HEALTHY AND WELL KIDS IN IOWA (HAWK-I)
September 18, 2000
BOARD MEMBERS: LEGISLATIVE BOARD MEMBERS:
Eldon Huston, Chair Senator Johnie Hammond
Terri Vaughan, Vice-Chair Senator Kenneth Veenstra (absent)
Stephen Gleason, D.O. (absent) Representative Brad Hansen
Mary Weaver (for Stephen Gleason) Representative Robert Osterhaus
Ted Stilwill (absent)
Diane Briest (absent)
DEPARTMENT OF HUMAN SERVICES: ATTORNEY GENERAL'S OFFICE:
Anita Smith Marne Woods
Deb Van Den Berghe
Alice Benge HAWK-I Outreach Worker
Larry Carl Iowa Chiropractic Society
Carla Beneke Iowa Department of Public Health – Covering Kids
Lucia Dhooge Child Health Specialty Clinic
Mary O’Brien Visiting Nurse Services
Jim Donoghue Broadlawns Hospital
Deb Anderson Legislative Fiscal Bureau
Lana Ross IA UMC
Pat Hildebrand Clinical Advisory Committee
Leila Carlson National Association of Social Workers
Jeanie Kerber Mercy – House of Mercy
Bill Brand Iowa Dept. Human Rights - Community Action Agencies
Sonni Vierling Iowa Department of Public Health – Covering Kids
Ed Conlow House Democratic Staff
Jennifer Dreibelbis Iowa Community Action Association
Marie Glancy John Deere Health
Cindy Groene John Deere Health
Wendy DeWitt Iowa Health Solutions
Frann Otte Wellmark
Dr. David Alexander Blank Children's Hospital
WELCOME & ANNOUNCEMENTS:
The Healthy and Well Kids in Iowa (HAWK-I) Board met on Monday, September 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 12:35 p.m. A quorum was not present.
Mr. Huston announced that Dr. Edward Schor would be the new Board designee representing the Iowa Department of Public Health. However, due to another commitment was unable to attend today’s Board meeting.
Anita Smith discussed various items of correspondence. The first item was an August 21, 2000 letter from Cynthia Groene of John Deere Health responding to Ms. Smith’s inquiry concerning the treatment of chiropractic services under the John Deere Health plan. Ms. Groene’s letter clarifies that John Deere does cover chiropractic services when there is a physician’s referral. Ms. Smith stated that her office confirmed with the Iowa Attorney General’s Office that requiring a referral is allowed under the contract with the health plans. Ms. Smith said she had spoken to Ms. Groene who indicated that they are still discussing the issue and trying to schedule a meeting with Larry Carl, Iowa Chiropractic Society, and a John Deere vice-president to further discuss the issue.
The next item of correspondence was an August 30, 2000, letter from Wellmark Health Plan of Iowa, Inc. to Ms. Smith indicating that two separate physicians specialty groups intend to drop their Wellmark contracts as of December 31st. The Iowa Clinic, P.C. (Des Moines) will continue to participate in the Classic Blue program but not in Wellmark’s managed care products. Physician’s Clinic of Iowa, Inc. (Cedar Rapids) is dropping from the managed care plan and it is not known if they will continue to participate in the indemnity plan. Wellmark believes there will be adequate coverage in their network and Ms. Smith said minimal impact is anticipated on the HAWK-I program, but the situation will be monitored.
Mr. Huston stated that often times when groups indicate they no longer will participate in a program, discussions continue and the groups reconsider. Mr. Huston suggested that the Board contact Wellmark and encourage them to continue discussions with these two specialty groups.
Also included in the correspondence were a variety of articles from various publications. Ms. Smith summarized those.
The February, 2000 issue of "The Medicaid Letter" included several articles on the uninsured and CHIP. These articles addressed issues in Washington, D.C., Ohio, Texas, and Wisconsin. Ms. Smith said she most particularly wanted to draw the Board’s attention to the article concerning Wisconsin because the Board had previously discussed the possibility of asking for a waiver to do family coverage in HAWK-I. In February, Wisconsin officials were reporting that 34 percent enrolled in their BadgerCare program were children and 87 percent were from families below 150 percent of the federal poverty level. The article discussed that there was a lot of pent-up demand on the part of the parents in the program and the HMO’s were asking for a premium increase. An article from the August 28, 2000, "Chicago Tribune" indicates the Wisconsin state health care system is going broke. Wisconsin did approve an increase for their health care plan, but out of the total enrollment, 68 percent of the enrollees are parents and only 32 percent are children. There has been a lot of criticism that this program was designed to insure under-privileged children and it serves too many adults who are more expensive.
The May, 2000 "State Coverage Initiatives Issue Brief" discussed family coverage by covering parents through Medicaid Section 1931. Without a waiver, Iowa can cover parents of children participating in Medicaid. This would be regular Medicaid matching rates, not the enhanced rate. However, covering parents of HAWK-I eligible children would have to be funded out of Title XXI. This is a way that some states are manipulating funds to spread them further.
Mary Weaver asked what it would cost Iowa if this option were considered. Ms. Smith stated that before an estimate could be made a decision would have to be made on a benefit package, which would be priced different for adults. The services offered would need to be determined, referred to an actuary to arrive at a premium, and enrollment estimates made.
Representative Osterhaus requested a fiscal note so that cost estimates could be determined if Iowa were to do this for Medicaid and for HAWK-I. The Board directed that the state employees benefit package be used to arrive at these estimates.
Terri Vaughan arrived at the meeting at this time and a quorum was present.
Ms. Smith referred the Board to the August 14th, "State Health Notes" article on employer-based coverage. The article discusses while this concept is easier for families because they can go to the same provider networks, it is a significant burden on states to administer. The proposed regulations are requiring a 60 percent employer contribution before the state could pay a premium. Wisconsin did a survey and out of 16,347 employers only 186 contributed enough to meet the guidelines. To date, Wisconsin has approved only 5 families under their employer buy-in program.
Ms. Smith shared information on two new bills that have been introduced in Congress. Senators Grassley and Kennedy introduced the "Family Opportunity Act". If passed, this Act would allow parents to buy into Medicaid for children with disabilities as defined by SSI. Ms. Smith said she felt this would have little impact on HAWK-I because most children with disabilities were either already in Medicaid or insured. The "Family Care Act of 2000", if passed, would be an option to cover parents of Medicaid and SCHIP eligible kids and Iowa would no longer need a waiver. This would also allow coverage of pregnant women, coverage of legal immigrants, and children ages 19 and 20.
In follow up to the letter to Tribal Counsels from HCFA shared at last month’s Board meeting, Congress did pass legislation to allow certain Indian and Alaskan native tribes to provide health services to their members that are currently provided by the federal government. ("Tribal Self-Governance Amendments of 2000"). Ms. Smith said the impact on Iowa is unknown at this time, but may be hearing more about this in the future.
The September 2000, "State Health Watch" features an article on the states’ search for ways to keep children in CHIP programs and highlights a study done in Alabama. This study showed the two main reasons for CHIP ineligibility at the time of review were that families were either over the required income limit or they were below the income and went to Medicaid. Other reasons included nonpayment of premiums, requested cancellation, obtained other insurance, over age limit, or didn’t respond.
The Board was provided with the New York Times article Bill Brand referred to at the August Board meeting, "Short of People, Iowa Seeks to be Ellis Island of Midwest". Ms. Smith stated that the uninsured numbers continue to go up and a significant number is attributed to newly arrived immigrants or immigrants working in jobs that don’t offer insurance. This brings issues such as translation services to the forefront.
The latest "HAWK-I News" (Issue #3) features an article which addresses approval for HAWK-I vs. enrollment in HAWK-I. Ms. Smith said there seems to be a lot of misunderstanding so the article outlines the steps. MAXIMUS is contractually required to make a decision on whether or not a child is eligible within 10 days of receiving an application. The process doesn’t stop there. The family has to select a health plan and pay a premium and, in some cases, select a primary care physician. Also included in the newsletter are the instructions for accessing the monthly reports on-line.
ROLL CALL AND INTRODUCTIONS:
Mr. Huston announced that a quorum was now present. Anita Smith took the roll call and 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 AUGUST 28, 2000, MEETING MINUTES
Terri Vaughan asked that the minutes be clarified on page 11, fourth paragraph. The last sentence of the paragraph should be changed to read "Ms. Voss stated she could include the necessary language in the Insurance Division’s bill this year to resolve this issue if that was what the Board wished to do. Ms. Vaughan stated that HAWK-I coverage is currently creditable coverage for the Comprehensive Health Association. For it to be creditable coverage for other private health insurance plans there would be an assessment on the premiums and the Board would need to decide if they were going to incur that cost.
Ms. Vaughan explained the issue for the Board. Federal law (HIPAA) requires that policies be creditable coverage and the mechanism for that is the Comprehensive Health Association. Pre-existing condition exclusions do not have to be re-satisfied when going into the Comprehensive Health Association. Anyone with insurance coverage, including people who are in self-insured plans, can go into the Comprehensive Health Association and get credit for the previous coverage. In addition, state law says if you have private, commercial health insurance coverage, that qualifies to go into other commercial health insurance coverage without having to satisfy pre-existing conditions and you can go to a basic or standard plan at some fixed rates. In order to fund the costs, the entire industry is assessed by the State to cover those losses based on the proportion of the premiums. So if HAWK-I is considered a part of this, HAWK-I would be part of the pool of the premiums that are assessed and it would, therefore, affect the rates, assuming the carriers would charge. Ms. Vaughan said the losses are climbing in this pool, what started out a quarter of one percent or half of one percent is now at 1 percent and projections show that it could go to 2, 3, or 4 percent down the road. Currently HAWK-I is treated the same as Medicaid.
Ms. Smith said the question came up whether or not HAWK-I was creditable coverage under HIPAA and she was not aware there were two separate issues; HIPAA law and the state’s separate requirement. Ms. Smith said HAWK-I is creditable coverage for HIPAA purposes.
Ms. Vaughan said that when someone goes into the Comprehensive Health Association there is a surcharge, approximately 15 to 25 percent above standard market rates. After one year in the Comprehensive Health Association, the policy holder is eligible to go into the standard market at standard rates, so there is essentially a one year surcharge that individuals would be subject to, which they would not be subject to if these policies qualified under Iowa’s individual health insurance reform law.
If a child is on HAWK-I and a parent then has coverage available through the employer, they can move from HAWK-I to the employer coverage without a pre-existing condition issue because it is considered creditable coverage under HIPAA. However, if the parent is self-employed and buys coverage, that is where it becomes the individual market and pre-existing conditions could be imposed. The difference is the type of insurance they go into after leaving HAWK-I.
Another potential problem area would be a child covered by HAWK-I, the parents don’t have insurance, the child has a medical condition and is now going to buy their own insurance upon reaching age 19. At that point, they may not be able to get it in the standard market for one year, they would go to the Comprehensive Health Association, get one-year coverage, and after that period would be portable into the individual market.
If the HAWK-I Board wants to ensure that any child leaving HAWK-I does not have the pre-existing exclusion if they go into the individual market, HAWK-I would have to pay the additional tax or surcharge on the premium in order for that to occur. Otherwise, when a child leaves HAWK-I, they may or may not be subject to pre-existing condition exclusions.
Ms. Weaver asked if the cost is already included in the coverage that is being paid for. Ms. Vaughan said that Susan Voss surveyed the companies and they are treating it essentially the same as Medicaid, which means it is not included in the premiums.
Senator Hammond asked about doing a cost benefit. Senator Hammond suggested that rather than paying approximately a dollar a month for this benefit, that dollar per month could be put into a pool for HAWK-I children who would not be covered due to pre-existing conditions so they could be covered by the state for a year.
Mr. Huston said that the issue is complicated and asked the DHS staff to look at the cost implications and make a recommendation to the Board one way or another.
Mr. Huston said that the motion was still before the Board to approve the August 28th minutes with that one clarification. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
Ms. Smith informed the Board that the CHIP Budget’s Final Report for State Fiscal Year 2000 showed expenditures of just over $5 million, which was under the $5.9 million projected. Expenditures were $150,000 less than projected for the Medicaid expansion, about $500,00 less than projected for HAWK-I premiums, about $25,000 less than projected for fiscal agent costs of processing Medicaid claims, and outreach was $6,000 less than projected. Expenditures were over projections for HAWK-I administration by about $60,000. This was due to starting the year with a deficit with the carryover from the start-up year, as well as the additional costs associated with re-contracting for the third party administrator. Interest earned on the HAWK-I trust fund was $222,227. The amount in the HAWK-I Trust Fund that was carried over was $7,780,226.
The latest estimates from DHS budget staff indicate a probable reversion of about $6.1 million from the federal fiscal year 98 CHIP allotment. Ms. Smith shared a background document she prepared as a result of a conference call between the National Governor’s Association and the states on September 5th. The states and the NGA are hoping for last minute legislation to allow states to keep all or a portion of the money that is currently scheduled to revert to the reallocation pool. A total of 38 states stand to revert money; with Texas and California in the $500 million range. Three states need close to $100 million to meet their current needs (North Carolina, Indiana, and New York).
Several proposals were made during the conference call:
Ms. Smith stated she was contacted by Iowa’s Washington D.C. office and was asked to call Senator Grassley’s office. The next day there was a meeting scheduled between representatives from Iowa, Texas, California, Rhode Island, and Florida trying to gain support for the "Chafee Bill", which is the bill that was introduced to allow states an additional year to spend the money.
Mr. Huston stated he would call Senator Grassley’s office on behalf of the Board to encourage passing legislation allowing Iowa to keep these funds. Ms. Smith indicated a letter was being drafted for Governor Vilsack’s signature encouraging support for the "Chafee Bill".
Enrollment & Statistics:
Mr. Huston asked if the monthly Medicaid expansion number from the graph could be added to the summary page that comes from MAXIMUS.
Ms. Smith told the Board that for Medicaid there was a significant increase, approximately 500 kids were added in August. Due to retroactive enrollment the August number will go up even further. There was a 4 percent increase in HAWK-I enrollment over July. Even though 594 kids were added to HAWK-I in August, 354 were disenrolled for a net gain of 240. Ms. Smith said the number of disenrollments is not anticipated to be that high in the future. The high number of disenrollments for August was due to the fact that MAXIMUS was not disenrolling anyone until after their quality assurance review to make sure that no one was disenrolled that shouldn’t be.
Senator Hammond noted that the majority of disenrollments, 287, were listed under "other" for reason of disenrollment. Ms. Smith said that was part of the data conversion. If MAXIMUS could not attribute a specific reason from the data transfer it went into the "other" category. This category will disappear from the reports once transition and conversion are completed.
The HAWK-I Call Center Activity Report shows that a total of 12,328 calls have come into the call center since MAXIMUS took over as third party administrator. The report also shows a significant increase in the number of calls during the first week of August. Ms. Smith said this is most likely attributed to increased outreach activities at school registration.
The HAWK-I Application Count by County shows that approximately 372 applications are received a week. This is significantly higher than the number being received a year ago at this time.
The HAWK-I Application and Referral Report by County shows that about 43.7 percent of all applications are being referred to Medicaid. However, in 44 counties over 50 percent of the applications are being referred to Medicaid and some counties over 80 percent. Ms. Smith said staff is working with outreach workers to ensure the applications go to the right place, and are encouraging people to send the application to the program they think they might qualify for rather than just to HAWK-I. In response to an inquiry about the number of applications that get referred to Medicaid and the percentage of those actually being eligible for Medicaid, Ms. Smith said that for the past 6 months it averages about 25 percent. Only about a fourth of the people who are referred to Medicaid become eligible and the number one reason was they do not follow through with the process for whatever reason.
The denial reports by county shows a change in the top five reasons for denial. The number one reason for denial was because they were receiving Medicaid; number two is they refused the Medicaid referral; number three was over income, number 4 they had other health insurance; and number 5 they weren’t citizens or qualified aliens. In August, 32 were denied because they were not citizens or qualified aliens --10 were from Woodbury County.
Mr. Huston noted that the Application Pending Report by County shows 1,266 pending due to Title XIX. Ms. Smith said she asked for statistics and the average processing time from the time a HAWK-I application is received until a decision is made on Medicaid is 25 days -- 15 days from the date the application is actually referred to Medicaid. A total of 589 applications received in August went to Medicaid and 309 from July so the referral rate is still high.
HAWK-I Family Size by Poverty Level Year to Date shows that 59 percent of families are under 150 percent of poverty, so they are not being assessed a premium.
The Board was given a copy of the legislative package reflecting the change which was approved by the Board at their August meeting.
SWAT Team Update:
Ms. Smith informed the Board at an earlier meeting that a committee has been developed representing 7 states (Iowa, Utah, Georgia, California, Alabama, New Jersey, and Arizona) to look at enrollment, retention, and disenrollment within CHIP programs. The committee is looking at why families do or do not enroll, why families do or do not re-enroll, and why families leave CHIP before their enrollment period ends. The National Academy of State Health Policy (NASHP) originally said they would fund the project and wanted to hire an independent consultant to come into these states and do focus groups or telephone surveys. However, the cost is going to be prohibitive so they are now looking at states to fund this.
Report to the Legislature:
Ms. Smith said that Shellie Goldman will be preparing the annual report to the Legislature and a draft will be presented at the October Board meeting.
CLINICAL ADVISORY COMMITTEE LEGISLATIVE RECOMMENDATIONS:
Dr. David Alexander, Chair of the Clinical Advisory Committee, brought to the Board the Clinical Advisory Committee’s recommendations for changes to the current benefits of the HAWK-I program. Dr. Alexander said it was the Committee’s understanding that to change the benefit plan, the Board is now required to go through the legislative process. The Committee’s legislative recommendations cover six areas: Care coordination; case management; dental; mental health and substance abuse; nutrition services; and physical and occupational therapy services. Dr. Alexander said that the fundamental change the Board will see from the Committee’s past recommendation is the first sentence – "In order to ensure that coverage provided under HAWK-I addresses the unique health care needs of children, the following benefits should be added to the list of current benefits." Dr. Alexander said this is a fundamental, philosophical change in the way the program’s benefit plan has been constructed. When the program was put together there was a concern that in order to get a plan out there it would be necessary for the insurance companies to pull something off the shelf otherwise it would be too difficult. The Committee has now had several years to have the opportunity to create a plan that just doesn’t give kids insurance, but to give them a health plan that addresses their needs. Dr. Alexander urged the Board to move these recommendations forward.
Ms. Smith stated that she asked Anna Ruggle to send the Clinical Advisory Committee’s recommendations to the actuary and have them priced out. Ms. Ruggle prepared a chart showing each proposal, what currently happens, and the cost estimate for the recommendation.
Ms. Ruggle explained that under item 1, she listed the definition of care coordination provided by Dr. Lobas separately. Dr. Lobas recommends that rather than the health plans providing care coordination, it be carved out and administered elsewhere. Ms. Ruggle stated that a carve out would be subject to the 10 percent administrative cap fee. To arrive at the projections given to the Board, Ms. Ruggle said she used the projection of average of monthly eligibles totaling 17,293. This is the same number used to make budget projections.
Ms. Smith said the cost estimate for care coordination would be $103,758 to $155,367 annually if it were added to the current premium. If it is carved out it would be $342,397. That figures assumes that every family receives one hour of care coordination services based on the current Medicaid reimbursement rate; which is $31.68 per hour per family. Therefore, depending upon how much care coordination is actually received, the $342,397 estimate could go up or down.
Dr. Alexander said his feeling is that the Board should define the benefit and let the plans figure out whether they want to provide it or contract with someone else to do it. Discussion followed.
Dennis Headlee asked if there had been any clarification with HCFA regarding the covered service and regarding the definition. Mr. Headlee said that while not required, he would recommend seeking HCFA’s reaction. There are certain things HCFA may define as eligible as a covered benefit under the HAWK-I plan, there also may be some definitions by which they will provide payment depending on whether or not the definitions of that covered benefit are met.
Mary Weaver made a motion to accept the Clinical Advisory Committee’s recommendation #1 for care coordination under the health plans. Susie Poulton seconded the motion. Unanimous approval was made by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
The second recommendation was providing case management for children with special health care needs. Ms. Poulton asked with the definition provided in the recommendation would the insurance plans be able to come up with the service based on the definition or do they feel they are already doing it? Dr. Alexander said that case management as defined by insurance plans is not what is defined in the Clinical Advisory Committee’s recommendation.
Terri Vaughan moved to accept the Clinical Advisory Committee’s recommendation regarding case management for children with special health care needs. Barry Cleaveland seconded the motion. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
The third recommendation is to increase the yearly maximum of dental benefits to $1,500. It was noted that one of the health plans already uses $1,500 as their maximum. Ms. Smith said an earlier discussion indicated that by increasing from $1,000 to $1,500 there wouldn’t be much affect in additional premiums. However, when the recommendation was reviewed by the actuary the actuary estimated it would result in a cost of $.75 to $1.00 per member per month. Therefore, a total annual cost is projected at $207,516.
Susie Poulton moved to accept the Clinical Advisory Committee’s recommendation number 3 regarding dental benefits. Barry Cleaveland seconded the motion. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
The Clinical Advisory Committee’s fourth recommendation was for comparable mental health and substance abuse benefits across the health plans. Dr. Alexander said the main thing is to get comparable benefits across the plans and to make sure the whole continuum is covered on all the plans. Currently there is a lot of variability among plans.
Mr. Huston said this approach would provide for minimum benefits for these areas. Mr. Huston asked about the number of inpatient and outpatient days. Ms. Ruggle said the actuary said it would be $.25 per member per month to make the plans comparable based on 60 inpatient hospital days and 30 outpatient visits.
Mary Weaver moved to accept the Clinical Advisory Committee’s recommendation number 4 regarding mental health and substance abuse benefits as clarified in discussion. Susie Poulton seconded the motion. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
The fifth recommendation concerns nutritional services and supplements. Ms. Ruggle said she broke the cost estimates down into counseling for nutritional services and then nutritional supplements so the Board could see the different costs. Mr. Huston said the Board needs to make it very clear to the health plans what the actuarial assumptions are. Ms. Smith said that currently the legislation just says these services will be covered. When drafting the amendments she will make sure the language is worded so it will be very clear what is covered.
Representative Hansen entered the meeting at this time.
Susie Poulton moved to accept the Clinical Advisory Committee’s recommendation number 5 regarding nutritional services and supplements. Barry Cleaveland seconded the motion. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
The sixth recommendation is regarding physical and occupational therapy services. Ms. Ruggle said that this is basically a clarification that physical and occupational therapy services would be covered with a physician’s referral and it was included in the original pricing assumptions.
Mary Weaver moved to accept the Clinical Advisory Committee’s recommendation number 6 regarding physical and occupational therapy services. Barry Cleaveland seconded the motion. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
Dr. Alexander said the Committee had hoped to be back to the Board with some functional outcome data, but it now appears that the data will come a little more slowly than they had hoped.
ADMINISTRATIVE RULES FOR NOTICE:
Ms. Smith said these are the amendments to the Board’s administrative rules that were discussed at the last Board meeting. The amendment concerning a child who is participating in another federal means-tested program being deemed eligible for HAWK-I is not included in these amendments. These are being brought for formal approval for notice.
Terri Vaughan moved to approve the proposed amendments and file as Notice of Intended Action. Barry Cleaveland seconded the motion. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
Ms. Smith gave a progress report to the Board concerning the amendment for a child who is participating in another federal means-tested program to be deemed eligible for HAWK-I. Currently she is working with some of these programs to see how income can be verified. A suggestion was made that the HAWK-I application ask the family if the child is participating in any of these programs and if the answer is yes, simply take their word for the income reported on the application. If it appears they would be Medicaid eligible a referral to Medicaid is made, at which point they would have to verify their income. Otherwise, for HAWK-I, they would be enrolled and have some kind of post-eligibility verification. Ms. Smith said that if this concept is agreeable to the Board the rule amendment could be drafted with an effective date of April 1 to coincide when new HAWK-I applications and brochures are printed.
Ms. Poulton expressed concern that families may get confused on what they are eligible for and asked if it was possible to have families sign a consent to contact these other programs to verify their income. Representative Hansen said that was his concern also and feels there needs to be some kind of income verification, even if it is a random check, to ensure against fraud. Ms. Smith said that consent could be a part of the HAWK-I application. Ms. Smith said that Georgia and New Jersey are both very flexible on verifying income. Georgia uses self-declaration, but now their state auditors are saying they’ve been too flexible. Ms. Smith said she would continue working on the verification of income issue and keep the Board apprised of her progress.
Larry Carl, Executive Director of the Iowa Chiropractic Society, addressed the Board. Mr. Carl expressed the Iowa Chiropractic Society’s concern that the John Deere Health program is requiring a medical gatekeeper prior to any access to chiropractic care and appears to the Society to be a significant departure from the legislative intent of the 1998 legislature. Mr. Carl said it was very clear to the Iowa Chiropractic Society that the intention was that there would be a chiropractic benefit included in the HAWK-I program, and they feel that allowing a medical gatekeeper many times results in a phantom chiropractic benefit. Mr. Carl said that medical physicians, although highly skilled and highly trained, are not qualified to determine the appropriateness of chiropractic care and there is a well documented history that the medical profession has a substantial history of bias against chiropractic care.
Mr. Carl said that when Iowa Health Solutions came on board their proposed program had a highly questionable chiropractic benefit. The Society contacted DHS staff and asked them to intervene. Mr. Carl said that DHS staff did contact Iowa Health Solutions and that resulted in an agreement between the chiropractic profession and Iowa Health Solutions that has been highly acceptable to all parties. Mr. Carl stated that he recently spoke with key representatives from Iowa Health Solutions and was assured that they were very pleased with the kind of agreement that was worked out and that feedback from chiropractic physicians that are involved with Iowa Health Solutions are pleased with the arrangements.
Mr. Carl said the Society recently held a conference call with representatives of John Deere Health Care and from the Society’s point of view the representatives did not appear to want to resolve the issue. Mr. Carl said once again that he believes that what John Deere Health Care is offering is a departure from the intent of the legislature and history proves that whenever there are artificial barriers placed in front of the chiropractic profession it results in a phantom benefit. Mr. Carl said he believes that the profession has demonstrated their willingness to cooperate and work through any difficulties relative to the HAWK-I program, and offered the example of Iowa Health Solutions. Mr. Carl asked the Board to direct the DHS HAWK-I staff to aggressively pursue a resolution with John Deere Health Care and the chiropractic profession.
Senator Hammond said she could affirm what Mr. Carl said about the legislative intent on behalf of the Senate. Senator Hammond said the issue was discussed and it was hoped that patients would have choice of physician, but what wasn’t in the language was that there would be direct access in order to assure that. Senator Hammond said the Senate tried initially to avoid the kind of conflicts when one provider group is pitted against another.
Representative Hansen said that the House made a conscience effort not to delineate benefits provided by specific providers. The legislation covered services, not providers. For example, instead of saying chiropractic care, the language says physician services, which by Iowa Code, includes chiropractic services. Representative Hansen asked Mr. Carl if John Deere Health was treating HAWK-I patients differently than they are patients in other John Deere Health programs with respect to patients who need chiropractic care. Mr. Carl said he thinks the have both direct access and gatekeeper type offerings that they make, but since he is speaking specifically of HAWK-I doesn’t know what John Deere does in their other plans.
Mr. Huston asked if it is known if there have been referrals to chiropractors under John Deere HAWK-I. Mr. Carl indicated he didn’t know. Mr. Huston said his question would be whether John Deere’s plans differ in other areas that they cover, for instance, is John Deere at Davenport any different than John Deere at Waterloo, or John Deere in Dubuque. Mr. Huston said he would like DHS staff and representatives of the Board to take a look at this program see what has actually happened, discuss the issue with John Deere and then report back to the Board next month.
Outreach Coordinator Deb Van Den Berghe reported that HAWK-I brochures were included in a recent issue of "Iowa Farmer Today" in conjunction with Farm Safety Week. This is a weekly publication that is mailed to 83,000 subscribers. Ms. Weaver shared her copy with the Board.
Ms. Smith said that the Iowa Bankers have requested several presentations and there will be at least four different presentations to agricultural lenders given in the next several weeks.
Ms. Van Den Berghe said that those targeted audiences are really important. She has seen a need for continued physician education. All of the health plans have tried and are continually doing informational pieces through their newsletters, but outreach needs to make sure the employees who perform billing and appointment scheduling functions for the physicians are informed. Ms. Van Den Berghe said at a recent rotary presentation in Nevada a dentist and optometrist both mentioned that they have turned patients down telling them they don’t cover HAWK-I patients when, in fact, they are both Wellmark providers so they do cover HAWK-I patients. Ms. Van Den Berghe said this is an example of why it really takes one-on-one contact. Physicians are surprised to find out HAWK-I is part of the Wellmark plan.
Ms. Van Den Berghe told the Board that approximately $66,000 will be returned to the HAWK-I Trust Fund from unspent outreach funds from FY 2000 contracts. Some of this funding was never distributed because contracts were never let. $244,000 was distributed and utilized for local outreach activities last fiscal year. Ms. Van Den Berghe said she has been notified that both Linn and Woodbury Counties are losing their full-time coordinators; Linn has someone who is taking that role on but she doesn’t know what will happen in Woodbury County.
Ms. Van Den Berghe said she will be holding a meeting with outreach coordinators the week of September 25th. The meeting will start with an open house at MAXIMUS so the coordinators can tour the facility and be introduced to staff. The meeting will cover communication with clients, reinforcing exceptions to rules, clarifying issues, and sharing ideas.
In follow-up to last month’s 1115 waiver discussion Ms. Smith prepared a handout showing issues that have been discussed by Board members at previous meetings around possible waivers. Ms. Smith was also asked to find out what other states were doing in the way of waivers. Ms. Smith told the Board to keep in mind that a legislative proposal would be necessary because additional state funding would be needed in order to draw down additional federal dollars. There were six different areas the Board had discussed for possible waivers. Three of those, the choice between Medicaid and HAWK-I, coverage of dependents of state employees, and elimination of the 10 percent cap on administration and outreach, are items that HCFA specifically states are not waiverable. The other three waiver discussions were: coverage of underinsured children; coverage of parents of eligible children; and children with special health care needs. Ms. Smith said she wasn’t sure if there will be any flexibility from HCFA for coverage of underinsured.
Ms. Smith said she sent an e-mail to CHIP directors of states with separate CHIP programs or combination programs and asked what they were doing in the way of waivers. Only four states responded and in all four cases they are looking at covering parents of children. New Jersey shared their draft plan which they intend on submitting to HCFA. Ms. Smith outlined New Jersey’s plan for the Board. The coverage of parents would be done under Medicaid expansion under Section 1931. They are developing a state-only program to supplement the federal allotment so that as more kids are enrolled in CHIP they would have the state-only dollars to fall back on for the parents. In other words, they are going to cover the parents until they have to use the money for kids. At that point, coverage of parents would transfer to a state-only program. They are going to include lawfully admitted aliens who do not meet the definition of "qualified aliens". These are newly arrived immigrants that are here lawfully, but currently don’t qualify under federal means-tested programs.
Discussion followed. Representative Hansen asked if HCFA has given any indication they would agree to waivers similar to Wisconsin’s. Ms. Smith said HCFA would if the states have the money. For states with Medicaid expansion, once the Title XXI money is used up, they can revert to the Title XIX money to continue to cover the parents at regular match. But for Title XXI, once that money is gone the program either has to stop or be funded with 100 percent state dollars. Some states are proposing the enhanced match up to the point they’ve spent it all then revert to Medicaid match.
Ms. Poulton said she would be interested in learning more about covering parents and also the children with special health care needs. Ms. Ruggle said that she has talked to Dr. Lobas and it is his preference to wait until next year so a more complete plan for children with special health care needs can be submitted. Ms. Weaver suggested having DHS staff explore and report back to the Board in November or December so the Board can decide what type of recommendation to put together.
Shellie Goldman discussed the draft report "Healthy and Well Kids in Iowa (HAWK-I) Quality Assessment and Improvement Plan" with the Board. HCFA conducted a site review and in their final report, dated May, 2000, stated concern that there was not a quality plan in place for the HAWK-I program. Iowa responded that a plan would be prepared. Ms. Goldman said that the draft report has not been presented to the Quality Committee yet, but wanted the Board to know it is in the process and will be finalized soon.
Ms. Goldman said the draft report reflects goals and objectives outlined in the current state plan. These goals and objectives were incorporated into the draft quality plan, as well as what is currently written in under the health plan contracts regarding confidentiality, adequate access, fraud and abuse, et cetera. Ms. Goldman said that soon they will be able to look at the population a little closer based on the functional health assessment survey to determine if other measurements should be developed. HEDIS measurements will soon be developed and data captured based on the encounter data, which is as close as possible to the new HIPAA guidelines. Ms. Goldman said she and MAXIMUS have been working continuously with the plans, who have been very cooperative. The health plans are currently submitting the data for drug claims, then will proceed with processing provider services claims, dental claims, and so forth.
Ms. Goldman also updated the Board on a new project called Comp Care. Comp Care is sponsored by two federal agencies, HCFA and HRSA. Technical assistance is provided to states who wish to pursue quality related projects. In collaboration with DHS, University Hospitals, the Department of Public Health, and other key stakeholders, the Iowa Comp Care project will focus on establishing standardized quality guidelines for Iowa’s health care delivery systems. The group is headed by Dennis Headlee and Dr. Lobas and will take place over a five-year period of time. Currently there are numerous sets of quality plans within the different agencies. The goal is to have quality guidelines and measurements so the same information is consistently collected and validated utilizing the same value of systems.
Ms. Goldman told the Board that she has received feedback from most of the doctors on the Quality Assessment and Improvement Committee that there is a lot of duplication of effort. Most members of the Quality Committee also serve on the Clinical Advisory Committee and they just do not have the resources, time-wise, to make themselves available for both. Ms. Goldman requested that the two committees be combined into one so the benefits can be tied together along with the quality issues. Ms. Goldman said this will be important as the HEDIS measurements are developed.
Ms. Goldman said this will need to be a collaborative effort and would like the health plans to be active in putting together quality measurements and helping the Committee work through this process. This will not be an additional burden for the health plans because the encounter data has already been agreed to. This is merely documentation for HCFA.
The Quality Assessment and Improvement Committee will be combined with the Clinical Advisory Committee by acclamation of the Board.
PROVIDER NETWORK MONITORING:
Ms. Goldman told the Board that based on the Balanced Budget Act, Iowa is required to describe in the state plan the strategy to be used to assure the quality and appropriateness of care, particularly with respect to providing well baby care, well child care, well adolescent care, and child and adolescent immunizations. Access to covered services, including emergency services and covered post-stabilization services, must be assured and access of services under the state plan are required to be monitored.
Questions were raised at a previous Board meeting that if the plans are currently using provider network monitoring (geo mapping) why does the Board need to implement that as part of the quality assurance program. Ms. Goldman said that there is an obligation based on the state plan to monitor, and the only way to monitor is to be able to receive the provider directories and run them through a process based on standardized access guidelines to ensure the plans are compliant. At a number of meetings the Clinical Advisory Committee has expressed concern whether or not the plans have adequate access, particularly for children to pediatric specialists and dental care.
There are two proposals, one from MAXIMUS and the other from the Iowa Foundation for Medical Care. Ms. Goldman prepared budget specifications and a comparison sheet for each proposal. The Department reviewed both proposals and found that while both proposals provide the ability to evaluate access and availability of medical ancillary services for HAWK-I enrollees, the MAXIMUS proposal provides a more efficient means to obtain the necessary database files needed to evaluate access.
Discussion followed. Ms. Goldman clarified for the Board that as far as HCFA is concerned, even though the health plans have their own guidelines on fraud and abuse, HCFA is very adamant that another mechanism be in place to monitor fraud and abuse. Likewise, it is necessary to monitor the provider directories. Currently Iowa has nothing in place to show HCFA that this monitoring is being done. Ms. Goldman said the Committee’s recommendation is based on the fact this is a child population and in a lot of instances adult specialists don’t serve a pediatric population.
Discussion occurred around other ways to obtain this information such as using outreach workers, Consultec, et cetera.
Senator Hammond exited the meeting at this time.
Barry Cleaveland made a motion to approve the recommendation to amend the contract with MAXIMUS. Susie Poulton seconded the motion. Unanimous approval by Terri Vaughan, Mary Weaver, Susie Poulton, Barry Cleaveland, and Eldon Huston.
Ms. Goldman did an overview of HIPAA for the Board. With the implementation of HIPAA there will be a very large change to the health system. HIPAA creates standardized coding and claims payment systems. Currently, health plans have their own claims payment forms and submission of claims in order to be paid so providers deal with possibly a hundred different formats they have to submit. Under the Balanced Budget Act of 1996 it was decided that it would be more cost effective if there were standardized claim payment submissions with standardized transaction codes, procedure codes and diagnostic codes so every provider will use the same set. By October, 2002, health plans, providers, and clearing houses will need to have in place the first set of HIPAA regulations that was just finalized. Additional regulations will be submitted and finalized based on confidentiality and whether or not a patient chooses to have information released. This will have a large impact on insurance plans. There has also been discussion about establishing standardized clinical guidelines, whereas if you have a primary care physician there would be a standard format and for coordination of care, each physician would have access to that particular person’s record and the coordination of care would work much smoother that way. There will also be national provider identifiers. Currently, different states give different licensing numbers, so with national provider identifiers it will be possible to track interstate to find where a provider practices.
HAWK-I will be affected in several areas. For example, encounter data. The health plans cannot be asked to submit more than the standardized format established by HIPAA guidelines. That is why the encounter data is set up the way it is. Ms. Goldman said HIPAA’s specifications were reviewed and the encounter data elements were subsequently developed. The financial impact is expected to be significant for the health plans.
Mr. Huston told the Board an issue had come up concerning the outreach contracts recently awarded by the Department of Human Rights. When the Iowa Legislature appropriated the $100,000 the legislation said that the plan be submitted to the HAWK-I Board for approval. Bill Brand did present the plan to the Board and the Board approved it at their June 19, 2000, Board meeting. Currently Mr. Brand is in the process of formalizing the contracts with the four agencies who were awarded the contracts and the question has arisen as to whether or not those contracts require approval of the HAWK-I Board.
Marne Woods said that the legislative language says the Board shall approve all contracts, so she believes these could certainly fall into the definition of all contracts.
Ms. Weaver noted that when the Iowa Department of Public Health received a Robert Wood Foundation grant it was in turn subcontracted out to local agencies for SCHIP outreach activities. Ms. Weaver said that neither the contract or subcontracts were brought before the HAWK-I Board. Ms. Woods suggested that when those contracts come up for renewal they should be brought before Board.
Mr. Huston asked Mr. Brand about the status of the outreach contracts. Mr. Brand said the contracts have been issued, signed, and the agencies are commencing with their activities. Mr. Brand said the legislation said the funds appropriated should be utilized pursuant to a plan approved by the HAWK-I Board. Mr. Brand said his agency’s interpretation of the legislation is that he needed to bring a plan to the Board for approval before moving forward and that was done. In the RFP that was issued the final authority identified is the Department of Human Rights and there is an appeal process set forth and appeals are to the Department of Human Rights.
Mr. Huston said he thinks the Board needs to be very careful in the future to be more thorough. Mr. Huston suggested that the Board decide that in the future the HAWK-I Board will review all contracts. This was agreed to by the Board members.
There was no other new business to present before the Board.
The Board’s next meeting is Monday, October 16, 2000, at 12:30 in the Oak Room at the Des Moines Botanical Center.
The meeting was adjourned at 4:10 p.m.