Shared community-based teams are a growing trend among states seeking to build provider capacity, especially for small and rural practices. This brief explores Iowa’s path to piloting shared community-based teams, from conception and planning to launch, and offers a framework for policy action for states and other organizations considering leading similar efforts. Iowa was one of six states selected to participate in NASHP’s 15-month Medicaid-Safety Net Learning Collaborative, supported by a cooperative agreement with the Health Resources and Services Administration (HRSA).
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States around the country are actively working to improve service delivery under the Medicaid benefit for children and adolescents (also known as the Early and Periodic Screening, Diagnostic, and Treatment benefit or EPSDT), Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. The benefit provides tens of millions of children with access to a range of preventive, screening, and treatment services, as well as vision, dental, and hearing services. The benefit is critical to early identification of health conditions, as well as to maintaining and improving the health of low-income children, making it a key priority for states as they strive to improve population health.
This webinar will draw together Medicaid officials from three states for a conversation about how they have worked to improve the Medicaid benefit for children in their states. Speakers from Iowa, the District of Columbia, and Minnesota will discuss strategies for improving access and service delivery for Medicaid-enrolled children. The conversation will have a particular emphasis on efforts in these states to better coordinate care, use public health resources to deliver benefits, collect data on and improve quality, and enhance access and delivery of behavioral health services for children. This webinar is the first in a series on the Medicaid benefit for children and adolescents: future webinars will delve more deeply into oral health, adolescent health, and care coordination.
- Eliot Fishman, Director of the Children and Adults Health Programs Group, Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services
- Glenace Edwall, Director of the Children’s Mental Health Division, Minnesota Department of Human Services
- Colleen Sonosky, Associate Director of the D.C. Department of Health Care Finance
- Jennifer Vermeer, Medicaid Director, Iowa Department of Human Services
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- There were a total of 440,993 beneficiaries enrolled in Iowa Medicaid as of July 2011. Of these, 401,785 were enrolled in managed care.
- Physical health services are delivered through a primary care case management (PCCM) system, known as the Medicaid Patient Access to Services System (MediPASS). Children and adults who qualify for Medicaid because they belong to an income-eligible family (Section 1931) are required to enroll. Of these, 196,450 were enrolled into the PCCM program. A number of categories of beneficiaries are excluded, including children with special health care needs. Those not enrolled in the PCCM program receive their health services through a fee-for-service system.
- Mental health and substance abuse services are delivered to almost all Medicaid beneficiaries through a behavioral health organization (BHO). Both 1931-eligible and SSI children are required to enroll. Only a few groups, such as dual eligibles and presumptive eligibles are excluded. As of July 2011 401,785 Medicaid beneficiaries were enrolled into this BHO.
- Iowa’s Children’s Mental Health Waiver provides home and community-based services to Medicaid-eligible children with serious emotional disturbance (SED). Medicaid-eligible children with an SED diagnosis can choose to enroll in the waiver, at which point a targeted case manager helps to coordinate services for the child and family.
Iowa’s Medicaid program covers medically necessary services offered by participating providers. It has a single medical necessity definition for all services. It does not have distinct definitions for children, oral health services, or behavioral health services. In Iowa, in order to be medically necessary, services must:
|Initiatives to Improve Access
Primary care providers (also known as patient managers) in the primary care case management (PCCM) program are required to provide 24-hour access for their members and must establish a 24-hour access telephone number for scheduling appointments, accessing information, and for use by members when the provider’s office is closed.
When a child or adolescent is due for an EPSDT Care for Kids screening provided through the PCCM program, the Department of Public Health is required to issue a reminder to the family.
Iowa uses specialized software, verification of provider appointment availability and 24-hour access, and a review of referral documentation to monitor access to the PCCM program.
|Reporting & Data Collection||
Iowa uses its fee-for-service claims payment system to keep track of services for mandatory reporting to CMS. The state also analyzes its CMS Form-416 data at a county-by-county level and uses this data to pinpoint where in the state Medicaid-enrolled children face issues in accessing dental and physical health services.
Primary Care Case Management
As outlined in the procedural guide for the primary care case management (PCCM) program, known as the Medicaid Patient Access to Services System (MediPASS), Iowa Medicaid provides participating providers with information on the utilization of enrolled families and children on a quarterly basis. Providers may also receive a Quarterly Member Utilization Exception Report. Quality Assurance/Utilization Reviews are performed by Medicaid on a quarterly basis to collect and analyze provider information on 24-hour access, appointment access for urgent and routine care, and proper use of referral numbers.
Child and Adolescent Reporting System
The Title V child health agencies that deliver many services under the Medicaid benefit all use a Child and Adolescent Reporting system electronic health record to record the provision of services. The system provides a clinical record for all children receiving services at one of the agencies, not only children enrolled in Medicaid.
Currently, Medicaid pays for general developmental screens, social-emotional developmental screens, and autism screens all under the 96110 CPT code. Iowa uses claims data to, among other things, produce the CHIPRA core measure on developmental screening.
Contract language for the Iowa Plan for Behavioral Health requires the behavioral health organization (BHO), Magellan Health Services, to submit monthly or quarterly reports (depending on the specific indicator) to the Department of Public Health and the Department of Health Services on child-specific measures, including 7-, 30-, and 90-day mental health readmission, integrated services and supports, involuntary hospitalizations, and improvement in the psychosocial domain of Medicaid children and adolescents who are receiving services.
In Iowa, Medicaid behavioral health services are carved out of physical care and are available through the Iowa Plan for Behavioral Health. The Iowa Plan is a managed care program that delivers mental health and substance abuse services to almost all Medicaid beneficiaries in Iowa through a behavioral health organization (BHO), Magellan Health Services.
The state produced a behavioral provider manual that contains codes that providers in Iowa can bill for health and behavior assessments, including 96510 and 96511 (health and behavior assessment, initial assessment and re-assessment).
1st Five Healthy Mental Development Initiative
The Iowa Department of Public Health’s 1st Five Healthy Mental Development Initiative was designed to bridge public and private health care systems to improve early detection of social-emotional delays and promote prevention of mental health problems among young children. The model promotes the use of standardized screening tools, educates and supports medical practices in implementing developmental screening tools, and uses trained care coordinators who work with families to assure follow-up and access to services. 1st Five care coordination for Medicaid beneficiaries is reimbursed as a covered EPSDT service.
For more information about behavioral health services for children enrolled in Medicaid, see "Behavioral Health in the Medicaid Benefit for Children and Adolescents: Iowa."
|Support to Providers and Families||
Support to Families
The Iowa Department of Public Health (IDPH) has contracted with local Title V agencies to establish regional EPSDT Care for Kids Coordinators who are available in every county in Iowa. EPSDT Care For Kids Program Coordinators help families of children from birth to age 21 access health care services. These positions are funded by Medicaid through an Interagency Transfer Agreement with the IDPH to conduct outreach and care coordination functions for the EPSDT program.
Iowa’s EPSDT Care for Kids also offers the Healthy Families line, a 1-800 number that connects families to a local EPSDT Provider Training Consultant to facilitate access to additional screening, evaluation, or intervention services.
Support to Providers
The state operates the EPSDT Care for Kids provider website which provides information on screening codes, billing tools, and additional program resources. The EPSDT Care for Kids Newsletter, published three times per year, is also posted on the site to provide health care providers with information and resources on child preventive health topics.
Iowa Medicaid published a provider manual for screening centers, which are paid for health screenings for Medicaid members who are under 21 years of age. The manual outlines covered services, content of screening examinations, payment policies, and other procedures.
A handbook for EPSDT Care for Kids Program Coordinators is also available. In addition to their work with enrollees and their families, the EPSDT Care for Kids Program Coordinators help health care providers identify local resources for developmental services for children at risk.
Section 2703 Health Homes
Iowa has two approved Section 2703 health home state plan amendments. The first, approved in June 2012 and effective July 1, 2012, is for Medicaid enrollees with two qualifying chronic conditions, or one qualifying chronic condition and risk for a second; a body mass index over 85 for the pediatric population is one of the qualifying chronic conditions. The second health home state plan amendment is for adults with serious mental illness and children with a serious emotional disturbance, and was approved on June 18, 2013. Specifically, Iowa is planning to establish two types of health homes to serve three groups of children with at least one mental health condition:
Iowa’s Department of Public Health, under an agreement with Iowa Medicaid, has established contracts throughout the state with regional Title V agencies to both assist families in accessing EPSDT services and assist primary care providers in linking families to services. All of these agencies also participate in the State Medicaid program. The regional Title V agencies have four responsibilities for EPSDT: informing, care coordination, screening, and diagnosis and treatment. The agencies bill the Department of Public Health for informing and care coordination on a fee-for-service basis and bill the Medicaid agency for Medicaid-covered services (such as EPSDT screens) through the claims processing system, as would any other qualified provider.
Dental hygienists at Title V agencies in Iowa can be reimbursed by Medicaid for providing oral screenings and fluoride varnish applications to Medicaid-enrolled children.
The state’s I-Smile dental home initiative began as a result of legislation passed in 2005 which stated:
“… every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive services, diagnostic services, treatment services, and emergency services as defined under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) program.”
The I-Smile initiative seeks to connect children to dental services, and to promote the delivery of dental care in alternative settings as well as dentists’ offices. It relies on dental hygienists employed by regional Title V agencies who serve as care coordinators. The I-Smile Oral Health Coordinators work in communities and establish relationships with local dentists and physicians. I-Smile coordinators also assist EPSDT beneficiaries with making appointments, keeping appointments, arranging transportation, and understanding the importance of good oral health.
(As of April 2013)
At a Glance
- A unique partnership between the Department of Public Health and the Department of Human Services (Medicaid) uses care coordinators at local Title V agencies to help children access Medicaid services
- A provider website crosswalks developmental and mental health screening codes to specific tools
- Three major sources of mental health treatment are available for children: the Iowa Plan for Behavioral Health, Behavioral Health Intervention Services for children in communities or residential settings, and a Children’s Mental Health Waiver for children with a serious emotional disturbance
Iowa, through close collaboration between its Department of Human Services, Department of Public Health, and regional Title V agencies, has developed a robust system for providing services, including screenings (e.g. developmental and behavioral health screenings), under the Medicaid children’s benefit and linking children to follow-up services. In Iowa, Medicaid behavioral health services are available through the Iowa Plan for Behavioral Health. The Iowa Plan is a managed care program that delivers mental health and substance abuse services to almost all Medicaid beneficiaries in Iowa through a behavioral health organization (BHO), Magellan Health Services. Both 1931-eligible and SSI children are required to enroll. Only a few groups, such as dual eligibles and presumptive eligibles are excluded.
A behavioral health design effort in the state will seek to extend a Systems of Care approach to children with behavioral issues using specialty health homes. The state has convened a workgroup that made preliminary recommendations in late 2011. Final reports from several workgroups, including a Children’s Disability Services Workgroup, were released in December 2012. The report from the children’s workgroup reiterated a call to use health homes to coordinate services for Medicaid-enrolled children with serious emotional disturbances, while also foreseeing that “the system will eventually evolve to include children with mental health, behavioral, intellectual, developmental and physical challenges.”
Coordination and Collaboration
While Iowa Medicaid is located in the Department of Human Services, Iowa’s Department of Public Health, under an agreement with Iowa Medicaid, has established contracts throughout the state with regional Title V agencies both to assist families in accessing Medicaid services and to assist primary care providers in linking families to services. All of these agencies also participate in the state Medicaid program. The regional Title V agencies have four responsibilities for the Medicaid children’s benefit: informing, care coordination, screening, and diagnosis and treatment. The agencies bill the Department of Public Health for informing and care coordination on a fee-for-service basis and bill the Medicaid agency for Medicaid-covered services (such as various screens) through the claims processing system, as would any other qualified provider.
The Department of Public Health supports the regional Title V agencies with an internet-based system that helps them identify families in need of informing, assist with linkages to community services and coordination across systems, and bill public health for care coordination services. The public health agency has also created a manual to help coordinators perform these tasks, which includes information on how to form and support community linkages and establish referral pathways.
The Iowa Department of Public Health’s 1st Five Healthy Mental Development Initiative was designed to bridge public and private health care systems—building partnerships between physician practices and public service providers—to improve early detection of social-emotional delays and promote prevention of mental health problems among young children. The model promotes the use of standardized screening tools, educates and supports medical practices in implementing developmental screening tools, and uses trained care coordinators who work with families to assure follow-up and access to services. The initiative also offers the Healthy Families line, a 1-800 number that connects families to a local EPSDT Provider Training Consultant to facilitate access to additional screening, evaluation, or intervention services.
Community Circle of Care, a collaboration among the Iowa Department of Human Services, Iowa Child Health Specialty Clinics, and the Center for Disabilities and Development, offers care coordination, diagnosis, and assessment services to children and youth with emotional and behavioral challenges in Northeast Iowa in collaboration with local service providers. The organization uses care coordinators and wraparound plans to ensure that the child and his/her family are involved in treatment decisions and to facilitate delivery of community-based care.
Screening, Assessment and Referrals
Supported by its participation in the Assuring Better Child Development program, Iowa has bolstered its commitment to developmental and mental health screenings and services. Iowa Medicaid pays for developmental screening, including screening for delays in social emotional development and autism. This coverage grew out of the recommendations of the Healthy Mental Development Panel, a group of public and private stakeholders that identifies standards, tools, and referral processes for early identification of developmental problems in children. This panel recommended that Iowa establish three levels of behavioral and developmental services for children, focusing on (1) preventive services, including behavioral and developmental screening, assessment, family risk factors, counseling, and care coordination for all Medicaid eligible children; (2) developmental services, such as problem-based counseling and coordination of care for all Medicaid eligible children identified at risk for developmental or emotional problems; and (3) intensive developmental or mental health services for those children identified in need of therapy. This approach and the information needed to provide and bill for these services has been broadly disseminated to providers in Iowa.
The state also supports Iowa’s EPSDT Care for Kids provider website which suggests screening tools and billing codes for developmental and social-emotional screening tools. Some tools—including the Ages and Stages Social Emotional tool, the Brief Infant-Toddler Social and Emotional Assessment, the Child Development Review and Infant Development Inventory, and the Modified Checklist for Autism in Toddlers—can be billed using the 96110 CPT code for developmental screening. Other recommended tools, like the Iowa Child Health and Development Record (Iowa-CHDR, a state-developed tool) and the Pediatric Intake Form, are not billed separately from a comprehensive physical examination.
Iowa’s Medicaid provider manual for physicians (see Chapter E, page 139) contains the Child Mental Health Screen, an optional tool developed for use in Iowa’s Medicaid benefit. The tool allows the physician to make a mental health referral based on the conclusions of the screening. Medicaid also has a specific screening center manual for agencies that wish to serve as health screening centers for children receiving Medicaid benefits. The manual discusses mental health assessments for children, beginning with compiling a psychosocial history and proceeding to the use of clinical screening tools. The manual offers several examples of screening tools for use as part of a well-child exam and their unique attributes—including the Pediatric Intake Form, the Pediatric Symptom Checklist, Conners’ Rating Scales for ADHD, and the Children’s Depression Inventory—but does not recommend a specific tool.
The state’s behavioral provider manual also contains codes that providers in Iowa can bill for health and behavior assessments, including 96510 and 96511 (health and behavior assessment, initial assessment and re-assessment). Since 2008, the Medicaid fee schedule for physicians has also covered screening and brief intervention for alcohol and drug use under CPT codes 99408 and 99409; an informational letter to providers identified the AUDIT (Alcohol Use Disorders Identification Test) and DAST (Drug Abuse Screening Test) as the preferred tools to be used for these screenings.
Through Iowa Medicaid’s relationship with the Department of Public Health and local Title V agencies, Iowa has defined a referral process using local care coordinators that assures all children are referred to and connected with appropriate services. Care coordinators at the Title V agencies assist families with referrals and help link them to needed follow-up services under the Medicaid children’s benefit.
Iowa’s Medicaid program offers three primary sources of mental health services for children: the Iowa Plan, Behavioral Health Intervention Services, and a Children’s Mental Health Waiver. While there is technically no age restriction on Iowa Medicaid’s habilitation services program for beneficiaries with chronic mental illness, in practice children often do not meet the program’s needs-based criteria.
The Iowa Plan is managed by Magellan Behavioral Care of Iowa. Magellan is responsible for arranging access to a range of Medicaid-covered behavioral health services, including mental health services and substance abuse treatment services determined necessary following a screening. The Iowa plan also provides services to the families of some children with mental illness, offering parent support services for families of children and youth with a serious emotional disturbance. Behavioral services reimbursed by Magellan include those offered at community mental health centers, such as day treatment programs for children.
Magellan is also responsible for Behavioral Health Intervention Services (formerly the Remedial Service Program), a set of services provided in community-based or residential group care environments to improve a child’s level of functioning as it relates to mental illness. These services include: behavior intervention to modify a range of factors that affect a child’s functioning and to teach and develop skills; crisis interventions to stabilize acute symptoms of mental illness or emotional distress; and family training to enhance the family’s ability to interact with the child and support his functioning at home and in the community.
Iowa’s Children’s Mental Health Waiver is aimed at providing home and community-based services to children with serious emotional disturbance (SED). Medicaid-eligible children with an SED diagnosis can choose to enroll in the waiver, at which point a targeted case manager helps to coordinate services for the child and her family and convenes an interdisciplinary team. The team draws from professionals in or near the child’s community and includes: the child and family; the targeted case manager; one or more service managers; mental health professionals; others that the child and family choose to include. Children enrolled in the waiver have an individualized outcome achievement planned, developed in collaboration with the interdisciplinary team, to identify goals and service activities.
The authors wish to thank the many state officials and stakeholders who contributed to and reviewed the information in this document.
This document was prepared by NASHP for the Centers for Medicare & Medicaid Services (CMS) under a contract to NORC at the University of Chicago. It does not reflect the views of CMS.
Iowa’s 2008 Health Care Reform Act (House File 2539) charged the Iowa Department of Public Health with convening a Medical Home System Advisory Council to craft recommendations for implementing a statewide patient-centered medical home (PCMH) system. The stated purpose of a patient-centered medical home is to provide for the, “coordination and integration of care, focused on prevention, wellness, and chronic care management, using a whole person orientation through a provider-directed medical practice.” The Advisory Council has also convened a Multipayer Collaborative Workgroup to explore the potential for a multi-payer medical home project in the state.
The Council has guided the state in re-launching IowaCare as a medical home program for a select group of low-income adults. IowaCare operates under the authority of an 1115(a) waiver. Previously, IowaCare included a limited benefit package and only offered two providers. In accordance with Senate File 2356, beneficiaries are now assigned to one of eight recognized geographically dispersed medical homes. (The program launched with two federally qualified health centers (FQHCs) in October 2010, and has incrementally increased the number of medical homes since then.) All but two of the medical homes are FQHCs. As per the special terms and conditions of the 1115(a) waiver, the goals of the program are as follows: IowaCare member satisfaction with health care.
Improve statewide access of IowaCare members to quality health care.
Reduce duplication of services.
Enhance communication among providers, family, and community partners.
Improve the quality of health care to IowaCare members through the patient-centered medical home model.
Promote and support a plan for meaningful use of health information exchange (HIE) in accordance with the Federal Register requirement.
On June 8, 2012, CMS approved a Section 2703 health home state plan amendment for Medicaid enrollees with chronic conditions, which became effective July 1, 2012. To be eligible, patients must have two qualifying chronic conditions, or one qualifying chronic condition and risk for a second. A second health home state plan amendment for adults with serious mental illness and children with a serious emotional disturbance was approved on June 18, 2013. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
IowaCare: The Iowa Medical Home System Advisory Council (MHSAC) is made up of legislators and a variety of stakeholders including Medicaid, the state chapter of the American Academy of Family Physicians (AAFP), the state chapter of the American Academy of Pediatrics (AAP), the physician assistant association, the osteopathic society, the nursing association, the chiropractic society, the medical society, the dental association, consumers, private payers, and the primary care association (PCA). MHSAC is supported by 1.5 full-time staff at the Iowa Department of Public Health and has published two issue briefs to educate policymakers and stakeholders in Iowa about issues regarding the medical home model.
A full list of MHSAC members is available here.
|Defining & Recognizing a Medical Home||
IowaCare: According to Iowa’s 2008 Health Care Reform Act (House File 2539), a patient-centered medical home means an, “approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient’s family; utilizes the partnership to access all medical and nonmedical health-related services needed by the patient and the patient’s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the characteristics specified in section 135.158.” Section 135.158 identifies the following characteristics:
IowaCare: Participating IowaCare medical homes are expected to obtain recognition from either the National Committee for Quality Assurance (NCQA) “or the equivalent, as determined by the” state. This is specified in the IowaCare 1115(a) waiver. Iowa has agreed to accept the Joint Commission primary care medical home designation as an acceptable alternative to NCQA recognition.
In addition to medical home recognition (NCQA) or certification (Joint Commission) practices are expected to meet standards related to:
Further details on the additional standards are available on pages 36-38 of the IowaCare 1115(a) waiver.
ACA Section 2703 Health Homes: Participating practices are required to achieve NCQA-PCMH recognition under the 2011 standards, as well as complete a self-assessment and submit the results to the state. Health homes are also required to meet additional standards, such as maintaining continuity of care documents for eligible patients; designating a dedicated care coordinator with responsibility for health home enrollees; adopting electronic health records; implementing a formal behavioral health screening process; and reporting annually to the state on process and outcome measures.
|Aligning Reimbursement & Purchasing||
IowaCare: The special terms and conditions of the IowaCare 1115(a) waiver waive certain requirement pertaining to the prospective payment system for the federally qualified health centers (FQHCs) serving as IowaCare medical homes. The special terms and conditions also provide for Iowa Medicaid to pay IowaCare sites using the physician fee-for-service methodology. In addition to fee-for-service reimbursement, IowaCare sites receive ongoing care management fees delivered as per member per month (PMPM) payments. The amount of these payments vary:
During first 18 months: $3.00 PMPM
Medical home recognition below highest level (i.e., National Committee for Quality Assurance (NCQA) Levels 1 or 2): $2.50 PMPM
Medical home recognition at highest level of recognition system: $3.50 PMPM
Practices without medical home recognition: $1.00 PMPM
Practices are also eligible for performance-based payments that are calculated on a PMPM basis but delivered annually. The amount of these potential PMPMs vary as well:
During first 18 months: $1.00 PMPM
Medical home recognition below highest level: $1.00 PMPM
Medical home recognition at highest level: $1.50 PMPM
Practices without medical home recognition: $1.50 PMPM
Practices are judged to be eligible for performance-based payments on the basis of criteria related to:
Further detail on the performance measures is available on pages 42-43 of the IowaCare 1115(a) waiver.
In addition to these payments, the IowaCare waiver established reimbursement for peer-to-peer provider consultation. This allows remote hospital-based specialists to receive payment for consulting with IowaCare primary care providers. The consultations are reimbursed at fees ranging from $20.30-$44.37 depending on the length and method of consultation (telephone, e-mail, or video conference). Further details are available on pages 40-41 of the waiver.
ACA Section 2703 Health Homes: Health homes receive a complexity-adjusted per-member-per-month (PMPM) on top of fee-for-service reimbursements for patients with chronic diseases based on a Patient Tier Assessment Tool:
IowaCare: The Iowa Healthcare Collaborative, a non-profit organization dedicated to educating and equipping health care providers across Iowa, leads a Medical Home Learning Community. The leader of the Iowa Healthcare Collaborative is also chair of the Iowa Medical Home System Advisory Council (MHSAC).
The IowaCare 1115(a) waiver states, “The State must collaborate with the State’s HIE [health information exchange] designated entity to ensure that primary network providers are a high priority for connecting to the State’s HIE.”
ACA Section 2703 Health Homes: Iowa is in the process of implementing a statewide health information exchange which health home practices will be required to join.
IowaCare: IowaCare will draw on clinical information from patient registries and provider records to evaluate progress in several key areas of interest, including:
A draft of the full evaluation design is available here.
ACA Section 2703 Health Homes: Iowa is working to measure success toward the state’s two goals for this state plan amendment:
Specific measures, drawn from the National Quality Forum and CHIPRA core measure sets, include hospital admissions and readmissions, emergency department utilization, and skilled nursing facility visits.
The state is also tracking the program’s administrative costs, total cost savings, patient outcomes, and patient satisfaction, as well as gathering input from patients and providers on the implementation process and lessons learned.
Scope of Services: The Iowa Wellness Plan members will receive a comprehensive, commercial-like benefit package based on the State Employee Plan benefits, which will ensure coverage for all of the essential health benefits as required by the Affordable Care Act. Iowa will supplement the State Employee Plan services with supplemental dental benefits, similar to those provided in the Medicaid State Plan. Mental health and substance use disorder and dental benefits will be provided on as carved out benefits on a contracted basis.
Eligible Provider Population: Iowa’s ACO strategy under its Iowa Wellness Plan is centered on Patient Managers, providers that signed both a Wellness Provider Agreement and a Medicaid Provider Agreement, are part of an ACO, and agree to accept the terms of the agreement with the ACO to serve as a primary care/patient-centered medical home for the member.
Eligible Patient Population: The Iowa Wellness Plan is targeted for individuals who are between ages 19 through 64 who do not have access to Medicare or other comprehensive Medicaid coverage, and who are not eligible for cost-effective employer-sponsored coverage. Individuals, who do not have access to cost-effective employer-sponsored coverage, with income up to and including 100 percent of the federal poverty level (FPL) based on the modified adjusted gross income methodology, are considered eligible, and individuals with income up to 133 percent of the FPL who are medically frail will be considered eligible.
Attribution: Medicaid beneficiaries enrolled in the Iowa Wellness Plan choose a primary care provider (known as a Patient Manager); the beneficiary is assigned to the ACO if the primary care provider is participating. If a beneficiary does not choose a provider, he is assigned to the provider with whom he had the highest number of unique visits (using evaluation and management codes in the most recent 12 months of claims history).
The Iowa Health and Wellness Plan was authorized by Chapter 138 of the Acts of 2013. Iowa has submitted to CMS a request for an 1115 Demonstration Waiver to implement the Iowa Wellness Plan. It is also using funds from a State Innovation Model grant to plan for a multi-payer accountable care organization model.
Under a draft accountable care organization (ACO) agreement released by Iowa Medicaid, an ACO must possess the corporate resources and structure necessary to perform its responsibilities under the agreement and successfully implement and operate the ACO. ACOs must enter into written agreements or contracts with the patient managers (PMs).
ACOs must also established a governing body with responsibility for setting policy, developing and implementing a model of care, establishing best practices, setting and monitoring quality goals, and assessing PM performance and addressing deficiencies. The ACO must also demonstrate meaningful involvement of a Chief Medical Officer and PMs in the governance structure.
The agreement also stipulates that the ACO shall have a consumer advisory board that meets regularly and advises on ACO policies and programs including cultural competency, outreach plans, member education materials, prevention programs, member satisfaction surveys, and quality improvement programs.
|Criteria for Participation||
A draft accountable care organization (ACO) agreement released by Iowa Medicaid clarified that ACOs must be active Iowa Medicaid providers. They must also be able to demonstrate an integrated delivery system and share clinical information in a timely manner; and implement a model of care and financial management structure that promotes provider accountability, quality improvement, and improved health outcomes.
Among other responsibilities for ACOs that wish to participate in the Wellness Plan are that they must:
In the first year of the operation of an accountable care organization (ACO), primary care physicians in it will initially be paid on a fee-for-service basis, and they will receive a care coordination payment for managing referrals and coordinating care. The ACO will receive bonus payment according to the performance targets and methodology detailed in a Value Index Score Medical Home Bonus Document.
If the ACO qualifies, the Medicaid agency will pay the ACO three bonus payments:
In subsequent years, ACOs will be subject to a risk-adjusted global budget with shared savings (and, within five years of the initial contract year, two-way risk sharing) based on quality performance.
|Support for Infrastructure||
Under a draft accountable care organization (ACO) agreement released by Iowa Medicaid, the Department of Human Services will:
|Measurement and Evaluation||
Shared savings opportunities for ACOs participating in the Iowa Wellness Plan begin in their second year of operation and will eventually be contingent upon performance on quality metrics. These quality metrics will be implemented in a phased approach and may include attributed participant experience, primary and secondary prevention, tertiary prevention, population health status, continuity of care, chronic and follow-up care, and efficiency. Implementation of quality metrics is required within three years of the ACO contracting with the Iowa Wellness Plan.
In the first year of operation, one of the bonus payments for which ACOs are eligible will be a medical home bonus payment. The payment will be based on performance on metrics that fall under four categories: (1) person-focused care; (2) first contact with the health care system; (3) comprehensive, coordinated care and (4) transfer of information.
The National Academy of State Health Policy (NASHP) conducted a survey in the summer of 1999 of the 31 states known to be using financial penalties or incentives in their Medicaid managed care contracts. This paper is based upon information provided by the 28 states that responded and examines recent trends in the use of these financial tools in managed care contracts. It also details the experiences of three states – Iowa, Massachusetts, and Rhode Island – that have the most extensive experience with innovative payment strategies.
This report is the final phase of the National Academy for State Health Policy’s contribution to a larger study of Medicaid managed care enrollment and disenrollment, funded by The Pew Charitable Trusts and conducted by Cornell University and Virginia Commonwealth University. It focuses on the enrollment and disenrollment policies and experience of Medicaid managed care programs in four states: Iowa, Minnesota, Rhode Island and Utah. All of these state have had managed care programs in place for a minimum of five years; Minnesota’s program has been operational since 1981.
This report reflects the discussion of nine states participating in “Transitioning to Managed Care: Medicaid Managed Care in Mental Health.” The symposium was funded by the Henry J. Kaiser Family Foundation and the federal Health Care Financing Administration (HCFA).