April 1 marks the one year anniversary of Iowa Medicaid’s switch to managed care organizations (MCO)s. After being delayed twice (originally slated to start January 1, 2016 – delayed until March 1, 2016, and delayed a final time until April 1, 2016) the MCOs were still not completely staffed or properly trained for the switch-over date.
While most providers had contracts in place, these contracts were still relying on draft formats of provider manual and some vague answers on how to handle unique situations. By fall of 2016 the Governor’s office was citing statistics from the MCOs such as 95% of “clean claims” were being processed. This does not mean the providers were being paid. Providers struggled with large amount due to them by the MCOs as they tried to figure out how to modify the claims to meet the needs of the payers – to receive payment.
An oversight committee was appointed with members from the State House of Representatives and the State Senate (https://www.legis.iowa.gov/committees/committee?groupID=24165 ). Providers and provider associations have on-going conversations with the oversight committee and the three MCOs. At the center of discussion is payment. Providers have a right to suspend (non-critical) treatment to patients if payment has not been received by their insurer. The oversight committee communicates to the providers they need to work that situation out with the payers. The payers come back to the providers and state they do not have enough money to cover the services requested and the providers must talk with the legislators.
Who is stuck in the middle? The patients – Iowa’s most vulnerable population. 40% of children in Iowa qualify for Medicaid benefits, one in seven adults (including Medicare eligible adults) qualify for Medicaid, and persons with disabilities qualify for Medicaid. The switch from one source of information to three continues to be a barrier for the Medicaid enrollees. The Des Moines Register covered a story on March 29 revealing massive losses for the three for-profit MCOs. The State of Iowa enrolled in “risk-corridor” agreements with the MCOs to limit financial exposure for both the State and the MCOs. This means a $225million shortfall will need to come from the Federal Government under the Affordable Care Act.
Oversight needs to be strengthened. This is the law of the land. MCOs are not going away soon. Providers must work within the confines of the MCOs interpretation of Iowa Medicaid. Patients must research and be aware of their coverage and continuously ask if their insurer is still accepted at their provider’s office. Iowan’s need to be aware it affects their children, their grandparents, the disabled, and it affects them/us/all of us – it is our tax dollars.