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HEALTHY AND WELL KIDS IN IOWA (HAWK-I)
June 19, 2000
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)
LEGISLATIVE BOARD MEMBERS:
Senator Johnie Hammond
Senator Kenneth Veenstra
Representative Brad Hansen (absent)
Representative Robert Osterhaus (absent)
DEPARTMENT OF HUMAN SERVICES:
Deb Van Den Berghe
ATTORNEY GENERAL'S OFFICE:
Kehla Garrett John Deere Health
Frann Otte Wellmark
Mary O'Brien Visiting Nurse Services
Carla Beneke Iowa Department of Public Health
Jennifer Dreibelbis Iowa Community Action Association
Barbara Fox-Goldizen MAXIMUS
Jan Ruff MAXIMUS
Bill BrandIowa Dept. Human Rights - Community Action Agencies
Jeanie Kerber House of Mercy
Jennifer Davis Iowa Medical Society
Dr. Jeff Lobas Child Health Specialty Clinics
Jennifer Krapfl-Oberbroeckling Child Health Specialty Clinics
Perry Beeman Des Moines Register
Kathie Obradovich Lee News
April Gordon Iowa Hospital Association
Dr. David Alexander Blank Children's Hospital
WELCOME AND INTRODUCTIONS:
The Healthy and Well Kids in Iowa (HAWK-I) Board met on Monday, June 19, 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 MAY 16, 2000, MEETING MINUTES
Mary Weaver made a motion to approve the May 16, 2000, minutes as written. The motion was seconded by Susie Poulton. Unanimous approval was made by Eldon Huston, Mary Weaver, Susan Voss, Susie Poulton, Diane Briest, and Barry Cleaveland.
Mr. Huston noted that at their May 16th meeting, the HAWK-I Board requested a letter be sent to Iowa's Congressional Delegation seeking their support in amending the law to allow families to choose between Medicaid and the HAWK-I program. This letter was sent under Mr. Huston's signature on June 12, 2000. Also, a letter requesting a waiver was sent to the Health Care Financing Administration by Dennis Headlee, State Medicare Director. To date, no response has been received to these letters.
MAXIMUS RESPONSE TO NEWSPAPER ARTICLES:
Recently several newspaper articles appeared concerning the new Third Party Administrator, MAXIMUS. Board members had been provided with a copy of a May 22, 2000, letter to Anita Smith from MAXIMUS CEO, David V. Mastran, which addressed the issues raised in these articles. Jan Ruff, Project Director for MAXIMUS, addressed the Board. Ms. Ruff explained that MAXIMUS has about 3,000 clients and the issues involved relate to one client and one potential client. The client that is the subject of publicity is the State of Wisconsin, a welfare reform welfare-to-work project. The potential client is New York City. Ms. Ruff said that MAXIMUS bid on a contract in New York City for welfare-to-work and it has become part of an ongoing political struggle between the city comptroller and the mayor of the city. Ms. Ruff said that all of the officials that have been involved in New York have said that MAXIMUS has done nothing wrong and there is a court case pending. Ms. Ruff stated that because of the political struggle between the mayor and comptroller, as well as a senate race, the New York Times has printed a lot of articles raising various issues.
In Wisconsin there are two issues. The first issue relates to employee allegations of discrimination. Ms. Ruff stated that MAXIMUS has a zero tolerance policy for discrimination. The company has approximately 4,000 employees and has never been sanctioned by any equal opportunity commissions for any kind of discrimination. The company believes that will be the case in Wisconsin as well, but it is still under investigation. The other issue in Wisconsin is related to whether employees of the welfare reform project properly billed for their time when they were working on activities outside the state. Ms. Ruff said that MAXIMUS undertook its own investigation and found that there were a small number of hours (272 of a total 800,000 hours worked) that were improperly billed. MAXIMUS has reimbursed Wisconsin and implemented additional procedures across the country to ensure that it does not happen again. Ms. Ruff stated that the company as a whole has a fantastic performance record and a high ethic standard so it has been unfortunate that these incidents have been brought to light and have received a lot of attention.
Ms. Smith stated that prior to any contact from the press, MAXIMUS provided the Department with advanced notice that there were issues and provided the May 22nd letter. After being contacted by the press, Ms. Ruff met with Mr. Headlee and Ms. Smith and explained the issues. Ms. Smith stated that from her perspective, the Department of Human Services believes that everything has been taken care of in the appropriate manner and has no reason to believe that there will be any issues for Iowa.
Mr. Headlee stated that the contract was let in accordance with the State's procurement processes. Everything was checked out subsequent to the contract being let and there have been no issues with regard to performance that would lead the agency to believe that MAXIMUS is anything else than what was found during the procurement process.
Mr. Huston asked if any of the Board members had questions for Ms. Ruff. There were no questions.
Transition to MAXIMUS:
Ms. Smith stated she thought the transition from ESI to MAXIMUS has gone very well. The transition took an incredible amount of cooperation from ESI, the health plans, University of Iowa, and other partners, and Ms. Smith stated she could not say enough about everyone's willingness to ensure a smooth transition.
Ms. Ruff provided the Board with a summary of all the start-up activities which occurred between March and June, 2000. With a few exceptions, everything went very smoothly. All staff was hired on time, were trained, and on board when the project came on-line. A great deal of time was spent understanding the processes and creating a policy and procedures manual to be used not only for training, but also as a resource guide for staff. This manual also formed the basis for what the systems programmers used to program the system to support the HAWK-I project.
The State's income maintenance worker staff moved in on May 25. The telephone changeover from ESI to MAXIMUS occurred the week of May 29th and on June 1 MAXIMUS officially began answering the telephones. The automated call distribution system was not installed until the next day, but that did not affect their ability to answer calls. Staff has been provided with instruction on the use of the special line for hearing impaired as well as the language line. All computers have been installed and staff has been working furiously on the design of the system, the testing, and implementation. Ms. Ruff said that as of right now, the system works the way it was intended to, but the last three weeks were very difficult.
Ms. Ruff said MAXIMUS worked closely with the health plans on development of file formats and file transfer procedures so that they can notify the plans electronically of all of their enrollments. This is done through use of an electronic bulletin board. The plans also use the bulletin board to give MAXIMUS their provider files so they can assist people in selection of a primary care provider. The first official file went out to the plans on Friday, June 16. Ms. Ruff stated that her staff have also been working with DHS on Title XIX eligibility files to make that a more automated process.
Ms. Ruff said her staff has also worked very closely with the previous contractor, ESI, to understand the ESI data system and to set up some ground rules of when files would be transferred for testing purposes and then for final transfer of the files. There were some real difficulties in understanding the ESI files, partly because there was a lack of documentation of the system that was in operation and the people who are at ESI now are not the people who were there when it was designed. Ms. Ruff said it was a struggle on everyone's part to understand what data was there and how to convert that data to the system that MAXIMUS was putting up. The final file transfer from ESI did not occur when it was suppose to on June 1 but rather on June 5. Ms. Ruff stated that a number of problems with the data in the files received have been discovered. To correct this, ESI was asked to furnish their last member files which were sent to the health plans, and each of the health plans have been asked to submit their enrollment files. A comparison will be made to ensure that starting from day one, MAXIMUS has a complete data base of who the plans think they have and who the data system says they have. Discrepancies will be worked out on a one-by-one basis.
Mr. Huston asked if Ms. Ruff was aware of anyone being denied service because of the confusion between the records. Ms. Ruff stated not that they are aware of, but are very concerned and want to make sure that is not the case. Ms. Ruff verified that no cases have been closed, nor will they be, until MAXIMUS is sure everything has been cleared up.
Ms. Ruff stated that MAXIMUS has been working very closely with the plans on the encounter data processing and have reached agreement on the file format and the process that will be undertaken beginning in August. Ms. Ruff stated that MAXIMUS has a premium processing arrangement with Bankers Trust which automatically updates daily who has paid premiums. That system has been running since June 2 and the first premium notices are scheduled to go out June 20 or 21. These notices were delayed due to the problems that occurred with the conversion of data.
Per the agreement reached between DHS, ESI, and MAXIMUS, ESI stopped processing applications on May 24 and MAXIMUS began processing on June 1. MAXIMUS is current on processing all the applications in the system, but notification of the results will take place the week of June 19. Ms. Ruff stated that improvements have been made to the website and would welcome suggestions for other items the Board would like included. The website is both in English and Spanish. All of the monthly reports generated will be on the website and a special password will be given to the appropriate people to allow access. The first reports will come out early in July.
Ms. Ruff shared an organization chart with staff responsibilities and sample letters with the Board. Ms. Ruff also provided the Board with statistics to date from the call center.
Ms. Smith stated that under the previous contract with ESI enrollments were sent to the health plans on a weekly basis, and now that will be available to them on a daily basis. Ms. Smith informed the Board that they would see format changes in the monthly reports. Zip code-specific demographic data has been requested so that will be available in addition to the county-by-county data.
Barbara Fox-Goldizen, MAXIMUS Project Manager, stated that they have been receiving questions via the website and those questions are being answered on-line. Ms. Fox-Goldizen said that this new feature of the website has been working quite well and they have received positive feedback.
Mr. Huston expressed the appreciation of the Board for all the efforts put forth by everyone.
Enrollment and Statistics:
Ms. Smith reported that the HAWK-I program had a modest increase in May. Over the past 6 months there has been an average increase of 556 children per month enrolled in the program. A substantial increase in Medicaid occurred in May, that number will increase due to retroactivity.
Ms. Smith stated that the "Applicant Status Summary" report indicates the top five reasons for denial have not changed, but the pending numbers have gone down considerably since the glitch in the system was corrected last month. There are 228 pending enrollments due to MAXIMUS awaiting additional information and 789 pending that were referred to Medicaid. The "How You Heard of Us" report is showing that more and more families are hearing about the program through word-of-mouth. Ms. Smith said that this report also shows that community action networks and Kids Health Net have had a significant amount of referrals. It also appears that outreach workers, particularly in Marshall County, have had a lot of activity.
Senator Hammond stated she was concerned about the number of voluntary withdrawals and the referral to Medicaid refusals shown on the "Applicant Status Summary" Report. Ms. Smith stated that some wording changes to the brochure will hopefully have a positive impact. Ms. Smith said another change will be made in correspondence from the income maintenance staff located at MAXIMUS. In the past when a referral is made to Medicaid all correspondence is sent on Department letterhead and in a DHS envelope. From now on, all of that correspondence will go out on HAWK-I letterhead in HAWK-I envelopes. Staff felt that it was possible that families that do not want anything to do with the Department were not looking at the correspondence to find out what was going on. Sometimes families indicate they sent in a HAWK-I application and have heard no response. It could be that they received the letter informing them they had been referred to Medicaid and did not realize the connection.
Ms. Smith reviewed the "Disenroll Reason by County" report for May that shows that out of 52 kids disenrolled, 26 were due to turning age 19. The "Progress Monitoring Report" shows that the bulk of the counties are falling into the 30 to 50 percent range, so good progress is indicated. Two counties, Montgomery and Ringgold, have gone over 60 percent. Ms. Smith reminded the Board that the counties requested the figures represent 100 percent, so they counties are a lot closer to their goals than it would initially appear. Ms. Smith said that the counties asked for a report to show how many completely new children enter Medicaid each month and how many drop off in order to get a feel for how effective their outreach efforts are. The first draft report showed that approximately 6,000 new kids were added statewide, however, there were also 6,000 kids that dropped off. This would indicate that even though outreach is getting kids in, they are not being retained. Ms. Smith said that once the monthly reporting requirements change in October, it is likely there will be a significant change in the retention of kids on Medicaid.
Ms. Smith informed the Board that HAWK-I enrollments during state fiscal year 00 have increased an average of 13.5 percent. When developing the budget, an average monthly increase of 13 percent was used, so for budgetary purposes, everything is on target. Ms. Smith said that not as much cost sharing was collected as budgeted.
Ms. Smith updated the Board on the status of a bill that has been introduced in Congress to take away the $1.9 billion in federal fiscal year 1998 CHIP funds to pay for a $2.3 billion increase to the National Institute of Health. Passage of this bill would mean that not only would the states not be allowed an additional year to spend the funds or to have the $1.9 billion redistributed to the 13 states that have, this legislation would take the $1.9 billion completely away from the program. Senators Harkin and Specter are the sponsors of the bill.
Ms. Weaver asked if it would help if the HAWK-I Board wrote a letter asking for the expansion or the additional year to be able to keep the funds. Discussion followed. Susan Voss made a motion to send a letter to the Iowa congressional delegation addressing the issue. The motion was seconded by Barry Cleaveland. Unanimous approval was made by Eldon Huston, Mary Weaver, Susan Voss, Susie Poulton, Diane Briest, and Barry Cleaveland.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS:
Dr. Jeff Lobas, Chair of the Special Health Care Needs Committee, provided the Board with an update. The Committee has been working for approximately a year and a half and the question which comes up repeatedly is; who is a child with special health care needs and who are these kids? Dr. Lobas stated there is a misconception nationally that all the kids are taken care of in SSI and are on Medicaid, so there is no need to worry about them in CHIP programs or private insurance. Dr. Lobas provided the Board with three examples of children with special health care needs. Dr. Lobas said that for the most part, primary care physicians in the state are not prepared to deal with these special health care needs, either by training or by office time, and there is a need for coordination of these cases. Managed care does not tend to have expertise with rare and complex illnesses and although rare, they are high cost diseases. Dr. Lobas stated that HAWK-I data and enrollment forms show that between 8 and12 percent of the children enrolled in HAWK-I have special health care needs, but the data does not show how they are doing. At this point in time there is not a good way to identify these children except in a very generic survey format.
Dr. Lobas explained that legislation was passed to establish an advisory committee to make recommendations to the Board and to the General Assembly on or before January 1, 1999, concerning the provision of health insurance coverage to children with special health care needs under the HAWK-I program. After this report was presented to the Legislature in January of 1999, the Committee came before the Board and asked if they wanted them to continue looking at this group of children or disband. The Board voted they should continue and so they have been meeting about every other month.
Dr. Lobas stated the American Academy of Pediatrics and Maternal Child Health Bureau has proposed a definition of children with special health care needs to be used nationally. This definition is: "Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." Nationally, children who meet this definition make up between 12 and 15 percent of the population. Dr. Lobas said that without specific data it is difficult to define any interventions or work with the plans at improving things for these children, and it is the Committee's hope that within the next year they can work with DHS and the Board to develop a plan using encounter data. Dr. Lobas stated that the Committee is looking for direction from the Board.
Ms. Poulton asked Dr. Lobas to talk more about some of the concerns the Committee has with the health care needs of these children under a typical commercial health insurance plan. Dr. Lobas said that what is called mainstream managed care does not tend to deal with this population well. Managed care does very well with the high incidence diseases such as asthma or diabetes, they develop protocols and case management, but when it comes to the rare and complex diseases, most managed care companies have not developed the expertise to really know the appropriate things to do. Dr. Lobas stated that particularly in a rural state such as Iowa there are very few subspecialists. Dr. Lobas stated that he thinks the approach managed care companies use is case management aimed at reducing benefits when these kids really need coordination to look at what is the best global plan; how to engage the community, the AEA's and those types of resources.
Mr. Huston asked Dr. Lobas how the Board can be of assistance. Dr. Lobas stated that the first thing would be to direct the Committee to work with DHS to develop and collect data to start identifying these children and develop a quality assurance plan around these kids to see how they are doing.
Mr. Huston stated that Ms. Poulton has been the Board's representative working with the Special Health Care Needs Committee and if any other Board member had an interest in working with Ms. Poulton and the Subcommittee to let him know.
Dr. Lobas said that an interesting statistic from a study recently done in Ohio is that out of 10 percent of their special needs children, they spend 50 to 60 percent of their resources. Once these children are identified, interventions can be identified to improve care and that may actually reduce costs.
Ms. Smith stated that even though the health plans have agreed to resubmit all the encounter data to MAXIMUS so all data is available from day one of the program, the actuary from Deloitte and Touche does not think there would be sufficient data at this point in time. It may provide some preliminary information, but the actuary did not feel there would be sufficient encounter data until January of 2001. Ms. Smith said the summaries of the first round of follow-up surveys should be available about that same time.
The Board asked Dr. Lobas to keep them apprised of the Committee's activities and to inform them of any barriers.
Mr. Huston indicated that no one had requested an opportunity to address the Board.
CLINICAL ADVISORY COMMITTEE:
Update on Benefit Recommendations:
Dr. David Alexander, Chair of the Clinical Advisory Committee, was introduced. The Committee raised some issues concerning coverage and needed clarification by the plans. A letter was sent to each of the plans to ask about seven different areas of coverage for the HAWK-I program. Ms. Voss summarized the responses for the Board. Ms. Voss stated it was her conclusion that there are some inconsistencies. For example, the Committee was under the understanding that nutritional services and formulas were covered. The responses show there is a difference on whether these are actually covered. The biggest area of difference was in mental health/substance abuse and AXIS 1 diagnoses.
Dr. Alexander stated that the responses confirmed what the Committee had felt from the beginning. The Committee's concern has been that these areas are not clearly specified in any benefit plans and when the Committee met informally with the plans, they were told yes this is covered or we think this is covered. Dr. Alexander stated that the seven areas presented by the Committee came out of a year's worth of discussion concerning apparent gaps in care and clarifying what benefits are required to be covered. Dr. Alexander said that the functional assessment data clearly shows the most common need identified by families was mental health services. Dr. Alexander said that there are clearly some gaps and inconsistencies and even the things that are consistent may not be adequate, such as the lack of full availability of all the options between inpatient care and physician's office care.
Mr. Huston stated that it had been the Committee's hope that these issues could be addressed administratively, that the inconsistencies were not that dramatic. However, the responses show the inconsistencies are more dramatic than anticipated. Mr. Huston said the question for the Board is, does the Board try to make these consistent, which is the recommendation of the Clinical Advisory Committee, and in doing so does the Board get away from the concept of letting health plans administer their program as they see fit. Mr. Huston stated that the Board went into this to be a part of the commercial market and to buy a program off of the shelf, but that does not mean that they cannot ask that this be considered and negotiate with the health plans to make it consistent.
Ms. Voss stated that even though attempts were made to phrase the questions in order to get responses that could be compared, many times plans are willing to do trade-offs on specific cases or when they are contacted. This makes it hard to compare responses. Dr. Alexander stated that one difference between this and the regular market is that in many counties there is no other choice of plans. Dr. Alexander said that gives the Committee a different level of responsibility; a child with PKU in one county has their formula covered but a child in a different county may not.
Ms. Smith stated that as requested by the Clinical Advisory Committee, a letter had been sent to the health plans indicating that, at a minimum, the health plans provide the same benefits that the actuary used in development of the rates. Ms. Smith said that if the Board wants a commercial product where the health plans design the packages within certain parameters, that is what they have today. The legislation states that certain things must be provided such as inpatient, hospital, et cetera, but the legislation does not state what is an acceptable level or minimum level. Ms. Smith stated that if the Board wishes to specify levels of benefits, they may want to take that before the Legislature.
Mr. Huston asked if there had been responses to the letter. Ms. Smith stated that Iowa Health Solutions has responded by agreeing to the current contract terms. The requirements were laid out in the current contract. Ms. Smith said that they are still clarifying several issues with Iowa Health Solutions, but the letter indicates what the expectation is in the contract.
Frann Otte from Wellmark told the Board that the letter was received with the contract for renewal and that is how Wellmark is approaching it, as a part of contract negotiations. Ms. Smith verified that John Deere's contract is not up for renewal at this time, but will receive the letter of expectations when the contract is up for renewal.
Mr. Huston asked Board members how they wanted to approach the inconsistencies addressed by the Clinical Advisory Committee. Mr. Huston stated the Board's philosophy in the past was to accept a plan available on the open market and not specify further, other than what the Board is trying to get done with the letter. Another approach would be to say the Board wants the commercial contract modified in keeping with the recommendations from the Clinical Advisory Committee. Mr. Huston said that asking to have the plans include the additional guidelines as part of the regular contract would be a change of direction for the Board.
Discussion followed. Ms. Weaver asked for clarification on the actuarial package. Ms. Voss stated that, for example, if a plan has to provide mental health/substance abuse benefits, it is not specifically stated that it has to be so many days inpatient and so many days outpatient, the plans make that determination. If the plans are told they have to have some kind of case management, they are not told specifically what the case management has to be, they are allowed to do that based on people within their own plan and how they design it. Ms. Voss said that to go back and say that the Board has determined that mental health has to be 30/60 or 40/50, for example, would make it necessary to actuarially determine what that cost would be and determine if it would be an increased cost.
Ms. Weaver stated that she feels the Board needs to assure that children will receive minimum benefits that are consistent statewide. Senator Hammond agreed that there should be some minimum level statewide and those levels defined. Senator Hammond also agreed with Dr. Alexander that it is inconsistent to have a child with PKU covered in one county and not another county. Ms. Weaver asked how many counties did not have a choice among plans. Ms. Smith stated that 33 counties have at least 2 health plans and 5 counties have 3.
Mr. Huston summarized the discussion. During legislative debate there were some who wanted to simply expand the Medicaid program and under that concept coverage would be the same throughout the state, no variation. Iowa legislators chose not to do that, but chose to put it into the private market. Now the Board is discovering through its Clinical Advisory Committee that there are variances in the plans. The plans are all providing care coordination, case management, mental health and substance abuse, and AXIS 1 diagnosis; but they are doing it differently. The Clinical Advisory Committee is recommending negotiating with the three providers so that they are the same in these areas. The plans are saying this is a new approach and they have to look at the contract, and what is charged for the contract.
Ms. Smith clarified that when the statement is made that the plans are different, that is a true statement. However, all plans have been certified as meeting the benchmark or benchmark equivalent and have been certified by an actuary as required under federal law. Dr. Alexander stated that the plans certainly meet the letter of the law, but personally feels the goal is not to just provide insurance but to improve health to the maximum.
Susan Voss made a motion to approve the contracts as submitted with a recommendation that an amendment resolving the seven Clinical Advisory Committee recommendations be offered to the carriers by the end of this year. Motion was seconded by Susie Poulton. Roll call vote was taken: Eldon Huston, aye; Susan Voss, aye; Mary Weaver, nay; Diane Briest, aye; Barry Cleaveland, aye; Susie Poulton, aye; Ted Stillwell, absent. Motion carried.
HEALTH PLAN CAPITATION RATES FOR FY 01:
Ms. Smith stated that when the contracts were sent to the health plans they were informed that the Department of Human Services was going to recommend a rate increase for the upcoming contract year, but it would be up to the Board to determine the amount. Iowa Health Solutions has accepted the contract with the understanding that there would be some type of a rate increase. Ms. Smith furnished the Board with a handout showing the budgetary impact of increases from 1 to 12 percent. The Department is recommending a 7 percent increase.
Ms. Smith said that when the capitation rates were first figured for this program the managed care rates were around $77.00. When the actuary looked at the rates again it was recommended that the managed care rates be increased to $84.97 (a 10 percent increase). This was done in July of 1999, six months after the contracts were originally agreed to. At that time, a higher capitation rate was implemented for infants, up to $407.00 (a 500 percent increase), and a $5,000.00 lump sum payment was added if the health plan would have to pay for the delivery of a baby. Ms. Smith stated that while a 7 percent increase is modest compared to what is happening in the private market, given the fact that there have already been increases within this contracting period and given the absence of encounter data, a 7 percent increase can be supported. This would make the per member per month for managed care $90.92 (up from $84.97) and for indemnity $118.37 (up from $110.63). This translates to an additional $287,000 in state dollars. Ms. Smith said that because enrollments are lower than expected, this increase can be absorbed into the current budget.
Barry Cleaveland made a motion to approve the 7 percent increase as recommended by the Department. The motion was seconded by Susan Voss. Unanimous approval was made by Eldon Huston, Mary Weaver, Susan Voss, Susie Poulton, Diane Briest, and Barry Cleaveland.
IFMC Standards for Establishing Adequate Provider Network:
The HAWK-I Board requested that the health plans be asked how they are currently measuring access. Shellie Goldman reported that she had sent the plans a list of questions and had received responses from each of them. Ms. Goldman summarized the responses to the Board's questions as follows. Three out of the four health plans do utilize geo mapping or geo access technology when determining whether or not there is an adequate provider network. Iowa Health Solutions was the only one that did not utilize that technology. The Iowa Foundation for Medical Care considers adequate access for dental to be 30 minutes/30 miles and that would be the same for the industry standard for physicians, family practice, general practice, internal medicine, and pediatrics. Certain specialized services can be as far as 50 to 60 miles depending on what specialist or subspecialist is needed. Most of the plans utilize a 30 minute/30 mile rule when measuring access. Wellmark's responses for Unity Choice were broken out more specifically. They use primary care practitioners to within 20 miles; co-care managers (obstetricians and gynecologists) one within 45 miles; specialty services, one in each specialty within 45 miles; other specialty services not critical when opening a service area, one within 45 miles; and a hospital, one within 30 miles. Wellmark indicated they do not have access standards for a dental network, however, a recent geo report for a large rural statewide group showed that 84 percent of the people had access to one dentist to within 10 miles of their home and 92 percent had access within 12 miles. Wellmark currently contracts with 75 percent of the dentists, which is equal to over 1,100 dentists in their network. Ms. Goldman stated that since Iowa is such a rural state it is difficult to say how far someone would have to travel if they needed a pediatric subspecialist for extensive work, such as bottle mouth. Someone from Sioux City may have to go as far as Des Moines.
Mr. Huston said that most of the Board's questions have been whether Iowa Health Solutions has an adequate number of providers in their areas and asked Ms. Goldman if she had an evaluation relating to that question. Ms. Goldman said that after she received Iowa Health Solution's response she sent them an additional question regarding adequate access in a county. If a county does not list any dentists or have enough, how does Iowa Health Solutions determine whether or not an enrollee knows they can go to any noncontract personnel within the state. Ms. Goldman stated she had not received a response to that question at this time.
Ms. Goldman reported that Iowa Health Solutions does not have geo mapping and state they have one primary care physician per 1,000 members. Ms. Goldman stated she does not know how that data was arrived at because physicians contract with several insurance groups. Ms. Goldman will follow up with Iowa Health Solutions.
CONTRACTS FOR CONSIDERATION:
University of Iowa Public Policy:
Ms. Ruggle stated that due to a delay, this contract will be brought to the Board next month.
Outreach Coordinator Deb Van Den Berghe informed the Board that a total of 450 participants (including speakers) attended the "Still Searching for Austin" outreach conference held May 17th. Participants represented 5 states, at least 66 Iowa counties and included participants from the Departments of Human Services and Public Health, schools, and cap agencies. Conference evaluations came back with an overall ranking between the 4 and 5 range, based on a scale of 1 to 6 with 6 being the best ranking. Registrations ($6,490) combined with sponsor contributions generated total income of $28,040.00. Expenses totaled $27,289.01. The balance will be used for miscellaneous expenses such as copies and postage for follow-up packets, CEU mailings, thank you notes, and additional videos.
Although it is too early to determine whether applications increased as a result of the conference, Ms. Van Den Berghe stated that she has been doing post-conference county visits and has received favorable responses. Ms. Van Den Berghe described the new reporting structure that has been developed for the local outreach coordinators. The new structure will allow counties to comply with all the reporting requirements listed in their outreach contracts and will provide measurable statistics to utilize in calculating successes around the state. The report defines a target audience, an action, a benefit and barriers column, and stresses evaluation and follow-up.
Ms. Smith told the Board that the new brochure should soon be available and 300,000 are to be delivered as soon as they are printed so staff can distribute across the state.
Bill Brand of the Department of Human Rights presented the Board with handout describing the role of community action agencies in Iowa and the draft copy of the proposed plan for the $100,000 appropriation for the HAWK-I Outreach Pilot Project
Mr. Brand stated the pilot project will involve three to four community action agencies, each receiving $30,000 to $40,000. The Division of Community Action Agencies will match some of those dollars, up to approximately $20,000, to help beef up the effort. Mr. Brand stated that the entire $100,000 appropriation and the additional dollars the agency puts in will go out to the communities; Human Rights will not retain any administrative dollars. The intent is that the pilot areas will include urban and rural areas, and at least one county with a high concentration of non-English speaking population. Agencies will be selected based on a competitive application that is focused around: capacity to increase HAWK-I applications and enrollment, capacity to utilize and develop innovative community partnerships to achieve enrollments, and capacity to effectively measure and report results. Agencies participating in the pilot will meet on a regular basis to share information and act as a support network. The pilot agencies will also coordinate with the DHS community outreach efforts, Covering Kids activities, and other related outreach efforts. Mr. Brand will be working with Ms. Van Den Berghe on training and a reporting mechanism to maintain consistency. Coordination will be designed to increase learning, minimize duplication, and maximize HAWK-I enrollment. A final report which will discuss the impact of the project, what the results were, and what can be learned from the project, will be made to the HAWK-I Board and to the Iowa Legislature.
Ms. Smith stated that there are already community action agencies which are the primary contractors for their share of the $300,000 in outreach dollars. Ms. Smith asked Mr. Brand if those agencies are eligible to submit a plan and receive the additional money, and if so, how will they ensure there is not a duplication of efforts? Mr. Brand said that those agencies will be eligible and he believes the agencies who are the most active will be the ones most interested in applying because they will view it as an opportunity to do something significant, such as creating a new position to be devoted to outreach. A selection committee will review the applications and make recommendations. Mr. Brand stated that he has asked Ms. Van Den Berghe to be on the selection committee and will have a representative of the community action association, and an employee from his division on the committee as well. Mr. Brand said he would like to get the application document out soon and ask that applications be submitted by mid-July so the money can be distributed in August.
Ms. Poulton asked if consideration will be made for counties who aren't doing as well, who have lower enrollment. Mr. Brand stated that has not been factored in. Mr. Brand said he would like to get the strongest projects with agencies who can demonstrate they will be able to achieve results. Senator Veenstra asked if rather than 3 to 4 pilots at $30,000 to $40,000 each if it wouldn't be better to have 6 or 8 pilots each getting $20,000. Mr. Brand stated that the counties where community action is the lead tend to be smaller populated counties and received only $1,000 to $2,000 in outreach funding.
It was felt that the larger dollar amount could provide a more significant boost to an agency's outreach efforts.
Motion to approve the plan for the HAWK-I Outreach Pilot Project was made by Barry Cleaveland. The motion was seconded by Mary Weaver. Unanimous approval was made by Eldon Huston, Mary Weaver, Susan Voss, Susie Poulton, Diane Briest, and Barry Cleaveland.
ELIMINATION OF MONTHLY REPORTING FOR MEDICAID:
Mike Baldwin of the Department of Human Services informed the Board that effective October 1, 2000, monthly reporting and retrospective budgeting will be eliminated for all Family Medical Assistance Program (FMAP) related Medicaid. FMAP-related Medicaid are coverage groups for families and children.
The change from retrospective budgeting to the anticipated income method is being made because the monthly reporting process has been recognized nationwide as one of the largest barriers to keeping people on Medicaid once they get there. Mr. Baldwin said the committee that worked on this project cited a monthly reporting case where an 18-month study showed the Department canceled the case 11 times in those 18 months. All but one of those times was due to monthly reporting. Mr. Baldwin said he believed in all the cases the client was able to comply and get reinstated, but DHS still had to send out the cancellation notice, and then turn around when they complied and notify them of reinstatement, and so on.
Ms. Smith clarified that elimination of monthly reporting is different than continuous eligibility. The difference is that on continuous eligibility kids are set up for a year and they are eligible no matter what. By eliminating monthly reporting the case will be reviewed once a year. Changes must be reported and DHS acts on those changes within the 12 months, so eligibility is not guaranteed like continuous eligibility. Ms. Smith said that a recently developed report is designed to show how many new kids come onto Medicaid a month and how many come off. The first draft of the report showed about 6,000 new kids came on and almost as many went off in the same month so the next gain statewide was only 148. Ms. Smith said that by using the anticipated income method and projecting income like is done with HAWK-I, the programs will be much closer in how income is calculated than in the past.
Mr. Baldwin stated that the monthly reporting is being eliminated only for Medicaid. People who receive Medicaid and food stamps or Medicaid and FIP, or all three will have to monthly report for those programs. If they do not, they will get cancelled for those programs, but their Medicaid will not get cancelled because it is no longer a condition of eligibility for the program.
HCFA'S FINAL REPORT ON SCHIP - IOWA REVIEW:
Shellie Goldman reviewed HCFA’s report on Iowa’s SCHIP program. In September of 1999, the Health Care Financing Administration (HCFA) conducted a review of Iowa's SCHIP program. The review focused primarily on whether or not Iowa has the appropriate policies and procedures in place to administer SCHIP efficiently. Information was collected through June of 1999 -- Medicaid expansion had been in effect for one year, the HAWK-I program had been in effect for less than six months. Ms. Goldman outlined the issues identified by the report and the action steps being taken in response to those issues.
Highlights of the report included:
In response to the issues for HAWK-I program integrity, the Department has a formalized check list in place to make sure all the documents that are required on a quarterly basis do get turned in. There was a lot of concern regarding fraud and abuse and the health plans are required to submit not only their quality plan, but also their fraud and abuse plan by April 1st of every year for the Department's review. The Department is working with the Department of Inspections and Appeals to be able to utilize their 1-800 fraud abuse number. That number would be available to beneficiaries, providers, or who ever might be concerned that some kind of fraud or abuse may be occurring within the program. Additionally, DHS will continue to work closely with the Division of Insurance in the event they receive any complaints about the HAWK-I program.
There was no new business to present before the Board.
The next HAWK-I Board meeting is scheduled for Monday, July 17, 2000, at 12:30 in the Oak Room at the Des Moines Botanical Center.
The meeting was adjourned at 4:30 p.m.