Overview of MCOs in Iowa Rebecca A. Brommel BrownWinick 666 Grand Avenue, Suite 2000 Des Moines, IA 50309-2510 Telephone: 515-242-2452 Facsimile: 515-242-8552 E-mail: brommel@brownwinick.com

Iowa’s Managed Care Organizations AmeriGroup Iowa, Inc. AmeriHealth Caritas Iowa, Inc. UnitedHealthcare Plan of the River Valley, Inc.

What is Managed Care? Health care delivery system Contractual arrangement with Medicaid MCO accepts set per member per month (capitation) payment MCO enters contracts with providers MCO pays the providers for services rendered to members

How is Managed Care Different? Traditional Medicaid is “fee for service” IME – Division of DHS Controlled by IME and its contractors (“best of breed”) Claims and preauthorization decisions made by IME or its contractors

History of MCOs in Iowa 1986 – pilot with one MCO in one county 1990 – pilot became Primary Care Case Management (PCCM) called MediPass in 7 counties 1999 – Behavioral Health provided through managed care March, 2012 – Beneficiaries in 19 counties given option to enroll with single MCO 2012 – Statewide health homes initiative available in 25 counties By 2014 – MediPass expanded to approximately 75 counties Contracts were with Meridian Health Plan and Magellan (Behavioral Health)

History of MCOs in Iowa (cont.) Early 2015 – Governor announced intent to transition all Medicaid to MCO February, 2015 – RFP Released August, 2015 – Winning Bidders Announced December, 2015 – One Winning Bidder Terminated after Litigation April 1, 2016 – MCO Implemented in Iowa

Benefits & Objectives of Managed Care Manage costs to state Better manage utilization of health services Improvement in performance, health care quality and outcomes Similar to insurance plan in private marketplace “Extras” to Members (stop smoking, healthy living, community supports)

MCOs in Other States As of March, 2016, 39 states had MCOs Anywhere from 1 (North Dakota) to 25 (New York)

What Does an MCO Do? Step into the shoes of Medicaid Signs up members Reviews pre-authorizations and claims Handles appeals of claims

Medicaid & MCOs – By the Numbers As of August 30, 2016: 422,183 enrolled in Medicaid 57% children 19% disabled 16% adults 7% elderly

MCO Appeals Same general process as that used by IME Internal appeals with MCO must be exhausted first DHS (not MCO) determines whether appeal is ripe

State Fair Hearings – General Overview In front of Administrative Law Judge Typically via telephone Same process that was employed prior to MCO’s involvement MCO stepped into shoes of DHS Different from grievance procedures

State Fair Hearings – Appeal Summary Submitted within 10 days of the issuance of the Notice of Appeal Prepared by MCO Outlines what information was submitted, history of decisions Filed on AIS system but also mailed to appellant and appellant representatives (providers, attorneys, parent/guardian) identified in the documentation Accompanied by Exhibits for hearing

State Fair Hearings – The Hearing ALJ reviews materials that have been filed/submitted Appeal Summary and Exhibits accepted into evidence if no objections Opening Statements Each side presents evidence MCO typically will have 1 witness Closing Statements

State Fair Hearings – Decision & Further Appeal ALJ issues Proposed Decision Unsuccessful Applicant appeals to Director of Department MCO can also appeal, but request goes to Appeals Advisory Committee, unless directly chosen by Director for his review Appeals due within 10 calendar days of the ALJ’s signature on the Proposed Decision To appeal Final Decision by Director or Committee – Petition for Judicial Review under Iowa Code chapter 17A in District Court

State Fair Hearings – No Shows If no one appears for the Appellant, the appeal is considered abandoned ALJ issues a Notice/Order of Dismissal due to Abandonment Appellant has 10 days to ask (in writing) to reopen the record To reopen record, Appellant must show “good cause” for missing the hearing The request to reopen must be accompanied by at lease one sworn Affidavit “of a person having knowledge of each stated fact” or must be accompanied by business records or acceptable documentation from a disinterested third party that substantiates a claim of good cause

State Fair Hearings – By the Numbers As of October 1, 2016: Submitted within 10 days of the issuance of the Notice of Appeal 193 per month vs. average 300 per month in the 6 months prior to transition These numbers include eligibility decision (which are not made by MCO) and appeals for the small number of individuals who remain on fee-for-service (ie: initial new members who had not yet selected MCO) ** Source: Sam Langholz, Administrator of Administrative Hearings Division of DIA

Future of MCOs in Iowa IME conducting several public comment sessions (as recently as December 7) Legislature’s Health Policy Oversight Committee meets December 13 Continuing Issues: Oversight and reporting MCO’s reports of large losses Provider networks Impact of changes to ACA (rollback of Medicaid expansion programs?)

Website: www.brownwinick.com Toll Free Phone Number: 1-888-282-3515 OFFICE LOCATIONS: 666 Grand Avenue, Suite 2000 Des Moines, Iowa 50309-2510 Telephone: (515) 242-2400 Facsimile: (515) 283-0231 616 Franklin Place Pella, Iowa 50219 Telephone: (641) 628-4513 Facsimile: (641) 628-8494 DISCLAIMER: No oral or written statement made by BrownWinick attorneys should be interpreted by the recipient as suggesting a need to obtain legal counsel from BrownWinick or any other firm, nor as suggesting a need to take legal action. Do not attempt to solve individual problems upon the basis of general information provided by any BrownWinick attorney, as slight changes in fact situations may cause a material change in legal result.