iowa department of human services · q1 sfy18 letter gerd stated that this letter is currently...

April 27, 2018

Full Council Meeting

MAAC MATERIALS

FULL COUNCIL MEETING

May 3, 2018

1. Agenda of Meeting for May 3, 2018

2. February 19, 2017 Roll Call Sheet1

3. February 19, 2017 Meeting Minutes2

4. Q2 SFY18 - Recommendations Letter3

5. Action Items of the Executive Committee

6. Quarter 2, SFY18 Managed Care Report4

1 https://dhs.iowa.gov/sites/default/files/MAAC_Full_Council_Roll_Call_Sheet_February_19_2018.pdf

2 https://dhs.iowa.gov/sites/default/files/FC_Minutes_021918_Summary_0.pdf

3 https://dhs.iowa.gov/sites/default/files/MAAC_Recommendations_Letter_04_17_2018.pdf

4 https://dhs.iowa.gov/sites/default/files/SFY18_Q2_Report.pdf

Medical Assistance

Advisory Council MAAC

Iowa Department of Human Services

Michael Randol, Medicaid Director

https://dhs.iowa.gov/sites/default/files/MAAC_Full_Council_Roll_Call_Sheet_February_19_2018.pdf

https://dhs.iowa.gov/sites/default/files/FC_Minutes_021918_Summary_0.pdf

https://dhs.iowa.gov/sites/default/files/MAAC_Recommendations_Letter_04_17_2018.pdf

https://dhs.iowa.gov/sites/default/files/SFY18_Q2_Report.pdf

https://dhs.iowa.gov/sites/default/files/MAAC_Full_Council_Roll_Call_Sheet_February_19_2018.pdf


https://dhs.iowa.gov/sites/default/files/MAAC_Recommendations_Letter_04_17_2018.pdf


April 23, 2018


Full Council Meeting Thursday, May 3, 2018

Time: 1:00 p.m. Iowa State Capitol Building

Senate Room 116 Des Moines, IA

Dial: 1-866-685-1580 Code: 515-725-1031#

AGENDA

1:00 Introduction and roll call – Gerd Clabaugh

1:05 Approval of minutes from previous meetings – Gerd Clabaugh

Full Council Meeting Minutes: February 19, 20181

1:10 Long-Term Care Ombudsman Report – Cynthia Pederson

1:30 Q2 SFY18 Recommendations Letter – Gerd Clabaugh

1:50 Election of MAAC Members Update – Gerd Clabaugh

2:10 Summary: Consumer Assessment of Healthcare Providers and Systems (CAHPS) – Lisa Cook

2:30 Managed Care Quarterly Report Update – Lisa Cook

SFY18 Q2 Report2

2:55 Update from the Medicaid Director – Michael Randol

(Electronic Visit Verification (EVV), Legislative Update, Action Items, MCO RFP Update Transition and Choice Updates, Process Improvement Working Group Update)

3:20 Updates from MCOs – MCOs

Amerigroup Iowa, Inc. (15 minutes)

UnitedHealthcare Plan of the River Valley (15 minutes)

3:50 Open Comment (Open Comment Opportunity for Members) – Gerd Clabaugh

4:00 Adjourn

1 https://dhs.iowa.gov/sites/default/files/FC_Minutes_021918_Summary_0.pdf

2 https://dhs.iowa.gov/sites/default/files/SFY18_Q2_Report.pdf

Medical Assistance Advisory Council

MAAC







February 20, 2018

MAAC Full Council Meeting February 19, 2018 Roll Call Sheet

MAAC Co-Chairpersons

Gerd Clabaugh – Co-Chairperson and Executive Committee (Iowa Department of Public Health)

Present Call-in

David Hudson – Co-Chairperson and Executive Committee (Public Member)

Present Call-in

Please indicate with an “X” mark to designate ‘present”.

Voting Council Members – Professional and Business Entities

Dennis Tibben – Executive Committee (Iowa Medical Society)

Present Call-in

Casey Ficek – Executive Committee (Iowa Pharmacy Association)

Present Call-in

Dan Royer1 – Executive Committee (Iowa Hospital Association)

Present Call-in

Cindy Baddeloo2 – Executive Committee (Iowa Health Care Association)

Present Call-in

Shelly Chandler – Executive Committee (Iowa Association of Community Providers)

Present Call-in

Richard Shannon (Iowa Developmental Disabilities Council)

Present Call-in

Doug Cunningham (ARC of Iowa) Present Call-in

Sue Whitty (Iowa Nurses Association) Present Call-in

Wendy Gray (Free Clinics of Iowa) Present Call-in

Sherry Buske (Iowa Nurse Practitioners Society) Present Call-in

Dave Carlyle (Iowa Academy of Family Physicians)

Present Call-in

Steve Bowen3 (Iowa Occupational Therapy Association)

Present Call-in

Patricia Hildebrand (Iowa Academy of Nutrition and Dietetics)

Present Call-in

Gary Ellis (Iowa Optometric Association) Present Call-in

Maria Jordan (Iowa Adult Day Services Association)

Present Call-in

Leah McWilliams (Iowa Osteopathic Medical Association)

Present Call-in

1 Dan Royer is the interim designee for the Iowa Hospital Association

2 Brandon Hagan attended for Cindy Baddeloo

3 Steve Bowen replaces Leanne O’Brien


MAAC



February 20, 2018

Dan Royer (Iowa Alliance for Home Care) Present Call-in

Matt Eide (Iowa Physical Therapy Association) Present Call-in

Bev Thomas (Iowa Association of Hearing Health Professionals)

Present Call-in

Larry Carl (Iowa Dental Association) Present Call-in

Janine Petitgout (Iowa Association of Nurse Practitioners)

Present Call-in

Aaron Todd (Iowa Primary Care Association) Present Call-in

Ed Friedmann (Iowa Association of Rural Health Clinics)

Present Call-in

Penny Osborn (Iowa Physician Assistant Society) Present Call-in

Maribel Slinde (Iowa Caregivers Association) Present Call-in

Kevin Kruse (Iowa Podiatric Medical Society) Present Call-in

Flora Schmidt (Iowa Behavioral Health Association)

Present Call-in

Karen Loihl (Iowa Psychiatric Society) Present Call-in

Tom Scholz (American Academy of Pediatrics) Present Call-in

Dave Beeman (Iowa Psychological Association) Present Call-in

Denise Rathman (National Association of Social Workers)

Present Call-in

Barbara Nebel (Iowa Speech-Language-Hearing Association)

Present Call-in

Molly Lopez (Iowa Chiropractic Society) Present Call-in

Deb Eckerman-Slack (Iowa State Association of Counties)

Present Call-in

George Appleby (Iowa Council of Health Care Centers)

Present Call-in

Matt Blake4 (Leading Age Iowa) Present Call-in

TBD (Assoc. of Area Agencies on Aging) Present Call-in

Peggy Huppert (National Alliance on Mental Illness) Present Call-in

Anthony Carroll (American Association of Retired Persons - AARP)

Present Call-in

Eric Kohlsdorf (hawk-i Board)

Present Call-in

Kristie Oliver (Coalition for Family and Children’s Services in Iowa)

Present Call-in

VACANT POSITION (Opticians Association of Iowa)

Matt Flatt (Midwest Association for Medical Equipment Services)

Present Call-in

VACANT POSITION (Iowa Coalition of HCBS for Seniors)


4 Shannon Strickler attended for Matt Blake

February 20, 2018

Voting Council Members - Public Representatives

Lori Allen – Executive Committee (Public Member)

Present Call-in

Brandi Jensen (Public Member) Present Call-in

Richard Crouch – Executive Committee (Public Member)

Present Call-in

Thomas Ryan (Public Member) Present Call-in

Marsha Fisher (Public Member) Present Call-in

David Selmon (Public Member) Present Call-in

Julie Fugenschuh – Executive Committee (Public Member)

Present Call-in

Jodi Tomlonovic – Executive Committee (Public Member)

Present Call-in

David Hudson – Co-Chairperson and Executive Committee (Public Member)

John Dooley5 (Public Member) Present Call-in

Please indicate with a “X” mark to designate ‘present”.

Non-Voting Council Members – Professional and Business Entities

Carrie Malone6 (Iowa Department of Aging) Present Call-in

Jennifer Harbison (UI College of Medicine) Present Call-in

Cynthia Pederson (Long Term Care Ombudsman)

Present Call-in

VACANT POSITION (Osteopathic Medical Ctr.)


Non-Voting Council Members – General Assembly

Joe Bolkcom (Senate) Present Call-in

Timi Brown-Powers (House of Representatives) Present Call-in

Tom Greene (Senate) Present Call-in

Kevin Koester (House of Representatives) Present Call-in


5 John Dooley is a new Public Member

6 Brian Majeski is replaced by Carrie Malone as designee of the Iowa Department on Aging

March 1, 2018



Michael Randol, Iowa Medicaid Director MAAC

Introduction and Roll Call Gerd called the meeting to order and performed the roll call. Full Council attendance is as reflected in the separate roll call sheet. Quorum was not met.

Approval of the Full Council Meeting Minutes of November 7, 2017 Minutes of the Executive Committee meeting of November 7, 2017 was not put to a vote because quorum was not met.

Long-Term Care Ombudsman Report Cynthia Pederson reviewed the January 2018, Managed Care Ombudsman Monthly Report and the Managed Care Ombudsman Quarterly Report for the last calendar quarter of 2017 available in the materials packet. She stated that the office also provides a quarterly report that reflects a three month compilation of data gathered from the monthly reports. She underscored that the last quarter of 2017 which included the transition period from AmeriHealth Caritas did not result in an increase in the number of contacts received by the Ombudsman program during the quarter. She noted trends involving an increase in contacts regarding selecting or changing an MCO, an increase in contacts regarding continuity of care and services during the transition, and an increase in AmeriHealth members needing assistance in connecting with new case managers. She also noted the decrease in the number of contacts regarding grievances, appeals, and fair hearings.

Recommendations Update Q4 SFY17 Director Foxhoven Reply Gerd gave a brief background regarding the questions posed to the Director and a copy of the reply was made available in the materials packet. Q1 SFY18 Letter Gerd stated that this letter is currently awaiting response from Director Foxhoven but that the items on the recommendation are already being addressed.

Update from the Medicaid Director (Electronic Visit Verification (EVV), Legislative Update, Action Items, MCO RFP Development, Status of Choice given only two MCOs) Mike Randol stated that a vendor(s) had not yet been determined for the EVV initiative nor whether there would be separate vendors for MCOs and Fee-for-Service (FFS). He stated that the EVV is to be implemented by January 1, 2019, and a process timeline is currently being developed to meet that implementation date that covers both education and communication on how to move forward. Mike stated that he did not have a legislative update at that time. In regards to the MCO Requests for Proposals (RFPs), he stated that due dates for RFPs is March 6, 2018, and they will follow standard process of RFP evaluation.. He stated that there may be one or two additional MCOs added to the managed care program with an effective contract date for the selected MCO(s) of July 1, 2019. He stated that as of March 1, 2018, Amerigroup will begin accepting the members who were temporarily transitioned to Fee-for-Service and as of May 1, 2018, they will begin accepting new and choice members. Mike and Liz Matney confirmed that the objective of HSB 632 is to ensure that the data that is being reported is useful data that allow for meaningful analysis. There was a suggestion that the MAAC or a subcommittee of the MAAC hold future discussions with the department to discuss what data elements will be useful for the MAAC especially in light of data reporting changes that will result from HSB 632. Liz added that it is important to understand that data elements will continue to be

Full Council Summary of Meeting Minutes

February 19 2018

March 1, 2018

collected but that the reports should be able to meaningfully answer questions that are being asked. Mike stated that there is now a process improvement working group and one of the sub-groups is data transparency dashboards which can help in answering questions about the data. Mike also reviewed the action items document and provided an update on the status of each item.

Action Item: Add to action items a presentation at a future Executive Committee meeting on value-based

purchasing threshold requirements for MCOs.

Long-Term Care Services and Support (LTSS) Presentation Deb Johnson handed out copies of the document, “Medicaid Home-and Community-Based Services (HCBS) Program Comparison Chart” which outlines the various services under LTSS. She stated that LTSS consists of Home- and Community-Based Services (HCBS) Waivers and Institutional Care:

Home- and Community-Based Services (HCBS) Waivers Deb stated that HCBS is part of the Social Security Act and is referred to as the 1915c HCBS Waivers. There are seven waivers; Health and Disability; AIDS/HIV, Elderly, Intellectual Disability, Brain Injury, Physical Disability, and Children’s Mental Health. HCBS Waivers provide service funding and individualized supports to maintain eligible members in their own homes or communities who would otherwise require care in a medical institution. She stated that waiver services are meant to complement or supplement the state plan or other resources that are available. Waiver participants have access to the full state plan but that they still need to meet the institutional Level of Care and services have to be cost-effective or less expensive in aggregate than what it would cost in an institution.

Institutional Care: Nursing Facilities (NFs), Skilled Nursing Facilities (SNFs), Intermediate Care Facilities (ICFs), and Intermediate Care Facilities for the Intellectually Disabled (ICF/IDs) Deb stated that members receiving these services need to meet the same Level of Care and income guidelines as in waiver programs. There are monthly maximums or caps on the financial amount for services in each program and this is important in determining the aggregate for cost neutrality. She added that cost-effectiveness of services is determined on an individual basis and is based on a variety of variables. Deb provided clarification on the distinction and relationships between Level of Care, service plan, and care coordination.

Care-Coordination and Conflict-Free Case Management Amerigroup Iowa, Inc. Kelly Espeland provided the Centers for Medicare and Medicaid Services (CMS) definition of Conflict-Free Case Management and stated that it is a requirement for the MCOs per their contracts with the State. Additionally, the MCOs must administer case management in a conflict-free manner consistent with the Balancing Incentive Program. The Balancing Incentive Program rebalances the State’s program and aims to get more persons into the community and out of facilities. She stated that the MCOs complete member assessments, inform the state of the member’s care needs and the State makes the final eligibility determination. In regards to the SIS assessment, the Case Manager (CM) is a facilitator and does not determine the score or the member needs as this is carried out by the team. The information then goes to the CM, the team reviews the information, and the CM provides the service coordination to develop the member’s person-centered plan based on identified needs. The Utilization Management (UM) team looks at the assessment and care plan that has been developed, and a determination is then made regarding services in accordance with the Iowa Administrative Code. Conflict-Free Case Management oversight is carried out through regular reports provided to the State and involvement from stakeholder groups such as the MAAC.

UnitedHealthcare Plan of the River Valley, Inc. Paige Pettit stated that UnitedHealthcare’s process is similar to Amerigroup’s with slight distinctions. UnitedHealthcare’s CMs focus on person-centered planning while ensuring compliance with state and federal regulations. UnitedHealthcare’s CMs are nurses as well as social workers and have extensive training in LTSS. Upon hiring, CMs are put through training in LTSS and each CM hired is paired with a mentor. Quality is assured through case reviews, ride-alongs, peer reviews, ongoing education and maintenance of certification is mandatory for all assessors.

Amerigroup Iowa, Inc. Updates Transition Update Natalie Kerber stated that when AmeriHealth exited the market, Amerigroup determined that in order to serve a large but unidentified influx of new members, the organization would need to build more

March 1, 2018

capacity. Since that time, Amerigroup has been working closely with the IME in building said capacity. As of March 1, 2018, Amerigroup will begin accepting the members who were temporarily transitioned to Fee-for-Service and as of May 1, 2018, they will begin accepting new and choice members.

Integrated Health Home Funding Natalie stated that Amerigroup continues to support the work of the Integrated Health Home (IHH) program and they will continue to work with the Department, UnitedHealthcare, and Health Home providers to identify ways to strengthen the program.

Value-Based Purchasing Amerigroup’s contract benchmarks for members covered by Value-Based provider arrangements are 30% by July 1, 2018, and 40% by the end of 2018. Natalie stated that Amerigroup is on track to meet these goals and they are currently approaching 30% in Value-Based arrangements and fully anticipate meeting their goals. Additionally, Amerigroup has been piloting two quality incentive programs with LTSS providers; Anthem Nursing Facility Quality Incentive Program and Anthem Personal Attendant Care Quality Incentive Program. In these programs, providers are measured on outcomes over an entire year and then there are quarterly reports that are designed to discuss the quality measures with participating providers in order to coach them on improving their performance to meet the pilot goals throughout the year.

UnitedHealthcare Plan of the River Valley Updates Transition Update Paige Pettit stated that UnitedHealthcare has hired 525 new employees to accommodate new members and of the 525 new employees, 470 are CMs. Community-Based Case Managers (CBCMs) continue training and member outreach, and all members have been assigned a CBCM. Provider advocates are also traveling across the state to meet with providers on a weekly basis.

Integrated Health Home Funding The Department is currently conducting a review of the State’s health plan program and the associated state plan amendments; the Department will work collaboratively with both MCOs through this process. Given the potential for program changes to occur as a result of the review, the MCOs have delayed the IHH transition. As of March 1, 2018, the IHHs will need to complete for UnitedHealthcare the appropriate documentation to enroll individuals into the IHH that assures compliance with the state plan amendment. As of last week, UnitedHealthcare’s clinical staff had conducted joint operating committee meetings with 25 of the IHHs to address their questions.

Quarterly Data Report Update The Q1 SFY18 report was made available in the materials packet and Liz Matney stated that the report had been updated with information requested from oversight entities and the information had been restructured. She provided data on claims payment accuracy, rate reprocessing, consumer satisfaction survey specific to LTSS members receiving HCBS services, employment services for HCBS Waiver members, HRA completion, claims timeliness, service levels, and Prior Authorizations (PAs).

Secret Shopper Methods and Metrics Liz stated that someone in the Iowa Medicaid managed care bureau made daily calls to different MCO helplines; provider services, member services, Non-Emergent Medical Transportation (NEMT), and hawk-i. The questions utilized for calls are based on information that the IME is receiving from stakeholder groups, legislators, members, and providers. This information is included in the quarterly report and will be ongoing.

Open Comment (Open Comment Opportunity for Members) Marsha Fisher stated that her son is an LTSS member. She stated that she has received emails from persons in north eastern Iowa stating that they have gone through repeated appeals to obtain LTSS services, and it seems as though this is what the MCOs expect; this is the process for obtaining LTSS services. Marsha gave an example of a woman whom she knows and who has two small children with severe disabilities receiving LTSS services and her children have been denied services; requiring they go through the appeals process. She stated that the appeals process was frustrating, and requires a lot of effort. Marsha expressed concern if whether this was the process for obtaining LTSS services and stated that it is a problem that the Department needed to be aware of.

Marsha Fisher also stated that she does not agree with the requirement to prove that the services requested are a true need. Marsha noted that the needs are seen by the Care Coordinator, there is an assessment, and there are many persons working with the individual during their care planning

March 1, 2018

although when it goes to the Utilization Management team, the member and their team are required to prove that the services are a true need; to prove beyond the information that is provided to the Utilization Management team that the services requested are needed.

Marsha Fisher stated that communication continues to be a problem without personalization and individualization. She identified that she had received a satisfaction survey from her son’s MCO that had the correct address although was addressed to someone else and the document was in Spanish. She stated that she was concerned about the validity of some of the documents provided to members in the general Medicaid population as well as LTSS members.

Potential Topics for Future Recommendations: Percentage of claims that are suspended; suspended versus denied claims. Request that

information be provided in future quarterly reports. In regards to data within reports, request the addition of measures and information regarding

quality. Example: Is the decision made timely and is the decision made correctly? Request clearer guidelines of what information is required when requesting services for LTSS

members. (See Marsha Fisher’s comments outlined above).

Adjourn 4:02 P.M.


April 17, 2018

Mr. Jerry R. Foxhoven Director Iowa Department of Human Services Hoover State Office Building, 5th Floor 1305 E. Walnut Street Des Moines, IA 50319-0114

Dear Mr. Foxhoven:

Pursuant to Iowa Administrative Code 249A, 4B, subsection 6, based upon the deliberations of the Medical Assistance Advisory Council (MAAC) and the Executive Committee, the Executive Committee would like to make the following recommendation regarding the policy and administration of the medical assistance program.

Claims-related data reporting

MAAC recommends the Department clarify the reporting of metrics relating to claims which appear in the quarterly MCO reports. In particular, MAAC has discussed its interest in such metrics as percentage of claims that are suspended, claims suspended versus denied, the definition of suspensions versus denials, and the consistency among MCOs in collecting and reporting this data. MAAC offers its support to IME staff with development and presentation of this information in future quarterly reports by providing feedback as these metrics are identified and developed.

Clearer communication regarding program changes

MAAC recommends the IME and MCOs continually work to improve communications with beneficiaries and providers relating to services, process and policy changes. For example, MAAC has received information that some beneficiaries of LTSS services receive communications about changes in services levels without clarity regarding the rationale for these changes or the recourse available to individuals in appealing these decisions. Additionally, recently MCOs were directed to recoup overpayments made to hospitals for non-emergent use of the Emergency Room without warning that a recoupment effort was underway. MAAC commits to being available to support IME staff and MCOs to develop more proactive processes that enable clearer, more effective communication across the program.


MAAC



We look forward to continuing to work with the Department in an effort to improve health and medical care services under the medical assistance program. Please feel free to contact the MAAC should you have any additional questions regarding the recommendations or referrals outlined above.

Sincerely,

Iowa Department of Public Health Co-Chairperson

Public Representative Co-Chairperson

Iowa Department of Human ServicesMedical Assistance Advisory Council (MAAC)

Outstanding Items for the Executive Committee ‐ May 3, 2018

Number Date Added Action Item Who is Responsible for Follow-Up

Status (Outstanding / Complete / In Process / To Be Scheduled)

1 11/4/2016Update on the new CMS managed care rules and whether changes are necessary to be in compliance.

Medicaid Director Ongoing

2 2/23/2017

To have presentations regarding Integrated Health Homes and the Health Homes project. UPDATE on March 14, 2017: Deb Johnson and Joyce Vance are to be invited to a future Executive Committee meeting to continue the discussion on Chronic and Integrated Health Homes UPDATE on April 11, 2018: Deb Johnson to present updates at future Executive Committee meeting.

Medicaid Director To be discussed at future Executive Committee meeting.

3 8/8/2017Consider a discussion relating to the federal discussions on block granting Medicaid dollars, and how the state is positioned relative to this possible outcome.

EC Members and Medicaid Director

Ongoing

4 2/19/2018The Department and MCOs to present on value‐based purchasing arrangements. * 30 percent threshold by the end of 2018.

Medicaid Director and MCOs To be discussed at future Executive Committee meeting.

Action Page 1


Outstanding Recommendations for the Executive Committee ‐ May 3, 2018

Number Date Added Action Item Iowa Department of Human Services

Status (Outstanding / Complete / In Process / To Be Scheduled)

1 1/22/2018

Mental Health: MAAC's Executive Committee recommends that Department of Human Services staff facilitate a meeting between the chair of the Mental Health and Disability Services Commission and the co‐chairs of MAAC to discuss earlier recommendations relating to Medicaid and Mental Health made in 2017. The intent of this meeting is to discuss the earlier recommendations and any progress or collaborative work that should or can be undertaken to move important work in this area forward.

Medicaid Director To Be Scheduled

2 4/17/2018

Claims‐related data reporting: MAAC recommends the Department clarify the reporting of metrics relating to claims which appear in the quarterly MCO reports. In particular, MAAC has discussed its interest in such metrics as percentage of claims that are suspended, claims suspended versus denied, the definition of suspension versus denials, and the consistency among MCOs in collecting and reporting this data. MAAC offers its support to IME staff with development and presentation of this information in future quarterly reports by providing feedback as these metrics are identified and developed.

Medicaid Director In Process

3 4/17/2018

Clearer communication regarding program changes: MAAC recommends the IME and MCOs continually work to improve communications with beneficiaries and providers relating to services, process and policy changes. For example, MAAC has received information that some beneficiaries of LTSS services receive communications about changes in services levels without clarity regarding the rationale for these changes or the recourse available to individuals in appealing these decisions. Additionally, recently MCOs were directed to recoup overpayments made to hospitals for non‐emergent use of the Emergency Room without warning that a recoupment effort was underway. MAAC commits to being available to support IME staff and MCOs to develop more proactive processes that enable clearer, more effective communication across the program.

Medicaid Director In Process

Recommendations Page 2


Completed Items for the Executive Committee ‐ May 3, 2018

Number Date Added Item Responsible Party Status (Outstanding / Complete / In Process / To Be Scheduled)

1 1/19/2017Public Comment Recommendation: The Department Develop a new methodology to track consistency or prior authorization determinations within each MCO.

Medical Assistance Advisory Council (MAAC)

Completed ‐ Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.

2 1/19/2017

Public Comment Recommendation: The Department to enforce and communicate to the MCOs the cap after which a PA request is deemed approved (seven days) if a determination has not been made. The MCOs are then to communicate the determination to providers.

Outstanding Items from the Executive Committee Meeting of

July 11, 2017

Completed ‐ Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.

3 1/19/2017

Public Comment Recommendation: Encourage the MCOs to develop consistent service groups or crosswalk standards for PAs to allow for instances where approval is obtained for a specific service or products. Recommend that each of the MCOs develop an exemption process based on medical necessity.

Medicaid DirectorCompleted ‐ Director Response Letter dated June 27, 2017, reviewed by MAAC Full Council on August 8, 2017.

4 1/19/2017Public Comment Recommendation: Require MCOs to provide a plain language explanation to Iowa Medicaid members and providers for PA denials.


5 1/19/2017

Public Comment Recommendation: The Department to determine the differences in credentialing requirements between the MCOs and develop a comparison grid of what additional measures beyond the IME's universal credentialing is required by each MCO.


6 1/19/2017Public Comment Recommendation: Require the MCOs explain the rationale for additional credentialing requirements beyond what is contractually required by the IME.


7 1/19/2017Public Comment Recommendation: Determine the percentage of clean claims payments that are paid on time and accurately based upon the established rate floors to track the accuracy of provider payments.


8 1/19/2017

Public Comment Recommendation: Regarding clearinghouse to clearinghouse issues: Request that the MCOs provide data related to the initial denail rates from their clearinghousees and include this data in the Managed Care Quarterly Report.


9 1/19/2017Public Comment Recommendation: Include the accuracy and consistency of information provided by the MCO Customer Service Representatives to both providers and members in the Managed Care Quarterly Report.


10 1/19/2017Public Comment Recommendation: Include secret shopper results to the Managed Care Quarterly Report.


11 1/19/2017Public Comment Recommendation: Request that the MCOs report information regarding outreach efforts to increase access to care in areas identified in the MCOs' GeoAccess Reports as limited access areas.


12 1/19/2017Public Comment Recommendation: Request that MCOs present on results of outreach efforts in order to determine outstanding issues that the MAAC may be able to address.


Completed Page 3




13 1/19/2017

Public Comment Recommendation: Request summaries of the MCOs' Consumer Advisory Panels and Clinical Advisory Panels. Request that MCOs make a periodic formal presentation to the MAAC regarding the timely data and feedback obtained from their required advisory panels.


14 1/19/2017

Public Comment Recommendation: Encourage the development of a standardized process across the MCOs to create consistent member material to inform members on what services are provided by each MCO, the process for denying services, and what resources will be given to review available services


15 1/19/2017Public Comment Recommendation: Require MCOs to provide a plain language explanation to Iowa Medicaid members on all MCO denials.


16 1/19/2017Public Comment Recommendation: Require that all MCO provider manuals be clearly posted in an easily accessible format and location on the MCOs' websites and available in hardcopy.


17 1/19/2017 Explanation and definition of plain language standards Medicaid Director Completed ‐ Discussed in March 14, 2017 Executive Committee meeting.

18 2/14/2017Executive Committee to meet with Iowa Medicaid Communications Specialist to discuss reconfiguration of the Iowa Medicaid website for ease of navigation for members/consumers.

Medicaid Director Completed ‐ Discussed in March 14, 2017 Executive Committee meeting.

19 2/14/2017Request that the MCOs assist in advertisement of the IA Health Link Public Comment meetings

Medicaid DirectorCompleted ‐ Confirmed by the State at March 14, 2017 Executive Committee meeting that MCOs were assisting by way of newsletters, the clinical advisory and the community advisory committees.

20 2/23/2017

Update on the new CMS managed care rules and whether changes are necessary to be in compliance. UPDATE on February 23, 2017: Matt Highland to present information and progress on new standardization of member content and format in publications at the March 14, 2017, Executive Committee meeting. Within presentation, Matt will also discuss how standardization will impact the grievance and appeals process.

Medicaid DirectorCompleted ‐ Matt Highland presented on the communications standardization of managed care regulations in March 14, 2017 Executive Committee meeting.

21 2/23/2017General Recommendation: Enforce regulation that Managed Care Organizations (MCOs) follow established state Preferred Drug List (PDL), as required within their contracts.


22 2/23/2017General Recommendation: Encourage the MCOs provide data regarding medication denial rates for MAAC Executive Committee to monitor for future recommendations.


23 2/23/2017General Recommendation: Extend the allotted 30 day nursing facility stay for HCBS waiver recipients to 120 days.

Medicaid Director In rules process for change.

24 2/23/2017

Secondary Payer: * Clarify MCOs as a secondary payer. * To have presentation on the coordination between Medicaid and Medicare for dual eligible members in the waiver programs.

Medicaid Director Completed ‐ Discussed at October 10, 2017 Executive Committee meeting.

Completed Page 4




25 3/14/2017Matt Highland to give an update regarding Communications Standardization for Managed Care Regulations at a future Executive Committee meeting.

Medicaid Director Completed

26 4/11/2017

Gather previous quarterly report data regarding the top five reasons for grievances and appeals for comparison to assist in determination if there are systemic trends in the information. The Department is to determine if a quarter by quarter comparison chart regarding this topic should be included in future quarterly reports.

Medicaid Director Completed ‐ Discussed at August 24, 2017, Executive Committee meeting.

27 4/11/2017

Determine average aggregate cost per member per day for special needs members in ICF/ID. UPDATE July 11, 2017: Additionally, break down by: * Community‐based ICF/ID providers * State resource centers * Out‐of‐state placement


28 4/11/2017

Examine out‐of‐state placement for members in facilities to determine the impact on members as well as program. * Border Issues * Medical Conditions * Ages * Other factors leading to out‐of‐state placement

EC Members and Medicaid Director Completed ‐ Discussed at August 24, 2017, Executive Committee meeting.

29 6/15/2017

Identify trends involving payment issues: * The largest issues * Where issues are most prevalent and if this trend changes over time * Where issues continue to reside * If the same issues affect different provider types * The proportion of issues that occur with the MCOs versus with provider organizations * The top reasons why payment issues persist * Identify if the top reasons for payment issues change over time

EC Members and Medicaid Director Completed ‐ Discussed at August 24, 2017, Executive Committee meeting.

30 7/11/2017

Provide data on grievance and appeals ‐ at the State Fair Hearing: * How many cases are ruled in favor of an MCO * How many never go through the entire appeals process * How many issues are resolved at the MCO level and never go to the level of the State Fair Hearing.


31 7/11/2017 Updates on the EVV stakeholder workgroup meetings. Medicaid Director Completed ‐ Discussed at September 12, 2017, Executive Committee meeting.

32 7/11/2017Research national benchmark on Program Integrity fraud rate data with home health providers.

Medicaid Director Completed ‐ discussed at October 10, 2017 Executive Committee meeting

33 8/8/2017Review the process involving transfer of member information from one MCO to another MCO when a member chooses to change their MCO

EC Members and Medicaid Director Completed ‐ discussed at September 12, 2017, Executive Committee meeting.

34 8/8/2017

Managed Care Division to provide a review of managed care quality performance measures ‐ HEDIS and HSAG UPDATE on October 10, 2017: Managed Care Division to provide 12 months of HEDIS data when it becomes available and provide a list of what data is being tracked in the HEDIS measures.

Medicaid Director ‐ Managed Care Division

Completed

Completed Page 5




35 8/8/2017

Have future discussion on the role of care coordinators and case managers responsible for waivers. Which set of activities is making the greatest impact on improving outcomes? UPDATE on October 10, 2017: MCOs to present on the service planning process between the member's Interdisciplinary Team (IDT) and Utilization Management (UM) team to ensure conflict‐free case management. UPDATE on November 16, 2017: The Department to discuss the process of how care coordination moves through conflict‐free case management within an MCO, through the Utilization Management (UM) process to delivery of care payment and/or denial of payment for services.

EC Members and Medicaid Director and MCOs

Completed ‐ discussed at January 4, 2018, Executive Committee meeting.

36 10/10/2017The Department and MCOs to present on secret shopper methodologies and metrics.

Medicaid Director and MCOs Completed ‐ discussed at December 19, 2017, Executive Committee meeting.

37 10/12/2017

Public Comment Recommendation: Ensure clear and consistent guidelines and protocols are published to guide decisions around prior authorization both within the Managed Care Organizations and the durable medical equipment (DME) providers. Ensure that the published guidelines are share with DME providers.

Medicaid DirectorCompleted ‐ Director Response Letter dated November 14, 2017, reviewed by MAAC Executive Committee on December 19, 2017.

38 10/12/2017

Public Comment Recommendation: Ensure that training on these prior authorization guidelines is provided to internal Manage Care Organization staff in order to ensure a consistent application in the decision‐making process.


39 10/12/2017

Public Comment Recommendation: Ensure that Managed Care Organizations are communicating clearly and in a timely manner with providers, including ensuring that denial communication in the pre‐authorization process clearly delineates reasons for denial so that providers can address those denials as well as learn improved processes for the future.


40 10/12/2017Public Comment Recommendation: Ensure that durable medical equipment providers are notified in a timely way when changes to fee schedules occur.


41 10/12/2017

Public Comment Recommendation: Ensure the MCOs are using case managers effectively and efficiently to assist clients in navigating access to services. The Executive Committee requests information from Medicaid staff to better understand how conflict‐free case management operates in the Iowa program, including interactions in care planning between utilization management and interdisciplinary teams.


42 10/12/2017Public Comment Recommendation: The department is to develop a new methodology to track consistency of prior authorization determination within each MCO.


Completed Page 6




43 10/12/2017Public Comment Recommendation: Include the accuracy and consistancy of information provided by the MCO customer service representatives to both providers and members in the Managed Care Quarterly Report.


44 10/12/2017Public Comment Recommendation: Include secret shopper results to the managed‐care quarterly report.


45 11/16/2017 The Department to present on tiered rates. Medicaid Director Completed ‐ discussed at December 19, 2017, Executive Committee meeting.

46 12/11/2017

The Department to present on LTSS ‐ Deb Johnson *Who is covered *What services are covered *Costs and funding *Potential expansion of participation *MCO contractual requirements *Understanding of where home health, CDAC, nursing homes, and other providers fit

Medicaid Director Completed ‐ discussed at future Executive Committee meeting.

47 12/11/2017Presentation by the IME and UnitedHealthcare (Kim Foltz) regarding issues pertaining to the transition.

Medicaid Director and MCOs Completed ‐ discussed at December 19, 2017, Executive Committee meeting.

48 1/22/2018

Transition of Members to UnitedHealthcare: MAAC's Executive Committee recommends that staff update the Council and Executive Committee regarding the transition of members from AmeriHealth to UnitedHealthcare. Both the Full MAAC and its Executive Committee had had strong interest in understanding both the transition of members away from AmeriHealth, as well as receipt of those member enrollments by UnitedHealthcare resulting from the transition of AmeriHealth out of the Medicaid program, effective December 1, 2017. Because time has been of the essence relating to this transition, both Deputy Director Stier and staff from UnitedHealthcare have apprised the Executive Committee in December and January of the status of this transition. We ask they provide similar status updates for the Full MAAC at its upcoming meeting in February 2018.

Medicaid Director and Managed Care Organizations

Completed ‐ discussed at February 19, 2018, Full Council meeting.

49 3/14/2017Matt Highland and representatives from the MCOs are to present information regarding mobile applications at a future Executive Committee meeting.

Medicaid Director Completed ‐ discussed at February 27, 2018, Executive Committee meeting.

50 11/16/2017The Department to present on Consumer Assessment of Healthcare Providers and Systems (CAHPS).

Medicaid Director Completed ‐ discussed at March 20, 2018, Executive Committee meeting.

51 12/19/2017 Deb Johnson to present on LTSS Medicaid DirectorCompleted ‐ discussed at January 2018, February 2018, and March 2018 Executive Committee and Full Council meetings.

Completed Page 7




52 1/22/2018

Long Term Services and Supports: MAAC's Executive Committee recommends Department staff bring to the MAAC's Executive Committee and the Council background information on the diversity of services and populations that make up LTSS for Iowa Medicaid. These presentations will be provided over a series of meetings to allow MAAC members to understand demographics and health needs of the populations enrolled in LTSS services, understanding what services are covered, better understand both costs and funding of these services, managed care contractual requirements for LTSS services including care coordination and planning with service recipients and providers, and related issues. These presentations have already begun with a presentation from Deb Johnson at the January 4, 2018, Executive Committee meeting discussing populations and demographics of enrollees.

Medicaid DirectorCompleted ‐ discussed at January 2018, February 2018, and March 2018 Executive Committee and Full Council meetings.

Completed Page 8

Iowa Medicaid Enterprise

Managed Care Organization Report: SFY 2018, Quarter 2

(October-December 2017) Performance Data

Published March 28, 2018

Quarterly MCO Data 1

CONTENTS Executive Summary ....................................................................................................................................................... 2 Plan Enrollment By Age ................................................................................................................................................. 4 Plan Enrollment by MCO ............................................................................................................................................... 5 Plan Enrollment by Program .......................................................................................................................................... 5 Plan Disenrollment by MCO .......................................................................................................................................... 7 All MCO Long Term Services and Supports (LTSS) Enrollment ...................................................................................... 8 Care Coordination Reporting ......................................................................................................................................... 9 Chronic Condition Health Home Assignment .............................................................................................................. 11 Non-LTSS Update of Care Plans ................................................................................................................................... 12 Behavioral Health: Integrated Health Home Enrollment ............................................................................................ 13 Special Needs: LTSS Home and Community-Based Care Coordination ....................................................................... 14 Iowa Participant Experience Survey Reporting............................................................................................................ 20 Biannual Waiver Employment Services Reporting ...................................................................................................... 21 Consumer Protections and Supports ........................................................................................................................... 22 MCO Program Management ....................................................................................................................................... 26 MCO Financials ............................................................................................................................................................ 49 Program Integrity......................................................................................................................................................... 54 Health Care Outcomes ................................................................................................................................................. 55 Appendix: HCBS Waiver Waitlist ................................................................................................................................. 59 Appendix: Compliance Remedies Issued .................................................................................................................... 60 Appendix: Glossary ..................................................................................................................................................... 61


EXECUTIVE SUMMARY

Legislative Requirements: This report is based on requirements of 2016 Iowa Acts Section 1139. The legislature grouped these reports into three main categories:

• Consumer Protection • Outcome Achievement • Program Integrity

The department grouped the managed care reported data in this publication as closely as possible to House File 2460 categories but has made some alterations to ease content flow and data comparison. This publication content will flow in the following way:

• Eligibility and demographic information associated with members assigned to managed care

• Care coordination related to specific population groupings (General, Special Needs, Behavioral Health, and Elderly)

• Consumer protections and support information • Managed care organization program information related to operations • Network access and continuity of providers • Financial reporting • Program integrity actions and recoveries • Health care outcomes for Medicaid members • Appendices with supporting information

This report is based on Quarter 2 of State Fiscal Year (SFY) 2018 and includes the information for the Iowa Medicaid Managed Care Organizations (MCO):

• Amerigroup Iowa, Inc. (Amerigroup, AGP) • AmeriHealth Caritas Iowa, Inc. (AmeriHealth, ACIA) • UnitedHealthcare Plan of the River Valley, Inc. (UnitedHealthcare, UHC)

Notes about the reported data:

• AmeriHealth Caritas Iowa, Inc. did not have members enrolled in December 2017. o Measures that provide a snapshot of the last months of the quarter, including but

not limited to demographic information and case management assignment, will be reported as 0 (zero) or N/A.

o Measures with November snapshots or aggregate data for the reported period will still include AmeriHealth Caritas Iowa, Inc. data.

• For this reporting period, it is noteworthy to consider how transition of AmeriHealth Caritas members to UnitedHealthcare or Fee-for-Service may have impacted reporting.

• This quarterly report is focused on key descriptors and measures that provide information about the managed care implementation and operations.

• While this report does contain operational data that can be an indicator of positive member outcomes, standardized, aggregate health outcome measures are reported


annually. This will include measures associated with HEDIS®1 CAHPS2, and measures associated with the 3M Treo Value Index Score tool developed for the State Innovation Model (SIM) grant that the state has with the Centers for Medicare and Medicaid Services (CMS).

• The reports are largely based on managed care claims data. Because of this, the data will not be complete until a full 180 days has passed since the period reported. However, based on our knowledge of claims data this accounts for less than 15% of the total claim volume for that reporting period.

• The Medical Loss Ratio information is reflected as directly reported by the MCOs. • The Department validates the data by looking at available fee-for-service historical

baselines, encounter data, and by reviewing the source data provided by the MCOs. More information on the move to managed care is available at http://dhs.iowa.gov/ime/about/initiatives/MedicaidModernization Providers and members can find more information on the IA Health Link program at http://dhs.iowa.gov/iahealthlink

1 The Healthcare Effectiveness Data and Information Set (HEDIS®) is a standardized, nationally-accepted set of performance measures that assess health plan performance and quality. 2 The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized, nationally-accepted survey that assesses health plan member satisfaction.

http://dhs.iowa.gov/ime/about/initiatives/MedicaidModernization

http://dhs.iowa.gov/iahealthlink


PLAN ENROLLMENT BY AGE

324,141 55.6%

234,719 40.3%

23,954 4.1%

Managed Care Enrollment by Age Total MCO Enrollment = 582,814*

0-21 22-64 65+

*December 2017 enrollment data as of January 31, 2018 – data pulled on other dates will not reflect the same numbers due to reinstatements and eligibility changes. This includes hawk-i enrollees. 75,417 members are in the Fee-for-Service (FFS) program.


PLAN ENROLLMENT BY MCO

*December 2017 data as of January 31, 201 – data pulled on other dates will not reflect the same numbers due to reinstatements and eligibility changes. This differentiates hawk-i enrollees due to differences in hawk-i enrollment procedures. In most cases, hawk-i members select an MCO prior

to beginning benefits whereas other programs have default assignment with self-selection occurring after default assignment. 75,417 members are in the Fee-for-Service (FFS) program.

190,561 32.7%

391,921 67.3%

MCO Plan Enrollment Distribution Total MCO Enrollment = 582,814*

Amerigroup UnitedHealthcare

UnitedHealthcare Plan Assignment

Default Assignment

hawk-i

Self-Selection

343,923 87.7%

32,754 8.4%

15,244 3.9%

Amerigroup Plan Assignment

Default Assignment

hawk-i

Self-Selection

165,174 86.7%

10,636 5.6%

14,751 7.7%


PLAN ENROLLMENT BY PROGRAM

*December 2017 enrollment data as of January 31, 2018 – data pulled on other dates will not reflect the same numbers due to reinstatements and eligibility changes. 75,417 members are in the Fee-for-Service (FFS) program.

43,722 7.5%

400,566 68.7%

138,526 23.8%

All MCO Enrollment by Program Total MCO Enrollment = 582,814*

hawk-i Medicaid Iowa Wellness Plan

47,560 34.3%

90,966 65.7%

Iowa Wellness Plan Enrollment = 138,526

Amerigroup

UnitedHealthcare

132,365 33.0%

268,201 67.0%

Traditional Medicaid Enrollment = 400,566

Amerigroup

UnitedHealthcare

10,636 24.5%

32,754 75.5%

hawk-i Enrollment = 43,722

Amerigroup

UnitedHealthcare


PLAN DISENROLLMENT BY MCO

*Q2 SFY18 enrollment data as of December 31, 2017 – data pulled on other dates will not reflect the same numbers due to reinstatements and eligibility changes. Disenrollment does not include members in the hawk-i program. Disenrollment refers to members who have chosen to change their enrollment with one MCO to an alternate MCO. The chart above indicates the number of members disenrolling from the MCO to another MCO. This includes members changing MCOs within the 90 day “choice period” that they can change for any reason as well as “good cause” disenrollments after the 90 day choice period. Members leaving AmeriHealth in November and December are not being counted because there was not member choice. Reasons for “Good Cause” Disenrollment for Q2 SFY18

Members can disenroll for good cause any time during the year after their 90 day choice period if certain criteria are met such as:

• The member needs related services to be performed at the same time; not all related services are available within the network; and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk.

• Other reasons, including but not limited to, poor quality of care, lack of access to services covered under the contract, lack of access to providers experienced in dealing with the member’s health care needs, or eligibility and choice to participate in a program not available in managed care (i.e. PACE).

• MCO does not, because of moral or religious objections, cover the service the member seeks.

Summary Reason Count Established provider in another MCO network 1,398 Continuity of care 112 Lack of access to services covered under the contract 32 Lack of access to providers experienced in dealing with the member’s health care needs 27 Quality of care 9

576

1,166

804 779 740

359

0

200

400

600

800

1,000

1,200

1,400

Q1 SFY18 Q2 SFY18 Q3 SFY18 Q4 SFY18

Active Member Disenrollment by MCO* Amerigroup AmeriHealth UnitedHealthcare


ALL MCO LONG TERM SERVICES AND SUPPORTS (LTSS) ENROLLMENT

Total MCO LTSS Enrollment by Plan

*December 2017 enrollment data as of January 30, 2018 – data pulled on other dates will not reflect the same numbers due to reinstatements and eligibility changes.

21,739 62.3%

13,160 37.7%

LTSS Managed Care Enrollment by Location MCO LTSS Enrollment = 34,899*

Community Based Services Facility Based Services (ICF/ID, Nursing Facility, PMIC)

3,760 47.6%

4,138 52.4%

Amerigroup LTSS Enrollment = 7,898

Community Based Services

Facility Based Services

17,979 66.6%

9,022 33.4%

UnitedHealthcare LTSS Enrollment = 27,001

Community Based Services

Facility Based Services


CARE COORDINATION REPORTING Members who have a health care coordinator have special health care needs and will benefit from more intensive health care management. The special health care needs include members with chronic conditions such as diabetes, COPD, and asthma. Special health care needs may be identified through the initial health risk assessment, standard industry predictive modeling, claims review, or physician referral. Care coordination can also occur at the request of the member or caregiver. This is a new and more comprehensive health care coordination strategy than was available in fee-for-service.

Population-Specific Supporting Data for Q2 SFY18 Data are cumulative

for the quarter Amerigroup AmeriHealth UnitedHealthcare Count % Count % Count % Initial HRAs Completed Timely for Seniors (Ages 65& Up)

276 90% 191 99% 333 89%

Initial HRAs Completed Timely for Adults(Ages 18-64)

1,057 86% 504 94% 1,071 94%

Initial HRAs Completed Timely for Children (Under Age 18)

1,119 61% 517 75% 810 74%

At least seventy percent (70%) of the MCO’s new members, who have been assigned to the MCO for a continuous period of at least ninety (90) days and the MCO has been able to reach within three attempts, must receive an initial health risk assessment. This data includes all MCO populations. This data element does not have a direct benchmark to compare to historical fee-for-service data.

73% 2,452

86% 1,212

0%

20%

40%

60%

80%

100%


Totals: Percentage and Number of Members Receiving Initial Health Risk Assessments Completed Timely

Amerigroup AmeriHealth UnitedHealthcare

78% 2,820

94% 1,961

70% 1,142

85% 2,214


Health risk assessments were not required for all Medicaid members in fee-for-service prior to managed care implementation. Health risk assessments were considered a Healthy Behavior for members in the Iowa Health and Wellness Plan which would assist in premium reduction if completed. Members identified as having a special health care need through the initial health risk assessment or other means may be assigned a care coordinator with an MCO Care Coordination Program, a Chronic Condition Health Home, or an Integrated Health Home. This data element does not have a direct benchmark to compare to historical fee-for-service data.

Data is as of December 2017. AmeriHealth did not have any members enrolled in December 2017.

Population-Specific Supporting Data for Q2 SFY18 Data Reported as of December 31, 2017 Amerigroup AmeriHealth UnitedHealthcare Count of Non-LTSS Seniors (Ages 65& Up) Assigned a Health Care Coordinator

197 0 140

Count of Non-LTSS Adults (Ages 18-64) Assigned a Health Care Coordinator

2,945 0 3,167

Count of Non-LTSS Children (Under Age 18) Assigned a Health Care Coordinator

1,203 0 1,819

4,854 4,345

2,833

3,845

5,126

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000


Totals: Non-LTSS Members Assigned a Health Care Coordinator Amerigroup AmeriHealth UnitedHealthcare


CHRONIC CONDITION HEALTH HOME ASSIGNMENT

Alternatives to MCO Health Care Coordinators are Chronic Condition Health Home care coordination and Integrated Health Home care coordination. This section focuses on Chronic Condition Health Homes. Chronic Condition Health Homes are medical offices that provide care coordination services on behalf of the Managed Care Organization.

Population-Specific Supporting Data for Q2 SFY18

Data Reported as of November 30, 2017 Amerigroup AmeriHealth UnitedHealthcare Count of Non-LTSS Seniors (Ages 65& Up) Enrolled in a Chronic Condition Health Home

205 272 143

Count of Non-LTSS Adults(Ages 18-64) Enrolled in a Chronic Condition Health Home

1,427 1,284 1,270

Count of Non-LTSS Children (Under Age 18) Enrolled in a Chronic Condition Health Home

416 384 495

2,082 2,048

1,793 1,940

1,661 1,908

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000


Totals: Members Enrolled in a Chronic Condition Health Home Amerigroup AmeriHealth UnitedHealthcare


NON-LTSS UPDATE OF CARE PLANS Non-LTSS Members identified as having special health care needs and requiring ongoing care coordination have care plans developed and managed by the MCO. Federal regulations require that revisions to care plans for these members occur at least annually. This measure does not have a fee for service benchmark. All plans have indicated that their care coordination works to provide health care coordination such that members are prepared to discharge within twelve months, which is why the data reported indicates that few or zero care plans have been updated.

Population-Specific Supporting Data for Q2 SFY18 Data are cumulative

for the quarter Amerigroup AmeriHealth UnitedHealthcare Count % Count % Count % Non-LTSS Care Plans Updated Timely for Seniors (Ages 65& Up)

0 N/A 0 N/A 0 N/A

Non-LTSS Care Plans Updated Timely for Adults(Ages 18-64)

1 100% 0 N/A 0 N/A

Non-LTSS Care Plans Updated Timely for Children (Under Age 18)

0 N/A 0 N/A 0 N/A

*Amerigroup data percentage for Q1 has been updated to reflect a correction identified after the publication of last quarter’s report.

100% 1 N/A

0 0%

20%

40%

60%

80%

100%


Totals: Percentage and Number of Members with Non-LTSS Care Plans Updated Timely


100%* 11

N/A 0

N/A 0 N/A

0


BEHAVIORAL HEALTH: INTEGRATED HEALTH HOME ENROLLMENT Integrated Health Homes specialize in the coordinated care of members with serious and persistent mental illness and serious emotional disturbances. Members receiving Habilitation program services and Children’s Mental Health Waiver services may receive care coordination through the Integrated Health Home instead of from MCO care coordinators or community-based case managers.

Population-Specific Supporting Data for Q2 SFY18 Data Reported as of November 30, 2017 Amerigroup AmeriHealth UnitedHealthcare Count of Seniors (Ages 65& Up) Enrolled in an Integrated Health Home

124 123 89

Count of Adults(Ages 18-64) Enrolled in an Integrated Health Home

4,898 5,540 3,756

Count of Children (Under Age 18) Enrolled in an Integrated Health Home

3,266 3,475 2,465

8,207 8,288

9,321 9,138

5,765 6,310

0

5,000

10,000

15,000

20,000

25,000


Totals: Members Enrolled in an Integrated Health Home Amerigroup AmeriHealth UnitedHealthcare


SPECIAL NEEDS: LTSS HOME AND COMMUNITY-BASED CARE COORDINATION Community-based case management is a service that is specifically-designed to manage members receiving long term services and supports (LTSS). This is a new and more comprehensive case management strategy than was available in fee-for-service. Key components of community-based case management include person-centered care planning, addressing member’s care and treatment needs, providing assurances for health and safety, and addressing potential risks related to members’ desire to live as independently as possible. The count of Members Assigned a Community-Based Case Manager represents unduplicated count of members assigned a community-based case manager (CBCM) on the last day of the quarter. 100% of members receiving Home- and Community-Based Services (HCBS) should be assigned a community-based case manager. The IME is working to resolve data timing issues that may be impacting reported assignment.

HCBS Waiver-Specific Supporting Data for Q2 SFY18 Data Reported as of December 31, 2017 Amerigroup AmeriHealth UnitedHealthcare Brain Injury Members Assigned a CBCM 202 0 947

Elderly Members Assigned a CBCM 1,322 0 5,816

Health and Disability Members Assigned a CBCM

542 0 1,046

HIV/ AIDS Members Assigned a CBCM 13 0 18

Intellectual Disability Members Assigned a CBCM

1,043 0 8,562

Physical Disability Members Assigned a CBCM

310 0 575

99% 3,432

N/A 0

0%

20%

40%

60%

80%

100%


Totals: Percentage and Number of HCBS Members Assigned a Community-Based Case Manager


98% 3,336 99%

16,550

91% 2,693

97% 16,964


At a minimum, community-based case managers must contact 1915(c) HCBS waiver members at least monthly in person or by phone with an interval of at least 14 calendar days between contacts. HCBS Members Receiving Monthly Contact monitors the count of members requiring and the count of members receiving timely contact during the quarter. There may be legitimate reasons a member cannot be contacted outside MCO control. The department monitors the volume and reasons for missed contacts.

On October 31, 2017, AmeriHealth Caritas announced their departure from the IA Health Link program, effective November 30, 2017. UnitedHealthcare assumed these members and this effort impacted the UnitedHealthcare results for December.

At a minimum, community-based case managers must visit members in their residence face-to-face quarterly with an interval of at least 60 calendar days between visits. HCBS Members Receiving Quarterly Face-to-Face Contact monitors the count of members requiring and the count of members receiving timely face-to-face contact during the quarter. There may be legitimate reasons a member cannot be contacted outside MCO control. The department monitors the volume and reasons for missed contacts.

84% 87% 89% 80%

93% 80%

0%

20%

40%

60%

80%

100%


Percentage of HCBS Members Receiving Minimum Monthly Contact Timely


89% 96%

74% 80%

99%

80%

0%

20%

40%

60%

80%

100%


Percentage of HCBS Members Receiving Minimum Quarterly Face-to-Face Contact Timely




Community-Based Case Management Ratios The ratios below reflect combined adult and child populations for these settings where applicable. Data Reported as of December 31, 2017 Amerigroup AmeriHealth UnitedHealthcare

Members in Facility per Community-Based Case Manager

59 N/A 38

Members in Community per Community-Based Case Manager

40 N/A 33

Unduplicated LTSS Members per Community-Based Case Manager

67 N/A 46


Service Plans Waiver service plans must be updated annually or as the member’s needs change.

Members will continue to receive the same level of services regardless of whether service plan has been updated timely.

The department will be closely monitoring corrective actions to ensure that service plans are completed in a timely manner for all Medicaid members.

The percentage listed for AmeriHealth is as of November 30, 2017. The percentages listed for Amerigroup and United are as of December 31, 2017.

98% 99% 100% 100% 100% 98%

0%

20%

40%

60%

80%

100%


Percentage of Service Plans Completed Timely Amerigroup AmeriHealth UnitedHealthcare Contract Requirement


Level of Care Level of care (LOC) and functional need assessments must be updated annually or as a member’s needs change. D

Ninety-five percent (95%) of needs assessments must be completed annually or as a member’s needs change. There may be legitimate reasons for MCO failure to complete LOC Reassessments timely, such as member hospitalization or other extenuating member circumstances. The department requests MCO exception details for members that did not have LOC Reassessments completed timely. Exceptions are granted for one month only, with the requirement that MCOs complete the assessment in the following month, or request a new exception.

The department closely monitors these details in conjunction with corrective actions to ensure that LOC assessments are completed in a timely manner for all Medicaid members. This includes staffing contingencies implemented to ensure that adequate resources are available to perform level of care assessments for both new members as well as members that are due for their annual reassessment.

Members will continue to receive the same level of services regardless of whether level of care has been reassessed timely. LOC reassessment timeliness does not have an impact on a member’s eligibility for services.


98% 99% 97% 96% 96% 98% 95% 97% 95% 91% 95%

0%

99% 99% 99% 99% 99%

34%

0%

20%

40%

60%

80%

100%

July-17 August-17 September-17 October-17 November-17 December-17

Percentage of LOC Reassessments Completed Timely

Amerigroup AmeriHealth UnitedHealthcare Contract Requirement


Critical Incidents Home- and Community-Based Services (HCBS) Waiver and Habilitation providers and case managers/care coordinators are required to report critical incidents to the MCOs. These critical incidents are to be reported if the reporting entity witnesses the incident or is made aware of the incident. Critical incidents are events that may affect a member’s health or welfare, such incidents involving:

• Physical injury; • Emergency mental health treatment; • Death; • Law enforcement intervention; • Medication error resulting in one of the above; • Member elopement; or, • Reported child or dependent abuse.

Resolution indicates that the MCO has reviewed the incident and is working with the member or provider to mitigate the risk of events in the future.

Data Reported Amerigroup AmeriHealth UnitedHealthcare HCBS and Habilitation Members as of December 2017

5,862

AmeriHealth did not have any HCBS or

Habilitation members as of December 2017.

22,097

Critical Incident Q2 SFY18 Resolution Program Received Resolved Received Resolved Received Resolved Aids/HIV Waiver Critical Incidents Received in Q2 SFY18

0 N/A 0 N/A 1 N/A

Brain Injury Critical Incidents Received in Q2 SFY18

22 100% 73 62% 51 100%

Children’s Mental Health Critical Incidents Received in Q2 SFY18

24 100% 24 46% 40 100%

Elderly Critical Incidents Received in Q2 SFY18 60 100% 139 40% 99 100%

Habilitation Critical Incidents Received in Q2 SFY18

502 100% 443 49% 419 100%

Health Disability Critical Incidents Received in Q2 SFY18

25 100% 13 62% 16 100%

Intellectual Disability Critical Incidents Received in Q2 SFY18

124 100% 745 53% 272 100%

Money Follows the Person Critical Incidents Received in Q2 SFY18

1 100% 1 100% 10 100%

Physical Disability Critical Incidents Received in Q2 SFY18

10 N/A 16 81% 16 100%


IOWA PARTICIPANT EXPERIENCE SURVEY REPORTING

Iowa Participant Experience Survey Reporting The data below reflect the results of Iowa Participant Experience Survey (IPES) activities and results. IPES results are one component of the Iowa Department of Human Services Home and Community Based Services quality strategy.

Data Reported Amerigroup AmeriHealth UnitedHealthcare Iowa Participant Experience Survey Count of Members Surveyed Q2 SFY18

Aids/HIV 1 0 0 Brain Injury 7 2 4 Children’s Mental Health 1 0 0 Elderly 32 12 17 Habilitation 3 0 15 Health Disability 5 1 14 Intellectual Disability 8 16 9 Money Follows the Person 0 0 0

Physical Disability 6 0 20 Iowa Participant Experience Survey Aggregated Responses Q2 SFY18

Members Reporting They Feel They Have Been a Part of Planning Their Waiver Services

94% 87% 90%

Members Reporting Talking About Health Issues When Their Plan Was Being Developed

92% 90% 86%

Members Reporting Services Include All the Things They Told Their Team They Needed and Wanted

83% 94% 82%

Members Reporting They Feel Safe Where They Live

98% 100% 99%

Members Reporting it was Easy to Make Contact with Service Staff

94% 93% 92%

Members Reporting Their Services and Providers Make Their Life Better

98% 97% 87%

Members Receiving Employment Services that Report They Like Their Job

Not Reportable 36% Not Reportable

Percentages reflect the number of survey responses from all applicable waivers indicating “yes”. Other valid survey responses include “no,” “I don’t know,” “I don’t remember,” and “No/Unclear response.”


BIANNUAL WAIVER EMPLOYMENT SERVICES REPORTING

Biannual Waiver Employment Services Outcomes Supported employment services are provided to members on home and community based service waivers for Brain Injury, Habilitation, and Intellectual Disability. As stated in the Iowa Department of Human Services Employment Outcomes Vision, "Employment in the general workforce is the first priority and the expected and preferred outcome in the provision of publically funded services for all working age Iowan's with disabilities." In alignment with this vision, utilization and wage data for members receiving employment services is requested by case managers twice annually in April and October with a 90 day reporting lag.

Supported Employment Data The department collects labor and wage information for members in eligible waiver programs receiving supported employment services. Data Reported as of

October 31, 2017 Amerigroup AmeriHealth UnitedHealthcare Individual Jobs Services Outcomes

Brain Injury Waiver Members Served 9 56 5 Habilitation Members Served 156 302 79 Intellectual Disability Waiver Members Served 93 1,480 80

Small Group Employment Services Outcomes Brain Injury Waiver Members Served 0 15 2 Habilitation Members Served 53 92 25 Intellectual Disability Waiver Members Served 32 479 39

Facility-Based Services Outcomes Brain Injury Waiver Members Served 2 27 2 Habilitation Members Served 70 172 34 Intellectual Disability Waiver Members Served 23 807 51


CONSUMER PROTECTIONS AND SUPPORTS Member Grievances and Appeals

MCO Member Grievances and Appeals Grievance and appeal data demonstrates the level to which the member is receiving timely and adequate levels of service. If a member does not agree with the level in which services are authorized, they may pursue an appeal through the managed care organization. Grievance: A written or verbal expression of dissatisfaction. Appeal: A request for a review of an MCO’s denial, reduction, suspension, termination or delay of services. Resolved: The appeal or grievance has been through the process and a disposition has been communicated to the member and member representative.

This measure represents grievances resolved within the contractual timeframes and does not measure the member’s satisfaction with that resolution. Grievances with contractually-allowed extensions of resolution timeframe are excluded from the numerator and denominator. If a member is not satisfied with the MCO’s resolution to their grievance, the member may contact the Iowa Medicaid Enrollment Broker to disenroll if “good cause” criteria are met. This data element does not have a direct benchmark to compare to historical fee-for-service data.

100% 100% 100% 100% 99% 100%

0%

20%

40%

60%

80%

100%


Percentage of Grievances Resolved within 30 Calendar Days of Receipt



Supporting Data Amerigroup AmeriHealth UnitedHealthcare Grievances Received in Q1 SFY18 260 638 104

Grievances Received in Q2 SFY18 244 63 247

MCOs have different criteria for bucketing so the above numbers may represent each reason filed for the grievance with AmeriHealth and Amerigroup while representing unduplicated member grievances for UnitedHealthcare.

Top Five Reasons for Grievances for Q2 SFY18


# Grievances Count Grievances Count Grievances Count

1 Out of Network 275

Type of Grievance - Provider-Dissatisfied

with Treatment of Service

11

Administration – Enrollment/Member

Material – Request to enroll/change benefit plan did not occur within open

enrollment period

89

2 Transportation – Delay 72

Type of Grievance – Transportation – No

Pick-Up 8

Enrollee Access/Availability –

Provider Network Adequacy

65

3 Provider Balance Billed 40

Type of Grievance – Provider – Member

Received Bill 7

Benefit-Other - Ambulance /

Transportation - Dispute regarding non-ambulance methods of transportation

53

4 Provider Attitude/Rudeness 19

Type of Grievance – Transportation –

Excessive Waiting 6 Benefit-Other - Balance

Billing 20

5 Adequacy of

Treatment Record Keeping

15

Type of Grievance – Transportation – Environment of

Vehicle

4 Quality of Care 7

Members may file a grievance with the MCOs for any dissatisfaction that is not related to a clinical decision.


*Amerigroup data percentage for Q1 has been updated to reflect a correction identified after the publication of last quarter’s report. This measure represents appeals resolved within 30 calendar days of receipt. In state fiscal year 2017, appeals required resolution within 45 days of receipt. The first quarter may include appeals resolved in the quarter that were received prior to the 30 day requirement and may have met the previous timeliness standard of 45 calendar days. If a member is not satisfied with the appeal decision, they may file a state fair hearing request with the state.

Supporting Data Amerigroup AmeriHealth UnitedHealthcare Appeals Received in Q1 SFY18 521 430 127

Appeals Received in Q2 SFY18 499 244 154

This data element does not have a direct benchmark to compare to historical fee-for-service data as the managed care appeal process does differ from the administrative appeal process.

Top Five Reasons for Appeals for Q2 SFY18


# Appeals Count Appeals Count Appeals Count

1 Pharmacy - Non Injectable 208 Pharmacy 49

Benefit – Other - Pharmacy - Dispute of drugs that require

clinical coverage review.

102

2 BH – Op Service 50 LTSS – Long-Term Support Services 39

Benefit – Other - Pharmacy - Dispute of coverage of non-

preferred drugs

39

99%* 100% 98% 100% 98% 100%

0%

20%

40%

60%

80%

100%


Percentage of Appeals Resolved within 30 Calendar Days of Receipt




# Appeals Count Appeals Count Appeals Count

3 Surgery 34 Durable Medical Equipment 35

Benefit-Clinical - Utilization Review Determination - Dispute over the

medical necessity of a service or treatment.

34

4 Pharmacy - Injectable 32 Skilled Care/Nursing 32 Durable Medical

Equipment (DME) 18

5 DME 28 Prior Authorization 19 Benefit – Clinical - Personal Attendant

Services 9

State Fair Hearing Summary for Members in Managed Care Q2 SFY18

Supporting Data Amerigroup AmeriHealth UnitedHealthcare Level of Care 0 0 0 Medical Service Denial/Reduction 65 82 19

Pharmacy Denial/Reduction 62 3 2

Durable Medical Equipment Denial/Reduction

0 2 3

This data reflects the type of state fair hearing requests and does not reflect the disposition of the appeal. Most of the appeal requests received are dismissed or withdrawn due to resolution of the issue prior to hearing.


MCO PROGRAM MANAGEMENT

Member Helpline

This performance target measures the timeliness of answering the helpline calls. The department defines “timely” answers as calls answered in 30 seconds or less. Each MCO conducts internal quality assurance programs for their helplines. Additionally, the department conducts secret shopper calls to measure adequacy, consistency, and soft skills associated with the MCO helplines. The CAHPS surveys conducted annually also measure member satisfaction with their health plan.

Secret shopper calls are conducted by the Iowa Medicaid Enterprise at least weekly and assess MCO customer service representative soft skills and policy knowledge. For each day that call monitoring occurs, five questions are asked of Member helpline representatives to be monitored and scored. Each question can receive a maximum of 2 points, where 2 points indicate a full and complete answer free of errors was provided. Scores are aggregated for each day to

85% 87% 92% 93% 87% 89% 86% 89% 88% 86% 85% 81% 94% 93% 94% 92% 96% 97%

0%

20%

40%

60%

80%

100%


Service Level: Percentage of Member Helpline Calls Answered Timely


7.75 6.40 7.00 7.00

4.60 7.38

10.00 8.60 8.67 9.00 9.00 8.25 8.00 8.60 9.67 9.25 10.00 8.88

0

2

4

6

8

10


Secret Shopper: Member Helpline Average Monthly Score Amerigroup AmeriHealth UnitedHealthcare


achieve a daily score with a maximum of ten points. All results are provided to MCOs so they can address any training needs. The focus of these activities is continuous quality improvement, with topics changing based on current issues. In October, member helpline secret shopper topics focused on getting authorized to receive information regarding an adult child. In November, questions dealt with receiving information regarding the appeals process. In December, topics focused on receiving information regarding MCO choice options.

Top Five Reasons for Members Contacting Helplines for Q2 SFY18

# Amerigroup Count AmeriHealth Count UnitedHealthcare Count October 2017

1. Transportation Questions 9,844

Member Inquiries-Plan

Policy/Procedure Education

7,270 PCP Inquiry 4,635

2. Benefit Inquiry 1,119 Member Changes-

Demographic Changes

6,265 Benefits 3,550

3. Pharmacy Inquiry/Issue 854 Eligibility/Enrollment-

Member Eligibility 2,309 Eligibility Inquiry 2,541

4. Provider

Find/Change/Verify PCP

810 Member Request – ID Card Request 2,282 COB Information 1,778

5. Benefit Inquiry/Issue 802 Member Changes –

PCP Changes 1,690 Claims Inquiry 788

November 2017





2. Benefit Inquiry 1,187 Member Changes-

Demographic Changes

4,889 Benefits 3,991

3. Enrollment Information 771 Eligibility/Enrollment-

Member Eligibility 1,785 Membership Record 2,595

4. Eligibility Inquiry 720 Member Inquiries-General Benefit 1,132 COB Information 1,167

5. Find/Change PCP 573 Member Request – ID Card Request 735 General Inquiry 884

December 2017





2. Benefit Inquiry 1,187 Eligibility/Enrollment-Member Eligibility 824 Benefits 9,959

3. Enrollment Information 771

Member Billing Inquiries – Par

Billing issue 210 Eligibility Inquiry 4,804

4. Eligibility Inquiry 720 Member Inquiries – General Benefit 206 Change

Address/Phone # 3,801

5. Find/Change PCP 573 Member Changes-

Demographic Changes

181 General Inquiry 2,690


Provider Helpline

This performance target measures the timeliness of answering the helpline calls. The department defines “timely” answers as calls answered in 30 seconds or less. Each MCO conducts internal quality assurance programs for their helplines. Additionally, the department conducts secret shopper calls to measure adequacy, consistency, and soft skills associated with the MCO helplines.

Secret shopper calls are conducted by the Iowa Medicaid Enterprise at least weekly and assess MCO customer service representative soft skills and policy knowledge. For each day that call monitoring occurs, five questions are asked of provider helpline representatives to be monitored and scored. Each question can receive a maximum of 2 points, where 2 points indicate a full and complete answer free of errors was provided. Scores are aggregated for each day to achieve a daily score with a maximum of ten points. All results are provided to MCOs so they can address any training needs. The focus of these activities is continuous quality improvement,

83% 85% 92% 96% 80% 87% 87% 86% 88% 87% 83% 82% 91% 94% 93% 97% 99% 98%

0%

20%

40%

60%

80%

100%


Service Level: Percentage of Provider Helpline Calls Answered Timely


7.25 7.80 7.00 4.25

8.60 6.50 6.50

7.80 10.00

6.75 8.80

7.50 7.75 6.00

4.00

7.50 9.80 8.75

0

2

4

6

8

10


Secret Shopper : Provider Helpline Average Monthly Score Amerigroup AmeriHealth UnitedHealthcare


with topics changing based on current issues. In October, provider helpline secret shopper topics included issues with payments and authorizations, switching MCOs, and claims denial. In November, questions dealt exclusively with home health authorization. In December, topics focused on issues regarding the transition from three MCOs to two, including honoring authorizations, claims run-out, and finding out to which MCO members would be assigned.

Top Five Reasons for Providers Contacting Helplines for Q2 SFY18

# Amerigroup Count AmeriHealth Count UnitedHealthcare Count October 2017

1. Claim Status Inquiry 3,229 Claims-Claim Status 15,141 Claims Inquiry 13,172

2. Claims Inquiry 1,455 Provider Requests-Check Remittance

Advice 7,994 Benefits 3,671

3. Claim Denial Inquiry 1,065

Provider Inquiries-Plan


5,761 Authorization Related 1,093

4. Benefits Inquiry 998 Eligibility/Enrollment-Member Eligibility 2,540 COB Information 1,032

5. Transportation Questions 930 Claims-Claim Issues 2,159 Membership Record 573

November 2017




3. Claim Denial Inquiry 906




4. Transportation Questions 897 Claims-Claim Issues 2,204 COB Information 763

5. Benefits Inquiry 862 Eligibility/Enrollment-Member Eligibility 2,106 Membership Record 511

December 2017




3. Claim Denial Inquiry 804




4. Transportation Questions 787 Claims-Claim Issues 1,722 COB Information 1,574

5. Benefits Inquiry 756 Eligibility/Enrollment-Member Eligibility 1,391 Membership Record 1,400


Pharmacy Services Helpline

This performance target measures the timeliness of answering the helpline calls. The department defines “timely” answers as calls answered in 30 seconds or less. Each MCO conducts internal quality assurance programs for their helplines. Additionally, the department conducts secret shopper calls to measure adequacy, consistency, and soft skills associated with the MCO helplines.

88% 88% 89% 92% 91% 91% 93% 90% 86% 85% 85% 90% 100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Service Level: Percentage of Pharmacy Provider Helpline Calls Answered Timely



Medical Claims Payment Medical claims processing data is for the entire quarter. Does not include pharmacy claims.

This measure is a measure of timeliness of adjudication and does not represent the accuracy of payment by the MCOs. The department continues to monitor reimbursement accuracy through analysis, collaborative validation projects with the MCOs, as well as investigation and follow up when the department is made aware of provider reimbursement concerns.


100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 100% 100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of Clean Medical Claims Paid or Denied Within 30 Calendar Days


100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of Clean Medical Claims Paid or Denied Within 45 Calendar Days



78% 73% 75% 79% 72% 77%

0%

20%

40%

60%

80%

100%

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

Amerigroup Medical Claims Status **As of the end of the reporting period

Paid Denied Suspended

76% 76% 70%

76% 75% 71%

0%

20%

40%

60%

80%

100%


AmeriHealth Medical Claims Status **As of the end of the reporting period


63% 68% 67% 62% 70% 68%

0%

20%

40%

60%

80%

100%


UnitedHealthcare Medical Claims Status **As of the end of the reporting period



Top Ten Reasons for Medical Claims Denial as of End of Reporting Period

CARC and RARC are defined below table # Amerigroup AmeriHealth UnitedHealthcare 1. CARC-18 Exact duplicate

claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO).

CARC-27 Expenses incurred after coverage terminated. RARC-N30 Patient ineligible for this service.

CARC-252 An attachment/other documentation is required to adjudicate this claim/ service. RARC-MA04 Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

2. CARC-27 Expenses incurred after coverage terminated.

CARC-8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. RARC-N95 This provider type/provider specialty may not bill this service.

CARC-18 Exact duplicate claim/ service. RARC-N522 Duplicate of a claim processed, or to be processed, as a crossover claim

3. CARC-45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability) RARC-N381-Alert: Consult our contractual agreement for restrictions/billing/payment information related to these charges.

CARC-29 The time limit for filing has expired.

CARC-45 Charge exceeds fee schedule/ maximum allowable or contracted/legislated fee arrangement.

4. CARC-197 Precertification/authorization/notification absent.

CARC-18 Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO) RARC-N522 Duplicate of a claim processed, or to be processed, as a crossover

CARC-208-National Provider Identifier - Not matched. RARC-N77 Missing/incomplete/invalid designated provider number.



CARC and RARC are defined below table # Amerigroup AmeriHealth UnitedHealthcare

claim. 5. CARC-29 The time limit for

filing has expired. CARC-197 Precertification/authorization/notification absent. RARC-M62 Missing/incomplete/invalid treatment authorization code.

CARC-27 Expenses incurred after coverage terminated. RARC-N30 Patient ineligible for this service

6. CARC-252 An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). RARC-N479 Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

CARC-22 This care may be covered by another payer per coordination of benefits. RARC-N4 Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.

CARC-B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

7. CARC-256 Service not payable per managed care contract.

CARC-16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. RARC-MA 130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

CARC-26 Expenses incurred prior to coverage. RARC-N30 Patient ineligible for this service.

8. CARC-97 The benefit for this service is included in the payment/allowance for

CARC-16 Claim/service lacks information or has submission/billing error(s)

CARC-29 The time limit for filing has expired.




another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. allowed. N432 – Alert: Adjustment based on a Recovery Audit.

which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. RARC-N253 Missing/incomplete/invalid attending provider primary identifier.

9. CARC-16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. MA130 – Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

CARC-109 Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. RARC-N193 Alert: Specific federal/state/local program may cover this service through another payer.

CARC-256 Service not payable per managed care contract. RARC-N448 This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.

10. CARC 23 – The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

CARC-16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims

CARC-16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. RARC-M119 Missing/incomplete/invalid/de




attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. RARC-N329 Missing/incomplete/invalid patient birth date.

activated/withdrawn National Drug Code (NDC).

Claim Adjustment Reason Codes (CARC): A nationally-accepted, standardized set of denial and payment adjustment reasons used by all MCOs. http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

Remittance Advice Remark Codes (RARCs): A more detailed explanation for a payment adjustment used in conjunction with CARCs. http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes/


Claims Reprocessing and Adjustments The table below reflects the total count of claims processed including Rx and non-Rx claims, and the count of claims reprocessed or adjusted. Reprocessed or adjusted claims include clean provider adjustment requests, claims processing errors identified, and claims reprocessing projects.

Period Amerigroup AmeriHealth UnitedHealthcare Total Claims Processed October 2017

721,405 859,622 563,614

Total Claims Processed November 2017

648,999 803,332 588,926

Total Claims Processed December 2017

672,010 349,186 929,966

Claims Reprocessed or Adjusted October 2017

24,817 73,675 14,373

Claims Reprocessed or Adjusted November 2017

22,326 55,042 21,187

Claims Reprocessed or Adjusted December 2017

30,188 105,093 32,699

Plans have 30 days from the date of identification of an error or a clean provider adjustment request to reprocess 90% of the claims identified. Claims reprocessing projects may be processed on a different timeline with Agency approval.

*Amerigroup data percentages for Q1 (July, August, and September 2017) have been updated to reflect corrections identified after the publication of last quarter’s report.

100%* 100%* 100%* 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 99%

0%

20%

40%

60%

80%

100%


Percentage of Clean Provider Adjustment Requests and Errors Reprocessed Within 30 Days of Identification



Pharmacy Claims Payment Pharmacy claims processing data is for the entire quarter.


*Amerigroup data percentage for September 2017 has been updated to reflect a correction identified after the publication of last quarter’s report.


*Amerigroup data percentage for September 2017 has been updated to reflect a correction identified after the publication of last quarter’s report.

100% 100% 100%* 100% 100% 100% 100% 100% 100% 100% 100%

0%

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of Clean Pharmacy Claims Paid or Denied Within 30 Calendar Days


100% 100% 100%* 100% 100% 100% 100% 100% 100% 100% 100%

0%

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of Clean Pharmacy Claims Paid or Denied Within 45 Calendar Days



74% 73% 74% 74% 72% 74%

0%

20%

40%

60%

80%

100%


Amerigroup Pharmacy Claims Status **As of the end of the reporting period

Paid Denied

75% 76% 76% 75% 76%

0%

0%

20%

40%

60%

80%

100%


AmeriHealth Pharmacy Claims Status **As of the end of the reporting period

Paid Denied

72% 73% 73% 73% 72% 77%

0%

20%

40%

60%

80%

100%


UnitedHealthcare Pharmacy Claims Status **As of the end of the reporting period

Paid Denied


Top Ten Reasons for Pharmacy Claims Denial as of End of Reporting Period

# Amerigroup AmeriHealth UnitedHealthcare 1. Refill Too Soon No Pharmacy Claims

processed in December 2017. Refill Too Soon 2. Product Not On Formulary No Pharmacy Claims

processed in December 2017. Prod/Service Not Covered 3. Days Supply Exceeds Plan

Limitation No Pharmacy Claims

processed in December 2017. Prior Authorization Required 4. Product/Service Not

Covered – Plan/Benefit Exclusion

No Pharmacy Claims processed in December 2017. Filled After Coverage Term

5. Submit Bill To Other Processor Or Primary Payer

No Pharmacy Claims processed in December 2017. Plan Limitations Exceeded

6. Plan Limitations Exceed No Pharmacy Claims processed in December 2017. Submit bill to other processor

7. DUR Reject Error No Pharmacy Claims processed in December 2017. Prescriber is Not Covered

8. Prior Authorization Required No Pharmacy Claims processed in December 2017. DUR Reject Error

9. Scheduled Downtime No Pharmacy Claims processed in December 2017. Patient is Not Covered

10. This Medicaid Patient Is Medicare Eligible

No Pharmacy Claims processed in December 2017.

Non-Matched Pharmacy Number


Utilization of Value Added Services Reported Count of Members

Managed care organizations may offer value added services in addition to traditional Medicaid and HCBS services. Between the plans there are 40 value added services available as part of the managed care program.

Q2 SFY18 Data Amerigroup AmeriHealth UnitedHealthcare Total

Additional Benefits 924 12,108 485 13,517 Family Planning and Resources 0 0 772 772

Health and Wellness 67 7,934 118 8,119

Healthy Incentives 6,120 3,842 1,818 11,780 Tobacco Cessation 78 465 623 1,166

Services that could be considered as a value add for managed care may not be reflected in this table such as enhanced care coordination, 24/7 nurse call lines, and increased access to health care information.


Provider Network Access There are two major methods used to determine adequacy of network in the contract between the department and the MCOs:

• Member and provider ratios by provider type and by region • Geographic access by time and distance

As there are known coverage gaps within the state for both Medicaid and other health care markets; exceptions will be granted by the department when the MCO clearly demonstrates that:

• Reasonable attempts have been made to contract with all available providers in that area; or

• There are no providers established in that area. Links to time and distance reports for this reporting period can be found at:

• Amerigroup:

o https://dhs.iowa.gov/sites/default/files/GeoAccess-Standards-for-Exhibit-B-

Worksheet-AGP-12012017.pdf

• AmeriHealth Caritas: Not in operations during the reporting period.

• UnitedHealthcare:

o https://dhs.iowa.gov/sites/default/files/GeoAccess-Standards-for-Exhibit-B-Worksheet-UHC-12012017.pdf

GeoAccess maps reflect traditional time and distance standards. As of the date of this publication, all MCOs have submitted exception reports to the department but not all MCO submitted exceptions have been approved. The following table of Percentage of Members with Coverage in Time and Distance Standards provides a snapshot of available non-specialty measures (i.e., providers) for non-HCBS services across the respective regions.

https://dhs.iowa.gov/sites/default/files/GeoAccess-Standards-for-Exhibit-B-Worksheet-AGP-12012017.pdf

https://dhs.iowa.gov/sites/default/files/GeoAccess-Standards-for-Exhibit-B-Worksheet-AGP-12012017.pdf

https://dhs.iowa.gov/sites/default/files/GeoAccess-Standards-for-Exhibit-B-Worksheet-UHC-12012017.pdf

https://dhs.iowa.gov/sites/default/files/GeoAccess-Standards-for-Exhibit-B-Worksheet-UHC-12012017.pdf


Percentage of Members with Coverage in Time and Distance Standards

MCO Amerigroup AmeriHealth UnitedHealthcare Measure 30 Min/ 30 Mile 30 Min/ 30 Mile 30 Min/ 30 Mile Primary Care - Adult

100% 100% 100%

Primary Care – Child

100% 100% 100%

Hospital 100% 100% 100% Behavioral Health – Outpatient

100% 100% 100%

General Optometry 100% 100% 100%

Lab and X-ray Services

100% 100% 100%

Pharmacy 100% 100% 100% MCO Amerigroup AmeriHealth UnitedHealthcare Measure 30 Min/

30 Mile 60 Min/ 60 Mile

90 Min/ 90 Mile

30 Min/ 30 Mile

60 Min/ 60 Mile

90 Min/ 90 Mile

30 Min/ 30 Mile

60 Min/ 60 Mile

90 Min/ 90 Mile

ICF/SNF 100% 100% N/A 100% 100% N/A 100% 100% N/A ICF/ID 100% 100% N/A 100% 100% N/A 90% 100% N/A Behavioral Health – Inpatient

N/A 98% 100% N/A 100% 100% N/A 98% 100%

All MCOs have approved exception requests for the network standards in Exhibit B of the contract for HCBS services. The department continues to monitor network adequacy to ensure that these contract standards are met and will take additional steps towards progressive remedies if necessary.

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of Counties With ≥ 2 HCBS Providers Per County Per 1915c Program



Prior Authorization - Medical

This data element does not have a direct benchmark to compare to historical fee-for-service data as the managed care and fee-for-service prior authorization process and volume may differ. 99% of regular prior authorizations (PAs) must be completed within 14 calendar days of request to meet performance guarantees. The department continues to monitor corrective action to ensure that these performance targets are met as defined in the contract. If a PA request is not approved or denied within seven days, the authorization is considered approved.

This data element does not have a direct benchmark to compare to historical fee-for-service data as the managed care and fee-for-service prior authorization process and volume may differ. 99% of PAs for expedited services must be authorized within 72 hours of request to meet performance guarantees. The department continues to monitor corrective action to ensure that these performance targets are met as defined in the contract.

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of Regular Prior Authorizations (PAs) Completed Within 14 Calendar Days of Request


97% 98% 97% 100% 100% 97% 100% 100% 100% 100% 100%

0%

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of PAs for Expedited Services Authorized Within 72 Hours of Request



This data element does not have a direct benchmark to compare to historical fee-for-service data as the managed care and fee-for-service prior authorization process and volume may differ.



92% 92% 92% 93% 93% 93%

0%

20%

40%

60%

80%

100%


Amerigroup Medical PAs Status **As of the end of the reporting period

Approved Denied Modified

81% 83% 82% 84% 87%

0%

0%

20%

40%

60%

80%

100%


AmeriHealth Medical PAs Status **As of the end of the reporting period


92% 91% 93% 92% 92% 91%

0%

20%

40%

60%

80%

100%


UnitedHealthcare Medical PAs Status **As of the end of the reporting period



Prior Authorization - Pharmacy

This data element does not have a direct benchmark to compare to historical fee-for-service data as the managed care and fee-for-service PA process and volume may differ. 100% of regular PAs must be completed within 24 hours of request to meet performance guarantees. The department continues to monitor corrective action to ensure that these performance targets are met as defined in the contract.

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%


Percentage of Regular PAs Completed Within 24 Hours of Request



61% 63% 61% 61% 67% 66%

0%

20%

40%

60%

80%

100%


Amerigroup Pharmacy PAs Submitted Status **As of the end of the reporting period

Approved Denied

70% 74% 73% 73% 73%

0%

0%

20%

40%

60%

80%

100%


AmeriHealth Pharmacy PAs Submitted Status **As of the end of the reporting period

Approved Denied

84% 84% 85% 87% 86% 90%

0%

20%

40%

60%

80%

100%


UnitedHealthcare Pharmacy PAs Submitted Status **As of the end of the reporting period

Approved Denied


Encounter Data Reporting Encounter Data are records of medically-related services rendered by a provider to a member. The department continues the process of validating all encounter data to ensure adequate development of capitation rates and overall program and data integrity. Performance

Measure Amerigroup AmeriHealth UnitedHealthcare Encounter Data Submitted By 20th of the Month

Oct Nov Dec Oct Nov Dec Oct Nov Dec

Y Y Y Y Y Y Y Y Y

Any errors in encounter data are expected to be corrected within contractual timeframes. The department is engaged in ongoing validation and collaboration associated with the transfer of encounter data as well as continuous evaluation of the quality of data submitted.

Value Based Purchasing Enrollment MCOs are expected to have 40% of their population covered by a value based purchasing agreement by 2018.

Data as of December 2017 Amerigroup AmeriHealth UnitedHealthcare

% of Members Covered by a Value Based Purchasing Agreement Meeting State Standards

20% 0% 39%

All value based contracts are currently being discussed with MCOs to ensure that all components required are included. On October 31, 2017, AmeriHealth Caritas announced their departure from the IA Health Link program, effective November 30, 2017. Therefore, AmeriHealth had no members as of December 2017.


MCO FINANCIALS

MLR/ALR/Underwriting MCOs are required to meet a minimum medical loss ratio of 88% per the contract between the department and the managed care organizations.

• Medical loss ratio (MLR) reflects the percentage of capitation payments used to pay medical expenses.

• Administrative loss ratio (ALR) reflects the percentage of capitation payments used to pay administrative expenses.

• Underwriting ratio reflects profit or loss. A minimum medical loss ratio protects the state, providers, and members from inappropriate denial of care to reduce medical expenditures. A minimum medical loss ratio also protects the state if capitation rates are significantly above the actual managed care experience, in which case the state will recoup the difference.

Q2 SFY18 Data Amerigroup AmeriHealth UnitedHealthcare MLR 96.0% 97.3% 95.6% ALR 7.8% 10.9% 7.8% Underwriting -3.8% -8.2% -3.4% The department expects quarter-to-quarter fluctuations in financial metrics while the plans’ experience in the Iowa Medicaid market matures. The financial ratios presented above are common financial metrics used to assess MCO financial performance. The financial ratios presented here were reported by the MCOs and are consistent with Q4 calendar year 2017 (Q2 SFY18) financial information submitted to the Iowa Insurance Division by each MCO. The financial metrics presented here reflect financial performance for Q2 SFY18. Premium deficiency reserves and/or changes in premium deficiency reserves are excluded from the calculations. The department believes this approach most accurately reflects financial performance for service delivery under the contract. It is important to note that accounting and reporting differences among MCOs may result in variance among plans beyond the variance in medical expenses per member. The department is working with the MCOs to standardize financial metrics and limit or explain controllable variances for reporting purposes. Q2 SFY18 results reported for UnitedHealthcare include the AmeriHealth transition that occurred on December 1, 2017. As such, the reported results include one month of the AmeriHealth transitioned members. Due to timing of expenses and revenues related to the transition, the ALR for Q2 SFY18 is lower than for prior quarters.


Member Months and Average Costs Per Member Per Month (PMPM) Q1 SFY18 July, August, September 2017

Amerigroup

Population Member Months

Inpatient Hospital PMPM

Outpatient Hospital PMPM

Physician PMPM

Pharmacy PMPM

Ancillaries PMPM

LTSS PMPM Total PMPM

TANF Child 291,553 $29.71 $33.03 $63.64 $23.05 $3.11 $0.02 $152.56 TANF Adult 57,888 $51.80 $115.34 $107.64 $74.16 $9.60 $0.07 $358.61 Pregnant Women 6,863 $25.64 $136.83 $144.46 $20.78 $4.82 $0.03 $332.56 Wellness Plan 147,055 $86.93 $126.28 $113.06 $100.81 $12.94 $0.09 $440.11 Disabled 28,602 $236.57 $239.87 $323.81 $286.74 $58.48 $0.23 $1,145.69 Dual 33,311 $22.88 $86.98 $231.78 $7.72 $33.64 $0.15 $383.14 LTSS Physically Disabled 5,068 $238.43 $193.33 $198.67 $205.07 $200.75 $2,929.94 $3,966.18 LTSS Elderly 12,820 $42.04 $48.40 $38.48 $4.18 $40.74 $3,092.60 $3,266.44 LTSS Intellectually Disabled 4,558 $67.73 $71.35 $240.43 $124.80 $147.01 $6,770.71 $7,422.03 LTSS Children’s Mental Health 1,257 $51.33 $63.93 $430.23 $239.66 $21.54 $1,984.09 $2,790.79

Encounter Data Disclaimer: The data provided by the IME is provided “as is.” The IME cannot ensure the accuracy, completeness, or reliability of the data. The encounter validation process is not yet complete and a one percent (1%) error rate has not yet been achieved. Users accept the quality of the data they receive and acknowledge that there may be errors, omissions, or inaccuracies in the data provided. Further, the IME is not responsible for the user’s interpretation, misinterpretation, use or misuse of the data. The IME does not warrant that the data meets the user’s needs or expectations.



AmeriHealth




Physician PMPM

Pharmacy PMPM

Ancillaries PMPM






UnitedHealthcare




Physician PMPM

Pharmacy PMPM

Ancillaries PMPM





Capitation Payments Made to the Managed Care Organizations

MCO Q1 SFY18 Q2 SFY18 Q3 SFY18 Q4 SFY18 Amerigroup $252,059,197 $252,496,960

AmeriHealth $452,572,360 $304,552,047

UnitedHealthcare $213,334,385 $356,479,227

Managed Care Organization Reported Reserves Data reported Amerigroup AmeriHealth UnitedHealthcare

Acceptable Quarterly Reserves per Iowa Insurance Division (IID) (Y/N)*

Y N/A Y

Third Party Liability Recovery for Q2 SFY18 Data reported Amerigroup AmeriHealth UnitedHealthcare

Amount of TPL Recovered $9,493,182 $17,317,546 $16,846,120

Historical third party liability recoveries collected by the Iowa Medicaid Enterprise as part of payment for services was included in the capitation rates for the managed care organizations.


PROGRAM INTEGRITY

Program Integrity Program integrity (PI) encompasses a number of activities to ensure appropriate billing and payment. The main strategy for eliminating fraud, waste and abuse is to use state-of-the art technology to eliminate inappropriate claims before they are processed. This pre-edit process is done through sophisticated billing systems which have a series of edits that reject inaccurate or duplicate claims.

Increased program integrity activities will be reported over time as more claims experience is accumulated by the MCOs, medical record reviews are completed, and investigations are closed.

Fraud, Waste and Abuse

Program integrity activity data demonstrates the MCO’s ability to identify, investigate and prevent fraud, waste and abuse.

Q2 SFY18 Data Amerigroup AmeriHealth UnitedHealthcare Investigations Opened During the Quarter 4 90 19

Overpayments Identified During the Quarter 0 71 5

Cases Referred to the Medicaid Fraud Control Unit During the Quarter

1 9 2

Member Concerns Referred to IME 3 6 2

In prior reports, dollars recovered through Program Integrity efforts were reported on a quarterly basis. However, MCOs may not collect overpayment until review by the agency has been completed to assure law enforcement activities have been conducted. Given the review and approval process required by the state to collect dollars, recoveries may occur at a much later date. Due to the complexity of actual collection of dollars, recovery of overpayments will be reported on an annual basis. The plans have initiated 113 investigations in the second quarter and referred 12 cases to MFCU. The billing process generates the core information for program integrity activities. Claims payment and claims history provide information leading to the identification of potential fraud, waste, and abuse. Therefore MCO investigations, overpayment recovery, and referrals to MFCU would not occur until there is sufficient evidence to implement. It is anticipated that these activities will significantly grow with ongoing claims experience to be used for analytics.


HEALTH CARE OUTCOMES

*Member totals were calculated on the tenth day of the month following each reporting period – data pulled on other dates will not reflect the same numbers due to reinstatements and eligibility changes.

The data is based on claims paid for dates of service during the experience periods listed above and does not account for claims that have not yet been submitted. Data is pulled from encounters submitted to the IME by MCOs. Data is not risk adjusted for differences in MCO populations. Encounter Data Disclaimer: The data provided by the IME is provided “as is.” The IME cannot ensure the accuracy, completeness, or reliability of the data. The encounter validation process is not yet complete and a one percent (1%) error rate has not yet been achieved. Users accept the quality of the data they receive and acknowledge that there may be errors, omissions, or inaccuracies in the data provided. Further, the IME is not responsible for the user’s interpretation, misinterpretation, use or misuse of the data. The IME does not warrant that the data meets the user’s needs or expectations.

Hospital Admissions A goal of managed care is to reduce unnecessary hospital admissions by assuring that members receive effective care coordination and preventive services. Data reported Q2 SFY18 to allow 90 day claims

lag

Amerigroup AmeriHealth UnitedHealthcare Jul Aug Sep Jul Aug Sep Jul Aug Sep

Members (from IME)* 197,851 197,577 195,345 221,264 220,952 218,441 189,009 188,569 185,447 Total Inpatient Admissions 2,492 2,276 1,240 2,241 2,403 2,218 1,167 1,596 1,576 Readmissions within 15 days of Discharge 224 217 78 148 150 147 135 136 128

Readmissions between 16 and 30 days of Discharge 128 34 53 101 112 96 85 105 77




*Emergency department utilization is reported using revenue code 45X. Member totals were calculated on the tenth day of the month following the reporting period – data pulled on other dates will not reflect the same numbers due to reinstatements and eligibility changes. The data is based on claims paid for dates of service during the experience periods listed above and does not account for claims that have not yet been submitted. Data is pulled from encounters submitted to the IME by MCOs. Data is not risk adjusted for differences in MCO populations. ED Visits for Non-Emergent Conditions are reported per 1,000 member months.


Emergency Department* Data reported Q2

SFY18 to allow 90 day claims lag


Jul Aug Sep Jul Aug Sep Jul Aug Sep

ED Visits for Non-Emergent Conditions – Adult

36 36 32 29 28 27 33 30 32

ED Visits for Non-Emergent Conditions – Child

16 16 17 16 15 17 16 14 16

Supporting Data Members (from IME) 197,851 197,577 195,345 221,264 220,952 218,441 189,009 188,569 185,447 Members Using ED More Than Once in 30 Days 1,185 1,219 799 1,109 1,062 800 883 845 664

Members Using ED More Than Once between 31 and 60 Days

761 541 434 746 504 413 577 388 317


*The data provided is what has been uploaded to the Individualized Service Information System (ISIS) by income maintenance workers based on out of state case activity reports submitted. This process is important in ensuring that member eligibility is up to date and capitation rates are appropriately paid. The IME is working through encounter data validation processes, and numbers may differ from MCO placement counts. Data is not risk adjusted for differences in MCO populations.

Out-of-State Placement* Q2 SFY18 Data Amerigroup AmeriHealth UnitedHealthcare

Oct Nov Dec Oct Nov Dec Oct Nov Dec Members in Out-of-State PMIC 5 3 3 13 11 0 4 4 10

Members in Out-of-State Nursing Facilities and Skilled Nursing Facilities

22 18 17 44 38 0 11 10 57

Members Placed in an Out-of-State ICF/ID 5 4 4 4 3 0 4 3 8


APPENDIX


APPENDIX: HCBS WAIVER WAITLIST

HCBS Waiver Waitlist – January 2018*

HCBS waivers have a finite number of slots budgeted and authorized by CMS. These allow members to receive services in the community instead of a facility or institution.

Waiver AIDS Brain Injury

Children’s Mental Health

Elderly Health

and Disability

Intellectual Disability

Physical Disability

Number of Individuals on Waiver

36 1,430 906 7,920 2,210 11,894 921

Number of Individuals on Waiver Waitlist (DHS Function)

0 1,147 1,363 0 3,036 2,958 1,453

Waitlist Increase or (Decrease) 0 72 86 0 64 32 -26

As reported in January 2018. January data represents December eligibility statistics.


APPENDIX: COMPLIANCE REMEDIES ISSUED

Type of Report with Noncompliance by MCO During this Reporting Period

Identified Reporting or Compliance Issue Amerigroup AmeriHealth UnitedHealthcare Grand

Total Care Plan Reductions Report Care Coordination Report 2 3 1 6 Correct Coding Initiative Report 1 1 Cost Avoidance Report Consumer Reports Report Geographic Access Report Grievances and Appeals 1 1 2 Health Outcomes Report IPES Report LTSS Report 1 1 NEMT Report Non-PI Recoveries Report Planned Coordination Events Report Program Integrity Report 3 1 2 6 Provider Credentialing Report Provider Incentives Report Revised Assessments and Care Plans Reports Risk Assessment Report Third Party Liability Value Added Services Report Waivers Report 1 1 Grand Total 7 5 5 17

Type of Noncompliance Identified by MCO During this Reporting Period

Type of Noncompliance Amerigroup AmeriHealth UnitedHealthcare Grand Total

Did not meet performance standard 3 3 3 9 Incomplete/Untimely/Inaccurate 4 2 2 8 Grand Total 7 5 5 17

Remedies are subject to change due to review of information received from the managed care organizations following publication of this report.


APPENDIX: GLOSSARY MCO Abbreviations: AGP: Amerigroup Iowa, Inc. ACIA: AmeriHealth Caritas Iowa, Inc. UHC: UnitedHealthcare Plan of the River Valley Iowa, Inc. Glossary Terms: Administrative Loss Ratio: The percent of capitated rate payment or premium spent on administrative costs. Appeal: An appeal is a request for a review of an adverse benefit determination. A member or a member’s authorized representative may request an appeal following a decision made by an MCO. Actions that a member may choose to appeal:

• Denial of or limits on a service. • Reduction or termination of a service that had been authorized. • Denial in whole or in part of payment for a service. • Failure to provide services in a timely manner. • Failure of the MCO to act within required time-frames. • For a resident of a rural area with only one MCO, the denial of services outside

the • network

Members may file an appeal directly with the MCO. If the member is not happy with the outcome of the appeal, they may file an appeal with the Department of Human Services (DHS) or they may ask to ask for a state fair hearing. Appeal process: The MCO process for handling of appeals, which complies with:

• The procedures for a member to file an appeal • The process to resolve the appeal • The right to access a state fair hearing and • The timing and manner of required notices

Calls Abandoned: Member terminates the call before a representative is connected. Capitation Payment: Medicaid payments the Department makes on a monthly basis to MCOs for member health coverage. MCOs are paid a set amount for each enrolled person assigned to that MCO, regardless of whether services are used that month. Capitated rate payments vary depending on the member’s eligibility.


CARC: Claim Adjustment Reason Code. An explanation why a claim or service line was paid differently than it was billed. A RARC – Readjustment Advice Remark Code provides further information. Care Management: Care Management helps members manage their complex health care needs. It may include helping member get other social services, too. Chronic Condition: Chronic Condition is a persistent health condition or one with long-lasting effects. The term chronic is often applied when the disease lasts for more than three months. Chronic Condition Health Home: Chronic Condition Health Home refers to a team of people who provide coordinated care for adults and children with two chronic conditions. A Chronic Condition Health Home may provide care for members with one chronic condition if they are at risk for a second. Clean Claims: The claim is on the appropriate form, identifies the service provider that provided service sufficiently to verify, if necessary, affiliation status, patient status and includes any identifying numbers and service codes necessary for processing. Client Participation: Client Participation is what a Medicaid member pays for Long-Term Services and Supports (LTSS) services such as nursing home or home supports. Community-Based Case Management (CBCM): Community-Based Case Management helps Long Term Services and Supports (LTSS) members manage complex health care needs. It includes planning, facilitating and advocating to meet the member’s needs. It promotes high quality care and cost effective outcomes. Community-Based Care managers (CBCMs) make sure that the member’s care plan is carried out. They make updates to the care plan as needed. Consumer Directed Attendant Care (CDAC): Consumer Directed Attendant Care (CDAC) helps people do things that they normally would for themselves if they were able. CDAC services include:

• Bathing • Grocery Shopping • Medication Management • Household Chores

Critical Incidents: When a major incident has been witnessed or discovered, the HCBS provider/case manager must complete the critical incident form and submit it to


the HCBS member's MCO in a clear, legible manner, providing as much information as possible regarding the incident. Denied Claims: Claim is received and services are not covered benefits, are duplicate, or have other substantial issues that prevent payment. DHS: Iowa Department of Human Services Disenrollment: Refers to members who have chosen to change their enrollment with one MCO to an alternate MCO. Durable Medical Equipment: Durable Medical Equipment (DME) is reusable medical equipment for use in the home. It is rented or owned by the member and ordered by a provider. ED: Emergency department Emergency Medical Condition: An Emergency Medical Condition is any condition that the member believes endangers their life or would cause permanent disability if not treated immediately. A physical or behavioral condition medical condition shown by acute symptoms of sufficient severity that a prudent layperson, who possesses an average knowledge of health and medicine, could expect the absence of medical attention right away to result in:

• Placing the health of the person (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy

• Serious impairment to bodily function • Serious dysfunction of any bodily organ or body part

If a member has a serious or disabling emergency, they do not need to call their provider or MCO. They should go directly to the nearest hospital emergency room or call an ambulance. The following are examples of emergencies:

• A Serious Accident • Stroke • Severe Shortness of Breath • Poisoning • Severe Bleeding • Heart Attack • Severe Burns

Emergency Medical Transportation: Emergency Medical Transportation provides stabilization care and transportation to the nearest emergency facility.


Emergency Room Care: Emergency Room Care is provided for Emergency Medical Conditions. Emergency Services: Covered inpatient or outpatient services that are:

• Given by a provider who is qualified to provide these services • Needed to assess and stabilize an emergency medical condition

Emergency Services are provided when you have an Emergency Medical Condition. Excluded Services: Excluded services are services that Medicaid does not cover. The member may have to pay for these services. Fee-for-Service (FFS): The payment method by which the state pays providers for each medical service given to a patient; this member handbook includes a list of services covered through fee-for-service Medicaid. Fraud: An act by a person, which is intended to deceive or misrepresent with the knowledge that the deception could result in an unauthorized benefit to himself or some other person; it includes any act that is fraud under federal and state laws and rules; this member handbook tells members how to report fraud. Good Cause: Members may request to change their MCO during their 12 months of closed enrollment. A request for this change, called disenrollment, will require a Good Cause reason. Some examples of Good Cause for disenrollment include:

• A member’s provider is not in the MCO’s network. • A member needs related services to be performed at the same time. Not all

related services are available within the MCO’s provider network. The member’s primary care provider or another provider determined that receiving the services separately would subject the member to unnecessary risk.

• Lack of access to providers experienced in dealing with the member’s health care needs.

• The member’s provider has been terminated or no longer participates with the MCO.

• Lack of access to services covered under the contract. • Poor quality of care given by the member’s MCO. • The MCO plan does not cover the services the member needs due to moral or

religious objections. Grievance: Members have the right to file a grievance with their MCO. A grievance is an expression of dissatisfaction about any matter other than a decision. The member, the member’s representative or provider who is acting on their behalf and has the member’s written consent may file a grievance. The grievance must be filed within 30


calendar days from the date the matter occurred. Examples include but are not limited to:

• The member is unhappy with the quality of your care. • The doctor who the member wants to see is not an MCO doctor. • The member is not able to receive culturally competent care. • The member got a bill from a provider for a service that should be covered by the

MCO. • Rights and dignity. • The member is commended changes in policies and services. • Any other access to care issues.

Habilitation Services: Habilitation Services are HCBS services for members with chronic mental illness. HCBS: Home- and Community-Based Services, waiver services. Home- and Community-Based Services (HCBS) provide supports to keep Long Term Services and Supports (LTSS) members in their homes and communities. hawk-i: A program that provides coverage to children under age 19 in families whose gross income is less than or equal to 302 percent of the FPL based on Modified Adjusted Gross Income (MAGI) methodology. Health Care Coordinator: A Health Care Coordinator is a person who helps manage the health of members with chronic health conditions. Health Risk Assessment (HRA): A Health Risk Assessment (HRA) is a short survey with questions about the member’s health. Historical Utilization: A measure of the percentage of assigned members whose current providers are part of the managed care network for a particular service or provider type based on claims history. Home Health: Home Health is a program that provides services in the home. These services include visits by nurses, home health aides and therapists. Hospital Inpatient Care: Hospital Inpatient Care, or Hospitalization, is care in a hospital that requires admission as an inpatient. This usually requires an overnight stay. These can include serious illness, surgery or having a baby. (An overnight stay for observation could be outpatient care.) Hospital Outpatient Care: Hospital Outpatient Care is when a member gets hospital services without being admitted as an inpatient. These may include:


• Emergency services. • Observation services. • Outpatient surgery. • Lab tests. • X-rays.

ICF/ID: Intermediate Care Facility for Individuals with Intellectual Disabilities IHAWP: Iowa Health and Wellness Plan covers Iowans, ages 19-64, with incomes up to and including 133 percent of the Federal Poverty Level (FPL). The plan provides a comprehensive benefit package and is part of Iowa’s implementation of the Affordable Care Act. IID: Iowa Insurance Division IME: Iowa Medicaid Enterprise Integrated Health Home: An Integrated Health Home is a team that works together to provide whole person, patient-centered, coordinated care. An Integrated Health Home is for adults with a serious mental illness (SMI) and children with a serious emotional disturbance (SED). Level of Care (LOC): Members asking for HCBS waivers or facility care must meet Level of Care criteria. These must be consistent with people living in a care facility such as a nursing facility. Level of Care is determined by an assessment approved by DHS. Long Term Services and Supports (LTSS): Long Term Services and Supports (LTSS) help Medicaid members maintain quality of life and independence. LTSS are provided in the home or in a facility if needed. Long Term Care Services: • Home- and Community-Based Services (HCBS). • Intermediate Care Facilities for Persons with Intellectual Disabilities. • Nursing Facilities and Skilled Nursing Facilities. MCO: Managed Care Organization Medical Loss Ratio (MLR): The percent of capitated rate payment or premium spent on claims and expenses that improve health care quality. Medically Necessary: Services or supplies needed for the diagnosis and treatment of a medical condition. They must meet the standards of good medical practice.


Network: Each MCO has a network of providers across Iowa who their members may see for care. Members don’t need to call their MCO before seeing one of these providers. Before getting services from providers, members should show their ID card to ensure they are in the MCO network. There may be times when a member needs to get services outside of the MCO network. If a needed and covered service is not available in-network, it may be covered out-of-network at no greater cost to the member than if provided in-network. NF: Nursing Facility PA: Prior Authorization. Some services or prescriptions require approval from the MCO for them to be covered. This must be done before the member gets that service or fills that prescription. PCP: Primary Care Provider. A Primary Care Provider (PCP) is either a physician, a physician assistant or nurse practitioner, who directly provides or coordinates member health care services. A PCP is the main provider the member will see for checkups, health concerns, health screenings, and specialist referrals. PDL: Preferred Drug List Person-centered Plan: A Person-centered Plan is a written individual plan based on the member’s needs, goals, and preferences. This is also referred to as a plan of care, care plan, individual service plan (ISP) or individual education plan (IEP). PMIC: Psychiatric Medical Institute for Children Rejected Claims: Claims that don't meet minimum data requirements or basic format are rejected and not sent through processing. SMI: Serious mental illness. SED: Serious emotional disturbance. Serious Emotional Disturbance (SED) is a mental, behavioral, or emotional disturbance. An SED impacts children. An SED may last a long time and interferes with family, school, or community activities. SED does not include:

• Neurodevelopmental disorders. • Substance-related disorders. • Other conditions that may be a focus of clinical attention, unless they co-occur

with another (SED).


Service Plan: A Service Plan is a plan of services for HCBS members. A member’s service plan is based on the member’s needs and goals. It is created by the member and their interdisciplinary team to meet HCBS Waiver criteria. Skilled Nursing Care: Nursing facilities provide 24-hour care for members who need nursing or Skilled Nursing Care. Medicaid helps with the cost of care in nursing facilities. The member must be medically and financially eligible. If the member’s care needs require that licensed nursing staff be available in the facility 24 hours a day to provide direct care or make decisions regarding their care, then a skilled level of care is assigned. Supported Employment: Supported Employment means ongoing job supports for people with disabilities. The goal is to help the person keep a job at or above minimum wage. Suspended Claims: Claim is pending internal review for medical necessity and/or may need additional information to be submitted for processing. TPL: Third-party liability. This is the legal obligation of third parties (e.g., certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan. Underwriting: A health plan accepts responsibility for paying for the health care services of covered individuals in exchange for dollars, which are usually referred to as premiums. This practice is known as underwriting. When a health insurer collects more premiums than it pays in expense for those treatments (claim costs) and the expense to run its business (administrative expenses), an underwriting gain is said to occur. If the total expenses exceed the premium dollars collected, an underwriting loss occurs.

iowa department of human services · q1 sfy18 letter gerd stated that this letter is currently...

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