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HEALTHY AND WELL KIDS IN IOWA (HAWK-I)
July 17, 2000
Eldon Huston, Chair
Terri Vaughan, Vice-Chair (absent)
Angela Burke Boston (for Terri Vaughan)
Stephen Gleason, D.O. (absent)
Mary Weaver (for Stephen Gleason)
Ted Stilwill (absent)
Charlotte Burt (for Ted Stilwill)
LEGISLATIVE BOARD MEMBERS:
Senator Johnie Hammond
Senator Kenneth Veenstra
Representative Brad Hansen
Representative Robert Osterhaus (absent)
DEPARTMENT OF HUMAN SERVICES:
Deb Van Den Berghe
ATTORNEY GENERAL'S OFFICE:
Marie Glancy John Deere Health
Cindy Groene John Deere Health
Jennifer Dreibelbis Iowa Community Action Association
Bob Harpster Iowa Dental Association
Frann Otte Wellmark
Leila Carlson National Association of Social Workers
Jim Donoghue Broadlawns Medical Center
Stacey Cyphert University of Iowa Hospitals & Clinics
Steve Conway Senate Democratic Staff
Sonni Vierling Iowa Department of Public Health – Covering Kids
Carla Beneke Iowa Department of Public Health – Covering Kids
Anne Kinzel Iowa Department of Public Health
April Gordon Iowa Hospital Association
Barbara Fox-Goldizen MAXIMUS
Bill Brand Iowa Dept. Human Rights - Community Action Agencies
Jeanie Kerber House of Mercy
Jen Davis Iowa Medical Society
Mary O'Brien Visiting Nurse Services
WELCOME AND INTRODUCTIONS:
The Healthy and Well Kids in Iowa (HAWK-I) Board met on Monday, July 17, 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 12:30 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 JUNE 19, 2000, MEETING MINUTES
Barry Cleaveland made a motion to approve the June 19, 2000, minutes as written. Angela Burke Boston seconded the motion. Unanimous approval was made by Eldon Huston, Susie Poulton, Mary Weaver, Angela Burke Boston, Diane Briest, and Barry Cleaveland.
Anita Smith stated that a response has been received from HCFA on June 13, 2000, to the waiver request. HCFA will not allow a waiver for families to choose HAWK-I instead of Medicaid. The Department was told that this is not a waiverable issue and would require a statutory change.
On July 3, 2000, Iowa Health Solutions forwarded the results of their member satisfaction survey. Ms. Smith stated that her staff will be sending Iowa Health Solutions a letter asking what they intend to do with the results of their survey, and whether any changes will be made in procedures as a result of the survey. The responses to the question about transportation to health care appointments showed that 95 percent of the commercial respondents indicated they had transportation, 96 percent of the HAWK-I population, and 89 percent of the Medicaid population. Ms. Smith stated there have been past discussions about arranging transportation as part of care coordination as an additional benefit the HAWK-I population may need, but if this small survey is an indicator, then transportation may not be an issue for the HAWK-I population.
A letter dated June 23, 2000, from the Des Moines Health Center indicated they had not been getting cooperation from the Blue Dental program when they called to find out whether people were enrolled. They were very complimentary of the customer service they received when calling the HAWK-I 1-800 number. Ms. Smith responded to their concerns on July 10th and forwarded a copy of both letters to Wellmark.
A July 12, 2000, letter from Paul Carter, President of Iowa Health Solutions, responded to questions about what happens if there is not an adequate provider. Mr. Carter indicated that when Iowa Health Solutions has members in counties that do not have adequate provider networks the members are notified in writing that they can access the services from any provider in their area. The Department followed up with some additional questions. The response will be shared with the Board.
A letter is being sent from the HAWK-I Board to Iowa’s Congressional Delegation asking for their support of the legislation preventing the $1.9 billion reversion of unspent SCHIP funds. Ms. Smith indicated she has been told there is a commitment from the chair of the Senate Finance Committee that the funds will be restored, however, there are more and more questions as to why the dollars have not been spent.
Ms. Smith reported that the Department has been notified informally that the CHIP regulations are going to be out this summer and the states would not be happy. Iowa, as well as the other states, had extensive comments to the proposed regulations last winter. Indications are that these comments had little or no effect and the regulations are going to be the most restrictive for those states that have separate CHIP programs. Much of the flexibility that the states were guaranteed when the legislation was passed is being taken away by these regulations. Ms. Smith said that everything Iowa is doing now is in compliance within the regulations as originally proposed.
Ms. Smith told the Board that national "swat teams" have been created to look at: performance measures in the CHIP program; immigrant outreach issues, a review of administrative contractors; and the team she has been appointed to will look at retention and enrollment.
Ms. Smith said that only two states have submitted waivers thus far, Minnesota and Wisconsin. Both are 1115 states and already had waivers. Both states had already expanded their eligibility levels so high that by the time the CHIP money became available they didn’t want to go any higher and so were almost precluded from using the money.
Current FY Budget:
Ms. Smith reported that currently it appears as if there will be about a $1.9 million carryover. However, additional claims are still coming in so this figure will change. Current estimates show the program is $557,000 over the 10 percent administrative cap for the federal fiscal year. There are several reasons for that. Start-up costs in the amount of $450,000 were carried over from the first year; there were additional costs of going through procurement of a new administrative contractor; and enrollment is not where it was projected.
Representative Hansen entered the meeting at this time.
Mr. Huston asked if other states are experiencing the same difficulty and if there are any efforts to try to change the cap. Ms. Smith stated that everyone recommended a change when reviewing the proposed regulations. The start-up years are what caused the problem. Ms. Smith said that using delinking money for outreach has helped. In addition to the $150,620 in state dollars, $172,000 out of delinking money has been used for outreach. The $500 million was to be used for systems and training, additional workers, and outreach, but states were originally not using the funds because it was so prescriptive on how they could be used. HCFA loosened up the guidelines and told the states that they could use the funds for CHIP outreach as well. Iowa’s share was $4.7 million. Originally states had until December 31, 1999, to spend the funds, however, that sunset clause was removed.
Ms. Smith then discussed the State fiscal year 2002 CHIP budget request as presented to Director Rasmussen for approval. The first item expands Medicaid to 133 percent of federal poverty level at a total annual cost per eligible of $2,979. Ms. Smith pointed out that Medicaid costs have increased 37 percent in one year for this group of kids. The average cost in 1999 was $1,715 annually and in 2000 it was $2,355. At this time, it is not known what caused this significant increase.
A new line item in the FY 2002 budget request is the Medicaid expansion for infants for 200 percent of poverty. Ms. Smith said that even though that is Medicaid expansion, it is being funded with Title XXI dollars. The next two items are the anticipated premiums for children on HAWK-I. The ratio is currently 40 percent in indemnity plans and 60 percent in managed care. Total annual cost per eligible for indemnity plans is $1,666 and $1,280 for managed care. The budgeted amount includes a cushion for up to a 15 percent increase. The increase will depend on the recommendations of the actuary. For administration and outreach a total of $2,061,430 has been requested. This amount includes the total annual fee for the third party administrator; the functional assessment costs; outreach; postage; rent for the co-located income maintenance workers at MAXIMUS; and staff salaries. The salary budget includes an additional FTE bringing the total to 4 FTE’s. Also included is funding for geo mapping; medical chart review; and encounter data analysis.
Mr. Huston noted that the Board agreed at their last meeting to do more analysis of encounter data to try to find out where the special needs kids are and how much is being spent for them. Ms. Smith stated it will also help with measuring the effectiveness of the program and making sure there are appropriate providers in the health plans.
Ms. Smith said the calculation of the 10 percent cap for this budget assumes that the enrollment targets are met. The total program would be $53,732,927, so the 10 percent cap would be $5.3 million. Within this budget, administration is projected at $2.3 million; $3 million under what is allowable. Ms. Smith said that one of the items on the Department’s legislative agenda is presumptive eligibility for Medicaid. If passed by the 2001 General Assembly, there will be an impact on the administrative budget in the HAWK-I program.
Ms. Smith said that in FY 2000 the average monthly increase in HAWK-I was 12.8 percent. Enrollment projections for FY 2001 started at 8 percent and then level off. At the end of FY 2001, if the program stays on target, it would reach 53 percent of the enrollment goal and at the end of 2002 reach 85 percent of the enrollment goal.
Enrollment & Statistics:
Ms. Smith stated that due to unanticipated conversion problems from ESI to MAXIMUS the enrollment statistical reports were not available in time to present to the Board. Mr. Huston said that Ms. Smith had discussed this matter with him and it was his suggestion to give MAXIMUS an opportunity to continue through the transition process and have a chance to fine tune the reports and provide the Board with up-to-state statistics in August.
Ms. Smith reported that MAXIMUS was experiencing difficulty verifying the integrity of data. Rather than having MAXIMUS enter all data from scratch, the decision was made that MAXIMUS would try to convert ESI’s data and populate their system so that they could maintain all the history. Converting the data has proven difficult. MAXIMUS is manually reviewing 800 cases to make sure everything is correct. MAXIMUS has been told not to cancel anybody until absolutely sure that they shouldn’t be on the program. Ms. Smith said she has received an assurance from MAXIMUS that the final reports will be accurate and MAXIMUS has extended an offer to have someone from their corporate office come and talk to the Board about the reports and the difficulty they have had in converting the data.
Barbara Fox-Goldizen from MAXIMUS stated that other than the problems Ms. Smith addressed, they are having a smooth transition. Follow-up reports have been started, telephone calls are timely answered, and they are working closely with the health plans. Board members were furnished with a copy of a letter that went out to about 2,000 families who had been denied in the past because they were over income. This letter tells the families about the new income guidelines and includes the new brochure and application.
Ms. Smith then discussed a report that was brought to her attention by Dr. Ed Schor of the Iowa Department of Public Health. The report was a national study on the health status of SCHIP eligible children. The report showed that SCHIP eligible children are overwhelmingly in good health and most have no chronic health conditions. Ms. Smith said there have been some questions in the past about what this population looks like, do they look like commercially insured kids or do they look like Medicaid covered children? The report shows that 40 percent of the SCHIP eligible kids live in the southern states. The SCHIP group is more likely to have both parents employed than in the Medicaid group. Self-employed families are one of the biggest groups found to be uninsured. The report also points out that the proportion of Hispanics that are SCHIP eligible is very high and states need to pay attention to that. Ms. Smith said that this is an area where the Robert Wood Johnson Foundation may be able to help with outreach efforts.
Deb Van Den Berghe, Outreach Coordinator, told the Board that the outreach contracts for the current fiscal year are nearly complete with only six counties who have not contracted thus far. Three counties declined the funding (approximately $6,000), Calhoun, Pocahontas, and Webster.
Ms. Van Den Berghe said a lot of her time has been spent visiting the counties clarifying the program and answering questions. She has also been working closely with Ms. Fox-Goldizen at MAXIMUS to make sure both staffs are working well together.
Ms. Van Den Berghe told the Board she is in the process of putting together an annual plan for outreach so there will be a more formalized reporting system to the Board. The plan will include collaborations, marketing, outreach contracts, training, and education.
Mr. Huston noted that schools have been the most successful outreach group and asked Ms. Van Den Berghe if anything special is being done this year. Ms. Van Den Berghe stated the outreach workers have been gearing up for several months now and she recently sent out a survey to find out what activities are planned. The responses thus far indicate many of the schools are utilizing the free and reduced lunch programs and/or the school emergency contact cards to inform parents about HAWK-I. Ms. Van Den Berghe said that even though the free and reduced lunch program matches the target group of 200 percent poverty level, she feels a large segment is being missed because people who are eligible do not apply. Instead, the outreach coordinators are suggesting using the emergency contact card because one must be completed for every student in every school. Des Moines Public Schools will be using this method. When completing the emergency contact card every parent will be asked if the child has health insurance and if so, is it Title XIX or privately purchased. A waiver is also included asking if they would like more information or would they like someone to contact them personally.
Ms. Poulton stated she had two concerns. The first concern is getting cooperation from schools to ask the question because many think it is very personal information. Ms. Poulton said her second concern is once the schools put the question on the emergency card, who follows up by reviewing those cards and ensuring that the families who signed the waiver are contacted. Ms. Van Den Berghe stated that the approach this year will be different that in the past. This year each school has an outreach coordinator who is responsible for all the schools in that school district. For those areas where there is not a coordinator, other groups such as social workers or local clinics will be assisting. Someone in Polk County has indicated they want to work with the private schools. Additionally, Ms. Van Den Berghe has met with the Iowa School Nurses Board and also spoke at the administrative meeting for the Des Moines Public School nurses.
Charlotte Burt from the Iowa Department of Education mentioned that this also has been a project the Covering Kids group has been working on. They held an ICN in-service for school nurses this spring where they shared different forms and examples from across the country. Also, the Department of Education’s Bureau of Food Programs included in one of their mailings a form to be put out at the schools.
Ms. Smith gave the Board members a packet of information that will be sent to 7,000 registered in-home and child care centers on July 25th by the Covering Kids project. This will reach the zero to five-year-old population that is not reached through the school outreach programs.
Ms. Van Den Berghe stated the Iowa State Fair booth will be staffed from 11:00 a.m. to 2:00 p.m. and from 6:00 to 9:00 p.m. each day. Booth volunteers include staff from Covering Kids, the Iowa Department of Public Health, outreach coordinators from across the state, Department of Human Services’ Medicaid staff, and income maintenance workers. Gator the Clown will be strolling the grounds promoting HAWK-I.
Representative Hansen stated that he is still concerned about small employers who may not be offering health benefits and suggested working through local chambers of commerce or the National Federation of Independent Business. Ms. Van Den Berghe indicated Scott County currently has a pilot program where the chamber of commerce partnered with several small businesses to offer outreach. One of these businesses schedules a day where the outreach coordinator is there for a period of time to meet with individuals who may be benefited by the HAWK-I program. Ms. Van Den Berghe stated she is also currently working with agricultural lenders throughout the state as well as Iowa State University’s family support program. Ms. Smith added that she was recently contacted by the AFL-CIO in Washington wanting to know if Iowa was working with unions and small businesses regarding employer buy-in under HIPP, so information may be coming out at the national level as well.
Ms. Van Den Berghe indicated that the Requests for Proposal (RFP) for the Department. of Human Rights Outreach Pilot Project are due July 17, 2000. Five RFP’s have been received thus far and the committee will start reviewing them next week.
Update on Wellmark Contracts:
Anna Ruggle, Department of Human Services, informed the Board that she had received signed contracts from Wellmark for both the Classic Blue and Unity Choice plans. The contracts are for one-year terms instead of the three-year terms proposed by the Department.
Ms. Ruggle stated the contract between the Department and the University of Iowa Public Policy Center was ready for action by the Board. This is a renewal contract that has been expanded to include a follow-up survey as well as continuing with the baseline survey. This is a two-year contract.
There was a question from the Board as to the exact increase in cost from the previous contract. Ms. Ruggle reported that last year’s contract totaled $25,616 and this year’s contract totals $35,000. The new contract doubles the number of reports. Additionally, the University of Iowa will now conduct two surveys and print the follow-up survey. The contract also includes an increase in staff salaries and an additional research assistant.
Barry Cleaveland made a motion to approve the contract with the University of Iowa Public Policy Center. Susie Poulton seconded the motion. Unanimous approval was made by Eldon Huston, Susie Poulton, Mary Weaver, Angela Burke Boston, Diane Briest, and Barry Cleaveland.
Mr. Huston indicated that no one had requested an opportunity to address the Board.
CLARIFICATION OF LEGISLATION ON BENEFIT CHANGES:
Mr. Huston stated that there have been questions in the past about when the Board can change benefits under the program and when those have to go to the Legislature for approval so he asked Marne Woods to research the issue.
Ms. Woods informed the Board that Iowa Code Section 514I.5 addresses the powers and duties of the HAWK-I Board. Under Section 514I.5, it appeared that the Board had total discretion to do as they wish when it came to approving the benefit package design, reviewing the benefit package design on a periodic basis, and making necessary changes in the benefit design to reflect the results of that periodic review. However, Iowa Code Section 514I.9 gave that discretion only until on or before June 30, 1999. After that point, the Board must annually review the benefits to determine additions or deletions and must submit their recommendations to the Legislature. Ms. Woods said that this means the Board does not have the power to take a vote and change the benefits. The Board does have the power to take a vote to make a recommendation to the Legislature for a change to the benefits.
Ms. Weaver said she believed the Clinical Advisory Committee came forth with a proposal of several benefits they would like to see added so perhaps the Board should get that ready to submit formally when the Legislature reconvenes in January. Mr. Huston indicated that the Clinical Advisory Committee’s recommendations would be placed back on the HAWK-I Board’s agenda.
Ms. Weaver asked how Board members felt about proposing uniformity for minimum coverage that would be very concise and understood rather than the minimums in effect now, which vary from provider to provider. Senator Hammond said if that could be done so it is clearly understandable, she thinks it would be advisable. Senator Hammond stated the Board has to decide which is more important to have, uniformity in benefits, at least minimum benefits, or to accommodate the plans so that they don’t have to develop a specific proposal. Representative Hansen stated that it makes sense to have that as a legislative proposal, keeping in mind the cost and plan participation impact. Representative Hansen stated he would hate to see a minimum raised in one area that may force a plan to say they don’t have a plan that accommodates and may not see the wisdom in offering, or continuing to offer, that plan. Senator Hammond stated the legislative proposal could be less specific, such as the Legislature authorizing the HAWK-I Board to develop that minimum standard and to require that standard.
Ms. Smith told the Board the Department had received two proposals, one from the Iowa Foundation for Medical Care (IFMC) and the other from MAXIMUS, as to how they would do geo mapping for the HAWK-I program and what the cost would be. Geo mapping is a process that can map locations of providers to the HAWK-I population to ensure access. A comparison of the two proposals was furnished to the Board. MAXIMUS included several examples of what they are doing in other states and how the information can be used. Ms. Smith said that the advantage with this approach is that MAXIMUS already has the data. The health plans are already providing their provider files and MAXIMUS will also have all the data regarding the enrollees. This is a disadvantage for the Iowa Foundation for Medical Care as they would have to get that information from the third party administrator. Ms. Smith said there has been a lot of discussion about access with this program, making sure the health plans have the appropriate provider networks and that there is access for specialists. This is a way to map that as well as gather other demographic information about participating providers and enrollees. The MAXIMUS proposal provides for these reports monthly, while the IFMC proposal provides for these reports quarterly and not by all provider types. MAXIMUS can break their reports down into specificity, including provider specialty coverage, within a health plan, or by zip code. They also proposed providing maps and charts by zip code and county for each of the health plans to the Department on a monthly basis. IFMC’s proposal is $22,000 annually and the MAXIMUS proposal is $38,000 annually with some one-time start-up costs. Ms. Smith stated that the information provided by these reports is something that both the Clinical Advisory Committee and the Children with Special Health Care Needs Advisory Committee would like.
Representative Hansen asked why it was necessary to pay to have this done and inquired as to why the plans aren’t submitting this on an annual basis or when a contract is renewed to show they have the coverage. Ms. Smith said it was her understanding that the contract would provide a lot more information than just where the providers are. For example, the Department could take the Title XIX file and compare it to where providers are as well as the HAWK-I files. Also, asking for this information from the health plans would be an amendment to the contract and the Department would have to pay for the information either through an increased cost for the contract, or for the proposals submitted to the Board today. Ms. Smith said that Shellie Goldman could provide more information to the Board on this subject. Mr. Huston asked that this subject be placed on the agenda for the Board’s August meeting.
ABSENT PARENT BUY-IN PROJECT:
Ms. Smith told the Board that the Child Support Recovery Unit is looking for ways to assist absent parents in meeting their child support obligations. One of the things that they are looking at for those absent parents who have medical support obligations, but don't have affordable health insurance coverage available, is allowing a full premium buy-in into the HAWK-I program.
Two initiatives have been proposed. Absent parents would be allowed to buy in at full cost if their income is below 300 percent of the federal poverty level, so there would be no state or federal dollars sharing in the cost. The other proposal is to allow two parent families that are between 200 and 300 percent of poverty that don’t have insurance available to them to buy in at full cost.
The proposals are now being considered by the Governor’s Enterprise Teams and some people are referring to this as HAWK-I PLUS. This is not HAWK-I as per Title XXI of the Social Security Act; HAWK-I would just be the vehicle or plan that people could buy into in order to provide coverage to their children. Nor would the proposal be under the same rules for eligibility as the HAWK-I program as mandated by Title XXI. Cost figures have been prepared with administrative costs added onto the premiums that the family would have to pay. Some of the questions that have come up are: How would it be funded? How much support is there? How would the public be educated about this program so it is clear to people that this isn’t HAWK-I under Title XXI? What is the role of the HAWK- Board, if any? Does the HAWK-I Board want to be involved? Ms. Smith stated she wanted to share the proposals with the Board and get their feedback.
Mr. Huston stated that some noncustodial parents have asked about getting on HAWK-I but it is his understanding that present rules do now allow that. Ms. Smith stated that federal law would not allow it. However, with the two initiatives being proposed, the families would buy in at 100 percent of the cost (the health plan premium plus administrative costs) so there would be no federal money involved so Iowa could do whatever they want. These initiatives do require legislative action by the Iowa General Assembly. Ms. Smith said that because of the buy in cost, $91.00 plus $23.00 in administrative costs, the Department does not anticipate a large number of participants, particularly if there is more than one or two children, however it is an alternative for those absent parents or two parent families.
Mr. Headlee stated that at this time the Department has not taken any action or made any decision on whether it will move forward with either initiative. Mr. Huston asked Ms. Smith to keep the Board up-to-date on the discussions that come out of these proposals.
FAMILY COVERAGE OPTION UNDER CHIP:
Ms. Smith said that this agenda item is the result of a request from Representative Osterhaus for clarification on family coverage under CHIP. Ms. Smith shared with the Board a presentation she made at the National Conference of State Legislators in Portland, Oregon, several weeks ago. Ms. Smith also manages Iowa’s HIPP program for the Department of Human Services. The HIPP program buys into employer-related plans for people on Medicaid when it is cost effective, and it is possible that Iowa may use the HIPP concept to buy-in to employer plans for the CHIP program.
Ms. Smith said that Iowa has had the HIPP program since July 1991. Ms. Smith then explained how the HIPP program works. Once the HIPP Unit determines that the State is going to buy the insurance, the employer verifies who is covered, the effective dates of the coverage, and the employer is asked if the State can pay them directly in lieu of a payroll deduction. If the employer says it must be through payroll deduction, then State sends the individual the reimbursement check about the same time as they get their paycheck.
Ms. Smith said she believes this program prevents "crowd out" because once people become Medicaid eligible they oftentimes drop existing coverage since maintaining health care coverage is not a condition of Medicaid eligibility. With the HIPP program, the state gets the advantage of the employer contribution towards the cost because the state pays only the employee share. Ms. Smith pointed out that oftentimes only the kids are Medicaid eligible, but the family coverage must be purchased in order to cover those children. If it is determined to be cost effective, then the parents are covered as well. Generally, commercial plans do not provide as broad coverage as Medicaid. Ms. Smith explained that even though the employer’s health insurance plan is purchased, the individuals are still Medicaid eligible. The insurance plan pays first, and then Medicaid picks up what’s not covered.
Ms. Smith said that Iowa could now buy into employer plans for families when it is cost effective. However, the proposed regulations make the process much more complex than through the HIPP program. For example, the child cannot already be enrolled and must have been uninsured for the previous six months; the employer has to contribute at least 60 percent, unless the state can demonstrate that the average employer contribution across the state is something less; the services covered must be a benchmark or benchmark equivalent; and if the employer plan is not a benchmark or benchmark equivalent, a mechanism would have to be in place to provide wraparound services to bring the plan up to benchmark.
Ms. Smith said that most of the employer plans have deductibles or cost sharing so a wraparound package would have to provide the required noncovered services and pick up the cost sharing, because cost sharing for the families cannot be more than 5 percent of the family’s income. At this point if it is cost effective, then the State can buy in for the family and, similar to the HIPP program, reimburse the family for payroll deduction or pay the employer directly.
Ms. Smith said that if this is something that the Board is interested in pursuing it would require legislative action by the Iowa General Assembly.
Mr. Huston requested this issue be placed on the Board’s August agenda with the other legislative proposals.
There was no new business to present before the Board.
The Board rescheduled its August Board meeting for Monday, August 28, 2000, at 12:30 in the Oak Room at the Des Moines Botanical Center.
The meeting was adjourned at 3:30 p.m.