1. Overview of MCOs in Iowa
Rebecca A. Brommel
BrownWinick
666 Grand Avenue, Suite 2000
Des Moines, IA
Telephone:
Facsimile:

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

3. 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

4. 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

5. 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)

6. 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

7. 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)

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

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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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?)

19. Website: www.brownwinick.com Toll Free Phone Number: 1-888-282-3515
OFFICE LOCATIONS:
666 Grand Avenue, Suite 2000
Des Moines, Iowa
Telephone: (515)
Facsimile: (515)
616 Franklin Place
Pella, Iowa 50219
Telephone: (641)
Facsimile: (641)
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