly and that has resulted in longer application processing time frames. Ms. Smith said it is helpful to hear about specific cases so they can be tracked. Having specific information has helped to identify some system problems.

Ms. Van Den Berghe stated that they have done several activities with the schools and there will be continuing projects throughout the year. Ms. Van Den Berghe will also be working on a rural and farm outreach structure to address that audience.

Ms. Van Den Berghe told the Board that the Iowa State Fair experience went very well. HAWK-I had a wonderful spot at the Riley Stage which enabled staff to have a lot of positive response from everyone, not just families. The outreach coordinators are attending county fairs and more banners with the HAWK-I logo are being purchased for use in these activities.

ADMINISTRATIVE RULES FOR ADOPTION:

Ms. Smith told the Board that the rules expanding HAWK-I to 200 percent of poverty had completed the Notice of Intended Action phase and were ready for final adoption. The amendments to the rules are in accordance with legislation that was passed this year by the General Assembly.

Barry Cleaveland made a motion to approve the rules for adoption. Mary Weaver seconded the motion. Unanimous approval was made by Eldon Huston, Mary Weaver, Brenda Oas, Diane Briest, Barry Cleaveland, and Susan Voss.

UPDATE ON COVERING KIDS NOW STATE COALITION:

Denise Hill from the Iowa Medical Society appeared before the Board to provide an update on the activities of the Covering Kids Now Task Force. The task force last met on July 26. At that meeting the task force reaffirmed support for elimination of monthly reporting. The task force members believe this will make a substantial impact on the ability to enroll and retain children.

Ms. Hill also reported that the task force was delighted that the Department continued the practice of contacting families who were previously determined ineligible in order to notify them of eligibility changes which could make them eligible. Most recently this was contacting denied families notifying them about the increase to 200 percent of federal poverty level.

Ms. Hill said the task force was really impressed with the changes to the brochure. However, there was some discussion and concern about the current language in section 7. Ms. Hill said the task force is hoping that with the next printing of the brochure this will be clarified.

The task force also discussed the two full cost buy-in concepts currently being explored -- for absent parents to apply for HAWK-I even though the child is not living with them and for families over the income guidelines between 200 and 300 percent. The task force wishes to go on record as acknowledging this should be explored, evaluated, and seriously considered. One thing the task force is looking at is utilizing electronic verification income systems. This is the system that is used by issuing creditors and provides electronic access to tax records. Broadlawns Hospital currently uses that system to streamline their Title XIX eligibility determinations. The task force is exploring the feasibility of using this process for the HAWK-I program.

The task force is considering an intra-state agency outreach meeting. The idea is there are a lot of ways that current state agencies could provide outreach without having any additional costs to their current system. There are a lot of resources and processes they have in place and contacts with the population that aren’t being fully utilized because they are not aware of HAWK-I or haven’t really thought about the fact that they may have a place in reaching out to these families.

Ms. Hill said the task force is also looking at targeted packets to communicate to various groups who refer or enroll children. Ms. Hill said that the Covering Kids Initiative and Ms. Van Den Berghe have done a great job of targeting school nurses and child care providers and are encouraged to continue to customize and target various groups depending on the audience of outreach people. For example, tax preparers have been suggested, as have health care providers. A short multi-use video to get the point across about the nuts and bolts of the program would be very important. The task force also discussed the need for newspaper inserts for additional statewide publicity.

At their next meeting the task force will be revisiting continuous and presumptive eligibility; discussing insurance mandates for kids; buy-in options; results of the family services survey (stigma); education/school issues; intra-state agencies meeting update; and using tax documents for income verification. Ms. Hill will be attending the National Covering Kids meeting and doing a presentation on the ability of states to try to engage their medical society and showcasing some of the things being done in Iowa. Ms. Hill said if there are things the Board would like brought to the national stage to please contact her and let her know.

Ms. Smith asked Ms. Hill if the Iowa Covering Kids Coalition agreed with the Covering Kids report which states that six out of ten parents whose children qualify don’t believe their kids are eligible. Ms. Hill indicated she would take that to her group report back to the Board.

PUBLIC COMMENT:

Paul Stanfield asked to address the Board. Mr. Stanfield spoke from his position as chair of the advisory committee of the Department of Public Health’s compulsive gambling treatment program. Mr. Stanfield said he wanted the Board to be aware that the $100,000 appropriated to the Department of Human Rights for outreach came out of money earmarked for the compulsive gambling treatment program. Mr. Stanfield stated that he and the casino operators are in total agreement that this dipping should not continue and all the money that is earmarked ($3 million a year) should go to the treatment program. Mr. Stanfield stated he is aware that the HAWK-I Board did not ask for the $100,000 appropriation, but wanted the Board to know they should not count on receiving the appropriation every year because his group is going to try to keep the funds in the compulsive gambling treatment fund.

PROPOSED AMENDMENTS TO ADMINISTRATIVE RULES:

Ms. Smith prepared a document that shows suggestions for proposed amendments to the HAWK-I program’s administrative rules. Ms. Smith stated if the Board is in agreement with these suggested rule changes, a formal Notice of Intended Action would be drafted to go before the Administrative Rules Review Committee. Ms. Smith discussed the proposals with the Board.

Subrule 86.2(c), Verification of Income, would be amended to provider greater flexibility around income verification. Additionally, if the child is participating in another means-tested program they would be deemed eligible to participate and not have to go through the verification of income process again. Examples of means-tested programs are Title 5; Free and Reduced School Lunch Program; Women, Infants, and Children (WIC) Program; Child Care Assistance Program; Food Stamp Program. Except for Title 5, which is 200 percent of FPL, none are even close to the income limits of HAWK-I. Ms. Smith said that, while in theory, this is a good concept, it may be difficult to implement because of the Medicaid screening and premium requirements. It’s not just a matter of participating in the program, HAWK-I would need to know what the family’s income is.

Ms. Weaver suggested exploring Head Start as an additional means-tested program. Representative Hansen said he thought this is a great idea to pursue and acknowledged there may be some details to work out, such as if one program measures income one way and another a different way.

Ms. Smith said that suggested amendments to rule 86.5(514I) would clarify that there will be no break in coverage for an eligible child who comes to HAWK-I from Medicaid.

The suggested amendments to rule 86.7(514I), "Disenrollment", would assure health plans and providers of payment for children who are determined eligible for HAWK-I even if, at a later date, it is established that they were not eligible because of retroactive Medicaid eligibility, an administrative error, or applicant misrepresentation. Ms. Smith said it has become problematic when children have been approved for HAWK-I and are determined retroactively eligible for Medicaid, or after they’ve been on HAWK-I it is discovered they already had insurance. This forces a retroactive cancellation of the HAWK-I coverage, recouping the premium payment from the health plan, and the health plan in turn has to go back and get their payments from the providers who rendered the service. The Department would like providers to be assured that if a child presents a HAWK-I card they are going to get paid and the Department is not going to take the money back, nor do they want to recoup retroactively from health plans. This is how other states are approaching the issue. This will require the health plans to coordinate benefits. The proposed amendment would provide that if the child has other coverage, the other coverage is primary, HAWK-I will be secondary. If they have Medicaid, then HAWK-I is primary and Medicaid is secondary.

86.8(514I) Premiums and co-payments. This rule would be amended so that HAWK-I enrollees are not responsible for premiums to cover retroactive periods of coverage. There have been several situations where the initial screen indicates the family is eligible for Medicaid then it turns out that they are not and are placed on HAWK-I. By that time they may owe several months of premiums. This has been a burden to some families. Other states were polled and the majority begin assessing premiums once the eligibility determination is made and the family is notified. In many other states premiums are not collected retroactively for periods of time the family did not know they were eligible.

The Board was in agreement with the suggested rule changes. However, the Board asked that the rule regarding participation in federal means-tested programs be run separately as it could be controversial and the details of how it would be implemented still need worked out. Ms. Smith will finalize and bring the Notice of Intended Action to the September meeting for approval by the Board.

PROPOSED AMENDMENT TO THE CODE OF IOWA:

Ms. Smith informed the Board that the Department submitted the same package that the HAWK-I Board submitted last year with the provision that it was subject to the approval of the HAWK-I Board. Ms. Smith said that even though there have been some discussions about possible additional changes to the legislative language, they have not been included because there has not been a formal motion by the Board directing the Department to include additional items. This proposal merely reflects what was in the package last session. Mr. Huston noted that no action was taken by the Legislature.

Ms. Smith asked the Board if they wished to revisit the proposed change to the six month waiting period. This item was originally proposed last year, but removed by the Board before finalizing the legislative proposal. The first item listed is that a six month wait applies if the person lost health insurance due to loss of employment due to factors other than voluntary termination. In essence, as currently written, if someone is fired from a job, they do not have to wait six months to put their children on HAWK-I, but if they voluntarily quit to accept a job for more money or a better opportunity, then the six month waiting period is imposed. This is true even if the new job does not offer health insurance or if there is a waiting period before a new employee can enroll in the insurance. Ms. Smith said that the Department recommends that language be added that if a person leaves an employer, for any reason, and as a result insurance is no longer available to the child, the six month wait doesn’t apply.

Mr. Huston indicated there are still several legislative issues the Board needs to address. Mr. Huston asked that the Clinical Advisory Committee’s recommendations and the suggestion regarding minimum benefits be placed on the agenda for the September Board meeting.

Ms. Voss stated there has been an ongoing issue whether HAWK-I coverage is creditable coverage for purposes of portability and not having the pre existing condition period. Ms. Voss stated that HAWK-I coverage is creditable coverage, but not for pre-existing condition waiting period purposes because it is not one of the defined creditable coverages under statute. Ms. Voss stated she could include the necessary language in the Insurance Division’s bill this year to resolve this issue if that was what the Board wished to do.

Susan Voss made a motion to submit the legislative package as it went before the legislature last year, but to include the proposed change regarding the six month waiting period. Barry Cleaveland seconded the motion. Unanimous approval was made by Eldon Huston, Mary Weaver, Brenda Oas, Diane Briest, Barry Cleaveland, and Susan Voss.

Representative Hansen exited the meeting at this time.

 

1115 WAIVERS:

Ms. Smith discussed a July 31, 2000, letter from HCFA which provides guidance to the states to understand the types of demonstrations that HCFA will be considering and the types of information the state will have to present to gain approval.

Before HCFA will approve any demonstration projects the state needs to provide assurances that it has met the primary purpose of SCHIP by expanding eligibility to low income kids up to 200 percent of poverty and demonstrate that it is successfully reaching and enrolling eligible children. Since Iowa just expanded to 200 percent, it is not known whether expanded coverage is sufficient or if HCFA will require some proof that kids between 185 and 200 percent are actually being enrolled. HCFA will not consider proposals that will reduce benefits, nor will they accept proposals that would require cost sharing above the limits of the law. They support demonstration initiatives to extend coverage to low-income parents within the constraints of the SCHIP law and available funds. Ms. Smith said she does not believe Iowa could get a demonstration waiver to cover the parents of HAWK-I eligible children without first covering the parents of Medicaid-eligible children under section 1931. Iowa already has the ability to do that under Medicaid, and SCHIP legislation says states cannot have policies that would advantage higher income children over lower income children. Ms. Smith said she doesn’t know whether that applies to parents or not but assumes it would. This means if the Board is thinking about finding ways to expand to family coverage under HAWK-I, then Iowa would have to cover parents under Medicaid.

The guidance received from HCFA also gave a list of five policies and procedures in SCHIP and Medicaid. To be eligible for a waiver a state must demonstrate that it has adopted at least 3 of the 5 policies. Iowa does meet 3 of the 5 criteria.

The states are reminded that the primary purpose of the law is to provide health care coverage to low income children. HCFA wants to make sure that the kids are being reached before SCHIP money is used for other populations. Ms. Smith said that usually 1115 waivers must demonstrate budget neutrality, but HCFA clarifies that a waiver under SCHIP is different. The letter indicates each proposal will be considered on a case-by-case basis, and because something was approved in one state doesn’t mean it will be approved in another. The letter also outlines what types of demonstrations are not likely to be approved.

Ms. Smith told the Board that she had received a call from Dr. David Carlyle who asked to put on the table a universal mandate for child health care coverage. Ms. Smith said she didn’t know if that would fall under a waiver or some other mechanism.

Senator Hammond asked about a demonstration in order to cover children of qualifying public employees. Ms. Smith said this issue has been discussed and this is one of the issues that will not be waiverable.

Representative Osterhaus said he would like to see Iowa aggressively pursue a waiver for those people who have left the welfare rolls and go on the state payroll and are not able to afford health care for their children. Representative Osterhaus also said he would like Iowa to consider pursuing something for those employed parents who lose their job and don't have the opportunity to get a job with health insurance.

Mr. Huston asked if at one time when people left welfare for employment they kept Medicaid for a certain period of time. Ms. Smith said yes, there was a 12 month transitional period. If someone had been on Medicaid for 3 of the last 6 months and lose eligibility because of income from employment, they can get up to 12 months of transitional Medicaid where income is not considered. Ms. Smith said she believed some states had extended that transitional period to 24 months and believes that was done through waivers. Mr. Huston said the Board needs to take that into consideration and discuss. If someone had Medicaid for 12 months, maybe HAWK-I could pick up after that 12-month period. Ms. Smith stated that she believed the 12 months of transitional Medicaid only applies to certain families.

Ms. Weaver asked if this would be an opportunity to implement some of Clinical Advisory Committee recommendations through the 1115 waiver process. Ms. Smith said she believed it is because HCFA’s letter indicated they would consider proposals as long as they are provided to an identifiable group and represent an expansion in the services available. The letter also states the initiatives could be broad-based to address the significant health care needs of low-income children or focused on specific target populations. Examples given are coordinating community mental health and substance abuse services, addressing the special needs of children with chronic physical or mental health conditions, or providing health care services to a targeted group of underserved low-income children, such as children who lack access to dental services. The state must ensure that such a demonstration does not replace existing state public health services.

EMPLOYER BUY-IN OPTION:

Ms. Smith said there was little additional information from what she told the Board last month. There has been no flexibility from HCFA regarding the employer buy-in. They are still requiring that the employer contribute 60 percent before the state could buy in. Ms. Smith said this might be something for a demonstration project as opposed to through the current criteria in the legislation. Ms. Smith said HCFA argues that they want to prevent crowd out, however, she feels crowd out is promoted by requiring people to have the coverage through an employer or nothing. This is a way to support employer coverage and still allow people to participate in the program. Ms. Smith said if this is something the Board wants to pursue as a demonstration waiver, the Department can put some information together.

NEW BUSINESS:

Board members received copies of the first amendment to the contract for health care services under HAWK-I between the Iowa Department of Human Services and the four health plans. Anna Ruggle stated that the health plans have been meeting with MAXIMUS in order to get the encounter data so it works for all the health plans. The amendment basically replaces the encounter data format in the contracts and needs approval by the Board.

Susan Voss made a motion to approve the first amendment to the contracts. Barry Cleaveland seconded the motion. Unanimous approval was made by Eldon Huston, Mary Weaver, Brenda Oas, Diane Briest, Barry Cleaveland, and Susan Voss.

Ms. Smith informed the Board about a pilot project the Department is conducting to streamline eligibility. The pilot is being conducted for one month in five counties. When an application comes in, staff does a "what if" determination to see if the person would be determined eligible based on the information on the application. The information is set aside as the full blown eligibility determination is processed through the system. The results will be compared to see what the accuracy is. This process is being done for Medicaid, food stamps, and FIP.

There was no other new business to present before the Board.

The Board’s next meeting is Monday, September 18, 2000, at 12:30 in the Oak Room at the Des Moines Botanical Center.

The meeting was adjourned at 4:00 p.m.