State of Iowa
Department of Human Services
MEDICAL ASSISTANCE ADVISORY COUNCIL
Summary of Meeting
February 1, 2006
Dr. Mary Mincer Hansen (Chair) Iowa Department of Public Health (DPH)
Barbara Nebel Iowa Speech & Hearing Association
Dana Petrowsky Iowa Association of Homes & Services for the Aging
Don St. John Iowa Physician Assistant Society
Dr. Dave Carlyle Iowa Academy of Family Physicians
Dr. Richard Spencer Iowa Podiatric Medical Society
John Forbes, RPh Iowa Pharmacy Association
Marv Tooman Iowa Association of Community Providers
Jodi Tomlonovic Public Representative
Ken Dodge Iowa Psychological Association
Larry Carl Iowa Dental Association
Leah McWilliams Iowa Osteopathic Medical Association
Linda Goeldner Iowa Nurses Association
George Appleby Iowa Council of Health Care Centers
Dr. Bob Russell Iowa Department of Public Health
Rik Shannon Governor’s DD Council
Stacey Cyphert University of Iowa College of Medicine
Dr. Cindy Baddeloo Iowa Health Care Association
James Pullen Iowa Psychiatric Society
Kathleen Gradoville Iowa Association of Nurse Practitioners
Lorelei Heisinger Iowa Physical Therapy Association
Jay Cayner Iowa Chapter - National Assoc. of Social Workers
David Purdy Iowa HCBS for Seniors
Joe Hutter Iowa State Representative
Dr. Gene Handley Iowa Chiropractic Society
Ron Kemp Iowa/Nebraska Primary Care Association
John Grush Public Representative
Shannon Strickler Iowa Hospital Association
Karla Fultz McHenry Iowa Medical Society
Ed Friedmann Iowa Association of Rural Health Clinics
Gary Ellis Iowa Optometric Association
Bev Thomas Iowa Association of Hearing Health Professionals
Brian Sheesley Public Representative
Deborah Berry Iowa State Representative
Jill Davisson Iowa State Association of Counties
Jo Benson-Vorwald Iowa Adult Day Services Association
Sen. James Seymour Iowa State Senator
Margaret Stout Alliance for the Mentally Ill of Iowa
Rizwan Z. Shah MD Iowa Chapter of the American Academy of Pediatrics
Ron Bolar Opticians Association of Iowa
Sen. Jack Hatch Iowa State Senator
Mark Wheeler Iowa Association for Home Care
John Grush Public Representative
Vacant Iowa Occupational Therapy Association
Vacant Coalition for Family and Children's Services in Iowa
Vacant Des Moines University
Vacant Free Clinics of Iowa
Vacant Iowa Association of Area Agencies on Aging
Vacant Iowa Caregivers Association
Vacant Iowa Nurse Practitioner Society
Vacant The ARC of Iowa
Vacant (38) Public Representative
CeCe Zenti ACS
Kristi Oliver Iowa Assn of Homes & Services for the Aging
Julie Bueno IME Pharmacy Medical Services
Jennifer Vermeer DHS
Eileen Creager DHS
Patti Becker DHS
Carolyn Pritchard DHS
The Medical Assistance Advisory Council (MAAC) convened in the conference rooms at the Iowa
Medicaid Enterprise building on February 1, 2006 at 1:00 p.m.
Dr. Mary Mincer Hansen, Director of the Iowa Department of Public Health (IDPH), opened the
Approval of November Minutes
Mr. Larry Carl motioned and Dr. Marv Tooman seconded to accept the November minutes. All
agreed and the motion carried.
SSI/SSA Review Forms
Pregnancy Mothers and Children
Spousal Resource Allowance
Spousal Resource Allowance
3% Provider Increase
IowaCare Mental Health reimbursement
PDL Drug Changes
DSH Supplemental Hospital Payments
SSA Lower Income Limits
Ms. Jennifer Vermeer presented the budget update noting that the three staff from the
Departments of DHS, Management, and Legislature meet and agree monthly on a budget range.
The Legislative Service Agency publishes this range in their legislative update publication, which
is emailed monthly. This monthly projection will be emailed to the MAAC in the future.
Ms. Vermeer said as of the first of February, the FY '06 budget has a shortfall ranging from $30M
to $45M. This information was known last year and has been predicted for FY '06.
The projected increase for FY '07 is between $90M and $130M compared to the original
appropriations for FY '06.
Ms. Vermeer explained that HF 841 created a new committee called the Medical Assistance
Projections and Assessments Council (MAPAC). The primary responsibility is oversight of
IowaCare and the Medicaid program. It requires them to set the Medicaid number to be used for
budgeting for the legislative session. The committee met to discuss the Medicaid number to be
used for this legislative session when they met yesterday (January 31, 2006). She said there is a
model to use if interested in modifying assumptions. The Committee decided to wait for another
four or five weeks to set that forecast to gain as much data in as possible.
She mentioned that the 3% provider increase is still in process. She said that Mr. Eugene
Gessow is working to position the Department so it doesn’t have to give up something to get the
3% increase without a negative impact.
Ms. Vermeer said the $90m to $130M estimate assumes that the budget stays as it is today and if
there would be a provider rate increase or any new activity those numbers would increase.
Mr. Stacey Cyphert questioned about the monthly worksheet that was sent out this month that
indicated a 1% provider rate increase. Ms. Vermeer explained that was to give the committee the
option to build in money if needed and to show what another 1% or 2% increase would be. She
said that has not been built into any of the budget numbers provided today. Mr. Cyphert asked if
there is a recommendation from DHS related to a provider increase and Ms. Vermeer responded
that there has been no recommendation.
Ms. Vermeer related that 3% of last years $16M would be roughly $7M this year. She described
the difference of the Governor's budget being that his is reflecting a similar level of growth but it is
funded from different sources. His budget has the tobacco funds flowing into the Healthy Iowans
and the Senior Living Trust fund. It also recommended that a large amount be funded as
supplemental in the next session. In looking only at the general fund comparisons there is no
increase on the Governor's budget, but that is a distortion in that he is recommending from the
non-general funding sources and then also a delay until the next legislative session. Part of the
rationale is that it is unknown what the impact of Medicare Part D will be on Medicaid, so a
decision on a portion of the Medicaid budget is delayed until the next session when there will be a
better idea of the amount of increase.
Dr. Dave Carlyle asked if there is a sense yet of the Part D on the budget. Ms. Vermeer
responded that the Department received from the Social Security Administration (SSA) an
estimate of a substantial amount of Iowans (40,000 to 60,000) that would end up being eligible for
the low-income subsidy. About 10,000 Iowans have become eligible for that subsidy and is lower
than estimated probably because they used the IRS income data and lacked the information of
member resources. The Department will not know the impact on eligibility until after February.
For a while there was about $17M-$25M built into the FY '07 estimate and though there will be an
effect, it appears it will not be near that amount.
Ms. Vermeer continued with an update on the IowaCare program from the information presented
at the MAPAC meeting last week. She said the enrollment has leveled off to around 12,000 to
13,000 in the last couple months. There are about 100 in the chronic care condition program and
that would allow people who were formerly in the State Papers program but do not qualify for
IowaCare to continue to receive care at the University. There are 13 in the OB category.
She said that year-to-date there is about $20M in claims expenditures and the program has
served on an unduplicated basis of about 9,100 patients in the program. There are about 15,000
who have ever been enrolled at any point in the program over the course of the seven months and
of that total about 9,000 have accessed a service at one of the IowaCare network providers.
Ms. Vermeer stated that the IowaCare program has caps on it and the Department is watching
closely and is currently working on the projections to be ready by the end of February. The
Department is also working intently with the IowaCare providers on this.
The legislature has been very interested in the premium aspect of the IowaCare program and this
is gaining more interest since the federal health reconciliation bill would allow states to have
additional options in charging co-pays and premiums within the regular Medicaid population. It
has been a topic of interest, including how many are disenrolled for not paying a premium, and
what is being done to educate the people.
Ms. Vermeer added that there has been an ongoing dialog with CMS about IowaCare and the
nursing facility level of care state plan amendment (SPA). It came to a standstill in the fall and
there was recently a change in that CMS suggested that the Department take procedural action to
stop the clock on that SPA, as they wanted to continue discussions with the Department on it.
She referenced the last of the IowaCare Advisory Group meetings that are meeting on all of the
healthcare reform initiatives in HF 841. The Department is focusing its effort on doing things that
are small steps rather than changing a whole system at once. She said there have been great
insights from many people.
Ms. Dana Petrowsky asked if there is any connection between the ones who have fallen off of the
program and those who do not pay their premium. Ms. Vermeer agreed that some of those were
disenrolled for non-payment of premiums, others have become eligible for Medicaid, and some
have disenrolled voluntarily due to relocation or no longer interested.
Ms. Vermeer addressed how the penalty of being disenrolled would impact their future options.
She said if someone is disenrolled from the program and want to access healthcare services at
any of the IowaCare providers they will be billed for those services. If they wish to reenroll in the
program they must pay the back premiums.
In response to a question about a geographical analysis showing how the number of enrollees is
distributed throughout the state, Ms. Vermeer answered that the UI has provided some analysis of
comparison to the former state papers program. There is enrollment from all of the state. She
said Mr. Cyphert had reported many of those counties are seeing more participation in IowaCare
than in the state papers program. Mr. Cyphert reported that at the last MAPAC meeting he
presented a map of the patients that UI have treated in the IowaCare program and that report is
available on the website where you can also view some of the other presentations to the MAPAC
(http://www.legis.state.ia.us/aspx/Committees/Committee.aspx?id=70). He said that some of the
western counties have sent more patients under the IowaCare program than under the state
papers program. Ms. Vermeer said the IME website also has some statistical reports about
IowaCare that include the enrollment by county and other demographic information. You can get
to the link on http://www.ime.state.ia.us as well as to other reports.
Iowa Medicaid Enterprise (IME) Update
Ms. Vermeer reported that last week at the capitol an IME Performance review was presented that
is being designed for the website but has taken longer than expected. (It is now available at
http://www.ime.state.ia.us/Reports_Publications/index.html.) The report is detailed performance
data for each of the units of IME, statistical claims processing, level of care determination,
pharmacy, regular medical claims, electronic, paper, collections through TPL, and SURS. She
encouraged the members who are interested to review the reports on the site.
Ms. Vermeer spoke about the family planning waiver approved by CMS that begins February 1,
2006. It provides for a Medicaid expansion (for family planning services only) for women up to
200 percent of the federal poverty level (FPL). There was an informational release that went out
to the providers that explains how the program works and there is a manual with a listing of what
procedure codes for services and prescriptions are covered. Any qualified Medicaid provider in
the state can provide these services that are on the list posted on the website
Ms. Vermeer explained that the members on the waiver have a separate card that looks different
from both the IowaCare card and the regular Medicaid card. HF 841 required allowing people to
be in both IowaCare and the family planning waiver. That creates some special issues that are
highlighted in the informational release and providers are urged to be aware that if the members
have IowaCare they can receive their family planning services from any Medicaid provider but if
they are not on the waiver they will have to go to their IowaCare provider for any other services. It
is estimated to reach about 60,000 women and the Department is receiving a 90% federal match
for this program.
Chronic Care Council (CCC)
Dr. Hansen addressed what the legislature passed regarding more health promotion and
prevention and the charge to the IDPH to work with Medicaid to see what can be done in that
area. She asked Dr. Bob Russell to speak about what his group is doing with the Dental Home for
Dr Russell reported he has been working with Ms. Cathy Coppes, Policy Specialist and Mr.
Gessow from DHS and Dr. Peter Damiano from UI to develop a concept to utilize the existing
resources in Iowa to meet the needs of the children. It has been temporarily titled I-Smile. He
said he has received some positive feedback from the Iowa Dental Association, the Iowa Hygiene
Association, and a few other public health agencies. The idea has been to partner with the
existing dental providers and the public health agencies because many things are currently being
done especially though Title V, Internal Child Health, WIC, and Head Start organizations. Many
dental services, especially prevention services are offered through those agencies as well as
participatory guidance, care coordination and oral education. Since this is already taking place in
Iowa, this is not new but there are underfunded organizations and there is an irregularity among
them where some have a dental hygienist working with them and some do not. Some work
closely with the dental communities and some do not. On the east side of the state, Davenport
and Dubuque have two model programs that may roll out to rest of state. He said it is in the
beginning of the investigations of these programs and he will have more to share later.
He expressed that it looks very exciting plus there are two parts of the plan, Part A and Part B.
Part B is a general RFI that was put out on the IME website where any individual instate or out of
state can submit a proposal that would accomplish a dental home for around 165,000 or more
Medicaid enrolled children between the ages of twelve and below. Basically, there are about
55,000 Medicaid enrolled children ages 12 and below right now that receive some form of dental
treatment. Many of them are below the ages of four and most dental practices will not take a
dental patient below the age of four. The team is working very hard in getting prevention services
for that age group to avoid the decay process when the problems are most severe.
Dr. Hansen mentioned the return on investment and cost avoidance. Dr. Russell said of the
children between the ages of zero to four, last year there were approximately a little over 1,400
hospitalizations of children in that age group. In zero to twelve, a little over 500 were below age
four with one age 11 months.
Dr. Russell reported that dental decay in children starts very early. He said the future promotions
will include training that infections of the mouth in the mother are transmitted to the children.
Dental disease is an infectious disease that can be passed from caregiver to child through each
generation. Their habits may precipitate the child's dental decay. The agencies will be critical in
the process of getting information to families. Out of the $13M that was spent in annual dental
care visits; a little more than $3M was spent on hospitalizations for children that fall in that age
Mr. Carl confirmed that his group, the Iowa Dental Association, is interested in Plan B and has a
great deal of interest in the I-Smile concept. He said they will provide a comprehensive response,
they are working closely with Dr. Russell and others, and they are meeting on the east side of the
state next week to advance this program.
Dr. Tooman wondered in this overall review of children who have been admitted if consideration
has been given for secondary conditions of oral disease in terms of pulmonary issues or other
disease implications. Dr. Russell responded that this subject has had national implications and in
Massachusetts and Michigan there was a considerable amount of hospitalization increase when
adult Medicaid services were eliminated. The states found that when states removed dental care it
increased in expenditures in the long run. This has been a wake-up call that avoiding primary
dental care does not save money and the costs will eventually be absorbed. Iowa is especially
looking at this impact on children, their educational functions, socialization and other aspects.
Mr. Carl asked Dr. Russell to comment on a slight trend of smaller Iowa communities wanting to
give up the fluoridation of their water supply. Dr. Russell said this is a new situation for Iowa
although not for other states. He explained Iowa has had fluoridation for over fifty years and as
the equipment has gotten old some communities decide not to replace it. He provided an
example of Hampton in Franklin County. They had cut off water fluoridation equipment five years
ago and didn’t tell anyone. It suddenly became a public situation because the dentists and
specifically, the dental hygienists identified an increase in decay in their patients. That led to the
public awareness of the cutoff of fluoridation in that community. The latest information is that the
city council has voted to reinstate the fluoridation in that community. There are four or five other
communities of similar size primarily in the north and northeast areas of the state that have also
decided to discontinue fluoridation for the same reasons. Dr. Russell said he grew up in
Muskegon, MI, which was a test site of non-fluoridation, about 30 miles from Grand Rapids, MI
where fluoridation was born sixty years ago. The difference was dramatic in the improvement in
teeth in Grand Rapids versus Muskegon. The problem is that there is a reverse taking place and
the succession of the generation to come have no knowledge of losing their teeth at age 18 and
are now want to cut off the expense of fluoridation. For every dollar that is spent in fluoridation
nationally, it has saved $40 per person in health costs. He believes that if the fluoridation goes
away it will return people back to the pre-1940s and a drastic number of teens will be seen with
Prevention Strategies Update
Dr. Hansen stated that the tobacco control bureau is working with Medicaid on the Quitline
(www.quitlineiowa.org) and nicotine replacement therapy and DPH is still working with Medicaid to
see if WelButrin will be covered as part of the stop smoking issues and what can be done.
She noted that DPH is also working on nutrition and obesity. She said there are two nutritionists
advocating along with their Medicaid counterpart on reimbursement for nutritionists to do
counseling with overweight children who are on Medicaid.
Dr. Ken Dodge said that many of the barriers that prevent people from losing weight happen to be
psychological or emotional. Psychologists are in a better position to treat those symptoms than
are physicians and he would like reimbursement for counseling to be considered.
Dr. Hansen agreed that was a very good point that would also work for the stop smoking program,
and a better health outcome would be provided when doing the combination of the counseling with
the other therapies.
Expenditures and Eligibles
Ms. Patti Becker acknowledged another change that rather than her reading the numbers off of
the attachment, she will be present for any questions the Council may have for her.
Dr. Spencer asked questions about the PERM project and the reviews that were done. Ms.
Becker explained that project is complete and has ended for Iowa. Ms. Becker said that the claims
that were found to be in error were turned over to the IME Surveillance Utilization Review (SURS)
Unit to follow up. Ms. Becker said CMS implemented the PERM project permanently on October 1
2005 and sixteen states are participating every three years. Iowa isn’t scheduled to participate
again until October 1, 2008.
Preferred Drug List (PDL)
Ms. Eileen Creager said the PDL has now been up and running for a year since its implementation
on January 15, 2005. There have been estimated drug savings. The PDL in 2005 averaged
$17.8M in savings. For 2006 the estimate is $22M in savings. The 2005 estimate was only for six
months and the 2006 estimate is not much higher because the Department is losing the large
volume of members to Medicare Part D.
Ms. Creager reported that when the PDL began, the prior authorization (PA) requests were taking
an average of four to eight hours turnaround to make a determination back to the pharmacists.
That has dropped to 1.68 hours. The last quarter volume of PA calls received were 17,900 and
from that 10,300 were approved, 4,000 denied, 2,000 were incomplete and 700 plus that did not
require a PA. She said there has been a decrease of 30% in this past quarter of those that were
incomplete and that did not require a PA.
She gave the figures from the Point of Sale (POS) process where the claims are paid. The past
quarter there were 1.8 million pharmacy claims that passed through the IME building and paid
$114.5M. An average claim was running around $61.33.
Ms. Creager stated that the category of drugs is one of the three highest cost areas in Medicaid
and the PDL has helped bring back money.
Pharmaceutical and Therapeutic (P&T) Committee
Ms. Creager said the P&T committee establishes the requirements for the PDL. The P&T last met
in December and discussed and voted on the entire PDL and RDL. The Department has accepted
that and it went into effect January 16, 2006. The response to the training sessions has been
positive. She reported that this morning, February 1, 2006, the legislature had a mandate for the
P&T committee to form a study group to look at the mental health drugs and that report was
presented to the legislature and the legislature accepted the report.
The main concern was that when dealing with mental health drugs, a person's medication cannot
just be cut off; it has to be done through a therapy process. The major cost of drugs is pharmacy
and mental health drugs and in some cases generic may be more cost effective and in other
cases brands are more cost effective
Dr, John Forbes asked for comments about the P&T Committee looking at generic drugs. He
gave an example of MS Contin, under that generically are about two or three manufacturers and
not one specific manufacturer. Ms. Julie Bueno said that is only for the Oxycontin ER due to a
large supplemental rebate offer from one manufacturer. She said there is a time period through
April 1, 2006 allowing the pharmacy to use up their stock. The Endo brand of Oxycontin ER will
be available through the wholesalers so it is the hope there wont be any problems with supplies.
Dr. Forbes felt the concern is that it might be the first step towards using generics on the PDL, and
there is concern in the pharmacies about having to stock multiple generic brands and that is very
hard for the rural community pharmacy.
Ms. Creager agreed that it is a good comment in regards to the pharmacy's stocking both brand
and generic. The P&T is very aware of that and concerned of what the impact will be with
providers and consumers.
Preparation for Adult Living (PALS)
Ms. Mary Nelson, DHS Division Administrator of the Behavioral, Developmental, and Protective
Services for adults, families and children presented a Legislative proposal that was submitted this
year. She referenced her proposal handout on the Preparation for Adult Living (PALS).
She began by discussing that age 27 is the average age when most people become financially
and emotionally independent of their parents. She explained that the foster children in the State
of Iowa are expected to step into this independence when they become the age of 18.
Ms. Nelson stated the State of Iowa needs to be a better parent to the children in the foster
program and that each year a little over 500 youth turns age 18 and leave foster care. They do
not fare very well mainly because they do not have many supports to fall back on, including
healthcare. They are not poor enough to qualify for Medicaid and if they are employed, they are
not working in jobs that provide health coverage, and many have mental health needs and/or
other physical health needs. She expressed that this group tends to be a more needy population
than the average 18 or 19 year old.
The first part of the proposal is to continue to provide some financial support in terms of staying in
the foster family or support to live in an apartment while attending school or working towards self-
The second part of the proposal is asking the State to take advantage of a Chaffee Option
provided by the Congress that means as a state plan, the Department can add this population and
make them eligible for Medicaid. The proposal to do that is a little over $1M. Every youth aging
out of foster care under the 200 FPL would automatically qualify for Medicaid. It is in the
Governor's budget and also there is a statutory bill that would make this possible.
Ms. Nelson said although this proposal is receiving a generally receptive audience in the
legislature, the Department is trying to get this out to groups that touch this population in hopes
that others, including MAAC members, will be supportive of this proposal in their talks with
legislators because it provides an opportunity for a very vulnerable population to have access to a
set of healthcare benefits.
Mr. Cyphert asked if this was part of the $709M figure presented for the FY '07 budget or is this on
top of that. She presumed this is included because it is in the Medicaid budget. She said it is a
new program for FY '07.
Mr. Carl asked if the $1,053,000 stated in the handout would be the state portion of the total
program. Ms. Nelson agreed that is the states share although the total is about $3M. She
explained that for the first part of it, there is no federal match so that is total dollars, and that the
federal government generally does not participate in the care of kids after they turn 18. On the
Medicaid side, it is eligible for the full Medicaid match as a SPA since Congress has added this as
an option in the state plan.
Ms. Nelson directed a response to the question about the Medicaid wraparound regarding a
former foster child in the 18 to 21 age group, who is a Junior in college, doing well, turns 21 years
of age, and whether they are then on their own and may have to drop out. She said that
unfortunately this benefit would end when they turn 21 and one of the things being proposed is
that a youth will have access to case management so hopefully the person who is working with
them will help them plan for when they will turn 21 and the changes that come with that. This is as
far as Congress was willing to go so this is the proposal put before the legislature. Ms. Nelson
agreed that the idea that a youth in foster care is ready at 21 is better than 18 and there is still a
ways to go but this is moving in the right direction.
Someone asked if the 19-year-old youth who is in the system now would be eligible for this
program when it takes place. She said the proposal the FY '07 budget supports is actually a go-
forward proposal and affects kids that turn 18 or graduate from high school or GED this May 1,
2006 and does not pick up the youth that graduated or GED last year.
Ms. Nelson said there are some programs for the youth out there now. One example is called
ETV (Education and Training Vouchers). The Department can provide financial assistance to
youth who have aged and transitioned out of foster care and are going to any accredited
education or trade program. There is also an aftercare network. These programs will continue for
these kids and on the go-forward basis the youth will also have access to these as well.
She expressed her hope that everyone could be supportive of this proposal.
Discussion of the New Public Members
Dr. Hansen reported that Mr. Gessow is still working with the Governor's office to name the
appointed public members to the MAAC.
Discussion of the Executive Committee
Dr. Hansen thanked Mr. Carl for helping to coordinate the meeting of the business representatives
on the MAAC in selecting their representatives to the Executive Committee.
Meeting Dates for MAAC
The remaining 2006 quarterly meeting dates for the MAAC are scheduled for 1:00 on April 5, July
5, and October 4.
Meeting Dates for MAAC Executive Committee
Dr. Hansen said March 7, 2006, would be the first Executive Committee (EC) meeting. She said
Medicaid will bring specific issues to the EC and the EC will also bring its issues from the MAAC.
An agenda will be put out two weeks in advance of the meeting to the EC members and to the
MAAC. She confirmed that it is a public meeting.
(NOTE: At the March EC meeting, it was decided that the EC meetings are to be held on
Tuesdays in the middle of each month from 2:30 to 4:30.)
The meeting adjourned at 2:45.
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