Iowa moves to private Medicaid management Friday amid angst
By BARBARA RODRIGUEZ
DES MOINES, Iowa (AP) - Following several delays, Iowa's $4.2 billion Medicaid program will switch to private management on Friday. Some health advocacy groups have criticized the transition, originally slated to go into effect on Jan. 1 but delayed by federal officials amid concern about readiness.
Democrats continue to argue the system isn't ready, and lawmakers in the split Legislature are still debating what state oversight should be in place under the new system. State officials have said lingering issues over communication and expected services are being addressed.
At least 40 states have privatized some portion of their Medicaid services. But there are only a handful of states that have switched their entire system to private management.
As the new system begins, here are five things to keep in mind:
WHAT'S AT STAKE?
Medicaid provides health care services to about 560,000 poor and disabled Iowa residents, including 40,000 children under a program known as hawk-i. Both state and federal dollars pay for the program, which has been handled by the Iowa Department of Human Services.
Gov. Terry Branstad and DHS officials say the Medicaid program is gradually taking up more of the state budget. They contend a switch to private management, first announced in 2015, will save money and provide better care. Initially, they said it would save $51 million for the first six months of 2016, but the launch has since been delayed and that figure has become uncertain. Critics say they continue to receive complaints from constituents expressing confusion and concern about their Medicaid coverage.
The issue will enter a new chapter Friday as critics and supporters see how services are actually provided.
WHO'S IN CHARGE?
Three private, out-of-state companies - AmeriHealth Caritas, Amerigroup and UnitedHealthcare - won a bid last year to oversee Medicaid. Program recipients have been assigned to one of the companies, also known as managed care organizations, based on factors such as keeping multiple family members with one provider.
Representatives for the companies have testified that they're ready, but several lawmakers have expressed reservations. Those lawmakers, primarily in the Democratic-controlled Senate, have questioned whether there's adequate coverage available around the state and what level of data will be available to review the system.
CAN PATIENTS KEEP THEIR DOCTORS?
It depends. Medicaid is offered through service providers such as doctors and other medical professionals and specialists. A Medicaid recipient should be able to keep his or her doctor if that medical professional has contracted with the same insurance company assigned to them. A doctor without a contract will be considered out-of-network, and it's unclear how many will accept Medicaid under such a system. A doctor is also considered out-of-network if they're contracted but the insurance company differs from the one assigned or picked by the Medicaid recipient.
The expectation is that recipients should find services that are in-network. DHS spokeswoman Amy Lorentzen McCoy says Medicaid patients will be able to switch their assigned insurance company to one that is contracted with their doctor. She also says there's a system in place to ensure patients can keep their current care, from 90 days to one year for some services.
DHS has provided data that show most service providers have signed a contract with at least one of the managed care organizations. The agency says 96 percent had signed with at least one insurance company by Wednesday, about 75 percent with two and more than 68 percent with all three.
Health advocacy groups and lawmakers say they've received anecdotal evidence through letters and phone calls that some Medicaid recipients will need to travel long distances to receive in-network services.
WHERE DO PATIENTS GO TO ISSUE COMPLAINTS?
Medicaid recipients have been instructed to contact their new insurance providers if they have complaints or want to appeal a claim. The system for an independent review of more serious cases may be trickier.
Iowa has an ombudsman's office - an independent arm within the administrative system - that is designed to receive such complaints. A Medicaid-focused ombudsman's office was created last year, but the office has limited staff and their scope is technically aimed at certain patients who are in long-term care facilities and receive other similar services. That covers about 57,000 of the roughly 560,000 patients.
Deanna Clingan-Fischer, the state long-term care ombudsman, said her office has received phone calls from confused Medicaid recipients and her office won't turn away inquiries from any Medicaid patient. She encouraged patients to educate themselves about the new system. "Read the literature, read the material, talk to people ... what are my rights and responsibilities?" she said.
WILL THERE BE MORE STATE OVERSIGHT?
Iowa lawmakers are wrapping up the current legislative session and they have yet to agree on a measure that would provide more state oversight of the Medicaid program under private management. The Democratic-controlled Senate has voted in support of legislation that would require the three insurance companies to provide more information to the state about how the system is working. The Republican-majority House has not taken up the legislation, but leaders say they're working on their own oversight language that could be added to a budget bill. The session is slated to wrap up in mid-April, and it's unclear what may reach Branstad's desk. Senate President Pam Jochum, D-Dubuque, said the Senate is committed to passing oversight. "We have to do something. We cannot just let this system sit and not hold it accountable."