HEALTHY AND WELL KIDS IN IOWA (HAWK-I)
December 18, 2000
BOARD MEMBERS: LEGISLATIVE BOARD MEMBERS:
Eldon Huston, Chair Senator
Johnie Hammond (absent)
Terri Vaughan, Vice-Chair Senator
Kenneth Veenstra (absent)
Stephen Gleason, D.O. (absent)
Representative Brad Hansen (absent)
Edward Schor, MD (for Stephen Gleason)
Representative Bob Osterhaus (absent)
Ted Stilwill (absent)
Brenda Oas (for Ted Stilwill)
Susie Poulton (via telephone conference call)
Diane Briest (via telephone conference call)
Barry Cleaveland (via telephone conference call)
DEPARTMENT OF HUMAN SERVICES: ATTORNEY GENERAL'S OFFICE:
Anita Smith Marne Woods (absent)
Anna Ruggle (via telephone conference call)
Deb Van Den Berghe
Barbara Fox-Goldizen MAXIMUS
Sonni Vierling Iowa Department of Public Health – Covering Kids
Sara Schneider Iowa Department of Human Services, HAWK-I
Ed Conlow House Democratic Staff
WELCOME & INTRODUCTIONS:
The Healthy and Well Kids in Iowa (HAWK-I) Board met on Monday, December 18, 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 12:40 p.m.
Anita Smith took the roll call, a quorum was present. Due to severe weather, Board members Diane Briest, Barry Cleaveland, and Susie Poulton, and staff member Anna Ruggle, participated via telephone conferencing. 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 NOVEMBER 20, 2000, MEETING MINUTES
Barry Cleaveland made a motion to approve the November 20, 2000, minutes as written. Dr. Schor seconded the motion. Unanimous approval was made by Eldon Huston, Diane Briest, Susie Poulton, Terri Vaughan, Barry Cleaveland, and Edward Schor.
ADOPTION OF ADMINISTRATIVE RULES:
Ms. Smith told the Board that there had been no public comment or other changes to the Notice of Intended Action which was published on October 18, 2000, as ARC 0191B. These amendments make several changes to the HAWK-I administrative rules regarding retroactive cancellations when it is found children had other coverage; cost sharing will not be collected until the family is notified that they are eligible for the program; and various other administrative clean-up language. These amendments can now be adopted.
Terry Vaughan made a motion to approve the administrative rules for adoption. Dr. Schor seconded the motion. Unanimous approval was made by Eldon Huston, Diane Briest, Susie Poulton, Terri Vaughan, Barry Cleaveland, and Edward Schor.
MEDIA CAMPAIGN UPDATE:
Ms. Smith provided a handout detailing the budget and language modifications to make the Covering Kids commercials Iowa-specific. The budget for modifying the two commercials (one in English and one in Spanish) totals $14,583.72. The cost of modifying the Spanish commercial is higher because of the number of people in it. The Covering Kids Marion County project will provide the funding. Marion County was going to develop a commercial for their outreach efforts and that funding has now been redirected to this project. Ms. Smith told the Board that not all of the Iowa-specific information will be incorporated into the commercials. Greer, Margolis, Mitchell, and Burns was not comfortable incorporating all of the changes because they had not been tested and including everything requested would increase the commercial to 60 seconds rather than the current 30 seconds. The 1-800 number will be included both in the audio portion and as a tag line across the bottom of the screen. The commercials will also have a tag line showing HAWK-I includes medical and dental coverage. The commercials will indicate families earning $34,000 could qualify. Ms. Smith said this figure was arrived at by conferring with other states, plus the fact that the poverty level will go up in April. Ms. Smith said that the State of Maryland used this same commercial and it increased their applications 30 percent almost immediately.
Mr. Huston said the Board was criticized for the first campaign because some people felt the money could be better spent at the local level. The money has now been spent at the local level and enrollment has not increased as much as the Board would like it to. Mr. Huston said he personally feels running the commercials is worth a try and from his perspective it is a good move for the Board.
Mr. Cleaveland said he thinks it is well advised that the Board run the advertisements. Mr. Cleaveland said the commercials that the Board has discussed are well thought out, researched, and well done.
Barry Cleaveland made a motion to approve the proposed language for altering the commercials. Terri Vaughan seconded the motion. . Unanimous approval was made by Eldon Huston, Diane Briest, Susie Poulton, Terri Vaughan, Barry Cleaveland, and Edward Schor.
Ms. Smith told the Board that her office had received five letters of intent to bid on the media buyer RFP, so hopefully the proposals could be presented to the Board at their next meeting.
Ms. Smith discussed the various items of correspondence with the Board. The first item was a December 14, 2000, letter from Greg LaMair of LaMair, Mulock, Condon Insurance Company. Mr. LaMair has donated $2,400 to the HAWK-I program to assist families in paying their premiums. This money will be flagged specifically so that when it goes into the HAWK-I trust fund the legislature cannot appropriate it to use otherwise in the program. Ms. Smith said she talked to Mr. LaMair and asked him specifically how he wanted this money spent. Instead of cancelling a family for failure to pay a premium, this fund will be tapped to pay the premium for them for one month. If the family doesn’t pay the premium the second month, they will then be cancelled.
A letter of appreciation will be send to Mr. LaMair from Mr. Huston.
Dr. Schor suggested having this as an agenda item for a future meeting. Dr. Schor said the distribution of funds rests with the Board and they should have a policy of how future donations will be handled.
Ms. Smith shared a November 22nd letter she sent in response to a letter she had received from Ann Evans. Ms. Evans processes insurance claims for Dr. Thomas Evans, who practices pediatric dentistry. Ms. Evans expressed several concerns, one of which is that people were getting their insurance cards too soon, the effective dates are not on the cards so they did not know when coverage begins. Ms. Smith said that decision is up to the health plans on how the cards are issued. Ms. Evans letter also expressed concern about differences in the dental benefits between plans, retroactive coverage, and stated that kids were falling through the cracks due to rules and waiting periods. Ms. Smith asked Ms. Evans if she could provide specific examples so they can be addressed. At this time, Ms. Smith has not received a response.
The Cedar Rapids Gazette printed an article stating that Iowa ranks third in having health insurance coverage. In 1998 Nebraska was first and Iowa and Minnesota tied for second. In 1997 Iowa was ranked 15th. Ms. Smith reminded the Board that the CPS data that projected the potential kids that could enroll in HAWK-I came from 1990 census. Ms. Vaughan said the new study was not a surprise because it has been known for some time that Iowa was among the lowest uninsured states in the country.
A study on the uninsured which appeared in "The Medicaid Letter" indicates that Hispanics are three times as likely to be uninsured as the general population. Ms. Smith said that is why it is important to have the Spanish commercial promoting the program.
Also included in the correspondence were articles about other states (Idaho, Kansas, California, and New Jersey) that Ms. Smith shared with the Board.
Ms. Smith shared the National Governors Association’s health care reform agenda which includes several items they will be pursuing relating to Medicaid and CHIP. These items include eliminating or redefining the 10 percent cap; a proposal letting states charge what they want for cost sharing instead of having it dictated in federal law; eliminating barriers for states that want employer-buy-in; and allowing states to be able to cover parents through variances as opposed to applying for waivers.
The Board was provided with additional comments received on the functional health insurance survey. Barbara Fox-Goldizen noted that the vast majority of the comments received are positive, they have not received any critical responses recently.
Ms. Smith told the Board there is nothing new to report in the budget area except the delinking funds being used for outreach are almost gone. However, this was anticipated and already built into the budget.
Ms. Smith said that according to the information she received from Iowa’s Washington D.C. Office, the spending bill that Congress just passed contains a CHIP 60/40 compromise. This will allow states to retain 60 percent of the fiscal year 98 funds scheduled for reversion. The bill is awaiting signature, and the President is expected to sign.
Ms. Smith discussed a report from the Urban Institute entitled "Three Years into SCHIP: What States Are and Are Not Spending". Ms. Smith says this report does a good job of explaining why states have not spent their money. For instance, SCHIP start-up. SCHIP was funded as though it were a mature program instead of a gradual increase. The article indicates that states will probably spend less of their FY 99 funds than their FY 98, even though the program continues to grow. This is because states are going to be charging most of their expenditures to their 98 allotment until it is gone.
Ms. Smith prepared a chart which explains Iowa’s SCHIP allotments, when the money became available, how the program was implemented, and the balance. Attached to that is an Urban Institute chart that shows spending by the states. Iowa has spent 91 percent of their money and is ranked 13th out of the 50 states as far as expenditures.
Ms. Smith gave the Board a copy of correspondence she had received from the SCHIP director in North Carolina. North Carolina has submitted a plan amendment to HCFA to freeze new enrollments in their program and establish a waiting list. North Carolina’s allotment was based on having 72,000 kids in the program, they currently have 69,078 enrolled, and are enrolling new children at the rate of 1,000 a week with no signs of slowing. Based on this experience, North Carolina is now projecting 120,000.
Enrollment & Statistics
Ms. Smith shared a chart prepared by the NGA Center for Best Practices dated October 25, 2000. This chart shows state uninsured rates from 1995 through 1999. Ms. Smith said this ties in with the Cedar Rapids Gazette article discussed earlier, that Iowa ranked 3rd for the lowest percentage of uninsured at 8.3 percent. To compare to the other states in this region, Missouri is ranked 4th at 8.6 percent; Nebraska 9th at 10.8; and Kansas 17th at 12.1 percent. The state with the highest rate of uninsured is New Mexico at 25.8 percent and there are six states over 20 percent.
The November total CHIP enrollment shows a slight increase. HAWK-I increased by 59 kids and Medicaid increased 379. Ms. Smith said she does not have an explanation for the low increase in HAWK-I this month, other than the holidays and there were a larger number of disenrollments this month than in previous months. Ms. Smith said from the applications now coming in, December should show a fairly significant increase.
Ms. Smith then discussed the county by county enrollment report. The counties doing the best at reaching their enrollment goal are: Medicaid Expansion -- Appanoose, 78% of their goal; HAWK-I -- Ringgold, 58%; and for Combined Medicaid Expansion and HAWK-I -- Ringgold at 63%. Ms. Smith noted that the larger counties are not doing as well. Story County is at 15% of their target enrollment; Linn – 18%; Polk – 20%; Scott – 23%; Woodbury – 25%; Pottawattamie – 26%; and Black Hawk – 32%.
The demographic reports show 1,031 applications were received in November, enrollment remains split 60/40 between managed care and indemnity. A total of 46 percent of the applications were referred to Medicaid and that is higher than in recent months. Ms. Smith said staff is not sure why there was an increase in November. The top referral sources: number 1 is friends or word-of-mouth; number 2 DHS referrals; number 3 nurses and teachers; number 4 WICS, and number 5 all other DHS referrals.
The Applications Pending Report by County shows 1,147 applications that have been referred to Title XIX are still in a pending status. Sara Schneider, DHS, said that MAXIMUS ran a report for her and her review found that most of these applications have had a determination, they just haven’t been logged in the system. Ms. Fox-Goldizen said an additional field was added to the system and staff still needs to go in and enter a date in those fields. These would be applications from June, July, August, and September.
The Non-Enrolled by County reasons included: 453 refused Medicaid referral; 127 for failure to select a health plan. Ms. Smith said current rules are if there is a choice of more than one health plan families are required to make a selection. The health plans did not want the HAWK-I program to automatically enroll people into a plan. Ms. Smith said the Board may want to consider an auto-enrollment process so that if families don’t choose a plan a random selection will enroll them. This would require an amendment to the administrative rules. Mr. Huston said auto-enrollment should be explored because children should not be denied coverage because the parent doesn’t follow through with the process.
Dr. Schor suggested that someone call these families. Ms. Fox-Goldizen said that the families are called and encouraged to make a selection because MAXIMUS staff cannot make the decision for them. Ms. Fox-Goldizen said most of the time families are confused about what a primary care physician is, or if their doctor is with a certain health plan. The approval letter that MAXIMUS sends includes instructions on how to select a primary care physician and a plan comparison sheet is enclosed. Telephone numbers of the health plans are included in case additional information is needed.
Ms. Smith then discussed the disenrollment reports. The number one reason for disenrollment is families did not renew. Ms. Smith said this is not a surprise, based upon what other states are experiencing. The number two reason was failure to pay the premium, which is a misleading statistic for November. Ms. Smith explained that when premiums are paid they go into a lock box at the bank and then the bank sends a report to MAXIMUS. For some reason, three of those reports did not get loaded so those people showed up as being disenrolled on the report. This has since been corrected and the people were not disenrolled. Mr. Huston asked about the 218 non-renewals. Is there any information as to why they did not renew? For instance, did they leave the community? Ms. Smith said the reasons for not renewing are not known, however, this is an area that the national SWAT team will be addressing.
The call center activity report shows a total of 4,365 calls received in November. Ms. Smith asked Ms. Fox-Goldizen if they have noted an increase in calls this month. Ms. Fox-Goldizen said she does not have a total for December, but there appears to be a higher volume of incoming calls. Mr. Huston asked about the call centers change in hours. Ms. Fox-Goldizen said the change has been a welcome relief from their standpoint. The only instance of increased calls on the voice mail system was when the office was closed at 4:00 on a Friday due to inclement weather. Ms. Fox-Goldizen said there has not been much of an increase in missed calls by not having the call center staffed from 7:00 to 8:00 p.m. and 6:00 to 7:00 a.m.
Ms. Smith added that when the State of Iowa closed their buildings at 3:30 on Friday, December 15, she advised MAXIMUS to close as well.
Ms. Smith told the Board that staff is continuing to work with MAXIMUS on processes; finding ways to streamline. Staff is also working with MAXIMUS on encounter data; getting the formats from the plans and working with Pete Damiano on the analysis of the data. MAXIMUS is gearing up for the media campaign and hiring additional staff to support the mass media effort. Ms. Smith said that customer service complaints have dropped off dramatically. Ms. Smith said she has contacted several outreach workers and asked how things were going from their perspective and received very positive feedback.
Medicaid Simplification Project:
At last month’s Board meeting Ms. Smith discussed a pilot project to make the processing of HAWK-I applications that are referred to Medicaid simpler. Ms. Smith said that after implementing the pilot project there was an immediate change in the approval rate, going from 20 percent to 37 percent. As far as the elimination of monthly reporting, reinstatements for Medicaid have decreased from 11 percent of the caseload to 5 percent of the caseload. What that means is that families are not having to reapply, they are not getting disenrolled from managed care plans and having to be reenrolled, and the continuity of care is being maintained better because sometimes there is a wait when re-enrolling into a managed care plan.
SWAT Team Update:
Ms. Smith reminded the Board that at one of the previous Board meetings there was a public comment that the Board needs to revisit the impact of the premium. Ms. Smith said that the focus of the SWAT Team she is on is retention and disenrollmment. Lake, Snell, and Perry, will be conducting an analysis of why families did not pay the premium. Did they just not pay the premium because they didn’t need the program any longer, did they move out-of-state, is it an affordability issue? They will also look into enrollment issues. Why didn’t they send in their renewal form, did they get other insurance, is it too complicated? This project will be an in depth analysis of the reasons behind some of the actions, not just the actions themselves. Ms. Smith said that it is her recommendation that the Board wait to see the results of this study before taking actions concerning the premiums.
Dr. Schor asked about the time frame of the study. Ms. Smith said that a final draft of the report will go to the National Academy of State Health Policy on June 27, 2001. Focus groups will be conducted in 3 states, California, Utah, and New Jersey. Each state that is participating in the program will be providing 3,000 names for the survey (those currently on the program and people who have dropped off).
CHILDREN WITH SPECIAL HEALTH CARE NEEDS COMMITTEE UPDATE:
Ms. Smith said that Dr. Lobas was unable to attend today’s Board meeting due to the weather conditions. Dr. Lobas told Ms. Smith that he did not have any major items to report so he asked if he could be rescheduled for the January meeting.
Ms. Van Den Berghe told the Board that all of the outreach contracts for fiscal year 2001 have been completed with the exception of Iowa County. Ms. Van Den Berghe will follow up as to Iowa County’s status.
Ms. Van Den Berghe said she received a telephone call from a human resources representative whose company employs 170. The company is interested in looking at HAWK-I as an option for their employees. Also, one of the outreach coordinators was contacted about a plant closing in Fairfield and will be assisting with their transition.
Ms. Van Den Berghe said it was discovered that the 1-877 INSURE KIDS NOW hotline was not being forwarded correctly for Iowa calls. Notification from A T & T indicated that has been corrected on a permanent basis and several test calls to the number indicate everything is working as it should.
Brenda Oas entered the meeting at this time.
Ms. Van Den Berghe said that INSURE KIDS NOW has reached an agreement with H & R Block. H & R Block clients receive a checklist and one of the items on that list is the question, do you have health insurance? H & R Block will indicate on their report to the client that from the look of their taxes it appears they may be eligible for CHIP and provide the 1-877-INSURE KIDS NOW telephone number.
Mr. Huston indicated that no one had requested an opportunity to address the Board.
COVERING KIDS UPDATE:
Sonni Vierling of Covering Kids Now stated there currently are two items on their drawing board. The first is the possibility of conducting a workshop with outreach workers and other key players to discuss issues and share information. Ms. Vierling said she will keep the Board updated as to when this is scheduled. The second item will be the mass media campaign. Ms. Vierling said Covering Kids Now is excited to be a part of the effort and is looking forward to increasing enrollment.
Dr. Schor suggested that an "official" thank you to Marion County would be in order.
EXECUTIVE ORDER #8 – RULES REVIEW:
Shellie Goldman provided the Board with the background history of the administrative rules review process that all state agencies are undertaking. This rules review process is to identify and eliminate outdated, redundant, over-broad, ineffective, unnecessary, or otherwise undesirable rules.
The Department’s rules review plan was published to solicit comments and requests to be included in the review process. A mailing took place on March 15, 2000 to constituents and provider groups explaining Executive Order #8. Constituents had until April 15th to indicate which rule grouping reviews they wished to be involved in. HAWK-I received a list of 51 constituents indicating their desire to review the rules and statutes. HAWK-I rules were mailed to these constituents on November 1st with a due date for comments of December 1, 2000. Three responses were received: Iowa Managed Care Association, Legal Services Corporation of Iowa; and Diane Riley with SCICAP. Copies of these comments were provided to the Board.
After all comments are received, an assessment of each applicable rule is to be completed by October 1, 2001. Each division must prepare a schedule identifying the balance of its work for implementing the approved rule modifications no later than June 1, 2002. A final report summarizing the results of this review and documenting the rule changes is due to the Governor’s Office no later than December 31, 2002.
Ms. Smith said several of the changes requested from the constituents were changes that cannot be made because they are contrary to federal law. For instance, one person wanted to know why cost sharing is prohibited for Native American children. The response to these issues will be part of the assessment as to why the rule will not be modified. Ms. Smith said that the majority of the comments received were from Legal Services Corporation of Iowa. The new civil rights guidelines are being looked at from a Department-wide level because those guidelines affect all programs, not just HAWK-I.
UPDATE ON PROVIDER MAPPING:
Ms. Goldman reminded the Board that Dr. Schor expressed some concerns at the last Board meeting during the discussion of the amendment to the MAXIMUS contract for provider network analysis. Dr. Schor provided a list of his concerns to DHS staff who in turn provided a response for the Board’s review.
Dr. Schor ’s concern is that while the health plans can provide a list of physicians and dentists and where they practice, it may not mean that those providers are truly available to serve children on HAWK-I. Dr. Schor listed three levels of information that he feels would be helpful to assess the actual availability of physicians:
Ms. Goldman said that the MAXIMUS contract includes provider network analysis for HAWK-I only. The Medicaid expansion portion of Iowa’s CHIP program falls under the purview of Medicaid managed health care administration. Ms. Goldman said it was at the recommendation of the Quality Assessment and Improvement Advisory Committee and the HAWK-I Board that the Department proceeded to amend MAXIMUS’ contract to include provider network analysis. The purpose of the analysis is to plot member’s access to health plan providers in counties where the health plan is licensed. A separate provider network analysis is conducted by the Insurance Department.
Ms. Goldman then discussed her handout which outlines each of Dr. Schor’s concerns with what MAXIMUS is currently analyzing.
Mr. Huston asked for clarification of who is included in the term "primary care physician". This would be any licensed group that is able to participate in the program and would include dentists, chiropractors, optometrists, podiatrists, and other specialists. Ms. Goldman said the map that will be generated showing primary care providers and will be color-coded to designate whether the provider is primary care, dentist, or mental health.
Ms. Goldman said in order to map providers who have served a Medicaid or HAWK-I child in the past six months as Dr. Schor has requested, Consultec would have to provide MAXIMUS with a copy of the Medicaid claims file and this would be quite costly. Dr. Schor said the reason he raised the concern is that he keeps hearing there are not dental providers who will take Medicaid patients. Dr. Schor said he suspects that if one went by the provider panel lists it would appear that kids have great access to dental care, when in fact they may not. Dr. Schor said HAWK-I is a private system and pays different rates and he wants to make sure there is not a suttle "fending off" of HAWK-I kids. Dr. Schor said that the adequacy of the provider panel is based on location. If the family lives within 30 miles of a provider and that provider is not seeing those kids, then it is false access. Mr. Huston stated that many times dentists are treating HAWK-I patients and are not even aware of it because the health plan cards do not identify them as HAWK-I members.
Ms. Goldman said there is another caveat regarding dentists when reviewing these reports. John Deere Health Plan has open access so there is not a provider list. Iowa Health Solutions, because it has been difficult to get dentists to join, also has that same caveat. Patients can go to any dentist within their county as long as the dentist will take them and it is pre-approved by Iowa Health Solutions. Dr. Schor asked about the criteria for pre-approval. Ms. Ruggle said she doesn’t believe Iowa Health Solutions is denying anyone, they are informing the dentists of their requirements; pre-determinations and rate of pay. Ms. Goldman told the Board that when Iowa Health Solutions mails their packet they include an information sheet regarding dental access that instructs the member of what the member needs to do.
Mr. Huston asked if there has been any feedback regarding dental access recently. Ms. Smith said she has not heard any. Ms. Smith said she has never personally heard that a HAWK-I child did not have access, although other people have raised concerns about access. Ms. Ruggle said she has not heard any complaints either.
Ms. Smith told the Board that staff has not received any complaints about the health plans or services for a long time. Ms. Smith said that in order to track providers by encounter data that is not included in the scope of what MAXIMUS is doing right now would require a contract modification and would probably be quite costly. Ms. Smith said if this is an area the Board would like to pursue, it can be costed out. Mr. Huston suggested that the Board wait to see what the first two kinds of mapping provides. If the mapping is providing good information, fine; if not then go one level further.
Ms. Goldman said the analysis of encounter data should be available soon and will provide a view of how many children are receiving services as far as dental visits and that type of data.
Mr. Huston reminded the Board that at last month’s meeting it was requested the Board’s annual report to the legislature be withheld until after this meeting so December Board actions could be included.
Mr. Huston said that even though there has not been a great change in the membership of the Iowa Legislature, many of the committee chairs have changed. What affect that will have on the HAWK-I Board and their legislative recommendations is not known. Mr. Huston suggested the Board ask the chairs of these committees if they would like to hear from the Board rather than just from the Department of Human Services. Mr. Huston suggested that a Board member could attend these committee meetings and hearings along with DHS staff. Mr. Huston asked Board members for their reaction.
Dr. Schor said he thought it would be a good idea, particularly with the new committee chairs. This would be an opportunity to inform the chairs about HAWK-I. Mr. Cleaveland agreed it is a good idea. Ms. Poulton stated that the Board’s visibility would be valuable also.
There was no other new business to present before the Board.
The Board’s next meeting is Monday, January 22, 2001, at 12:30 in the Iowa Utilities Board Conference Room 4, at 350 Maple in Des Moines.
The meeting was adjourned at 2:25 p.m.