A State of Iowa
Department of Human Services
MEDICAL ASSISTANCE ADVISORY COUNCIL
Summary of Meeting
October 6, 2004
Jerry Karbeling (Chair) Iowa Pharmacy Association
Mark Peltan (Co-Chair) Iowa Psychological Association
Jennifer Davis Iowa Academy of Family Physicians
for Dr. Dave Carlyle
Lisa Sackett Iowa Assn of Homes & Services for the Aging
for Dana Petrowsky
Larry Breeding Iowa Association for Home Care
Dr. Gene Handley Iowa Chiropractic Society
George Appleby Iowa Council of Health Care Centers
Claire Sealey Iowa Health Care Association
for Steve Ackerson
Shannon Strickler Iowa Hospital Association
for Tracy Warner
Karla Fultz McHenry Iowa Medical Society
Chris Halston Iowa Optometric Association
for Gary Ellis
Leah McWilliams Iowa Osteopathic Medical Association
Lorelei Heisinger Iowa Physical Therapy Association
Dr. Richard Spencer Iowa Podiatric Medical Society
Joe Hutter Iowa State Representative
Stacey Cyphert University of Iowa College of Medicine
Kathleen Gradoville Iowa Association of Nurse Practitioners
Don St. John Iowa Physician Assistant Society
Barbra Nebel Iowa Speech & Hearing Association
Ed Friedman Iowa Association of Rural Health Clinics
Rik Shannon Governor’s DD Council
Karen Loihl Iowa Psychiatric Society
Jay Cayner Iowa Chapter - National Assoc. of Social Workers
Linda Goeldner Iowa Nurses Association
Margaret Stout Alliance for the Mentally Ill of Iowa
Larry Carl Iowa Dental Association
Michele Wray Iowa Association of Community Providers
Anne Kinzel Department of Public Health
Jodi Tomlonovic Public Representative
Orvil Nelson Public Representative
Vacant Des Moines University
Bev Thomas Iowa Association of Hearing Health Professionals
Rizwan Z. Shah MD Iowa Chapter of the American Academy of Pediatrics
Angela Hansen-Abbas Iowa Occupational Therapy Association
Jill Davisson Iowa State Association of Counties
Deborah Berry Iowa State Representative
Maggie Tinsman Iowa State Senator
Sen. Jack Holvack Iowa State Senator
Vacant Public Representative
Mary Ann Weber Public Representative
Vacant The ARC of Iowa
Sherey Swanson ACS
CeCe Zenti ACS
Susan Cameron GovCom
Carol A. Curtis AstraZeneca
Frank Severino Iowa Dental Association
Linda Sims IME
Dennis Janssen DHS
Eileen Creager DHS
Eugene Gessow DHS
Patti Becker DHS
Carolyn Pritchard DHS
The Medical Assistance Advisory Council (MAAC) convened in the Board Room of the Iowa
Hospital Association on October 6, 2004 at 1:00 p.m.
Mr. Jerry Karbeling opened the meeting. Everyone introduced himself and/or herself.
Approval of September Minutes
There was a motion and a second to accept the September minutes. All agreed and the motion
Ms. Patti Becker provided the information for August - the number of individuals enrolled in
Medicaid was 290,589 and the total expenditures were $171,997,892. The number of eligibles for
September was 293,442 and September expenditures were $212,420,436.
Mr. Stacey Cyphert asked about the increase in September. Mr. Eugene Gessow said the
increase is due to the beginning of school because Medicaid applications are sent out through the
schools. Ms. Becker added that hawk-i also does their outreach through the schools.
Payment Accuracy Measurement (PAM) Project Update
Ms. Becker presented a brief update on year three of the PAM project. As of October 1, 2004,
there were approximately ninety providers that have not submitted documentation for the claims or
the documentation was incomplete. She said that the week of October 4, Myers & Stauffer were
making calls to the providers asking that the claims documentation be submitted by October 8,
2004. Anything received after that date will be considered an error and the amount will be taken
back from the providers. She said the project officially ended September 30, 2004.
Ms. Becker said she will provide the MAAC with the list of providers who have not complied when
she has the list.
Ms. Becker explained that the payment error rate measurement (PERM) draft regulation comment
period has been extended to October 27, 2004. The Department has a workgroup that is working
on providing the State's comments and some provider organizations will be commenting.
The areas of main concern have to do with the threshold of the dollar amounts on the sample
claims that can have a claim for $1 and up. There is no clear definition of medical necessity. At
least one state, Washington, is having an issue with this because CMS is doing a re-review of
claims that have been submitted. CMS did not agree with what the State of Washington defined
on their claim documentation as medical necessity. There is a CMS workgroup that is working on
a clear definition of medical necessity. Their determination will be in the clarification in the future
regulations. Iowa claims have not been re-reviewed yet. Ms. Becker said that the Myers &
Stauffer medical review staff are using the individual policy based on each type of claim.
CMS also has a workgroup that is working on defining a denied claim.
The issue with the documentation generally has more to do with providers that are unorganized, in
that they do not belong to an association. For instance, home and community-based waiver
services, consumer directed attendant care (CDAC) that is provided by individuals. Those types
of providers are not members of organizations so those providers may be hit the hardest.
Representative Joe Hutter asked about the reasons given for not meeting the deadline. Ms.
Becker responded that it is anything from they didn’t receive the letter or they didn’t understand it.
Both agreed the staff is using a lot of time for follow-up. Representative Hutter asked if they could
wait for the next quarter. Ms. Becker said when this requirement goes live October 3, 2005 the
administrative issues will need to be decided and worked out because the resources will not be
available to make all the follow-up calls.
Representative Hutter said that Department efficiency should increase and suggested that
providers not meeting the rules and regulations should be penalized to encourage them to
cooperate with the rules.
Ms. Karla McHenry advised that some of those requests for physician practice documentation
were for $2.10. This is a critical piece for the Iowa Medical Society because physician offices are
struggling as everyone else is because of low reimbursement and unfunded mandates, of which
this is one of them. Some providers may be efficient by not responding because it is not worth
their time and expense and it would be better take the $2.10 hit. She understands the Department
must be able to show they have done all they can to verify the accuracy of the payment, but when
most of the claims for physician offices are under $50 that is burdensome to those offices.
Representative Hutter asked if there could be a rule by the DHS or a law passed saying that if not
answered by September 30, any funds under $50 will not be paid. Ms. McHenry said this is a
federal program so the federal regulations have to dictate how it will happen. Representative
Hutter said that needs to be resolved.
Medical Assistance Crisis Intervention Team (MACIT)
Mr. Karbeling said the Team has met four times. Since the last MAAC meeting, there have been
two MACIT meetings. About one-third of the MAAC members have been in attendance at one or
both of those meetings.
He said that input has been received at each of the meetings. The team has discussed some of
the recommendations and there has been review of the 152 potential options that Mr. Gessow
submitted to the team. One point of discussion has been the type of action to be recommended
by the intervention team. The individual organizational provider group representatives had been
asked about their comfort level with provider cuts, changes in eligibility and changes in levels of
services. The feedback was fairly negative.
Mr. Peltan reported that after the Dubuque meeting the Team came up with about 20
recommendations that they are considering to make at the end of the process – Mr. Cyphert
provided MAAC a handout of the letter to the congressional delegation containing the
recommendations, and stated the MACIT minutes and public comments can be accessed at
Mr. Peltan said at the last MACIT meeting Deputy insurance Commissioner Sue Voss talked
about long-term care insurance and how it could impact Medicaid. Mr. Karbeling added that Ms.
Voss mentioned positives but they would be a long-term impact and not necessarily resolve the
current potential shortfall items.
Representative Hutter asked about the impact of Wisconsin and Illinois (the proposal they have to
have an internet website that ties in with Canadian, British, and Irish websites.) Mr. Karbeling said
information retrieved from articles from the New York Times and the Chicago Business Publication
show that it still doesn’t resolve the question of legality. Representative Hutter said that Illinois is
proceeding with it. Mr. Karbeling said there is still the legal question about the way to provide
oversight and verification of those sites. He did not feel it would have an effect on Iowa yet.
Representative Hutter asked if Medicaid recipients or former recipients are ever on the
committees that are working through Medicaid solutions. Mr. Karbeling responded that a
requirement of one of the vacant positions on the MAAC is that he/she is a recipient of Medicaid.
Mr. Cyphert said that Ms. Debbie Spencer from Broadlawns is on the MACIT. She is a social
worker who works closely with recipients and was appointed to the Team in part because of her
contact with those clients. Because of the six meeting sites across the state, it takes much travel
time and is difficult to find recipients that can travel or offer the broad perspective of Ms. Spencer.
Mr. Larry Breeding said someone needs to point out to the legislature that they were told three
years ago that this was coming. It was known that intergovernmental transfers (IGT) were going
to be phased out and it started five years ago. The Senior Living Trust fund was going broke and
the legislature did nothing about it. They were stealing money from Peter to pay Paul. It got so
bad that now in a $200 million crisis, they're screaming for help. A little bit of foresightedness was
needed and if the legislature would have listened to what the Department was saying (this is prior
to Mr. Gessow and Mr. Concannon) to the legislature that a crisis was coming, the funding
streams should be changed and nobody did anything and that’s policy. The MAAC can't set policy
around here. A little of the blame needs to be put on the folks that created the MACIT because
they are the same folks that to a very large extent created the crisis.
Ms. Jennifer Davis said the Academy of Family Physicians would be supportive of the MAAC
formally supporting the MACIT to recommend additional revenue sources for the Medicaid
program. Many provider groups are from the years during the nineties when the providers saw no
increases and around the time of the national Tobacco monies coming into the state there were
finally some increases. Shortly after that they cut again and now it is coming into effect again.
For many years during good economic times and now during bad times the providers rate have
not been increased and/or have been decreased. MACIT feels that any cuts to eligibles or rates
or services would be detrimental to the program overall and would cause a bigger crisis with
access. Ms. Davis stated that the State has been pretty fortunate that most providers have hung
in there. Providers do support enhanced revenue and support tobacco tax used for Medicaid.
Ms. Lorelei Heisinger motioned and Dr. Handley seconded:
THAT THE MEDICAL ASSISTANCE ADVISORY COUNCIL (MAAC) NOTIFY THE MEDICAL
ASSISTANCE CRISIS INTERVENTION TEAM (MACIT) THAT MAAC OPPOSES ANY CUTS IN
ELIGIBILITY, SERVICES, OR REIMBURSEMENT RATES, AND ALSO SUPPORTS FINDING
ADDITIONAL REVENUE SOURCES TO SUPPORT THE MEDICAID PROGRAM.
The motion carried.
Iowa Health Solutions Update
Mr. Dennis Janssen provided the enrollment history of Iowa Health Solutions (IHS). IHS came to
Medicaid in October 1997 in Lee County with 155 enrolled, entered other counties and in May of
2004 had 40,016 enrolled. In September 2004 they had 32,386 enrolled. They will lose
Muscatine County the end of October because they could not maintain a provider panel. They will
be losing Clinton, Hamilton and Jackson counties the end of November. In December they will
have 20 counties with an expected enrollment of about 27,000.
The HMO has advised DHS they have reached agreement with the North Iowa PHO and they
expect to file papers with the Insurance Division and then the Department of Human Services to
expand into eleven counties in the north central part of the state. He has not received a formal
request from the plan. He has also received a letter from the North Iowa PHO saying they are in
discussion with the HMO on contract issues.
Mr. Janssen said that on March 26th the Department sent IHS a request for a corrective action
plan because of issues with timely claims payment. It was also requested that they submit
corrected encounter data because their contention was that part of the reason for errors was
because the encounter data was incorrect. In their corrective action plan they agreed to submit
the data, hire a claims trainer and two more claims processors, and that their MIS would look for
ways to expedite payments.
He mentioned that on the resubmitted encounter data, DHS originally showed that they were not
meeting the standard of 90% clean claims in 30 days and 100% in 90 days. The information now
provided is for all claims not just clean claims and shows that only 1% to 3% of their claims have
been paid in more than 90 days. They are close to meeting the standard.
Mr. Janssen said he did a comparison on encounter data with other plans for all claims from
March though July. IHS pays mostly in the 31-90 day period. The other two plans reviewed paid
mostly in the 0 – 30 days.
Since June 1991 Mr. Janssen has required that IHS send a monthly report of what is done with
clean claims. The standard federally, in the contract and in the rules says that 90% of clean
claims need to be paid within 30 days and 100% within 90 days.
The percentage of clean claims since June 2001 as a percentage of total claims have gone from a
range of 13.09% to 50.2% at various times during that period.
The other HMOs have stated that their clean claims are 97% of their total claims.
Mr. Janssen said that for July 2004, the most recent clean claims tracking report from IHS, shows
that 13.09% of claims were clean, 6.1% of those were paid in 0 – 30 days, and 93.9% were paid in
31-60 days. They are meeting a part of the standard that says 100% in 90 days. They are not at
90% in 30 days.
Mr. Janssen said the Insurance Division of the Department of Commerce has received some
complaints about IHS from some providers and has independently reviewed IHS.
On September 28, 2004, there was a meeting between the Insurance Division and IHS officials.
They discussed network adequacy, quality, and claims payments delays. The Insurance Division
sent one of their auditors to IHS in Nevada to review their claims process. They had a few
findings and recommendations:
Most county panels (contracted providers) are okay.
They did decertify Marshall County because they lost many providers and the hospital in the
Requested that IHS maintain a current provider directory because there is not a correct
On September 28, 2004, IHS was told they would be visited by IFMC on September 30 and
October 1, 2004, to do a quality review. Results are not in yet and it is not known if the
Insurance Division will share them with DHS.
Claims concerns were that there was no record of claims being received of the over 1200
claims they receive every day.
There were multiple processing steps, including a 2-day delay from the time of receiving the
claim until someone begins processing the claim.
Insurance Division recommended they:
o Implement a tracking system by provider so they can track the claim process,
o Eliminate delays caused by excessive handling,
o Add an appropriate number of staff.
IHS has until July 31 to implement and create changes in their system.
Dr. Robert Spencer said he recently had a call from a physician and IHS had informed the
physician that to be eligible for their program they wanted him to do chart audits as well as an
onsite evaluation. Dr. Spencer had also never heard of that for a re-evaluation.
Mr. Janssen said an onsite visit for re-credentialing is appropriate and is one of the standards that
JCOH and NCQA do have in place for re-credentialing a provider. An onsite visit is to make sure
they meet fire codes, and the Americans with Disabilities Act, etc.
Mr. Janssen said that he does an annual onsite review of HMOs and looks at credentialing and re-
credentialing. At all the HMO's he has seen where they have done their provider onsite visits,
there is a checklist done at a physical onsite review. He said it seems to make sense that if an
organization wanted to review the quality activities they may want look at benchmark practices to
make sure documentation and chart follows.
Ms. McHenry asked for a copy of the Insurance Division's recommendation to IHS. Mr. Janssen
said he had a copy of an unsigned copy of the September 28, 2004 letter that the Insurance
Division said was delivered. (This was emailed to the MAAC on October 6, 2004.)
Iowa Medicaid Enterprise (IME) Update
Mr. Gessow said the Department expects to send out the RFP for pharmacy point of services
(POS) claims adjudication by the end of next week. This was announced on the DHS website.
He stated that there will be a period of time to submit a letter of intent to reserve the opportunity to
bid. There will be a Bidders conference. In all State RFPs there is a specific directive that no one
should ask any state employee about the RFP other than the contracting officer.
He said he was in Kansas City to discuss the IME with Mr. Vince Cain, the regional systems
expert for CMS. He distributed a copy of his presentation that was submitted to Mr. Cain.
The primary focus of the conversation was on how Medicaid is an early adopter state for the MITA
principles. It will hopefully produce additional dollars so the Department can get up to 90% for a
larger share of two of the components of the system contracts, the medical services, and the cost
and provider audits. The point was that the Department is heading in the same direction as CMS
with the adoption of the MITA standards.
Ms. McHenry asked if MMIS is now on the State server. Mr. Gessow replied that it is not yet but it
is part of the process. The system will continue to pay benefits off the ACS mainframe systems
through July 29, 2005. The Department has loaded a copy of the software from the State system
and is installing it and making certain enhancements. The actual processing of claims will begin
June 30, 2005.
SFY '06 Budget Planning
Mr. Gessow provided an update on the FY '06 budget process. The Department submitted its
budget recommendation to the Human Services Council, which met and made its
recommendations to the Governor.
There is a new and enhanced budget evaluation process introduced by the Governor that is
proceeding and the Department has some deadlines to send additional documents. MACIT is one
of the new players in the budget process this year. Where it all ends up is up to the legislature.
One thing the Department is trying to do this year is to have as long and informed conversations
about Medicaid as possible in advance of budget decisions by the legislature. Mr. Karbeling asked
about the prescriptions drug package in the DHS Budget recommendation to the Human Services
Mr. Gessow explained that when the budget was constructed to submit to the Human Services
Council, the Department:
Fund all mandatory services for mandatory eligibles,
Finance all mandatory services for optional eligibles,
Make the payments to federal government under Medicare Part D,
Pay for as much pharmacy services as the Department had with the amount of funds that had
been identified to the Department as available.
Mr. Gessow explained it is possible under current federal Medicaid rules to limit the amount of
prescriptions a recipient receives from Medicaid. Some states have done this. The Department
would assume that this is the way to make cuts if required. Obviously doing that would mean
those most ill would be the most dramatically affected. It is not a recommendation. The only
choice made with the remaining dollars was to fund pharmacy first.
The funds that are available to Medicaid are functions of several factors, first what is currently
available from non-general fund sources that have been traditionally earmarked. The budget
assumed the Department would spend almost the entire amount, literally every penny in the
Senior Living Trust (SLT) and still be $25 million short from what was spent last year because
there would be nothing left in it. Mr. Gessow said it assumed the same amount of support from
the tobacco tax fund but noted that it also assumes that the IGTs will continue, which is very
uncertain. The balance of the funding is always the general fund. The prior year's budget is used
with a possible adjustment.
Mr. Gessow said that on September 28, 2004 he sent Mr. Dennis Smith at CMS an email asking
the status of the IGT's. On October 1st, he received an email saying they are still working on it.
Ms. Eileen Creager provided the update and explained that the Preferred Drug List (PDL) is part
of the IME project. The Medical Pharmacy Unit is working on the PDL.
She said that the P&T committee met for the first time on August 24, 2004 and was an
administration meeting only.
There was a two-day meeting September 28 & 29. That meeting was to discuss the how of
developing a PDL list. The majority of time was spent on public comment and there were 54
presenters which consisted of pharmacists, physicians, organizations, etc.
The P&T will meet October 27 & 28. They will review, discuss and make recommendations of the
final PDL to the department. The P&T will meet December 2 and 3, 2004 and January 6, 2005
and will then meet on a quarterly basis starting April 28, 2005.
At the same time the group is working on training packets. The first training will be held October
25. Training will be done throughout the State in October, November and to the middle of
December. If continued training is needed, there will be sessions in January. She said that
registration for the training is requested not required. There is one session every day at 11:30 and
another session at 6:30 pm that evening. They will continue with regular ICNs to work across any
issues or questions that may come up. The plan is for the PDL to be rolled out January 15, 2005.
Mr. Peltan asked when there would be a meeting about the psychiatric drugs and Ms. Creager
said that will be discussed at the December meeting.
Mr. Gessow mentioned that Part D of Medicare is scheduled to go into effect the middle of next
year. He said that the vast majority of drugs that dual eligibles receive now will then only be
available under Medicare. By federal statute, Medicaid will no longer be paying for them. It may
be perceived by beneficiaries as a substantial change in the Medicaid program. The Legislature
will need to make an informed decision whether any new 100% state funded wraparound program
will be provided for those individuals. These are unavoidable decisions that will be made as part
of the 2006 process.
Information, comments, meeting times and minutes can be found on www.iowaMedicaidpdl.com.
There is an email address on the site for any questions or comments email@example.com.
Ms. Creager is also available for questions at 515-281-5169.
Next Meeting Date for MAAC
The next MAAC meeting is scheduled for Wednesday, November 3, 2004.
The meeting adjourned.
Respectfully Submitted by: